Use of digital images to aid in the decision-making for acute upper extremity trauma referral

This study evaluated the use of digital smartphone images in the decision-making for acute upper extremity trauma referrals. Surgeons (n = 15) were presented with ten upper limb trauma scenarios for consideration of immediate transfer. Based on verbal history and with additional images, participants were asked questions regarding diagnosis, injured tissues, recommended management and diagnostic and treatment confidence. Statistical analyses evaluated confidence level changes and relationships between confidence levels and independent variables. Confidence levels for diagnosis and treatment were increased with the provision of smartphone images, and this was statistically significant. The decision to transfer was changed in 22%. The photographs were more useful for amputation versus non-amputation injuries (diagnosis and treatment) and hand versus forearm injuries (diagnosis), and these differences reached statistical significance. Smartphone digital images were shown to be useful for decision-making in acute upper extremity trauma referrals. This improved communication may have implications for health cost savings and patient burden by minimizing unnecessary acute transfers.

LEVEL OF EVIDENCE

Diagnostic Level III.

The SF-6D health utility index in carpal tunnel syndrome

Cost effectiveness is an important factor to consider when choosing between various hand surgical interventions. Health utility measures can be used to determine cost effectiveness. The SF-6D is a health utility index derived from 11 items of the SF-36 quality of life questionnaire; values range from 0.296 to 1.0 ("perfect" health). We evaluated the validity of the SF-6D in patients with carpal tunnel syndrome (CTS) who completed the SF-36 and the CTS symptom severity and functional status questionnaire before and 3 months after carpal tunnel release. Complete responses to the SF-6D items were available for 100 patients at baseline and 95 patients at baseline and follow-up. The mean SF-6D health utility index was 0.69 (SD 0.13) before surgery and 0.77 (SD 0.13) after surgery (moderate effect size). The SF-6D could discriminate between patient groups differing in self-rated global health and in whether, or not, they had a minimal clinically important improvement in CTS symptom severity after surgery. The SF-6D appears to be a valid measure of health utilities in patients with CTS and can be used in cost effectiveness studies.

Patient participation in the decision for replantation

It is widely accepted that medical decision making should consider the wishes of the patient. In contrast, traditional decision making in replantation has been based primarily on the expected functional outcome of the replantation as represented in the literature. Conflicts can occur when the patient seeks to exercise a positive right to replantation against the wishes of the surgeon. The field of decision science has developed a framework to study and consider this problem so that it can be applied to replantation. The concept of evidence-informed patient choice is applicable to replantation, but is tempered by several problems, including the need for decision making in an emergency situation.

The prevalence and characteristics of nerve compression symptoms in the general population

The purpose of this cross-sectional study was to evaluate the prevalence and intensity of nerve compression symptoms and to estimate the prevalence of carpal tunnel syndrome (CTS) in the general population. A survey that included the Katz hand diagram, the Carpal Tunnel Instrument (CTI), and the Short Form-36 questionnaire was sent to 1,559 people. A short telephone survey was conducted to a random sample of 110 nonresponders to determine if they were systematically different from the responders. Of the responders 35.1% had a symptom severity (CTI subscale) score of > or =1.5. Of the responders and the nonresponders 23.2% and 14.5%, respectively, reported waking at least once per night with numbness; 37.3% of the responders and 33.6% of the nonresponders experienced pain in the hand at least once per day. As determined by the Katz hand diagrams, 58 (16.3%) of the responders had classic or probable distributions of symptoms (likely to have CTS) and 298 (83.7%) had possible and unlikely distributions. After correcting for nonresponders our lowest possible estimate of CTS prevalence in the general US population is 3.72%, indicating a larger pool of symptomatic people than previously reported.

Different reference frames can lead to different hand transplantation decisions by patients and physicians

Different frames of reference can affect one's assessment of the value of hand transplantation. This can result in different yet rational decisions by different groups of individuals, especially patients and physicians. In addition, factors other than frames of reference can affect one's evaluation of hand transplantation, which can result in different decisions.

The role of emergency free flaps for hand trauma

Primary closure of a wound with free flap requires minimizing the risk of infection in an effort to cover vital exposed structures. Careful patient selection, radical débridement of the wound, and an experienced microsurgical team are important for the routine application of this technique. Primary reconstruction of all injured structures is an extension of this technique that enables efficient management of severe upper extremity problems in a single setting.

Patient and injury characteristics in the development of cold sensitivity of the hand: a prospective cohort study

In this prospective cohort study, we questioned whether cold sensitivity occurring after all types of injuries decreases, increases, or remains constant. We also questioned which patient and injury characteristics are most associated with the development of cold sensitivity. The degree of cold sensitivity of 123 patients with acute hand and forearm injuries was repeatedly scored from a prevalidated questionnaire over 11 months after injury. Twenty-five patients with more severe symptoms at 11 months were reassessed at 3 years. The patients' age, gender, smoking habit, workers' compensation status, mechanism of injury, level and orientation of injury, and injured structures were analyzed with respect to cold sensitivity. The results of our study indicate that the severity of cold sensitivity increased from the time of injury until 3 months following injury and then remained constant until 11 months following injury. At 3 years from injury, symptoms in patients with severe cold sensitivity had significantly reduced to 67% of the 11-month level. Cold sensitivity was common in all types of hand injuries, not just in amputations and in arterial or nerve injuries. A multiple linear regression analysis suggested that the severity of cold sensitivity was most related to the presence of bone injury. Cold severity was not specifically related to smoking or amputations.

Kienböck disease and negative ulnar variance

We compared the degree of ulnar variance, measured on standardized radiographs of the wrist, in forty-four patients who had Kienböck disease with that in ninety-nine control subjects who had been selected from a general clinic population and had radiographs of the wrist. The purpose of our study was to determine if there is a true relationship between negative ulnar variance and the development of Kienböck disease. Gender was not found to influence the degree of ulnar variance, but an association was found between age and negative ulnar variance in both the control subjects and the patients who had Kienböck disease. The findings of the present study confirmed an association between negative ulnar variance and the development of Kienböck disease even after correction for the influence of age on the measurement of ulnar variance.

Timing of critical thrombosis after replantation surgery of the digits

The time at which critical thrombosis occurred was assessed in a group of 63 patients (76 digits) following replantation surgery. The influence of smoking and mechanism of injury were examined with respect to the risk of thrombosis. The highest risk of critical thrombosis after replantation occurred in the first 3 days after surgery, although some risk remained up to 2 weeks. The higher risk of late failure in smokers may represent the effects of a return to smoking after discharge. Mechanism of injury did not appear to affect the timing of critical thrombosis. This report should help surgeons plan the timing of discharge against the known ongoing risk of replantation failure. Strong advice against resumption of smoking seems to be appropriate.

Use of outcome instruments to compare workers' compensation and non-workers' compensation carpal tunnel syndrome

Validated outcome instruments were used to compare treatment outcomes of carpal tunnel syndrome (CTS) in workers' compensation and non-workers' compensation patients. A self-administered questionnaire consisting of the generic Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the disease-specific Carpal Tunnel Syndrome Instrument was mailed to 277 patients randomly selected from all 1050 new patients treated for CTS during a 1-year period. A total of 212 patients (61 workers' compensation and 151 non-workers' compensation) responded to the survey 7-22 (mean, 14) months after the initiation of treatment, yielding a response rate of 76%. Workers' compensation patients had worse mean scores than non-workers' compensation patients in 6 of the 8 SF-36 scales and in the 2 Carpal Tunnel Syndrome Instrument scales, but validating multivariate analysis could not verify significant score differences in any of the scales. Thus, this study could not demonstrate inferior treatment outcomes of CTS in workers' compensation patients as measured by standardized generic and disease-specific outcome instruments.

Assessment of the carpal tunnel outcome instrument in patients with nerve-compression symptoms

The outcome movement in medicine has encouraged the development of patient-answered questionnaires as measures of well-being. A disease-specific questionnaire for carpal tunnel syndrome (CTS) was introduced by Levine et al. in 1993. We evaluated this questionnaire in 156 consecutive new patients presenting with pain, numbness, or tingling of the upper extremity. Of these, 114 correctly filled out the carpal tunnel outcome instrument. In addition, these patients completed the self-administered hand diagram developed by Katz and Stirrat for the diagnosis of CTS. The 114 patients were classified according to their hand diagram as classic or probable CTS (n = 47), possible CTS (n = 31), and unlikely CTS (n = 36). The mean symptom severity score in patients classified as classic or probable CTS was significantly higher than the mean score in patients classified as possible or unlikely CTS (p < .01). The mean scores of items regarding sensory symptoms were significantly higher in patients with classic or probable CTS compared to patients with possible or unlikely CTS (p < .0001). The scores were similar for CTS and non-CTS patients on the functional status subscale.

Nonunion rates of limited carpal arthrodesis: a meta-analysis of the literature

Numerous types of limited intercarpal arthrodeses have been reported in dozens of articles in the English-language medical literature. The nonunion rate varies considerably within and between the different types of arthrodeses. This may be due in part to the small number of cases in most studies. The data on the number of good results and nonunion rates for 27 different types of limited carpal arthrodeses reported in the English-language medical literature from 1946 to 1993 were collected, and for each study, the 95% confidence intervals (95% CI) were calculated. The studies were then combined for specific types of arthrodeses and the overall nonunion rates and confidence intervals were calculated to more accurately determine the actual nonunion rate expected for limited intercarpal arthrodeses. Nonunion rates (95% CI) for the most popular types of limited arthrodeses were as follows: of 385 scaphotrapezium-trapezoid arthrodeses reported, there was a 14% nonunion rate (95% CI, 11%-18%); of 104 lunotriquetral arthrodeses, the nonunion rate was 27% (95% CI, 19%-36%); and of 17 scapholunate arthrodeses, the nonunion rate was 47% (95% CI, 26%-69%).

Osteoid osteoma of the hamate: report of a case and review of the literature

There are 7 reported patients with osteoid osteoma of the hamate. Only 1 of these has involved the hook of the hamate. This article reports the second patient with osteoid osteoma involving the hook of the hamate. The clinical features, the diagnostic problems, and the management of this lesion are reviewed.

The burned hand

Like other work-related injuries, the performance and documentation of a thorough history and physical examination will allow optimal care of the burned worker by accepted management methods. Through understanding of the physical properties of electricity and improving understanding of the pathophysiology of the electric injury, state-of-the-art surgical reconstruction can be appropriately applied. The diversity of chemical compounds at the work place and the wide variety of early measures advocated for treatment requires prevention of chemical burns and careful on-site documentation of chemicals and availability of first aid measures.

Vibration white finger

Vibration white finger is a form of secondary Raynaud's phenomenon caused by vibratory hand tools. The pathophysiology is multifactorial, with involvement of the peripheral vascular system, sensory receptors, peripheral nerves, muscles, bones, and joints. The diagnosis of this condition is essentially clinical. In this article, the pathophysiology, clinical presentation, diagnosis, industrial standards of exposure, preventive measures, and treatment modalities have been reviewed.

Nonunion of the scaphoid: a critical analysis of recent natural history studies

To determine whether treatment of a disorder is effective, a surgeon must first understand the natural history of the disorder without treatment. We used guidelines for the performance of a valid natural history study that appear in the literature and applied them to articles on the natural history of scaphoid nonunion. No study satisfied all criteria. Moreover, none developed an inception cohort, which is the single most important method of a valid natural history study. In each study, the direction of the bias was identifiable: the natural history of scaphoid nonunion was distorted to make the outcome more severe than if methodologic problems had not been present. We conclude that the natural history of nonunion of the scaphoid is not as severe as has been reported in the literature. The magnitude of the difference is not known at this time.

Continuous intravenous regional anesthesia

This study evaluates the effectiveness of continuous intravenous regional anesthesia for prolonged operations on the upper extremity. The factors evaluated include patient's sex and age, number of procedures performed, tourniquet on and off times, anesthetic doses, adjunctive drugs used, technical complications, and side effects. Seventy-two procedures were done on 34 patients. The first tourniquet time averaged 58 minutes. Off time averaged 10 minutes. Second tourniquet time averaged 33 minutes, and the mean total tourniquet time was 91 minutes. The mean first anesthetic dose was 275 mg. Mean second anesthetic dose was 128 mg. Mean total anesthetic dose was 402 mg. There were two (6%) technical complications and two (6%) patients had side effects. Continuous intravenous regional anesthesia offers the prolonged anesthesia of brachial plexus block or general anesthesia and the safety, reliability, and ease of intravenous regional anesthesia. Continuous intravenous regional anesthesia should be considered an alternative choice of anesthetic method in upper extremity surgery.

The measurement of cold sensitivity of the hand

There is no widely accepted method of measuring the severity of cold sensitivity of the hand. A patient-answered questionnaire was developed. This consisted of seven items divided into two subscales: the first to measure the severity of cold sensitivity, and the second to grade exposure of the hands to cold at the workplace. The test-retest reliability was 0.92 for the severity subscale and 0.94 for the work exposure scale. An initial test of validity supports the use of the scale to measure cold sensitivity of the hand.

A case of neurofibroma of the palmar cutaneous branch of the median nerve

This case report describes a previously unreported entity, a neurofibroma of the palmar cutaneous branch of the median nerve. The lesion presented as a palmar mass with an overlying abnormality of the skin. Treatment consisted of excision of the lesion. Infiltration of the terminal branches of the nerve by the tumour prevented nerve reconstruction but provided a previously unknown diagnostic clue: fibrosis of an area of skin innervated by the involved nerve, which had the appearance of a callosity.

Haemangioma of the digital nerve: a case report

An intra-neural haemangioma of the digital nerve of the left index finger is described, the first report of such a lesion in a digit. Treatment consisted of excision of the tumour and the affected portion of the nerve, followed by direct coaptation of the nerve ends.

The nerve of Henlé

The nerve of Henlé, a branch of the ulnar nerve in the forearm, is thought to deliver sympathetic innervation to the ulnar artery. Forty cadaver forearms were dissected under magnification. Two distinct patterns of the nerve were found. In the typical pattern, 18 (45%) of 40 extremities, the nerve originates 16 cm proximal to the ulnar styloid, travels distally with the ulnar artery, and frequently, 13 (72%) of 18, branches to pierce the superficial fascia 6 cm proximal to the ulnar styloid and innervate the skin of the distal ulnar forearm. In the atypical pattern (12%), the nerve originates in the distal 8 cm of the forearm and travels briefly with the ulnar artery before branching to the skin. The palmar cutaneous branch of the ulnar nerve was absent in cadavers with the nerve of Henlé and may be a distal variant of that nerve.

A technique for replantation of the finger tip

The finger-tip replantation technique reported here has evolved over 15 years. Indications for surgery include both strong patient desire and specialized use of the finger tip. Palmar flaps are elevated as full-thickness skin grafts to avoid injury to palmar veins. Arteries and palmar digital veins are repaired using an open-vessel technique. Postoperative care varies from immediate discharge with follow-up to inpatient care using surgical leeches or continuous bleeding as a method of drainage should venous congestion develop. The survival rate of 26 finger tips replanted using this technique between 1981 and 1987 was 69%. Two-point discrimination returned in 75% of patients, and 25% had two-point discrimination of less than 5 mm. The distal interphalangeal joint retained an average range of motion of 56 degrees. Appearance was excellent, and patient satisfaction was high.

Vascular isolation of the rat cremaster muscle

The vascular supply to the rat cremaster muscle was completely isolated to provide a microvascular preparation with a controllable blood flow. The anatomy of the cremaster vascular supply and the surgical approach to isolate the cremaster muscle on its neurovascular pedicle are described. The functional integrity of this isolated cremaster preparation was tested using intravital video microscopy to evaluate the tissue's response to vasoactive agents and to peripheral nerve stimulation. The isolated cremaster muscle was positioned in situ in a controlled tissue bath and concentration response curves to the topical application of norepinephrine (NE) and acetylcholine (Ach) were determined. Vasoconstriction elicited by the topical application of NE or by stimulation of the genitofemoral nerve trunk was similar for both the isolated and standard cremaster preparations. Application of 10(-5) M Ach caused maximal vasodilation equal to that produced by 10(-3) M papaverine in both preparations. In summary, the isolated cremaster muscle of the rat is an acceptable model of a skeletal muscle microcirculation which can be used to investigate microvascular function when precise monitoring or control of perfusion to the entire muscle is needed.

Mycoplasma infection of the hand acquired from a cat

Mycoplasmas, the smallest known organism capable of a free existence, have been recognized as human pathogens for 25 years. However, a soft tissue cellulitis caused by a mycoplasma has never been reported in a human subject. This case report of a mycoplasma infection of the hand acquired from an infected cat describes the clinical presentation, operative findings, mycoplasmology, and treatment of this infection.