Frequency of Adverse Events in the Placebo Arms of COVID-19 Vaccine Trials: A Systematic Review and Meta-analysis

Importance

Adverse events (AEs) after placebo treatment are common in randomized clinical drug trials. Systematic evidence regarding these nocebo responses in vaccine trials is important for COVID-19 vaccination worldwide especially because concern about AEs is reported to be a reason for vaccination hesitancy.

Objective

To compare the frequencies of AEs reported in the placebo groups of COVID-19 vaccine trials with those reported in the vaccine groups.

Data Sources

For this systematic review and meta-analysis, the Medline (PubMed) and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched systematically using medical subheading terms and free-text keywords for trials of COVID-19 vaccines published up to July 14, 2021.

Study Selection

Randomized clinical trials of COVID-19 vaccines that investigated adults aged 16 years or older were selected if they assessed solicited AEs within 7 days of injection, included an inert placebo arm, and provided AE reports for both the vaccine and placebo groups separately. Full texts were reviewed for eligibility by 2 independent reviewers.

Data Extraction and Synthesis

Data extraction and quality assessment were performed independently by 2 reviewers, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline and using the Cochrane risk-of-bias tool. Meta-analyses were based on random-effects models.

Main Outcomes and Measures

The primary outcomes were the proportions of placebo recipients reporting overall, systemic, and local (injection-site) AEs as well as logarithmic odds ratios (ORs) to evaluate group differences. Outcomes were tested for significance using z tests with 95% CIs.

Results

Twelve articles with AE reports for 45 380 participants (22 578 placebo recipients and 22 802 vaccine recipients) were analyzed. After the first dose, 35.2% (95% CI, 26.7%-43.7%) of placebo recipients experienced systemic AEs, with headache (19.3%; 95% CI, 13.6%-25.1%) and fatigue (16.7%; 95% CI, 9.8%-23.6%) being most common. After the second dose, 31.8% (95% CI, 28.7%-35.0%) of placebo recipients reported systemic AEs. The ratio between placebo and vaccine arms showed that nocebo responses accounted for 76.0% of systemic AEs after the first COVID-19 vaccine dose and for 51.8% after the second dose. Significantly more vaccine recipients reported AEs, but the group difference for systemic AEs was small after the first dose (OR, -0.47; 95% CI, -0.54 to -0.40; P < .001; standardized mean difference, -0.26; 95% CI, -0.30 to -0.22) and large after the second dose (OR, -1.36; 95% CI, -1.86 to -0.86; P < .001; standardized mean difference, -0.75; 95% CI, -1.03 to -0.47).

Conclusions and Relevance

In this systematic review and meta-analysis, significantly more AEs were reported in vaccine groups compared with placebo groups, but the rates of reported AEs in the placebo arms were still substantial. Public vaccination programs should consider these high rates of AEs in placebo arms.

Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review

INTRODUCTION

Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction.

PATIENT AND METHODS

A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed.

CONCLUSION

Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.

The Weekend Warrior: Common Hand and Wrist Injuries in Athletes

Weekend warriors are individuals who condense their weekly physical activity into extended intervals over one or two days.1 Excessive physical activity can result in a multitude of overuse and traumatic upper extremity injuries. The purpose of this review is to highlight the etiology and management of the more common hand and wrist injuries in athletes.

Upper extremity disability and quality of life after breast cancer treatment in the Greater Plains Collaborative clinical research network

PURPOSE

Chronic upper extremity disability (UED) is common after breast cancer treatment but under-identified and under-treated. Although UED has been linked to quality of life (QoL), the role of UED as mediator between contemporary treatment practices and QoL has not been quantified. This investigation describes UED in a contemporary sample of breast cancer patients and examines its relationship with personal and treatment factors and QoL.

METHODS

Eight hundred and thirty-three women diagnosed at eight medical institutions during 2013-2014 with microscopically confirmed ductal carcinoma in situ or invasive stage I-III breast cancer were surveyed an average of 22 months after diagnosis. UED was measured with a modified QuickDASH and QoL with the FACT-B. The questionnaire also collected treatments, sociodemographic information, comorbidity, body mass index, and a 3-item health literacy screener.

RESULTS

Women who received post-mastectomy radiation and chemotherapy experienced significantly worse UED and QoL. Women who had lower income, lower health literacy and prior diabetes, arthritis or shoulder diagnoses had worse UED. Patients with worse UED reported significantly worse QoL. Income and health literacy were independently associated with QoL after adjustment for UED but treatment and prior conditions were not, indicating mediation by UED. UED mediated 52-79% of the effect of mastectomy-based treatments on QoL as compared with unilateral mastectomy without radiation. UED and QoL did not differ by type of axillary surgery or post-mastectomy reconstruction.

CONCLUSIONS

A large portion of treatment effect on QoL is mediated by UED. Rehabilitation practices that prevent and alleviate UED are likely to improve QoL for breast cancer survivors.

Associations between upper extremity injury patterns in side impact motor vehicle collisions with occupant and crash characteristics

INTRODUCTION

Side impact motor vehicle collisions (MVC) represent a significant burden of mortality and morbidity caused by automotive injury within the United States. The objective of this study was to evaluate the relationship between upper extremity (UE) injury patterns and contact sources in side impact MVC with occupant and crash variables.

METHODS

Crash Injury Research and Engineering Network data obtained from 1998 to 2012 were used to evaluate UE injuries in side impact crashes. First row drivers and passengers that were at least 16 years old with complete crash information were included. Side impact crashes were defined to have an area of deformation to the side of the vehicle and a principal direction of force between 60° and 120° or 240° and 300°. Injuries were stratified by type, anatomic location, and Abbreviated Injury Scale (AIS) severity. Occupant variables included age, sex, height, weight, body mass index, and Injury Severity Score. Vehicle and crash variables included in the analysis were change in vehicle velocity at the time of impact, maximum door intrusion, maximum B-pillar intrusion, seat track position, belt use, vehicle type, impact type, and injury source. Statistical analysis of the UE injury data included descriptive statistics, linear regression analyses with occupant variables, and logistic regression analyses with vehicle and crash variables.

RESULTS

There were 903 UE injuries among 408 case occupants. The most common injury type was soft tissue injury (72.5%). The majority of fractures were proximal to and including the humerus (70.3%) with the clavicle being the most common fracture location (N = 89). AIS 2+ UE injuries were associated with a significantly higher mean occupant Injury Severity Score than AIS 1 UE injuries (p = 0.01). Contact with the door was the leading cause of UE injury (34.2%). The odds (OR [95% confidence interval], p-value) of an AIS 2+ UE injury due to contact with the B-pillar (5.3 [3.1, 9.1], <0.0001), door (1.9 [1.3, 2.7], 0.0006), and steering wheel/assembly (2.7 [1.1, 6.3], 0.03) were significantly higher than all other injury sources combined. Scapula fractures were significantly associated with rearward seat track positions (1.46 [1.04, 2.05], 0.03).

CONCLUSIONS

This study provides insight into UE injury patterns in side impact MVC. The clavicle was the most common UE fracture location. Contact with the door resulted in the highest number of UE injuries and the B-pillar resulted in the most severe injuries. Additionally, exposure to greater B-pillar intrusion was associated with increased odds of scapula and clavicle fractures in side impacts.

Optimizing implementation of interventions in agriculture for occupational upper extremity musculoskeletal disorders: Results of an expert panel

BACKGROUND

Upper extremity musculoskeletal disorders (UEMSD) is reported worldwide as the second-largest occupational musculoskeletal disorder in agriculture.

OBJECTIVE

The objective of the study is to identify facilitators and barriers for employers and workers for implementing interventions to reduce work-related risk factors associated with occupational UEMSD in the agricultural sector, according to health and safety consultants.

METHODS

An expert panel was used comprising nine health and safety consultants from the Dutch agricultural sector.

RESULTS

Facilitators and barriers for employers and workers were categorized in the following themes: knowledge, skills, attitude, culture, costs, loss of income, facilitation and employability. There were no differences in facilitators and barriers between UEMSD.

CONCLUSIONS

Facilitators and barriers for implementing preventive interventions in agriculture were on organizational level, like diversity in choice of preventive devices, and personal level such as willingness if there is no work disability.

Severe soft tissue injuries of the upper extremity in motor vehicle crashes involving partial ejection: the protective role of side curtain airbags

INTRODUCTION

Partial ejection (PE) of the upper extremity (UE) can occur in a motor vehicle crash (MVC) resulting in complex and severe soft tissue injuries (SSTI). This study evaluated the relationship between partial ejection and UE injuries, notably SSTIs, in MVCs focusing on crash types and characteristics, and further examined the role of side curtain airbags (SCABs) in the prevention of partial ejection and reducing SSTI of the UE.

METHODS

Weighted data was analyzed from the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) from 1993 to 2012. Logistic regression models were used to assess the relationship of PE with SSTI of the UE and the effect of SCABs in both nearside impacts and rollover collisions. Crash Injury Research and Engineering Network (CIREN) case studies illustrated PE involving SSTI of the UE, and long term treatment.

RESULTS

Rollover and nearside impact collisions had the highest percentages of partial ejection, with over half occurring in rollover collisions. Annually over 800 SSTIs of the UE occurred in all MVCs. For nearside lateral force impacts, a multivariable analysis adjusting for belt use and delta V showed a 15 times (OR 15.35, 95% CI 4.30, 54.79) greater odds of PE for occupants without SCABs compared to those with a SCAB deployment. No occupants (0 of 51,000) sustained a SSTI of the UE when a SCAB deployed in nearside impacts, compared to 0.01% (114 of 430,000) when SCABs were unavailable or did not deploy. In rollover collisions, a multivariable analysis adjusted for number of quarter turns and belt use showed 3 times the odds (OR 3.02, 95% CI 1.22, 7.47) of PE for occupants without SCABs compared to those with a SCAB deployment. Just 0.17% (32 of 19,000) of the occupants sustained a SSTI of the UE in rollovers with a SCAB deployment, compared to 0.53% (2294 of 431,000) of the occupants when SCABs were unavailable or did not deploy. CIREN case studies illustrated the injury causation of SSTI of the UE due to partial ejection, and the long term treatment and medical costs associated with a SSTI to the UE.

CONCLUSIONS

The majority of severe soft tissue injuries (SSTI) of the upper extremity (UE) involved partial ejection out the nearside window of outboard seated occupants in nearside impacts and rollover collisions. Real world case studies showed that SSTIs of the upper extremity require extensive treatment, extended hospitalization and are costly. Occupants without a side curtain airbag (SCAB) deployment had an increase in the odds of partial ejection. SCAB deployments provided protection against partial ejection and prevented SSTIs of the UE, with none occurring in nearside impacts, and a small percentage and reduction occurring in rollover collisions compared to those where SCABs were unavailable or did not deploy.

Upper limb birth trauma in a Jordanian population: a prospective study at King Hussein Medical Centre, Amman, Jordan

OBJECTIVE

To determine the incidence of and the main risk factors related to upper limb injury at birth.

METHODS

This prospective study was conducted at the King Hussein Medical Centre, Amman, Jordan, from October 2014 to May 2015, and comprised newborns. The probable predisposing factors for upper limb birth injury and their relation to injury were analysed. SPSS 17 was used for data analysis.

RESULTS

Of the 5,030 live births, 5,003(99.46%) newborns were without and 27(0.54%) were with upper limb birth trauma (5.4 injuries per 1,000 live births). Moreover, 2,565(51%) were boys and 2,465(49%) were girls. Of the injured, 20(74%) patients had clavicle fracture, 3(11.1%) each had brachial plexus injuries and fractures to the humerus, and 1(3.7%) had olecranon fracture, translating into an incidence of 3.97, 0.6 and 0.2 per 1,000 live births, respectively.

CONCLUSIONS

Upper limb injury was not uncommon at birth. In most cases, such injuries were unpredictable and unpreventable.

Bilateral Primary Repair of Simultaneous Bilateral Distal Biceps Rupture

A case of simultaneous bilateral distal biceps tendon rupture in a recreational gymnast is presented. Achieving bilateral acute primary repair can be challenging as any immobilization will lead to disability and difficulty with self-care and activities of daily living. We have reviewed the evidence of this rare condition and demonstrate that modern rehabilitation techniques, which allow early mobilization, can make simultaneous bilateral primary repair a viable option in such cases.

Ergonomics and comfort in lawn mower handle positioning: An evaluation of handle geometry

Hand operation accompanied with any combination of large forces, awkward positions and repetition may lead to upper limb injury or illness and may be exacerbated by vibration. Commercial lawn mowers expose operators to these factors during actuation of hand controls and therefore may be a health concern. A nontraditional lawn mower control system may decrease upper limb illnesses and injuries through more neutral hand and body positioning. This study compared maximum grip strength in twelve different orientations (3 grip spans and 4 positions) and evaluated self-described comfortable handle positions. The results displayed force differences between nontraditional (X) and both vertical (V) and pistol (P) positions (p < 0.0001) and among the different grip spans (p < 0.0001). Based on these results, recommended designs should incorporate a tilt between 45 and 70°, handle rotations between 48 and 78°, and reduced force requirements or decreased grip spans to improve user health and comfort.

Statistical Evaluation of Causal Factors Associated with Astronaut Shoulder Injury in Space Suits

INTRODUCTION

Shoulder injuries due to working inside the space suit are some of the most serious and debilitating injuries astronauts encounter. Space suit injuries occur primarily in the Neutral Buoyancy Laboratory (NBL) underwater training facility due to accumulated musculoskeletal stress. We quantitatively explored the underlying causal mechanisms of injury.

METHODS

Logistic regression was used to identify relevant space suit components, training environment variables, and anthropometric dimensions related to an increased propensity for space-suited injury. Two groups of subjects were analyzed: those whose reported shoulder incident is attributable to the NBL or working in the space suit, and those whose shoulder incidence began in active duty, meaning working in the suit could be a contributing factor.

RESULTS

For both groups, percent of training performed in the space suit planar hard upper torso (HUT) was the most important predictor variable for injury. Frequency of training and recovery between training were also significant metrics. The most relevant anthropometric dimensions were bideltoid breadth, expanded chest depth, and shoulder circumference. Finally, record of previous injury was found to be a relevant predictor for subsequent injury. The first statistical model correctly identifies 39% of injured subjects, while the second model correctly identifies 68% of injured subjects.

DISCUSSION

A review of the literature suggests this is the first work to quantitatively evaluate the hypothesized causal mechanisms of all space-suited shoulder injuries. Although limited in predictive capability, each of the identified variables can be monitored and modified operationally to reduce future impacts on an astronaut's health.

Feasibility of Using Low-Cost Motion Capture for Automated Screening of Shoulder Motion Limitation after Breast Cancer Surgery

Objective

To determine if a low-cost, automated motion analysis system using Microsoft Kinect could accurately measure shoulder motion and detect motion impairments in women following breast cancer surgery.

Design

Descriptive study of motion measured via 2 methods.

Setting

Academic cancer center oncology clinic.

Participants

20 women (mean age = 60 yrs) were assessed for active and passive shoulder motions during a routine post-operative clinic visit (mean = 18 days after surgery) following mastectomy (n = 4) or lumpectomy (n = 16) for breast cancer.

Interventions

Participants performed 3 repetitions of active and passive shoulder motions on the side of the breast surgery. Arm motion was recorded using motion capture by Kinect for Windows sensor and on video. Goniometric values were determined from video recordings, while motion capture data were transformed to joint angles using 2 methods (body angle and projection angle).

Main Outcome Measure

Correlation of motion capture with goniometry and detection of motion limitation.

Results

Active shoulder motion measured with low-cost motion capture agreed well with goniometry (r = 0.70–0.80), while passive shoulder motion measurements did not correlate well. Using motion capture, it was possible to reliably identify participants whose range of shoulder motion was reduced by 40% or more.

Conclusions

Low-cost, automated motion analysis may be acceptable to screen for moderate to severe motion impairments in active shoulder motion. Automatic detection of motion limitation may allow quick screening to be performed in an oncologist's office and trigger timely referrals for rehabilitation.

Fractures Due to Gunshot Wounds: Do Retained Bullet Fragments Affect Union?

BACKGROUND

Many types of projectiles, including modern hollow point bullets, fragment into smaller pieces upon impact, particularly when striking bone. This study was performed to examine the effect on time to union with retained bullet material near a fracture site in cases of gunshot injury.

METHODS

All gunshot injuries operatively treated with internal fixation at a Level 1 Trauma Center between March 2008 and August 2011 were retrospectively reviewed. Retained bullet load near the fracture site was calculated based on percentage of material retained compared to the cortical diameter of the involved bone. Analyses were performed to assess the effect of the lead-cortical ratio and amount of comminution on time to fracture union.

RESULTS

Thirty-two patients (34 fractures) met the inclusion criteria, with an equal number of comminuted (17) and non-comminuted fractures (17). Seventeen of 34 fractures (50%) united within 4 months, 16/34 (47%) developed a delayed union, and 1/34 (3%) developed a nonunion requiring revision surgery. Sixteen of 17 fractures (94%) that united by 4 months had a cumulative amount of bullet fragmentation retained near the fracture site of less than 20% of the cortical diameter. Nine out of 10 fractures (90%) with retained fragments near the fracture site was equal to or exceeding 20% of the cortical diameter had delayed or nonunion. Fracture comminution had no effect on time to union.

CONCLUSIONS

The quantity of retained bullet material near the fracture site was more predictive of the rate of fracture union than was comminution. Fractures with bullet fragmentation equal to or exceeding 20% of the cortical width demonstrated a significantly higher rate of delayed union/nonunion compared to those fractures with less retained bullet material, which may indicate a local cytotoxic effect from lead on bone healing. These findings may influence decisions on timing of secondary surgeries.

LEVEL OF EVIDENCE

Level III.

Prevalence of Musculoskeletal Disorders Among Korean Police Personnel

This study was conducted to investigate efficient, systematic management of the Korean police and to examine the status and prevention of musculoskeletal disorders in Korean police officers. For police officers in special working environments, the importance of basic data is emphasized for human resources (HR) management and the prevention of industrial hazards from an industrial health care perspective. This study was conducted on police officers who visited the national police hospital and who underwent x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) for the diagnosis of musculoskeletal disorders. The results revealed that examinations for the lower extremities and spine were most frequently conducted using x-ray, CT, and MRI. In particular, knee and lumbar examinations were most frequently conducted among all lower extremity and spine examinations, respectively.

Office workers' computer use patterns are associated with workplace stressors

This field study examined associations between workplace stressors and office workers' computer use patterns. We collected keyboard and mouse activities of 93 office workers (68F, 25M) for approximately two work weeks. Linear regression analyses examined the associations between self-reported effort, reward, overcommitment, and perceived stress and software-recorded computer use duration, number of short and long computer breaks, and pace of input device usage. Daily duration of computer use was, on average, 30 min longer for workers with high compared to low levels of overcommitment and perceived stress. The number of short computer breaks (30 s-5 min long) was approximately 20% lower for those with high compared to low effort and for those with low compared to high reward. These outcomes support the hypothesis that office workers' computer use patterns vary across individuals with different levels of workplace stressors.

Iatrogenic nerve injuries in common upper extremity procedures

Iatrogenic nerve injuries frequently occur during procedures around the hand and wrist, although they are not always recognized at the time of injury or in the immediate postoperative period. Because preventing injuries is of paramount importance, extensive knowledge of the anatomy of the at-risk nerves is critical. Best results occur after immediate repair because a substantial delay before secondary surgery diminishes the chances for recovery from motor or sensory nerve dysfunction and relief from pain. It is helpful to review iatrogenic nerve injuries associated with common hand surgical procedures.

Evaluation of differences in health-related quality of life during the treatment of post-burn scars in pre-school and school children

OBJECTIVE

The aim of the research was an assessment of the differences in the self-evaluation of health-related quality of life during the treatment of post-burn scars on the upper limbs of pre-school and school children.

MATERIALS AND METHOD

a group of 120 children were examined--66 boys and 54 girls, divided into a pre-school group of 60 children (average age 4.3±1.7) and a primary school group of 60 children (average age 10.4±1.2). The structured interview and an adopted Visual Analog Anxiety Scale and Visual Analog Unpleasant Events Tolerance Scale were used to evaluate the level of plaster tolerance, and anxiety caused by the removal of dressings during treatment.

RESULTS

In the first test, In both groups, a low tolerance was noted to the pressure plaster, with the pre-school aged children obtaining worse results (x=18.9±SD 10.16) than those of school age (x=33.65±SD 13,21), regardless of gender. Pre-school children were afraid (x=47.5±SD 24.26), while school-aged children were not afraid of having the plaster removed (x=20.5±SD 9.46). The differences between the groups were statistically significant. In the fourth and final test on pre-school aged children, the tolerance of plasters had improved (x=23.24±SD 15.43) obtaining a value somewhat lower than for school-aged children (32.4±SD 6.45), as well as a noted fall in the anxiety level (30.83±SD 23.38) with an average value insignificantly higher than that recorded for the children of school age (15.83±SD 6.19).

CONCLUSIONS

The tests confirmed the appearance of differences in the self-evaluation of health-related life quality in pre-school and school-aged children.

Procurement of hand and arm allografts

Upper extremity transplantation has been at the forefront of vascularized composite allotransplantation. There have been more hand and upper extremity transplants than any other kinds of vascularized composite allotransplantation. However, it is a new and evolving field. Reconstructive surgeons are relative newcomers to the field of transplantation, and the procurement of upper extremity allografts has many subtleties that will differ depending on the intended recipient. However, there are certain principles that can be adhered to that this review serves to elucidate.

Sideswipes injuries of upper limbs: a case series report and review of literature

BACKGROUND

Sideswipe injuries are consequent to object striking an elbow on the window edge of a moving vehicle. It often results in severe soft tissue and bony injuries or partial amputation of the upper limb. Functional outcome in most patients is poor. The aim is to highlight the occurrence and functional outcome of these injuries.

METHOD

In our series we report three cases which presented to us in succession within four weeks.

RESULTS

Two of the patients were passengers of commercial buses while one patient is the driver of a private car. Two were males. All were protruding their arm from the open vehicle window at the time of impact. All presented within five hours of injury. All sustained open fracture-dislocations. All were managed with external fixation and soft tissue cover. They all had poor outcome as evidenced by joint stiffness.

CONCLUSION

The functional outcome of such injuries is usually poor especially if the dominant limb is involved. Therefore the need for prevention cannot be overemphasized. Simple measures like ensuring that no part of the limb is Sticking outside a moving vehicle, winding up glass up to mid window level etc will greatly reduce the occurrence of these injuries.

Armed Forces Health Surveillance Center (AFHSC). Arm and shoulder conditions, active component, U.S. Armed Forces, 2003-2012

This analysis estimated the incidence and health care burden of acute and chronic conditions of the arm and shoulder among active component service members of the Armed Forces from 1 January 2003 through 31 December 2012. There were 196,789 diagnosed incident cases of acute arm and shoulder conditions for a rate of 13.7 cases per 1,000 person-years. The annual incidence rates of sprains, the most common acute condition, nearly doubled during the period. Diagnoses of chronic conditions (overall rate of 28.8 per 1,000 person-years) increased 25 percent during the period, mainly associated with a doubling of the incidence of diagnoses of joint pain. Incidence rates of chronic disorders were progressively higher among successively older age groups of service members. The health care burden of all arm and shoulder conditions together steadily increased during the period, as indicated by numbers of health care encounters, individuals affected, and lost work time. The most commonly documented causes associated with acute and chronic conditions are described.

Comparative outcome of bomb explosion injuries versus high-powered gunshot injuries of the upper extremity in a civilian setting

BACKGROUND

Explosion injuries to the upper extremity have specific clinical characteristics that differ from injuries due to other mechanisms.

OBJECTIVES

To evaluate the upper extremity injury pattern of attacks on civilian targets, comparing bomb explosion injuries to gunshot injuries and their functional recovery using standard outcome measures.

METHODS

Of 157 patients admitted to the hospital between 2000 and 2004, 72 (46%) sustained explosion injuries and 85 (54%) gunshot injuries. The trauma registry files were reviewed and the patients completed the DASH Questionnaire (Disabilities of Arm, Shoulder and Hand) and SF-12 (Short Form-12) after a minimum period of 1 year.

RESULTS

Of the 157 patients, 72 (46%) had blast injuries and 85 (54%) had shooting injuries. The blast casualties had higher Injury Severity Scores (47% vs. 22% with a score of > 16, P = 0.02) and higher percent of patients treated in intensive care units (47% vs. 28%, P = 0.02). Although the Abbreviated Injury Scale score of the upper extremity injury was similar in the two groups, the blast casualties were found to have more bilateral and complex soft tissue injuries and were treated surgically more often. No difference was found in the SF-12 or DASH scores between the groups at follow up.

CONCLUSIONS

The casualties with upper extremity blast injuries were more severely injured and sustained more bilateral and complex soft tissue injuries to the upper extremity. However, the rating of the local injury to the isolated limb is similar, as was the subjective functional recovery.

Upper body musculoskeletal symptoms of Latino poultry processing workers and a comparison group of Latino manual workers

BACKGROUND

Upper body musculoskeletal injuries are often attributed to rapid work pace and repetitive motions. These job features are common in poultry processing, an industry that relies on Latino immigrants. Few studies document the symptom burden of immigrant Latinos employed in poultry processing or other manual jobs.

METHODS

Latino poultry processing workers (n = 403) and a comparison population of 339 Latino manual workers reported symptoms for six upper body sites during interviews. We tabulated symptoms and explored factors associated with symptom counts.

RESULTS

Back symptoms and wrist/hand symptoms lasting more than 1-day were reported by over 35% of workers. Poultry processing workers reported more symptoms than comparison workers, especially wrist and elbow symptoms. The number of sites at which workers reported symptoms was elevated for overtime workers and workers who spoke an indigenous language during childhood.

CONCLUSION

Workplace conditions facing poultry processing and indigenous language speaking workers deserve further exploration.

Pathomimie de l'enfant: à propos d'une observation

La pathomimie cutanée se définit comme une maladie factice, provoquée dans un etat de conscience claire par le patient lui-même, au niveau du revêtement cutanéo-muqueux et/ou des phanères. Rare chez l'enfant, il s'agit d'une manifestation psychopathologique potentiellement grave et souvent difficile à prendre en charge. Nous rapportons le cas d'une fillette de 10 ans présentant une pathomimie sous forme de lésions excoriées multiples du visage.

Extremity firearm trauma: the impact of injury pattern on clinical outcomes

As a group, the extremities are the most commonly injured anatomic region in nonfatal firearm trauma and are associated with high rates of vascular and bony injury. This study examines the epidemiology, incidence and distribution of firearm-related extremity trauma and the relationship between injury pattern and local or systemic complications. Review of the National Trauma Databank identified 6987 patients with isolated extremity firearm injury. Epidemiologic data, injury pattern incidence, and local and systemic complications were reviewed. Multivariate analysis identified the impact of extremity injury pattern on complications. Overall fracture incidence was 22 per cent. Fracture was associated with both vascular (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5 to 2.4; P < 0.001) and nerve injury (OR, 2.6; 95% CI, 1.9 to 3.5; P < 0.001). Isolated fracture increased risk of compartment syndrome (OR, 2.4; 95% CI, 1.1 to 5.3; P = 0.035). Vascular injury alone increased the risk of compartment syndrome (OR, 11.5; 95% CI, 5.0 to 26.2; P < 0.001) and deep venous thrombosis (OR, 7.9; 95% CI, 2.5 to 25.2; P < 0.001). Fracture and vascular injury together also increased risk of wound infection (OR, 9.7; 95% CI, 3.9 to 23.4; P < 0.001). In patients with extremity trauma, the injury pattern significantly impacts local but not systemic complication rates. Gunshot-related fracture, occurring in one-fifth of patients, increases the risk of vascular and nerve injury. Vascular injury, with or without fracture, is the biggest predictor of local complications.

Injuries among powered two-wheeler users in eight European countries: a descriptive analysis of hospital discharge data

Powered two-wheelers (PTWs--mopeds, motorcycles, and scooters) remain the most dangerous form of travel on today's roads. This study used hospital discharge data from eight European countries to examine the frequencies and patterns of injury among PTW users (age≥14 years), the predicted incidence of the loss of functional ability, and the mechanisms of the head injuries observed (all in light of increased helmet use). Of 977,557 injured patients discharged in 2004, 12,994 were identified as having been injured in PTW collisions. Lower extremity injuries accounted for 26% (25.6-26.7, 95% C.I.) of the total injuries, followed by upper extremity injuries (20.7%: 20.3-21.2), traumatic brain injuries (TBI) (18.5%: 18-19), and thoracic injuries (8.2%: 7.8-8.5). Approximately 80% of the lower extremity injury cases were expected to exhibit some functional disability one year following discharge (predicted Functional Capacity Index, pFCI-AIS98<100), compared to 47% of the upper extremity injury cases and 24% of the TBI cases. Although it occurred less frequently, patients that were expected to experience some functional limitation from TBI were predicted to fair worse on average (lose more functional ability) than patients expected to have functional limitations from extremity injuries. Cerebral concussion was the most common head injury observed (occurring in 56% of head injury cases), with most concussion cases (78%) exhibiting no other head injury. Among the AIS3+ head injuries that could be mapped to an injury mechanism, 48% of these were associated with a translational-impact mechanism, and 37% were associated with a rotational mechanism. The observation of high rates of expected long-term disability suggests that future efforts aim to mitigate lower and upper extremity injuries among PTW users. Likewise, the high rates of concussion and head injuries associated with a rotational mechanism provide goals for the next phase of PTW user head protection.

Paediatric injuries due to home treadmill use: an emerging problem

INTRODUCTION

The use of home exercise equipment is increasing and treadmills are becoming more popular. This has brought with it an emerging but preventable problem. We present our experience, highlight the importance and promote public awareness of this type of injury. To our knowledge this has not been reported previously in the UK.

METHODS

A retrospective review was conducted of the medical records at two regional burn units of children who sustained treadmill-related injuries between July 2003 and July 2009. Data on patient demographics, mechanism of injury, management, surgical intervention and outcome were recorded.

RESULTS

Twenty-nine children (15 boys, 14 girls) sustained treadmill-related injuries. The mean age was 3.8 years (range: 1-13 years). All injuries occurred at home and the majority of children trapped their hand under the running belt when an adult was using the machine. Most of the injuries were to the upper limb (97%) with less than 1% of the total body surface area burnt. More than two-thirds of patients had deep burns and 17 (58%) required surgical intervention. Five patients developed hypertrophic scars. All patients achieved a good functional outcome.

CONCLUSIONS

Treadmills can pose a significant danger to children. These injuries are preventable. Regulatory authorities, manufacturers and parents should take steps to prevent this emerging health problem.

Sonographic evaluation of peripheral nerve injuries following the Wenchuan earthquake

PURPOSE

To analyze retrospectively the sonographic characteristics of the peripheral nerve injuries (PNIs) resulted from Wunchuan earthquake.

METHODS

The sonographic images of 38 patients with surgically proved PNIs were reviewed and compared with the surgical findings.

RESULTS

A total of 78 nerves in 38 patients were found injured in surgery, which included 16 median nerves in the forearm (20.5%), 6 ulnar nerves in the forearm or arm (7.7%), 8 radial nerves in upper limb (10.0%), 8 sciatic nerves (10.3%) in gluteal region, 17 tibial nerves in the leg (21.8%), and 23 peroneal nerves (29.5%). The most common injured nerve in the lower extremity was the peroneal nerve (29.5%) and in upper extremity was the median nerve (20.5%). Sonography correctly diagnosed 72 earthquake-related nerve injuries (92.3%), which included 5 complete disruption (6.4%), 4 partial disruption (5.1%), 63 nerve entrapment (88.5%, included 1 entrapment by bone calus, 38 entrapments by the scar tissue, 13 entrapments by the thickened muscle or tendinous arch, and 11 entrapment in the narrowed osteofibrous tunnels).

CONCLUSIONS

Nerve entrapment injury was the common sonographic finding in earthquake-related PNI.

Determination of pre-impact occupant postures and analysis of consequences on injury outcome--part II: biomechanical study

This paper considers pre-impact vehicle maneuvers and analyzes the resulting driver motion from their comfort seating position. Part I of this work consisted of analyzing the driver behavior during a simulated crash in a car driving simulator. The configuration of the virtual accident led to an unavoidable frontal crash with a truck. The typical response to this type of emergency event was to brace rearward into the seat and to straighten the arms against the steering wheel, or, to swerve to attempt to avoid the impacting vehicle. In a turn crossover maneuvers, the forearm is directly positioned on the airbag module at time of crash. This position represents a potential injurious situation and is investigated in this Part II. Static airbag-deployment tests were realized in collaboration with Zodiac using conventional airbag (sewn cushion, pyrotechnical system and open event) and a Hybrid III 50th Male Dummy seated with the left arm positioned in the path of the deploying airbag. These experiments were numerically reproduced with Madymo and the ellipsoid Hybrid III dummy model. The dummy arm interaction with airbag was correlated with experiments. Then, a numerical simulation of a frontal collision at 56 km/h was realized. The results of the computational runs put forward injurious situations when the driver's arm was in front of the steering wheel. Indeed, in this case, the arm could hit the head under airbag deployment and induced serious neck bending and violent head launching. To mitigate head and neck trauma in this out-of-position situation, an airbag prototype (bonded cushion, two pure helium cold gas generators allowing mono- or multi-stage inflating, patented silicone membrane) was proposed by Zodiac. The results of static airbag-deployment tests with conventional and prototype airbags showed a significant reduction of the maximum linear head acceleration and neck bending with airbag prototype when a dual stage inflating was ignited, due to a reduced 'flinging' of the arm.

[Waveboard-related injuries. Greater protection is advised]

OBJECTIVE

Waveboarding, a type of skateboarding, is a new craze among children. The aim of this study is to describe how many children visit the emergency department as a consequence of waveboarding and the types of injury they have.

DESIGN

Retrospective, descriptive.

METHOD

All records of children aged 5 to 15 years who had visited the emergency department of the Medical Center Alkmaar in the period March to May 2010 were examined. If a case of waveboard-related injury was found then the type of injury was noted. For all of the injuries a phone call was made to try to find out if protective gear had been worn.

RESULTS

A total of 1418 records from 2010 were investigated. In 132 cases, a waveboard-related injury was found. Contusion was found in 31% of cases and a fracture in 64% of cases. The 2 most frequently occurring sites of injury were the forearm and wrist (53%) and the elbow (14%). In 3% of the waveboard-related injuries the child concerned had worn any protective gear.

CONCLUSION

Children who visited the emergency department due to waveboard-related injuries mainly had injuries to the wrists, forearm and elbow. Only 3% of the children wore protective gear when waveboarding. As effective protection against accident-related injuries exists for skaters, the wearing of protective gear during waveboarding can be expected to lead to a reduced number of injuries.

Treatment of post-burn upper extremity, neck and facial contractures: report of 77 cases

BACKGROUND

Post-burn contractures severely deteriorate life quality. We aimed to present our treatment protocols for post-burn sequelae and the contractures that cause functional limitations.

METHODS

Seventy-seven cases with post-burn contracture were treated in our clinic. Post-burn contractures occurring after a burn injury affected the upper extremity, face and neck in 60, 17 and 6 cases, respectively. Skin grafts, local flaps such as advancement flaps, Z-plasties, K-plasties, regional flaps such as posterior interosseous flap, tissue expanded flaps, and free flaps were used according to the severity of the contractures.

RESULTS

In one patient with type II axillary contraction, recurrence was seen. Full range of motion was achieved in the 3.6-year follow-up period in elbow contractures. Eight of 71 phalangeal joint contractures recurred. Two patients underwent reoperation for neck contracture recurrences.

CONCLUSION

Excellent results were seen with prefabricated flaps, which were used for the facial reconstruction.

Pain catastrophizing and lower physical fitness in a sample of computer screen workers with early non-specific upper limb disorders: a case-control study

In computer workers psychological factors and physical fitness may play an important role in the onset and course of non-specific work-related upper limb disorders (WRULD) beyond socio-demographic factors. Based on our experiences in daily practice we assumed that pain catastrophizing and other psychological variables such as perfectionism, anxiety state and trait, and low physical fitness, are possibly associated with the occurrence of WRULD. We aim to study the association between pain catastrophizing, perfectionism, anxiety (state and trait), physical fitness, sex and level of education and the occurrence of WRULD, controlling for age as a confounder. Eighty-eight computer workers with early non-specific WRULD, who had been recruited for an intervention study, were compared with 31 healthy computer workers (controls) recruited from different departments of a university. This cross-sectional case-control study examined the influence of aforementioned variables on WRULD by means of logistic regression analyses. Among the different predictor variables investigated, pain catastrophizing (OR=1.37; 95%CI 1.17-1.59) and lower physical fitness had a positive relationship with WRULD (OR=0.65; 95%CI 0.48-0.87). According to this study, pain catastrophizing and lower physical fitness seem to be associated with early non-specific WRULD in computer workers. Prospective studies are needed to unravel these relationships.

Acute trauma to the upper extremity: what to do and when to do it

The management of acute trauma to the upper extremity includes the urgent treatment of injuries and the timing and choice of surgical stabilization and reconstruction. To evaluate and treat severe upper extremity trauma, the orthopaedic surgeon should understand the principles of emergency department and operating theater management of commonly seen traumatic injuries to the distal humerus, elbow, forearm, wrist, and hand. A review of the principles for treating these complex injuries, including principles of soft-tissue coverage, will aid surgeons in achieving the goal of providing optimal treatment for their patients.

[Hand-arm vibration syndrome in a nurse carrying out gypsum cutting operations]

BACKGROUND

A professional nurse, employed mainly on gypsum cutting operations, developed a hand-arm vibration syndrome with Raynaud's phenomenon, neurosensitive disorders and impairment of the bone and joints apparatus of the hand and arm.

METHODS

The nurse underwent diagnostic investigations (cold test, X-ray of the upper limbs, blood tests); also the vibration levels transmitted from instrument were measured and the exposure times were established.

RESULTS AND CONCLUSIONS

Clinical investigations showed the presence of a hand-arm vibration syndrome with secondary Raynaud's phenomenon and environmental surveys revealed very high vibration levels, such as could be associated with the disease with a causal relationship. In the literature no reports exist of the vibration syndrome being associated with health care workers in orthopaedic departments. The case described in this study occurred because of peculiar organisational factors that most likely have never occurred in other hospitals or orthopaedic departments.

[Work-related musculoskeletal disorders: appropriateness of the requests of clinical consultation in occupational medicine departments]

BACKGROUND AND OBJECTIVES

The authors analyze the results of the clinical assessment of patients suffering from suspected work-related muscular-skeletal disorders (WMSDs), observed during the course of 2008 in the Department of Occupational Medicine of the Ospedali Riuniti hospital in Bergamo. The aim was to analyse the appropriateness of the requests of clinical consultation, comparing the cases sent by general practitioners and by occupational physicians.

METHODS

We assessed 149 patients (mean age 47 years, DS 9.4; mean work seniority 29.5 years, DS 10.2), investigating 218 disorders in different muscular-skeletal segments. The majority of patients (63.7%) for whom a clinical consultation was requested were sent by general practitioners, 32.9% by occupational physicians, 3.4% by the National Insurance Institute for Occupational Accidents and Diseases (INAIL). The assessment was made in two steps: first a clinical and instrumental definition of the disorders, prescribing the necessary medical investigations were the diagnosis was not already clear; secondly a definition of the aetiology, requesting documentation about working conditions when this was not clear from the medical history, experience and literature, or making an inspection.

RESULTS

A majority of the patients (40.2%) were employed in the construction industry. Regarding symptoms, 54.4% of the subjects reported low back pain, 74.5% upper limb disorders (some of the patients reported several problems in different segments). The clinical diagnosis was already clear at the first consultation for 62.8% of all cases; for the other 37.2% it was necessary to prescribe some instrumental examinations or specialistic (neurologic, physiatric, orthopaedic) medical examinations. We concluded for a diagnosis of WMSDs in 99 (45.4%) of the 218 cases (50% of the assessments requested by occupational physicians, 45.3% of the assessments requested by general practitioners). The most frequent reason for rejecting an occupational aetiology was the lack of correlation between type of disease and occupational exposure, both for patients referred by occupational physicians (58.1%) and by general practitioners (51.8%).

DISCUSSION

The results demonstrated that the appropriateness requests for clinical consultation was identical for general practitioners and occupational physicians. All physicians showed a high degree of attention for the upper limb disorders, which is a topical subject of great epidemiological interest. General practitioners and occupational physicians need to take more advantage of the diagnostic support and clinical evaluations offered by Occupational Medicine Departments and Universities for WMSDs.

Internal consistency, test-retest reliability and concurrent validity of a questionnaire on work-related exposure related to arm, shoulder and neck symptoms in computer workers

The aim of this study was to determine the internal consistency, test-retest reliability and concurrent validity of the RSI QuickScan, a newly developed questionnaire that aims to identify the presumed risk factors for neck, shoulder and arm symptoms in a population of computer workers. The internal consistency was calculated using item analysis. The test-retest reliability and concurrent validity were analysed by calculating the percentage of agreement, Cohen's Kappa and the Ppositive and Pnegative. The concurrent validity was also tested by comparing the results from the new questionnaire with those from the original questionnaires that the current questionnaire was based on, on-site expert observations and direct measurements. The results indicate that the RSI QuickScan is a measurement tool with acceptable internal consistency, reliability and concurrent validity. The questionnaire can be used as a means to rapidly collect data on a large population of office workers and at low cost.

Upper limb discomfort profile due to intermittent isometric pronation torque at different postural combinations of the shoulder-arm system

Twenty-seven right-handed male university students participated in this study, which comprised a full factorial model consisting of three forearm rotation angles (60% prone and supine and neutral range of motion), three elbow angles (45 degrees , 90 degrees and 135 degrees ), three upper arm angles (45 degrees flexion/extension and neutral), one exertion frequency (15 per min) and one level of pronation torque (20% maximum voluntary contraction (MVC) relative to MVC at each articulation). Discomfort rating after the end of each 5 min treatment was recorded on a visual analogue scale. Results of a repeated measures analysis of covariance on discomfort score, with torque endurance time as covariate, indicated that none of the factors was significant including torque endurance time (p = 0.153). An initial data collection phase preceded the main experiment in order to ensure that participants exerted exactly 20% MVC of the particular articulation. In this phase MVC pronation torque was measured at each articulation. The data revealed a significant forearm rotation angle effect (p = 0.001) and participant effect (p = 0.001). Of the two-way interactions, elbow*participant (p = 0.004), forearm*participant (p = 0.001) and upper arm*participant (p = 0.005) were the significant factors. Electromyographic activity of the pronator teres and biceps brachii muscles revealed no significant change in muscle activity in most of the articulations. Industrial jobs involving deviated upper arm postures are typical in industry but have a strong association with injury. Data from this study will enable better understanding of the effects of deviated upper arm postures on musculoskeletal disorders and can also be used to identify and control high-risk tasks in industry.

Free-fillet flap harvested in 'severe, high-energy landmine explosion' injuries of lower extremity: a case report

Fillet flaps harvested from the non-replantable or unsalvageable amputated segment can be used to cover tissue defects. We discuss the case of a patient who had suffered a severe high-energy landmine injury, including severe leg damage, resulting in a below-knee amputation and soft-tissue defect around the forearm region. We successfully harvested the fillet from the amputated part of the extremity to the forearm region. We conclude that harvesting of a fillet flap from severely injured lower extremity, resulting from a high-energy landmine explosion, is technically feasible.