[Severe and complex traumatic hand]

SEVERE AND COMPLEX TRAUMATIC HAND . Serious and complex traumatic injuries of the hand are multiple tissue injuries (skin, vascular, bone and nerves), requiring urgent surgical management. They are responsible for significant functional and aesthetic sequelae. Their incidence is clearly decreasing thanks to information, prevention and security measures. The absolute emergencies are injections under pressure, amputations-devascularizations, and serious mutilations. The objective of the management is to make a functional and aesthetic hand: restoration of the opposition of the thumb with a key-pinch, a sufficient length thumb, and restoration of the sensitivity of the reconstructed hand. This calls for numerous surgical and microsurgical techniques and must be undertaken by trained teams in specialized centers.

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort

BACKGROUND

Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis.

METHODS

A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis.

RESULTS

From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar.

CONCLUSIONS

Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

Restoring Function of the Flexor Tendons of the Hand: State of the Science in Kazakhstan

We conducted a literature review to highlight the diagnosis and treatment of hand flexor tendon injuries and discuss the current state of the science of hand surgery in the Republic of Kazakhstan. We reviewed the Google Scholar, PubMed, Web of Science, Elsevier, and National Center for Biotechnology Information databases and other printed sources for open access articles in three languages. We accepted relevant scientific articles that reflected the peculiarities of restoring function of the tendon flexors of the hand. We reviewed articles from the present to the previous 20 years and included 31 of these sources in our literature review. The medical examination of a patient who has sustained a flexor tendon injury should be thorough and gradual, supported by ultrasound and X-ray examination. For effective restoration of hand function following a hand injury, it is important for the surgeon to conduct a step-by-step assessment of the damage that has occurred to soft tissues, superficial and deep tendons, bones, nerves, and blood vessels. The main goal of tendon repair is to preserve tendon function. It is also known that early postoperative tendon movement leads to faster healing. The most frequent complications associated with flexor tendon repair include the development of adhesions, wound infection, tendon rupture, impaired hand function, and scar formation. Relative to the state of the science in the Republic of Kazakhstan, we conclude that hand surgery should be performed by highly skilled specialists in the field of microsurgery in a specialized department with microsurgical equipment.

Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies

BACKGROUND

Plain radiographs cannot identify all scaphoid fractures; thus ED patients with a clinical suspicion of scaphoid injury often undergo immobilisation despite normal imaging. This study determined (1) the prevalence of scaphoid fracture among patients with a clinical suspicion of scaphoid injury with normal radiographs and (2) whether clinical features can identify patients that do not require immobilisation and further imaging.

METHODS

This systematic review of diagnostic test accuracy studies included all study designs that evaluated predictors of scaphoid fracture among patients with normal initial radiographs. Quality assessment was undertaken using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analyses included all studies.

RESULTS

Eight studies reported data on 1685 wrist injuries. The prevalence of scaphoid fracture despite normal radiographs was 9.0%. Most studies were at overall low risk of bias but two were at unclear risk; all eight were at low risk for applicability concerns. The most accurate clinical predictors of occult scaphoid fracture were pain when the examiner moved the wrist from a pronated to a supinated position against resistance (sensitivity 100%, specificity 97.9%, LR+ 45.0, 95% CI 6.5 to 312.5), supination strength <10% of contralateral side (sensitivity 84.6%, specificity 76.9%, LR+ 3.7, 95% CI 2.2 to 6.1), pain on ulnar deviation (sensitivity 55.2%, specificity 76.4%, LR+ 2.3, 95% CI 1.8 to 3.0) and pronation strength <10% of contralateral side (sensitivity 69.2%, specificity 64.6%, LR+ 2.0, 95% CI 1.2 to 3.2). Absence of anatomical snuffbox tenderness significantly reduced the likelihood of an occult scaphoid fracture (sensitivity 92.1%, specificity 48.4%, LR- 0.2, 95% CI 0.0 to 0.7).

CONCLUSION

No single feature satisfactorily excludes an occult scaphoid fracture. Further work should explore whether a combination of clinical features, possibly in conjunction with injury characteristics (such as mechanism) and a normal initial radiograph might exclude fracture. Pain on supination against resistance would benefit from external validation.

TRIAL REGISTRATION NUMBER

CRD42021290224.

[ACUTE INJURY TO FLEXOR TENDONS OF THE HAND: ASSESSMENT, DIAGNOSIS AND TREATMENT]

Hand lacerations are common injuries seen by the primary care physician. Even seemingly small cuts carry a high risk of injury to flexor tendons of the hand which requires surgical treatment by a specialist. Elucidation of the relevant history, along with a dedicated and focused physical examination is imperative for an early intervention which, along with a meticulous surgical technique and dedicated rehabilitation by occupational therapists, will lead to a much improved functional prognosis for the patient. This is a brief review of the anatomy and physiology of flexor tendons injury and repair, with historical milestones of developments in the approach to the injury. The article also highlights the surgical procedure brought forth by the late Professor Isidor Kessler, one of the founders of surgery of the hand in Israel, presented here as an overview and guidance to the primary care physician.

Traumatic hand injury management and outcomes: A case report

Acute hand injuries are routinely managed by family medicine and primary care physicians. An appropriate initial assessment and treatment, early referral to a hand surgeon when indicated, and timeous referral to a hand therapist are imperative. A patient case report is presented reporting on the initial and subsequent assessment, treatment and outcomes at 3, 6, 7 and 9 months for a patient who sustained an acute finger injury. Finger range of motion (ROM), sensation, pain, time of wound closure, hand function measured with the standardised disability of the shoulder, arm and hand (DASH) questionnaire were the outcomes used. Pain, crepitus, decreased sensation, decreased ROM right index finger proximal interphalangeal joint (PIPJ) and dense scarring was measured at 9 months. Missed injuries or lack of recognition of injury severity leads to delayed referral to specialist hand surgeons and therapists, which lengthens recovery time and leads to sub-optimal outcomes. This article aims to provide the primary care practitioner with the initial management of a patient who sustained a traumatic hand injury whilst using a power tool.

Hand ulceration

In the American Southwest, a common problem can be diagnosed with the knowledge of the local environment and its inhabitants.

Absence of flexor digitorum profundus muscle and variation of flexor digitorum superficialis muscle in a little finger: two case reports

PURPOSE

Knowledge of rare variants of the FDP is of high clinical importance for physicians examining patients for tendon lacerations and especially for hand surgeons operating tendon injuries.

METHODS

During routine dissection at our Department of Anatomy both cases were observed.

RESULTS

Variations of flexor digitorum superficialis and flexor digitorum profundus muscles of the little finger were observed in two cadavers. In both cases, the flexor digitorum profundus muscle for the little finger was absent. Moreover, in the first case, the flexor digitorum superficialis muscle for the little finger was hypoplastic and in the second case it featured variable insertion.

CONCLUSION

There were found only four cases in previous literature describing absent flexor digitorum profundus tendon without any muscle attachment to the base of the distal phalanx. Furthermore, all previously described cases were observed in living patients. To our best knowledge, a case report in cadaver has yet not been reported and is of high importance for hand surgeons examining the hand for tendon injuries.

The validity and clinical utility of the Disabilities of the Arm Shoulder and Hand questionnaire for hand injuries in developing country contexts: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

The Disabilities of the Arm Shoulder and Hand Questionnaire has multiple language versions from many countries around the world. In addition there is extensive research evidence of its psychometric properties.

PURPOSE OF THE STUDY

The purpose of this study was to systematically review the evidence available on the validity and clinical utility of the Disabilities of the Arm Shoulder and Hand as a measure of activity and participation in patients with musculoskeletal hand injuries in developing country contexts.

METHODS

We registered the review with international prospective register of systematic reviews prior to conducting a comprehensive literature search and extracting descriptive data. Two reviewers independently assessed methodological quality with the Consensus-Based Standards for the Selection of Health Measurement Instruments critical appraisal tool, the checklist to operationalize measurement characteristics of patient-rated outcome measures and the multidimensional model of clinical utility.

RESULTS

Fourteen studies reporting 12 language versions met the eligibility criteria. Two language versions (Persian and Turkish) had an overall rating of good, and one (Thai) had an overall rating of excellent for cross-cultural validity. The remaining 9 language versions had an overall poor rating for cross-cultural validity. Content and construct validity and clinical utility yielded similar results.

DISCUSSION/CONCLUSIONS

Poor quality ratings for validity and clinical utility were due to insufficient documentation of results and inadequate psychometric testing. With the increase in migration and globalization, hand therapists are likely to require a range of culturally adapted and translated versions of the Disabilities of the Arm Shoulder and Hand. Recommendations include rigorous application and reporting of cross-cultural adaptation, appropriate psychometric testing, and testing of clinical utility in routine clinical practice.

A life saved at the cost of hand injury - A case of hand burn due to airbag deployment

According to the Malaysian Department of Statistics motor vehicle accidents are the third leading cause of death in Malaysia and accounts for 7.4% of premature deaths in 2016. With the invention of the airbag, the number of serious injuries and fatalities have been reduced significantly. However, there has also been a corresponding increase in the number of injuries attributable to these devices. The patient narrated in this case report sustained a mixed dermal thickness burn over the upper limb as a result of an airbag deployment. She recovered without other life threatening injuries.

Upper Extremity Care for Children: Unique Medical and Psychosocial Aspects

Hand surgeons encountering pediatric patients should be attuned to both technical and practical facets of caring for congenital and traumatic pathologies. Psychosocial aspects include engaging children in conversation and factoring in both self and external perception of deformity. Medical considerations are also unique, from including child abuse in the differential to having techniques to assess active motion and sensation in the nonverbal child. Certain universal principles, such as minimizing radiation exposure and limiting needle sticks, have higher emphasis in pediatric patients than in adults. With these aspects in mind, treating children and their families can be a mutually rewarding experience.

You're the Flight Surgeon

Doxey RJ. You're the flight surgeon: Ehlers-Danlos syndrome. Aerosp Med Hum Perform. 2019; 90(6):583-586.

Pediatric hand injuries: Practical approach for primary care physicians

OBJECTIVE

To present a practical and evidence-based approach for primary care physicians to the diagnosis and initial management of common pediatric hand injuries, and to identify injuries requiring prompt referral.

SOURCES OF INFORMATION

Clinical evidence and expert recommendations were identified by using MEDLINE and EMBASE for each topic presented.

MAIN MESSAGE

Pediatric hand injuries are a common reason for physician consultation. The most common and potentially problematic pediatric hand injuries include fingertip injuries, phalangeal fractures, tendon injuries, and hand burns. Management is limited by difficulties in proper assessment of the hand and the paucity of evidence to guide treatment. Nevertheless, outcomes in children are typically excellent.

CONCLUSION

Appropriate assessment, initial management, and, if necessary, timely referral of pediatric patients with hand injuries are paramount given the importance of the hand in function and child development. While some principles from managing adult hand injuries might apply, children often require special considerations.

Lumbrical muscle tear: clinical presentation, imaging findings and outcome

The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I-III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries ( p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy.

LEVEL OF EVIDENCE

IV.

Patients Transferred for Upper Extremity Amputation: Participation of Regional Trauma Centers

PURPOSE

Level-I trauma centers are required to provide hand and microsurgery capability at all times. We examined transfers to our center to better understand distant patient referrals and, indirectly, study referrals in our region.

METHODS

Records were reviewed from 2010 to 2015 to evaluate patients transferred to our level-I institution for upper extremity amputation. Patients were referred from 6 states to our institution over this period. We measured the straight-line distance from each patient's transferring facility to our facility and compared this distance with the straight-line distances from the zip code of the transferring facility to the zip code of each level-I trauma center.

RESULTS

We had data for 250 transferred patients (91% male, 9% female). For 110 patients (44%), our hospital was the nearest level-I trauma center; however, for the remaining 140 patients (56%), other level-I trauma facilities were located closer to the referring hospital. Among these 140 patients, the mean distance of the referring facility to the nearest level-I trauma center (30 miles; SD, 27) was significantly different from the mean distance of the referring facility to our facility (71 miles; SD, 60). A median of 4 (range, 1-10) level-I trauma centers were bypassed before patients arrived at our center. Medicaid and "self-pay" patients were more likely to be transferred to our facility.

CONCLUSIONS

Fifty-six percent of patients transferred to our hospital for upper extremity amputation had a level-I trauma center closer to their injury. Patients with upper extremity amputation are referred to our regional center despite the proximity of closer level-I trauma centers. This suggests that regional microsurgery expertise does not correlate with level-I trauma designation, and establishment of designated microsurgery centers and formal referral guidelines may be beneficial for management of these difficult injuries.

CLINICAL RELEVANCE

We believe that this study further supports the need for formal designation of regional centers of expertise for microsurgical hand trauma.

[Dislocation of the PIP-Joint - Treatment of a common (ball)sports injury]

Background Fractures or fracture dislocations of the proximal interphalangeal joint often occur during sports or accidents. Dislocations of the PIP-joint are the most common ligamentary injuries of the hand. As this kind of injury is so frequent, hand surgeons and other physicians should be aware of the correct treatment. Objectives This paper summarises the most common injury patterns and the correct treatment of PIP-joint dislocations. Materials and Methods This paper reviews the current literature and describes the standardised treatment of PIP-joint dislocations. Results What is most important is that reposition is anatomically correct, and this should be controlled by X-ray examination. Depending on the instability and possible combination with other injuries (e. g. injury to the palmar plate), early functional physiotherapy of the joint or a short immobilisation period is indicated. Conclusions Early functional treatment of the injured PIP-joint, initially using buddy taping, is important to restore PIP-joint movement and function. Depending on the injury, joint immobilisation using a K-wire may be indicated. Detailed informed consent is necessary to explain to the patient the severity of the injury and possible complications, such as chronic functional disorders or development of arthrosis.

Do hand outcome measures reflect cultural influences?

OBJECTIVE

The aim of this study was to compare the activities listed in DASH, MHQ, QuickDASH with the activities listed in Canadian Occupational Performance Measure (COPM) in a Turkish patient population with hand injury.

METHODS

COPM questionnaire was administered to 163 participants (61 male and 102 female; mean age 40.72 ± 13.70 years). The activities that were stated in COPM were categorized and checked whether they were present in DASH-T, MHQ, QuickDASH.

RESULTS

The highest rated stated activities were "carrying a heavy object" (39.2%), "cleaning the house" (25.7%) and "writing" (15.9%). DASH reflects 30% whereas MHQ and QuickDASH reflect 16.32% and 10.2% of the problematic activities, respectively.

CONCLUSION

None of three questionnaires have satisfactory results for reflecting the problematic activities among hand injured Turkish people. Open ended interviews should be irrevocable part of assessment process in order to describe a person-center treatment program.

Interest of the "compress test" in diagnosis of nerve injury in hand wounds

INTRODUCTION

Hand wounds are a common cause of emergency department admission. Digital nerve lesions are found in 5% of palm wounds. Early diagnosis reduces the risk of morbidity, sequelae and litigation. Screening for digital nerve injury by the usual tests is difficult in an emergency context. We assessed the diagnostic value of the simple "compress test" to screen for pulp sensibility disorder and the factors that may influence the value of this examination, with a view to validating routine use.

MATERIAL AND METHOD

A retrospective study included 821 palm wounds treated between January 2014 and May 2016. There were 605 male and 216 patients; mean age, 42.8 years (range: 18-90 years). The dominant hand was involved in 307 cases (37.4%). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the compress test were calculated. Diagnostic value was also calculated according to age, gender, affected digit, dominant side and examiner's experience.

RESULTS

Clinical deficit was found in 412 cases (50.2%). A digital nerve lesion was found intraoperatively in 277 cases (33.6%). Test sensitivity was 87.3%, specificity 68.6%, positive predictive value 58.5%, negative predictive value 91.4%, positive likelihood ratio 2.78 and negative likelihood ratio 0.18. The test was more effective for thumb wounds and for examination by a junior surgeon. There were no differences according to injured side, innervation territory or gender.

CONCLUSION

This clinical test is reliable, with very good negative predictive value and good sensitivity, allowing its use in routine clinical practice. Nevertheless, surgical exploration of deep palm injuries should remain the rule.

Finger reconstruction using induced membrane technique and ulnar pedicled forearm flap: a case report

INTRODUCTION

Injuries referred to as "rollover hands" are associated with multiple and complex lesions of the dorsal aspect of the hand. We present a case of a multitissular reconstruction following a severe injury of the dorsum of the fingers in a 45-year-old woman.

MATERIALS AND METHODS

The bone loss reconstruction was performed in two stages using the Masquelet induced membrane technique. In the first stage, a cement spacer was inserted into the phalanx bone defects. For the second stage, the membrane induced by the foreign-body reaction was opened, the spacer was removed, and an autologous cancellous bone graft was inserted into the defects. The skin coverage was obtained using a reverse ulnar artery forearm pedicled flap. The digits were covered jointly. Three surgical procedures over the course of a 2-month period were required to desyndactylize the fingers and to defat the flap.

RESULTS

At the 2-year follow-up examination, the patient exhibited good integration of their hand use in daily living. The esthetic result was deemed to be satisfactory. Definitive bone consolidation occurred 4 months after the second stage.

CONCLUSIONS

Rollover hands are typically a challenge for both the patient and the hand surgeon. The risk of septic complications, as well as the need for several stages of surgical reconstruction, makes the Masquelet technique particularly attractive for the treatment of phalanx bone defects consecutive to rollover injuries.

[Strategies for complex injuries of the hand]

The quality of the reconstruction, follow-up treatment and care determine the treatment outcome of complex hand injuries. The initial estimation and therapy are decisive. Optimal results necessitate a structured approach with strategic planning, including thorough débridement, precise analysis of the resulting defect and loss of function and if possible unilateral reconstruction and well-founded planning of secondary interventions. Within the framework of the detailed patient clarification the perspectives, possibilities and alternatives must be realistically presented. Taking these fundamental strategic steps into consideration, the primary aims of reconstruction and preservation of function, rapid occupational and social reintegration and avoidance of delayed complications can best be realized. There is no standard approach for these extremely variable injuries. Decisive is that even in cases of apparently harmless injuries, the involvement of functional structures must be considered early in the initial stages.

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.

An analysis of the most common types of hand injury mistakes and their cost in the acute setting

This study aimed to explore the most common hand injury errors occurring in Emergency Departments in England. A Freedom of Information request was made to the NHS Litigation Authority for claims data related to hand injuries in English Emergency Departments from 2004 to 2014. All successful hand injury claims against an individual DGH ED were also analysed. Two hundred and eighteen successful claims were made, costing a total of £6,273,688.22. Diagnosis error was the most common successful claim (97). Four successful claims were brought against the Emergency Department. Causes of error included the use of inappropriate views and failure to correlate imaging with clinical findings. Hand injury diagnostic error has been the most common cause of successful litigious claims against Emergency Departments over the past 10 years. This paper demonstrates that fracture recognition and clinical diagnosis of hand injuries are key areas to target to reduce error rates.

Fight bite injury: emergency department assessment and management

Human bite wounds to the hand are relatively common injuries and are associated with high infection rates. Given the unique anatomy of the hand, the bite mechanism and the organisms found in human saliva, even the smallest wound can result in an aggressive infection. Failure to recognise and treat human bite wounds appropriately, can therefore have negative outcomes for patients. This article outlines the diagnostic features of, and complications associated with, bite wounds and discusses the recommended treatment options.

[Examination of the wrist and hand]

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Hypothenar hammer syndrome is rare - or simply an unusually overlooked condition]

Hypothenar hammer syndrome is a possibly underdiagnosed but treatable cause of Raynaud's phenomenon and hand ischemia elicited by thombosis or aneurysm secondary to acute or chronic blunt trauma to the ulnar artery at the level of Guyon's canal. This paper provides a summary of the condition with some emphasis on prophylactic and therapeutic aspects.

Pedicled hypothenar perforator flap: Indications and clinical application

BACKGROUND AND AIM

Soft-tissue defects of the palm and the palmar aspect of the fifth finger are a constant problem in reconstructive hand surgery. We present a possible approach to planning and harvesting pedicled hypothenar perforator flaps for the reconstruction of such defects.

METHODS

A hypothenar perforator flap was used to reconstruct a soft-tissue defect on the ulnar aspect of the palm and the palmar aspect of the fifth finger of 17 patients. The defects were located over the proximal phalanx of the fifth finger (n = 9), the palm (n = 5), and across both areas (n = 3). The size of the defects was up to 7.9 cm(2).

RESULTS

Eleven of the flaps healed primarily, out of which partial flap necrosis was observed in six. Four of these six flaps required operative revision, including debridement and delayed primary wound closure, while two healed secondarily. After an average of 26.6 days (range 21-45 days), all 17 patients achieved complete functional recovery. Despite the complications described, all the primary defects remained covered.

CONCLUSION

The pedicled hypothenar perforator flap is an option for reconstruction of ulnar-sided, soft-tissue defects of the palm and little finger. The flap is thin and the donor-site morbidity is low. Hand surgeons may wish to consider this flap when presented with soft-tissue defects in this area.

Partial Flexor Tendon Laceration Assessment: Interobserver and Intraobserver Reliability

Accurate assessment of partial-thickness flexor tendon lacerations in the hand is difficult owing to the subjectivity of evaluation. In this study, we created 12 partial-thickness flexor tendon lacerations in a cadaveric hand, evaluated the accuracy of 6 orthopedic residents and 4 fellowship-trained hand surgeons in estimating the percentage thickness of each laceration, and assessed the groups' interobserver and intraobserver agreement. The 10 participants estimated each laceration independently and on 2 separate occasions and indicated whether they would repair it. The actual thickness of each laceration was calculated from measurements made with a pair of digital microcalipers. Overall estimates differed significantly from calibrated measurements. Estimates grouped by residents and fellowship-trained hand surgeons also differed significantly. Third-year residents were the most accurate residents, and fellowship-trained hand surgeons were more accurate than residents. Overall interobserver agreement was poor for both readings. There was moderate overall intraobserver agreement. Fellowship-trained hand surgeons and first-year residents had the highest intraobserver agreement. These results highlight the difficulty in accurately assessing flexor tendon lacerations. Accuracy appears not to improve with surgeon experience.

Do Upper Extremity Trauma Patients Have Different Preferences for Shared Decision-making Than Patients With Nontraumatic Conditions?

BACKGROUND

Shared decision-making is a combination of expertise, available scientific evidence, and the preferences of the patient and surgeon. Some surgeons contend that patients are less capable of participating in decisions about traumatic conditions than nontraumatic conditions.

QUESTIONS/PURPOSES

(1) Do patients with nontraumatic conditions have different preferences for shared decision-making when compared with those who sustained acute trauma? (2) Do disability, symptoms of depression, and self-efficacy correlate with preference for shared decision-making?

METHODS

In this prospective, comparative trial, we evaluated a total of 133 patients presenting to the outpatient practices of two university-based hand surgeons with traumatic or nontraumatic hand and upper extremity illnesses or conditions. Each patient completed questionnaires measuring their preferred role in healthcare decision-making (Control Preferences Scale [CPS]), symptoms of depression (Patients' Health Questionnaire), and pain self-efficacy (confidence that one can achieve one's goals despite pain; measured using the Pain Self-efficacy Questionnaire). Patients also completed a short version of the Disabilities of the Arm, Shoulder, and Hand questionnaire and an ordinal rating of pain intensity.

RESULTS

There was no difference in decision-making preferences between patients with traumatic (CPS: 3 ± 2) and nontraumatic conditions (CPS: 3 ± 1 mean difference = 0.2 [95% confidence interval, -0.4 to 0.7], p = 0.78) with most patients (95 versus 38) preferring shared decision-making. More educated patients preferred a more active role in decision-making (beta = -0.1, r = 0.08, p = 0.001); however, differences in levels of disability, pain and function, depression, and pain-related self-efficacy were not associated with differences in patients' preferences in terms of shared decision-making.

CONCLUSIONS

Patients who sustained trauma have on average the same preference for shared decision-making compared with patients who sustained no trauma. Now that we know the findings of this study, clinicians might be motivated to share their expertise about the treatment options, potential outcomes, benefits, and harms with the patient and to discuss their preference as well in a semiacute setting, resulting in a shared decision.

Flexor Tendon Injuries and Treatment Results of 67 Patients

Flexor tendon injury is the most commonly seen hand injury. Tendons are the structures which enable the muscles to adhere to the bones and transmit the movement starting from the muscle to the bones. They have significant role in hand movement. As treatment method, surgical repair: (1) Primary repair, (2) Secondary repair; techniques are used. With the scientific studies conducted, flexor tendon morphology, kinematics, biomechanics, biological properties and tendon improvement became quite understandable, good suturing materials were developed and consequently successful studies regarding primary repair results were published. Flexor tendon surgery has reached its current level with the accumulation of knowledge obtained from the increased clinical and experimental studies. This study addresses flexor tendon injuries and surgical treatment methods. We achieved 76.12% full functioning fingers in the results; we obtained following the physical treatment application that started on the 10th day after primary repair that we performed in 67 patients who applied with acute flexor tendon Zone 1-2 and 3 incision. Flexion restriction and contracture developed in 16 patients (23.88%) at various levels. Scar softening and revision surgery for contracture excision was performed in 8 patients (11.94%) with Zone 2 injury due to contracture. Superficial skin infection developed in 21 patients (31.34%) and was treated. Revision surgery was performed in 6 patients with Zone 1 injury due to rupture occurred during rehabilitation.

Percutaneous Distraction Pinning for Metacarpophalangeal Joint Stabilization After Blast or Crush Injuries of the Hand

BACKGROUND

Unstable, severely comminuted fractures of the metacarpophalangeal (MCP) joint are difficult to treat. Closed treatment and casting of these fractures often fail to maintain proper alignment and impede wound care where concomitant open injuries such as gunshot wounds are present. Conventional pinning or plating techniques are not feasible if extensive bone loss and comminution are present. A distraction pinning technique represents a potential alternative, but results with this approach, to our knowledge, have not been reported.

QUESTIONS/PURPOSES

The purposes of this study were (1) to evaluate the effectiveness (defined as osseous union and joint stability) of distraction pinning for comminuted fractures involving MCP joints after gunshot or crush injuries; (2) to report the short-term results in terms of pain and function in a small group of patients who underwent MCP distraction pinning; and (3) to evaluate complications and return to work status of these patients in the short term.

METHODS

We reviewed 10 patients with comminuted pilon-type fractures of the base of the proximal phalanx or metacarpal head treated with wire distraction fixation from 2005 and 2014. During that period, we used this technique to treat all patients whose fractures were deemed too comminuted for plating or pinning, and during that period, no other techniques (such as simple external fixation) were used for patients meeting those indications. The minimum followup was 6 months; eight of the 10 patients were accounted at a median of 10 months (range, 6-89 months). The median age was 47 years (range, 28-57 years), and seven of the eight were male. Kirschner wire fixation frames were removed 3.5 to 6 weeks after the index surgery when fracture consolidation was confirmed on radiography by the treating surgeon. Stability and range of motion of the MCP joint were assessed using physical examination, radiographs, and goniometer by the treating surgeon. Patients completed the Quick Disabilities of the Arm, Shoulder and Hand score at latest followup or by telephone, and complications were assessed by chart review.

RESULTS

All fractures were healed with stable MCP joints. Eight patients reported having no pain or minimal pain of their injuries to the hand. The median finger and thumb MCP arc of motion were 80° (range, 70°-105°) and 30° (range, 0°-60°), respectively. The median Quick Disabilities of the Arm, Shoulder and Hand score was 3 (range, 0-41). One patient underwent a second surgical procedure for bone grafting and soft tissue coverage. Three patients developed pin site irritations and were treated with oral antibiotics. Six patients returned to their original job.

CONCLUSIONS

The distraction pinning technique provides reliable osseous union and joint stability of comminuted pilon-type fractures of the base of the proximal phalanx or metacarpal head, even with associated open wounds. Future studies will need to evaluate these patients at longer term followup and compare this approach with other available techniques, because arthrosis, stiffness, and progressive loss of function seem likely to occur given the severity of these injuries.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Boxer's fracture: management and outcomes

Boxer's fractures are common hand injuries, but their management varies greatly. Two years ago, a boxer's fracture care pathway was developed for use in the Royal London Hospital emergency department to standardise management. This article describes a clinical service evaluation carried out to test the validity of the pathway. The evaluation examined the functional outcomes of patients with boxer's fractures with 50° or less palmar angulation who were discharged with no follow up. Findings show that most returned to work immediately and had good functional outcomes, which suggests that the pathway is safe for uncomplicated fractures with 50° or less palmar angulation.

Arthroscopically diagnosed scapholunate ligament injuries associated with distal radial fractures: a 13- to 15-year follow-up

PURPOSE

To evaluate the natural history of untreated complete or partial scapholunate (SL) ligament tears associated with displaced distal radius fractures.

METHODS

Between 1995 and 1997, 51 consecutive patients aged < 60 years with displaced distal radius fractures were examined arthroscopically to assess for concomitant soft tissue injuries. Thirty-two of 51 patients had an SL ligament tear, 10 had a complete tear (Lindau grade 3), and 22 had a partial tear (Lindau grades 1 and 2). Thirty-two patients had AO type-C fractures, 3 had type-B fractures, and 16 had type-A fractures. In 2010, 47 of the 51 patients were still alive, and they were invited for an interview, clinical examination, and radiography.

RESULTS

Thirty-eight of the 51 original patients participated in the long-term follow-up. Mean grip strength was 83% relative to the contralateral hand in patients with a complete tear, as compared with 92% in patients with partial or no SL tears (nonsignificant). Median Disabilities of the Arm, Shoulder, and Hand questionnaire score was 2 (range, 0‒55) for complete SL tears, compared with 9 (range, 0‒70) for the others (nonsignificant). No differences were found regarding visual analog scale pain or wrist motion/forearm rotation. None of the patients developed a static SL dissociation or a SL advanced collapse wrist.

CONCLUSIONS

No major differences were found in the subjective, objective, or radiographic outcome after a complete (grade 3) or partial (grade 1 or 2) SL untreated tear associated with displaced distal radius fracture. It should be noted that none of the patients had a grade 4 SL tear, which may have a different outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

The Management of Domestic Animal Bites to the Hand

Hand bites from domestic animals are extremely common. Though many may initially appear benign, it is important for treating physicians to be aware of the factors that place patients sustaining animal bites at additional risk for infection. As clinicians, we must be able to efficiently diagnose and treat these patients properly to avoid the morbidity that animal bites can provoke. The current paper reviews the evaluation and management of domestic animal bites to the hand.

Management of complications of extensor tendon injuries

Treatment goals for the management of extensor tendon injuries include restoration of function, minimizing disability, and decreasing the risk of complications. These goals can be achieved with an accurate understanding of the zone-specific concerns for extensor tendon injuries, early referral to hand therapy, and active communication between hand surgeons and therapists. This article reviews extensor tendon injuries by zone, outlines optimal management strategies that help prevent complications, and describes the treatment of these complications.

[Bilateral hypothenar hammer syndrome]

Hypothenar hammer syndrome is caused by ulnar artery occlusion subsequent to repeated blunt trauma such as by using the hypothenar as a hammer during work. Allen's test permits the detection of this frequent and often overlooked cause of hand pain and ischaemia. The four bilateral hypothenar hammer syndromes described in this case report occurred after several years of occupational exposure to hard shocks/impacts to the hypothenar from workpieces, which were held with a firm grip.

[A woman with a blast injury]

A 39-year-old woman presented with extensive soft tissue injury involving her upper legs and her left hand caused by the explosion of her cell phone. She suffered second and third-degree burns. She underwent surgery. She underwent surgical removal of metal slivers, wound debridement and repair of the soft tissue injury.

Evidence-Based Management Of Acute Hand Injuries In The Emergency Department

Although injuries of the hand are infrequently life-threatening, they are common in the emergency department and are associated with significant patient morbidity and medicolegal risk for physicians. Care of patients with acute hand injury begins with a focused history and physical examination. In most clinical scenarios, a diagnosis is achieved clinically or with plain radiographs. While most patients require straightforward treatment, the emergency clinician must rapidly identify limb-threatening injuries, obtain critical clinical information, navigate diagnostic uncertainty, and facilitate specialist consultation, when required. This review discusses the clinical evaluation and management of high-morbidity hand injuries in the context of the current evidence.