Road safety and road traffic accidents in Saudi Arabia. A systematic review of existing evidence

OBJECTIVES

To identify the changing trends and crucial preventive approaches to road traffic accidents (RTAs) adopted in the Kingdom of Saudi Arabia (KSA) over the last 2.5 decades, and to analyze aspects previously overlooked.

METHODS

This systematic review was based on evidence of RTAs in KSA. All articles published during the last 25 years on road traffic accident in KSA were analyzed. This study was carried out from December 2013 to May 2014 in the Department of Family and Community Medicine, Taibah University, Al-Madinah Al-Munawwarah, KSA.

RESULTS

Road traffic accidents accounted for 83.4% of all trauma admissions in 1984-1989, and no such overall trend was studied thereafter. The most frequently injured body regions as reported in the latest studies were head and neck, followed by upper and lower extremities, which was found to be opposite to that of the studies reported earlier. Hospital data showed an 8% non-significant increase in road accident mortalities in contrast to police records of a 27% significant reduction during the years 2005-2010. Excessive speeding was the most common cause reported in all recent and past studies.

CONCLUSION

Disparity was common in the type of reporting of RTAs, outcome measures, and possible causes over a period of 2.5 decade. All research exclusively looked into the drivers' faults. A sentinel surveillance of road crashes should be kept in place in the secondary and tertiary care hospitals for all regions of KSA.

Inflammation and the pathophysiology of work-related musculoskeletal disorders

Work-related musculoskeletal disorders (MSDs) have accounted for a significant proportion of work injuries and workers' compensation claims in industrialized nations since the late 1980s. Despite epidemiological evidence for the role of repetition and force in the onset and progression of work-related MSDs, complete understanding of these important occupational health problems requires further elucidation of pathophysiological mechanisms of the tissue response, particularly in the early stage of these disorders. Results from several clinical and experimental studies indicate that tissue microtraumas occur as a consequence of performing repetitive and/or forceful tasks, and that this mechanical tissue injury leads to local and perhaps even systemic inflammation, followed by fibrotic and structural tissue changes. Here we review work linking inflammation and the development of work-related MSDs. We also propose a conceptual framework suggesting the potential roles that inflammation may play in these disorders, and how inflammation may contribute to pain, motor dysfunction, and to puzzling psychological symptoms that are often characteristic of patients with work-related MSDs.

Blunt vascular trauma in the extremity: diagnosis, management, and outcome

BACKGROUND

Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity.

METHODS

A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted.

RESULTS

From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors.

CONCLUSION

Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.

Prevalence of musculoskeletal disorders among farmers: A systematic review

OBJECTIVE

To determine the prevalence of musculoskeletal disorders (MSDs) among farmers and to establish the most common regional MSDs reported.

METHODS

Comprehensive electronic searches of Pubmed, Web of Science, CINAHL, SCOPUS, EMBASE, Agris Database, and Cochrane Library were carried out using keywords for MSDs and farmers. Pooled estimates of prevalence with 95% confidence intervals were calculated for overall MSD prevalence and the most common regional MSDs reported.

RESULTS

Twenty-four studies fulfilled the inclusion criteria and were incorporated into this review. From these studies, life-time prevalence of any form of MSD among farmers was 90.6% while 1-year MSD prevalence was 76.9% (95% CI 69.8-82.7). The majority of studies focused on spinal MSDs with low back pain (LBP) the most frequently investigated. Life-time LBP prevalence was 75% (95% CI 67-81.5) while 1-year LBP prevalence was 47.8% (95% CI 40.2-55.5). The next most common regional MSDs reported were upper (range 3.6-71.4%) and lower extremities (range 10.4-41%).

CONCLUSIONS

The systematic review identified the prevalence of MSDs by body region in farmers and established that LBP was the most common MSD, followed by upper and then lower extremity MSDs. Reported trends suggest that the prevalence of MSDs in farmers is greater than in non-farmer populations. Case-definition uniformity among MSD researchers is warranted. More studies are needed regarding upper and lower extremity MSDs, gender, workplace, and task context of MSDs.

Pediatric upper extremity injuries

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems.

What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review

BACKGROUND

Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

QUESTIONS/PURPOSES

(1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients' upper extremity injuries?

METHODS

We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the "upper extremity", "outcome measurement", and "impairment, psychological, social or symptomatic" variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

RESULTS

Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

CONCLUSIONS

Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umeå, Sweden

In a study of a 12-year population-based injury register, Umeå, Sweden, we analyzed the fracture mechanisms and fracture pattern in men and women 50 years and older. Low-energy trauma was responsible for the major and costliest part of the fracture panorama, but the pattern differs between age groups.

INTRODUCTION

Osteoporosis-related fracture is a major health problem: the number of hip fractures is expected to double to 2030. While osteoporosis is one of many risk factors, trauma is almost always involved. Therefore, we analyzed injury mechanisms in patients aged over 50.

METHODS

We registered injury mechanism, cause, diagnosis in all trauma patients at Umeå University hospital, Sweden. This population-based register (1993-2004) comprises a total of 113,668 injuries (29,189 fractures). Patients >or=50 years contributed to 13,279 fractures.

RESULTS

Low-energy trauma (fall <1 m) caused 53% of all fractures >or=50 years and older. In those over 75 low-energy trauma caused >80%. The seasonal variation of fractures was maximally 25%. With increasing age, proximal fractures became more common, in both upper and lower extremities. Proximal locations predominate in older age groups.

CONCLUSIONS

Low-energy trauma was responsible for the largest and costliest part of the fracture panorama. In fact, almost all fractures in middle-aged and old people were caused by low-energy mechanisms; thus, most fractures in these patients have a fragility component, and the contribution of osteoporosis-related fractures is more important than previously thought. A better understanding of injury mechanisms also in low-energy trauma is a prerequisite for preventive interventions.

Profile of injuries arising from the 2005 Kashmir earthquake: the first 72 h

BACKGROUND

The Kashmir Earthquake of October 8, 2005 had widespread destructive effects with in excess of 86,000 people killed and over 80,000 severely injured. Most hospitals were destroyed and limited facilities were available for medical service in the immediate aftermath. A small military hospital in Forward Kahuta, Pakistan, remained functional and was inundated with severely injured patients over 72h.

METHODS

A retrospective review of medical records to document the injury patterns, subsequent treatment, infections and logistical requirements that occurred following this earthquake.

RESULTS

One thousand five hundred and two patients were triaged over 72h. Four hundred and sixty eight (31.1%) patients required admission. Three hundred and nineteen (68.2%) patients were managed non-operatively and 149 (31.8%) required a procedure under general anaesthesia. The most common type of injuries were: superficial lacerations (64.9%); fractures (22.2%); and soft tissue contusions/sprains (5.9%). There were 266 major injuries to the extremities (40.1% upper limb; 59.9% lower limb). Six patients had significant abdominal injuries, 66.6% of these required urgent laparotomy. 14.8% had clinically relevant infections at follow-up requiring surgical debridement or antibiotic therapy.

CONCLUSIONS

Disaster response in the early phase of earthquake relief is complex, with local facilities often overwhelmed and damaged. Limb injuries are most likely; however facilities should have clear plans to deal with severe trauma including head injuries and penetrating abdominal trauma. Coordinated effort is required for success, with lessons learnt to improve future disaster management.

Fall-related upper body injuries in the older adult: a review of the biomechanical issues

Although the epidemiology of fall-related injuries is well established for the elderly population over 65 years of age, the biomechanics of how, when and why injuries do and do not occur when arresting a fall have received relatively little attention. This paper reviews the epidemiological literature in the MEDLINE data base pertinent to the biomechanics of fall-related injuries, including data on fall rates, fall-related injury rates, fall directions and types of injuries available. It also covers primary sources not listed on MEDLINE, along with the pertinent biomechanics literature. Many falls in older adults are in a forward direction, and as a result the upper extremities are one of the most commonly injured structures, presumably in protecting the head and torso. In this review emphasis is placed on what is, and what is not, known of the biomechanical factors that determine the impact forces and injury risk associated with upper extremity injuries in forward falls. While decreased bone mineral density may be contributory, it is not a reliable predictor of fracture risk. Evidence is presented that fall-related impact forces can be reduced by appropriate volitional arrest strategies. Further theoretical and experimental research is needed to identify appropriate fall-arrest strategies for the elderly, as well as the physical capacities and skills required to do so. Inexpensive interventions might then be developed to teach safe fall-arrest techniques to older individuals.

Ultrasound of tendon tears. Part 1: general considerations and upper extremity

The role of ultrasound (US) in assessing musculoskeletal disorders is persistently increasing because of its low cost, readiness, noninvasiveness, and possibility of allowing a dynamic examination. Secondary to increased sport practice, tendon tears are more frequently observed in daily medical practice. They deserve early diagnosis to allow proper treatment that can limit functional impairment. The aim of this review article is twofold: to illustrate the US appearance of normal tendons and to describe the US findings of the most common tendon tears.

Nerve injury in severe trauma with upper extremity involvement: evaluation of 49,382 patients from the TraumaRegister DGU® between 2002 and 2015

BACKGROUND

Peripheral nerve injury (PNI) as an adjunct lesion in patients with upper extremity trauma has not been investigated in a Central European setting so far, despite of its devastating long-term consequences. This study evaluates a large multinational trauma registry for prevalence, mechanisms, injury severity and outcome characteristics of upper limb nerve lesions.

METHODS

After formal approval the TraumaRegister DGU® (TR-DGU) was searched for severely injured cases with upper extremity involvement between 2002 and 2015. Patients were separated into two cohorts with regard to presence of an accompanying nerve injury. For all cases demographic data, trauma mechanism, concomitant lesions, severity of injury and outcome characteristics were obtained and group comparisons performed.

RESULTS

About 3,3% of all trauma patients with upper limb affection (n = 49,382) revealed additional nerve injuries. PNI cases were more likely of male gender (78,6% vs.73,2%) and tended to be significantly younger than their counterparts without nerve lesions (mean age 40,6 y vs. 47,2 y). Motorcycle accidents were the most frequently encountered single cause of injury in PNI patients (32,5%), whereas control cases primarily sustained their trauma from high or low falls (32,2%). Typical lesions recognized in PNI patients were fractures of the humerus (37,2%) or ulna (20,3%), vascular lacerations (arterial 10,9%; venous 2,4%) and extensive soft tissue damage (21,3%). Despite of similar average trauma severity in both groups patients with nerve affection had a longer primary hospital stay (30,6 d vs. 24,2 d) and required more subsequent inpatient rehabilitation (36,0% vs. 29,2%).

CONCLUSION

PNI complicating upper extremity trauma might be more commonly encountered in Central Europe than suggested by previous foreign studies. PNI typically affect males of young age who show significantly increased length of hospitalization and subsequent need for inpatient rehabilitation. Hence these lesions induce extraordinary high financial expenses besides their impact on health related quality of life for the individual patient. Further research is necessary to develop specific prevention strategies for this kind of trauma.

Loss of productivity due to neck/shoulder symptoms and hand/arm symptoms: results from the PROMO-study

INTRODUCTION

The objective of the present study is to describe the extent of productivity loss among computer workers with neck/shoulder symptoms and hand/arm symptoms, and to examine associations between pain intensity, various physical and psychosocial factors and productivity loss in computer workers with neck/shoulder and hand/arm symptoms.

METHODS

A cross-sectional design was used. The study population consisted of 654 computer workers with neck/shoulder or hand/arm symptoms from five different companies. Descriptive statistics were used to describe the occurrence of self-reported productivity loss. Logistic regression analyses were used to examine the associations.

RESULTS

In 26% of all the cases reporting symptoms, productivity loss was involved, the most often in cases reporting both symptoms (36%). Productivity loss involved sickness absence in 11% of the arm/hand cases, 32% of the neck/shoulder cases and 43% of the cases reporting both symptoms. The multivariate analyses showed statistically significant odds ratios for pain intensity (OR: 1.26; CI: 1.12-1.41), for high effort/no low reward (OR: 2.26; CI: 1.24-4.12), for high effort/low reward (OR: 1.95; CI: 1.09-3.50), and for low job satisfaction (OR: 3.10; CI: 1.44-6.67). Physical activity in leisure time, full-time work and overcommitment were not associated with productivity loss.

CONCLUSION

In most computer workers with neck/shoulder symptoms or hand/arm symptoms productivity loss derives from a decreased performance at work and not from sickness absence. Favorable psychosocial work characteristics might prevent productivity loss in symptomatic workers.

Different risk factors for musculoskeletal complaints and musculoskeletal sickness absence

OBJECTIVES

The aim of this study was to investigate whether individual, work-related physical and psychosocial risk factors involved in the occurrence of musculoskeletal complaints also determine musculoskeletal sickness absence.

METHODS

This cross-sectional study used a self-administered questionnaire to collect data on individual and work-related risk factors and the occurrence of musculoskeletal complaints and musculoskeletal sickness absence among 373 employees of laundry-works and dry-cleaning establishments (response rate 87%). Logistic regression models were used to determine associations between risk factors and the occurrence of musculoskeletal complaints and sickness absence due to these complaints.

RESULTS

Both work-related physical and psychosocial factors showed strong associations with low-back pain and upper-extremity complaints. Work-related physical factors did not influence sickness absence, whereas psychosocial factors showed some associations with sickness absence. Sickness absence was associated with The Netherlands as the country of birth [odds ratio (OR) 0.3, 95% confidence interval (95% CI) 0.2-0.6], and female workers had an episode of sickness absence due to low-back pain less often (OR 0.5, 95% CI 0.3-0.9), but more often due to upper-extremity complaints (OR 2.2, 95% CI 1.14.5).

CONCLUSIONS

Work-related physical and psychosocial factors largely determine the occurrence of low-back pain and upper-extremity complaints, whereas individual factors predominantly determine whether persons with these musculoskeletal complaints take sick leave.

The Evaluation of Casualties from Operation Iraqi Freedom on Return to the Continental United States from March to June 2003

BACKGROUND

Most seriously wounded US Army casualties from the Iraqi theater of operations come through Walter Reed Army Medical Center on their return to the United States. General surgery and orthopaedic surgery services have developed a multidisciplinary team approach to triage and treatment of incoming casualties.

STUDY DESIGN

Prospective database of returning casualties to Walter Reed Army Medical Center from Operation Iraqi Freedom (OIF) from March 1 to July 1, 2003.

RESULTS

Of 294 casualties seen, 119 were triaged to inpatient status and treated within 1 hour of arrival; mean age 26.6 +/- 6.2 years (range 23 to 37). Time from original battlefield injury was a mean of 8 days (range 3 to 28 days). Forty-six (39%) sustained gunshot wounds, 37 (31%) sustained blast and shrapnel injuries, and 41 (34%) had blunt/motor vehicle collision mechanisms. There were a total of 184 wounded locations in these 119 casualties; of these, there were 29 head and neck, 25 chest, 20 abdomen, 74 lower extremity, and 36 upper extremity. Twenty-eight casualties (23%) required emergent surgical procedures on the night of arrival. Another 30 (25%) required an urgent surgical procedure within 48 hours of arrival.

CONCLUSIONS

Followup surgical procedures were urgently or emergently required in 43% of admitted battlefield casualties from OIF on transfer to Level V care in the continental United States. The injury pattern of wounds from this engagement is described. The Walter Reed Army Medical Center system of incoming battlefield casualty evaluation using multidisciplinary teams is successful in expediting care and ensuring evaluation of the full range of potential injuries.

A light load eccentric exercise confers protection against a subsequent bout of more demanding eccentric exercise

This study investigated the hypothesis that a light eccentric exercise (ECC) that does not induce a loss of muscle function and delayed onset muscle soreness would confer a protective effect against a more strenuous ECC. Eighteen young men were randomly placed into two groups: 10-40% (n=9) and 40% (n=9). Subjects in the 10-40% group performed ECC of the elbow flexors (six sets of five reps) using a dumbbell set at 10% of maximal isometric strength (MVC) at an elbow joint angle of 90 degrees , followed 2 days later by ECC using a dumbbell weight of 40% MVC. Subjects in the 40% group performed the 40% ECC only. Changes in MVC, range of motion (ROM), upper arm circumference (CIR), plasma creatine kinase (CK) activity and muscle soreness before, immediately after, 1-5 and 7 days following the 40% ECC were compared between groups by a two-way repeated measures ANOVA. No significant changes in any of the criterion measures were found immediately and 1-2 days after the 10% ECC. Following the 40% ECC, the 10-40% group showed significantly (P<0.05) smaller decreases in MVC and ROM, and smaller increases in muscle soreness compared with the 40% group, but no significant differences between groups were evident for CIR and plasma CK activity. These results suggest that the 10% ECC induced some protection against a subsequent bout of 40% ECC performed 2 days later. It appears that the light eccentric exercise preconditioned the muscles for exposure to the subsequent damaging eccentric exercise bout.

Nerve transfers in the hand and upper extremity surgery

Modern nerve-to-nerve transfers represent one of the greatest advances in peripheral nerve surgery. Lessons of tendon transfers have taught that nerves to specific musculotendinous units are expendable, and greater understanding of peripheral nerve topography has revealed redundant fascicles in peripheral nerves. Transfer of these redundant or expendable nerves to recipient nerves close to the end organ allows for earlier reinnervation and preservation of those musculotendinous units. Such nerve transfers provide significantly better treatment options in many cases of nerve injury where previous outcomes were expected to be poor, such as with proximal injuries, long nerve gaps, or unavailability of the proximal injured segment. This article will review current nerve transfers in the hand and upper extremity.

The QuickDASH is an appropriate tool for measuring the quality of recovery after upper limb burn injury

BACKGROUND

Upper limb (UL) burns commonly result in significant dysfunction. The measurement of disability is vital to assess recovery after burn injury. The QuickDASH questionnaire was developed to evaluate UL disorders. The aim of this study was to evaluate its validity, repeatability and responsiveness for burn patients.

METHODS

In 2006, 85 patients with UL burns were recruited at Royal Perth Hospital. Each completed both QuickDASH and Burns Specific Health Scale-Brief (BSHS-B) at regular intervals after their burn. Further, 67 patients repeated the questionnaire 1 day after completing it at discharge.

RESULTS

Validity-Criterion validity was demonstrated between QuickDASH and BSHS-B through good correlations (r(2)=-0.79 to -0.89). Construct validity was demonstrated using burn severity markers. QuickDASH scores significantly differed when grouped according to major burn, full thickness burn, surgery and need for hospital admission. Repeatability-QuickDASH showed excellent repeatability (ICC=0.93). Responsiveness-Effect size of QuickDASH was demonstrated to be greater than BSHS-B at all measurement points.

CONCLUSIONS

This longitudinal study confirms the validity, repeatability and responsiveness of the QuickDASH outcome measure in patients with upper limb burns. It supports the use of the QuickDASH in this population to help assess change in functional level.

Incidence of Nerve Injury After Extremity Trauma in the United States

BACKGROUND

Traumatic peripheral nerve injuries cause chronic pain, disability, and long-term reductions in quality of life. However, their incidence after extremity trauma remains poorly understood.

METHODS

The IBM® MarketScan® Commercial Database from 2010 to 2015 was used to identify patients aged 18 to 64 who presented to emergency departments for upper and/or lower extremity traumas. Cumulative incidences were calculated for nerve injuries diagnosed within 2 years of trauma. Cox regression models were developed to evaluate the associations between upper extremity nerve injury and chronic pain, disability, and use of physical therapy or occupational therapy.

RESULTS

The final cohort consisted of 1 230 362 patients with employer-sponsored health plans. Nerve injuries were diagnosed in 2.6% of upper extremity trauma patients and 1.2% of lower extremity trauma patients. Only 9% and 38% of nerve injuries were diagnosed by the time of emergency department and hospital discharge, respectively. Patients with nerve injuries were more likely to be diagnosed with chronic pain (hazard ratio [HR]: 5.9, 95% confidence interval [CI], 4.3-8.2), use physical therapy services (HR: 10.7, 95% CI, 8.8-13.1), and use occupational therapy services (HR: 19.2, 95% CI, 15.4-24.0) more than 90 days after injury.

CONCLUSIONS

The incidence of nerve injury in this national cohort was higher than previously reported. A minority of injuries were diagnosed by emergency department or hospital discharge. These findings may improve practitioner awareness and inform public health interventions for injury prevention.

Common tendinopathies in the upper and lower extremities

Overuse tendon injuries (tendinopathies) present a challenge to sports medicine patients and clinicians. Despite the high prevalence of tendinopathy in recreational and competitive athletes, treatment is often hampered by contradictory definitions and descriptions of the underlying pathology, with a limited repertoire of evidence-based treatments. This review provides the clinician with a basic overview of tendon structure and pathophysiology, and highlights the most common tendinopathies affecting the upper and lower extremities, including an update on recent advances in conservative management.

The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Patient Positioning and Impending Upper Extremity Nerve Injury During Spine Surgery: A Retrospective Analysis

Somatosensory evoked potential (SSEP) monitoring is used to prevent nerve damage in spine surgery and to detect changes in upper extremity nerve function. Upper extremity SSEP conduction changes may indicate impending nerve injury. We investigated the effect of operative positioning on upper extremity nerve function retrospectively in 1000 consecutive spine surgeries that used SSEP monitoring. The vast majority (92%) of upper extremity SSEP changes were reversed by modifying the arm position and were therefore classified as position-related. The incidence of position-related upper extremity SSEP changes was calculated and compared for five different surgical positions: supine arms out, supine arms tucked, lateral decubitus position, prone arms tucked, and the prone "superman" position. The overall incidence of position-related upper extremity SSEP changes was 6.1%. The lateral decubitus position (7.5%) and prone superman position (7.0%) had a significantly more frequent incidence of position-related upper extremity SSEP changes (P < 0.0001, Z-test for Poisson counts) compared with other positions (1.8%-3.2%). No patient with a reversible SSEP change developed a new postoperative deficit in the affected extremity. SSEP monitoring is of value in identifying and reversing impending upper extremity peripheral nerve injury.

Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity

BACKGROUND

As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded.

METHODS

The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures.

RESULTS

In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction.

CONCLUSIONS

The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

How to measure outcomes of peripheral nerve surgery

Evaluation of outcomes after peripheral nerve surgeries include several assessment methods that reflect different aspects of recovery, including reinnervation, tactile gnosis, integrated sensory and motor function, pain and discomfort, and neurophysiologic and patient-reported outcomes. This review lists measurements addressing these aspects as well as the advantages and disadvantages of each tool. Because of complexities of neurophysiology, assessment remains a difficult process, which requires researchers to focus on measurements best relevant to specific conditions and research questions.

A cross-sectional study of risk factors for musculoskeletal symptoms in the workplace using data from the General Social Survey (GSS)

OBJECTIVE

Assessments of potential risk factors for musculoskeletal disorders (MSDs) from large, national study populations using personal interviews are critical to our understanding of exposure-response relationships. To address this need, we analyzed two outcome measures--self-reported back pain and upper extremity pain--from the quality of work life (QWL) module of the General Social Survey (GSS). We investigated several individual, psychosocial, and physical factors for their relationship to these outcome measures.

METHODS

The study population included US adults, noninstitutionalized, English-speaking, aged 18 years or older, and employed at least part time (>or=20 hr/wk). Final sample size was 1484 workers.

RESULTS

Variables of physical exposure significantly increased the risk of both low back pain and upper extremity pain. Multiple injuries and some psychosocial factors were associated with MSDs, and there was an additive effect on risk of MSDs with exposure to both physical exposure and work stress.

CONCLUSIONS

A relationship between physical loads and musculoskeletal disorders was indicated by the results, which will enable creating a database for tracking reports of MSDs in the US working population.

Injuries in Australian Rules Football: An Overview of Injury Rates, Patterns, and Mechanisms Across All Levels of Play

CONTEXT

The nature of Australian rules football (Australian football) predisposes both unique and common injuries compared with those sustained in other football codes. The game involves a combination of tackling, kicking, high-speed running (more than other football codes), and jumping. Two decades of injury surveillance has identified common injuries at the professional level (Australian Football League [AFL]).

OBJECTIVE

To provide an overview of injuries in Australian rules football, including injury rates, patterns, and mechanisms across all levels of play.

STUDY DESIGN

A narrative review of AFL injuries, football injury epidemiology, and biomechanical and physiological attributes of relevant injuries.

RESULTS

The overall injury incidence in the 2015 season was 41.7 injuries per club per season, with a prevalence of 156.2 missed games per club per season. Lower limb injuries are most prevalent, with hamstring strains accounting for 19.1 missed games per club per season. Hamstring strains relate to the volume of high-speed running required in addition to at times having to collect the ball while running in a position of hip flexion and knee extension. Anterior cruciate ligament injuries are also prevalent and can result from contact and noncontact incidents. In the upper limb, shoulder sprains and dislocations account for 11.5 missed games per club per season and largely resulted from tackling and contact. Concussion is less common in AFL than other tackling sports but remains an important injury, which has notably become more prevalent in recent years, theorized to be due to a more conservative approach to management. Although there are less injury surveillance data for non-AFL players (women, community-level, children), many of these injuries appear to also be common across all levels of play.

CLINICAL RELEVANCE

An understanding of injury profiles and mechanisms in Australian football is crucial in identifying methods to reduce injury risk and prepare players for the demands of the game.