Hand injury costs

Inpatient or Outpatient: Does Initial Disposition Affect Outcomes in Trimalleolar Ankle Fractures?

Background The repair of trimalleolar fractures can be challenging for surgeons and may be managed as an inpatient or an outpatient. However, it is often unclear whether these patients should be admitted immediately or sent home from the emergency department (ED). This study aims to evaluate trimalleolar fractures treated surgically in the inpatient or outpatient settings to evaluate differences in outcomes for these patients. Methods A retrospective chart review of 223 patients undergoing open reduction internal fixation of a trimalleolar ankle fracture was performed from January 2015 to August 2022. Patients were classified by whether the fixation was performed as an inpatient or outpatient. Outcomes of interest included time from injury to surgery, complications, ED returns, and readmissions within 90 days. Results Inpatients had significantly higher ASA scores, BMI, and rates of comorbidities. Inpatient treatment was associated with faster time to surgery (median 2.0 vs. 9.0 days) and fewer delayed surgeries more than seven days from injury (18.4 vs. 67.9%). There were no differences in complications, 90-day ED returns, readmissions, or reoperation between groups. Conclusions Inpatient admission of patients presenting with trimalleolar ankle fractures resulted in faster time to surgery and fewer surgical delays than outpatient surgery. Despite having more preoperative risk factors, inpatients experienced similar postoperative outcomes as patients discharged home to return for outpatient surgery. Less restrictive admission criteria may improve the patient experience by providing more patients with support and pain control in the hospital setting while decreasing the time to surgery.

Effectiveness of occupational therapy interventions on function and satisfaction with occupational performance among adults with conditions of the hand, wrist, and forearm: a protocol for a systematic review

Background

Functional hand use post injury is important in enabling a person's engagement in daily living tasks. Without proper treatment, there may be difficulties in self-care, engaging in job roles, or leisure pursuits. Occupational therapists are key health care practitioners for people with upper limb conditions. This systematic review aims to appraise and summarise current evidence regarding effectiveness of occupational therapy interventions among adults with conditions of the hand, wrist, and forearm.

Methods

A systematic review of randomised control trials and quasi randomised controlled trials will be completed. MEDLINE OVID, CINAHL, CENTRAL, COCHRANE, PUBMED and EMBASE databases will be systematically searched. Grey literature will be searched for via Google Scholar. Studies will be included if they include provision of occupational therapy to adults with a hand, wrist, or forearm condition when compared to treatment as usual or an alternative treatment option. The primary outcome will be function. Secondary outcomes will include satisfaction with occupational performance, quality of life, pain experience, and participation. The Brief International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions will be used to categorise outcomes. The Cochrane Risk of Bias 2 (RoB 2) tool and the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) framework will be utilised to assess quality. A pooled meta- analysis will be completed using RevMan, depending on the uniformity and availability of data.

Results

This review aims to synthesise high quality evidence to identify the effectiveness of occupational therapy interventions with patients with a hand, wrist, or forearm condition, categorising outcomes in relation to the ICF Core Set for Hand Conditions.

Conclusions

By synthesising the evidence there is potential for improved evidence base for clinicians; improved outcomes for patients; as well as potential economic benefit.This study is registered with PROSPERO: CRD42022337070.

Effectiveness of occupational therapy interventions on function and occupational performance among adults with conditions of the hand, wrist, and forearm: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis examines the effectiveness of occupational therapy interventions for adults with conservatively managed conditions of the hand, wrist, and forearm.

METHODS

Searches were carried out in CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, MEDLINE (OVID), EMBASE, and PubMed. Grey literature was searched for via Google Scholar. A systematic literature search was undertaken for randomised studies that examined occupational therapy interventions for treatment of hand, wrist, and forearm conditions. The primary outcome was function, with secondary outcomes of occupational performance, satisfaction with occupational performance, pain, and quality of life. Meta-analyses were completed, and GRADE was used to determine the certainty of evidence.

RESULTS

Twelve studies with 1429 participants were identified. Interventions included combinations of occupation-based intervention, assistive device provision, education, orthosis provision, and exercise programmes for arthritis, carpal tunnel syndrome, and fracture and tendon injuries of the hand, wrist, and forearm. Occupational therapy resulted in an improvement of function (REM, SMD -0.27, 95% CI -0.00 to -0.53, I2  = 69%, low certainty evidence) (p = 0.05), occupational performance (REM, SMD 0.83, 95% CI 1.61-0.06, I2  = 91%, low certainty evidence) (p = 0.04), satisfaction with occupational performance (REM, SMD 0.74, 95% CI 1.42-0.05, I2  = 89%, low certainty evidence) (p = 0.03), and pain reduction (FEM, MD -1.35, 95% CI -0.84 to -1.86, I2  = 0%, moderate certainty evidence) (p < 0.00001).

CONCLUSION

Further high-quality research is recommended to determine the effects of occupational therapy interventions on specific upper limb conditions, inclusive of a broader range of clinical and patient reported outcome measures.

Management of everyday life after a hand operation-A qualitative study of patients with a weak sense of coherence

BACKGROUND

A hand-related disorder (HRD) has a more significant impact on participation in everyday life for patients with a weak sense of coherence (SOC) compared to those with a strong SOC. Therefore, understanding how patients with a weak SOC manage the conditions of everyday life after a hand operation is of clinical interest.

PURPOSE

This study aimed to explore how patients with a weak SOC experience and manage the conditions of everyday life after an operation for an HRD.

STUDY DESIGN

A qualitative design with a hermeneutic approach.

METHODS

An in-depth interview was conducted with each of eight adults-five women and three men-with an HRD and a weak SOC (SOC-13 score <52). Participants with varying HRDs were interviewed once between six and 13 weeks after the hand operation. Data were analyzed based on a hermeneutic approach.

RESULTS

The analyses resulted in five themes: even more conditions to handle, challenges in everyday life, managing everyday life, different expectations, and the influence of information on everyday life. The lives of most participants were significantly impacted: they experienced a range of difficulties managing their activities and roles after their operation. The participants felt uncertain about managing everyday life and the future and expressed unfulfilled expectations for different reasons. All wanted individualized information about what to expect.

CONCLUSIONS

Participants had several conditions in life that challenged their everyday lives, and the HRD made their everyday lives even more challenging. The extent to which they felt affected appeared to relate to their perception of their presurgery activities. They had several strategies to manage everyday life but used these to varying extent. Their expectations about the outcome had both positive and negative effects on their ability to manage everyday life, and individually adapted information was requested about what to expect and how to cope with everyday life after the surgery.

"Surthriving" Hand Rehabilitation: Proposing Interventions to Support Novice Occupational Therapists Working in Underserved Contexts

Hand rehabilitation delivered to underserved South African communities is often the responsibility of novice or generalist occupational therapists. Novice therapists typically work with restricted supervision, support, and resources. Little is known about how these therapists should be supported in order to strengthen the services that they deliver. This study is aimed at understanding how novice occupational therapists in their first year of practice describe their experience of delivering hand rehabilitation in order to identify their support and development needs and propose interventions to address these needs. A qualitative instrumental case study design was used. Data were collected from novice occupational therapists (n = 9) who participated in an online community of practice. Data collection techniques included photoelicitation, facilitated reflection activities, and case discussion. Reflexive thematic analysis was employed. Trustworthiness strategies included reflexive writing, prolonged engagement, data source triangulation, member checking, and peer audit. Analysis generated three themes: (1) "submerged: I had to drown a little" captured participants' experience of being saturated by contextual features including poverty and poor basic management of hand injuries. (2) "Starting somewhere" captured participants' journey of treating patients with hand injuries. They transitioned from an initial sense of having "no idea" to developing "some idea"; their clinical reasoning was challenged when working with no diagnosis, unfamiliar presentations, or when contextual features rendered traditional approaches to therapy inappropriate. Finally, (3) "dynamics of 'surthrival'" captured elements that contributed to participants either thriving or merely surviving their hand rehabilitation experience. The proposed strategies identified in this study to address the support and development needs of novice therapists include interventions focused on systems and health services; learning opportunities to support competency and physical resources; and emotional support. Beyond application to the South African context, these strategies may be considered for supporting generalist or novice therapists delivering hand rehabilitation in other low- to middle-income countries.

Simulation of low-energy impacts on the human hand for prediction of peak reaction forces and bone fracture

Hands of workers in extractive and heavy-duty industries are susceptible to suffering injuries of varying severity. Improved safety procedures and new technologies for production and maintenance tasks have contributed to reducing the severity of injuries. However, manual tasks with high-risk factors can still lead to hand injuries. Hand bone fractures and dislocations can be caused by relatively small objects impacting a region of the hand at velocities in the range of 1.3 to 1.6 m per second. This impact can produce significant functional, physical, and psychological consequences in those affected and result in high costs derived from medical care. This study presents the results of a finite element simulation study conducted to reproduce impacts with energies in the range of 7 to 10 Joules of an object on the dorsal region of the hand. Simulation results are compared to previous experimental results obtained from controlled impact tests performed using cadaveric hand specimens. The vertical peak reaction force (PRF) as a function of the impact position was used as a primary outcome for comparisons. Simulation results for all impact positions were within the standard deviation measured experimentally, with differences in the PRF values in the range of -5.3% to 4.9%. Bone stress analyses at the position of impacts showed the locations where the maximum principal stress exceeded the bone strength, as well as the variability in the correspondence between the stress distribution predicted by the FE models and the fracture rate distribution observed experimentally.

Development of optimal sizing system for tactical gloves applying empirical loss coefficient ratio

This study aims to improve Korean male soldiers' mission performance and protect them from safety accidents by establishing an optimal sizing system that considers the fit of tactical gloves and production and supply efficiency. First, the wearing condition of tactical gloves was investigated through in-depth interviews and surveys. The optimal glove fit and loss coefficient ratio was then analyzed through a glove size selection experiment. Finally, the sizing system was optimized and verified by comparing the coverage rate to the current sizing system. The empirically derived loss coefficient ratio was 0.075, and the optimal sizing system for tactical gloves was S-hand length: 168 mm, hand width: 81 mm, M-hand length: 177 mm, hand width: 83 mm, L-hand length: 184 mm, hand width: 86 mm, XL-hand length: 191 mm, and hand width: 89 mm. The coverage rate of the optimal sizing system proposed in this study was 86.4%, showing an improvement of approximately 21.1% compared to the current sizing system (65.3%). In conclusion, the optimal sizing system for tactical gloves proposed in this study can realistically solve current sizing issues, as it improved the coverage rate by 21.1% without incurring additional costs for production or hindering the supply efficiency.

Cost Analysis of Intramedullary Screw versus Plate Osteosynthesis for Phalangeal and Metacarpal Fractures: An Observational Study

Background: To compare the observed healthcare and societal costs of intramedullary screw (IMS) and plate fixation of extra-articular metacarpal and phalangeal fractures in a contemporary Australian context. Methods: A retrospective analysis, based on previously published data, was performed utilising information from Australian public and private hospitals, the Medicare Benefits Schedule (MBS) and the Australian Bureau of Statistics. Results: Plate fixation demonstrated longer surgical lengths (32 minutes, compared to 25 minutes), greater hardware costs (AUD 1,088 vs. AUD 355), more extended follow-up requirements (6.3 months, compared to 5 months) and higher rates of subsequent hardware removal (24% compared to 4.6%), resulting in an increased healthcare expenditure of AUD 1,519.41 in the public system, and AUD 1,698.59 in the private sector. Wage losses were estimated at AUD 15,515.78 when the fracture cohort is fixed by a plate, and AUD 13,542.43 when using an IMS - a differential of AUD 1,973.35. Conclusions: There is a substantial saving to both the health system and the patient when using IMS fixation over dorsal plating for the fixation of extra-articular metacarpal and phalangeal fractures. Level of Evidence: Level III (Cost Utility).

Cost Comparison of Kirschner Wire Versus Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures

BACKGROUND

Intramedullary screw fixation is a relatively new technique for fixation of metacarpal and phalangeal fractures. The objective of this study was to compare health care-associated costs and outcomes for intramedullary screw versus Kirschner wire (K-wire) fixation of hand fractures.

METHODS

A retrospective review of patients undergoing intramedullary screw fixation of hand fractures at a single center during 2016-2019 inclusive was conducted. Health care-associated costs were compared with age-matched and fracture pattern-matched controls who underwent K-wire fixation.

RESULTS

Fifty patients met the study inclusion criteria, incorporating 62 fractures (29 K-wire, 33 intramedullary screw fixation). The median age was 34.6 years (18.0-90.1 years). There was no significant difference in primary operative costs (£1130.4 ± £162.7 for K-wire vs £1087.0 ± £104.2 for intramedullary screw), outpatient follow-up costs (£958.7 ± £149.4 for K-wire vs £782.4 ± £143.8 for intramedullary screw), or total health care-associated costs (£2089.1 ± £209.0 for K-wire vs £1869.4 ± £195.3 for intramedullary screw). However, follow-up costs were significantly lower for the uncomplicated intramedullary screw cohort (£847.1 ± £109.1 for K-wire vs £657.5 ± £130.8 for intramedullary screw, P = .05). Subgroup analysis also revealed that overall costs were significantly higher for buried K-wire techniques. Complication rates, time to return to active work, and Disabilities of the Arm, Shoulder, and Hand scores were similar.

CONCLUSIONS

This study identified significantly lower outpatient follow-up costs for uncomplicated intramedullary screw fixation of hand fractures compared with K-wires, along with a trend toward lower overall health care-associated costs. In addition, buried K-wire techniques were also found to carry a significantly higher financial burden. Higher powered prospective studies are required to determine indirect costs.

Hand wounds: An analysis of topography and related damage to underlying structures

INTRODUCTION

Hand wounds account for 35 to 51% of hand traumas. Damage to underlying anatomical structures depends on the location of the wound. The objective of this study is to describe the topographic distribution of hand wounds allowing for subsequent evaluation of the link between affected surface area and underlying lesion.

METHODS

We retrospectively reviewed the medical records of 1058 patients with a total of 1319 wounds over a period of 2 years. Wound location was described according to the cutaneous projection of IFSSH zones for flexors and extensors. Any associated deep lesions were evaluated. Topographical distribution was modeled graphically using a heat-map. We compared the proportion of underlying lesions between each cutaneous zone. Sub-group analysis for lesions' rate regarding zone groups were performed.

RESULTS

58.9% of wounds were located on the palmar surface and 41.1% on the dorsal surface. 71% of wounds affected only the digits. The index finger was the most affected. The most damaged region was zone 2 for palmar wounds and zone 3 for dorsal wounds. 45.5% of wounds resulted in injury to a significant underlying anatomical structure. This frequency was 36.4% and 58.5% for palmar and dorsal wounds respectively. More than 50% of wounds in palmar zone 5 and dorsal zones 1, 3, 5, 6 and 7 presented at least one lesion. A lesion of major structure was more frequently found in palmar zone 5 (p <0.001). Dorsally, no zone predominated. Subgroup analysis for dorsal wounds revealed that wounds overlying joints had more major lesions including more tendons injuries and more articular violations with zone 3 presenting a rate of 68%.

CONCLUSION

We provided the first graphical representation for the topographical distribution of hand wounds. Dorsal wounds have a higher association with injury to underlying structures. These results generally support surgical exploration of all hand wounds regardless of their location.

LEVEL OF EVIDENCE

IV Study type: Epidemiological study.

The use of connective tissue growth factor mimics for flexor tendon repair

Intrasynovial flexor tendon lacerations of the hand are clinically problematic, typically requiring operative repair and extensive rehabilitation. The small-molecule connective tissue growth factor (CTGF) mimics, oxotremorine M (Oxo-M) and 4-PPBP maleate (4-PPBP), have been shown to improve tendon healing in small animal models by stimulating the expansion and differentiation of perivascular CD146+ cells. To enhance intrasynovial flexor tendon healing, small-molecule CTGF mimics were delivered to repaired canine flexor tendons via porous sutures. In vitro studies demonstrated that Oxo-M and 4-PPBP retained their bioactivity and could be released from porous sutures in a sustained manner. However, in vivo delivery of the CTGF mimics did not improve intrasynovial tendon healing. Histologic analyses and expression of tenogenic, extracellular matrix, inflammation, and remodeling genes showed similar outcomes in treated and untreated repairs across two time points. Although in vitro experiments revealed that CTGF mimics stimulated robust responses in extrasynovial tendon cells, there was no response in intrasynovial tendon cells, explaining the lack of in vivo effects. The results of the current study indicate that therapeutic strategies for tendon repair must carefully consider the environment and cellular makeup of the particular tendon for improving the healing response.

Etiological and epidemiological characteristics of surgically treated radial nerve lesions: A 20-year single-center experience

Introduction

Radial nerve lesions present a clinical entity that may lead to disability, psychological distress, and job loss, and thus requires great attention. Knowledge of the etiology and exact mechanism of the nerve impairment is of great importance for appropriate management of these patients, and there are only a few papers that focused on these features in patients with surgically treated radial nerve lesions. The lack of studies presenting the etiology and injury mechanisms of surgically treated radial nerve lesions may be due to a relatively small number of specialized referral centers, dispersion to low-flow centers, and a greater focus on the surgical treatment outcomes.

Aim

The aim of this study was to describe the etiological and epidemiological characteristics of patients with surgically treated radial nerve lesions of various origins.

Methods

This retrospective study evaluated 147 consecutive patients with radial nerve lesion, treated in the department during the last 20 years, from January 1, 2001, until December 31, 2020.

Results

The majority of patients belonged to the working population, and 70.1% of them were male. Most commonly, the etiology of nerve lesion was trauma (63.3%) or iatrogenic injury (28.6%), while the less common origin was idiopathic (4.1%) or neoplastic (4.1%). The most frequent location of the lesion was in the upper arm, followed by the elbow and forearm. Fracture-related contusion was the most common mechanism (29.9%), followed by postoperative fibrosis (17.7%), lacerations (17.7%), and compression (15.6%).

Conclusion

Based on the fact that traumatic or iatrogenic injuries constitute the majority of cases, with their relevant mechanisms and upper arm predomination, it is crucial to raise awareness and understanding of the radial nerve injuries among orthopedic surgeons to decrease the numbers of these patients and properly preserve or treat them within the initial surgery.

Wood-Splitter-Related Upper-Limb Injuries: A Single-Centered Case-Series Study

(1) Background: Injuries to the upper limbs during wood splitting can affect social and economic life. We aimed to describe the clinical information concerning these injuries in Japan. (2) Methods: We identified patients from our patient database from April 2015-November 2021 and extracted data from their medical records, which includes age, gender, occupation, month, time and location of the injury, diagnosis, duration of hospitalization, ICU admission, treatment interventions including surgery, outcome, and medical costs. (3) Result: Seventeen cases were identified. Most of the patients were male (n = 15), with median age being 68 years old. Regarding the patients' backgrounds, six were apple farmers and three were unemployed. Injuries to the index finger was most common (n = 9), followed by injuries to the thumb in five cases (n = 5). Most of the incidents occurred at home or on the patient's farm estate. No injuries were due to incidents at work. (4) Conclusion: The wood splitter-related injuries required long-term treatment and frequently damaged the thumb, a functionally important digit. All the injuries were sustained during non-occupational use of a wood splitter. Therefore, we suggest that safety training should be provided to prevent traumatic injuries when these products are being sold.

Effectiveness of occupational therapy interventions on function and satisfaction with occupational performance among adults with conditions of the hand, wrist, and forearm: a protocol for a systematic review

Background: Functional hand use post injury is important in enabling a person’s engagement in daily living tasks. Without proper treatment, there may be difficulties in self-care, engaging in job roles, or leisure pursuits. Occupational therapists are key health care practitioners for people with upper limb conditions. This systematic review aims to appraise and summarise current evidence regarding effectiveness of occupational therapy interventions among adults with conditions of the hand, wrist, and forearm. Methods: A systematic review of randomised control trials and quasi randomised controlled trials will be completed. MEDLINE OVID, CINAHL, CENTRAL, COCHRANE, PUBMED and EMBASE databases will be systematically searched. Grey literature will be searched for via Google Scholar. Studies will be included if they include provision of occupational therapy to adults with a hand, wrist, or forearm condition when compared to treatment as usual or an alternative treatment option. The primary outcome will be function. Secondary outcomes will include satisfaction with occupational performance, quality of life, pain experience, and participation. The Brief International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions will be used to categorise outcomes. The Cochrane Risk of Bias 2 (RoB 2) tool and the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) framework will be utilised to assess quality. A pooled meta- analysis will be completed using RevMan, depending on the uniformity and availability of data. Results: This review aims to synthesise high quality evidence to identify the effectiveness of occupational therapy interventions with patients with a hand, wrist, or forearm condition, categorising outcomes in relation to the ICF Core Set for Hand Conditions. Conclusions: By synthesising the evidence there is potential for improved evidence base for clinicians; improved outcomes for patients; as well as potential economic benefit. This study is registered with PROSPERO: CRD42022337070.

A Comparative Analysis of Nonthumb Metacarpal Fracture Treatments in New York City Civilians and Incarcerated Individuals

Nonthumb metacarpal (NTMC) fractures are common in the incarcerated and the underinsured civilian populations. However, certain social challenges contribute to high rates of follow-up noncompliance and complications in these unique populations. We conducted a retrospective review of the treatments, outcomes, and complications in the incarcerated and civilian patient population who were treated at a tertiary public hospital for NTMC fractures. Even though incarcerated patients were more likely than their civilian counterparts to undergo operative interventions, both populations showed similar complication profiles as well as low rates of treatment compliance and follow-up. This article affirms that incarcerated individuals do not receive inferior care compared with civilians, and both the incarcerated and underinsured civilians would benefit from careful consideration of treatment algorithms and additional access to hand therapy.

Forecasting the rate of hand injuries in Singapore

Purpose

This study aims to analyse the correlation between the incidence rate of hand injuries and various major economic indicators in Singapore. We hypothesise that the number of hand injuries is correlated to activity in the construction and manufacturing industries in Singapore.

Methods

Twenty thousand seven hundred sixty-four patients who underwent hand surgeries in a tertiary institution between 2012 to 2018 were reviewed. Two independent, blinded observers extracted the frequency of hand surgeries performed from Electronic Medical Records. Economic indicators pertinent to Singapore’s economic activity were collected and smoothed by simple moving average of the prior 3 months. Results were analysed using IBM SPSS v25.0.

Results

Significant independent univariate variables were Purchasing-Manager-Index and Industrial-Production-Index. Multiple linear regression of quarterly reported figures showed that Total-Livestock-Slaughtered, Total-Seafood-Handled, Purchasing-Manger-Index, Industrial-Production-Index, Gas-Tariffs, Construction-Index, Consumer-Price-Index, Total-Air-Cargo-Handled, Total-Container-Throughput, Total-Road-Traffic-Accident-Casualties, Food-&-Beverage-Services-Index were significantly correlated (p < 0.05) with hand injuries, with R² = 62.3%.

Conclusion

Quarterly economic indicators from major economic industries can be used to predict the incidence of hand injuries with a 62.3% correlation. These findings may be useful for anticipating healthcare resource allocation to treat hand injuries.

Type of study and level of evidence

Economic and decision, Level II.

The Necessity for Improved Hand and Finger Protection in Mining

Injuries associated with hands and fingers are highly prevalent in mining and identifying factors associated with these injuries are critical in developing prevention efforts. This study identifies nonfatal injury incidence rates, nature of injury, work activities, glove usage, and sources of hand and finger injuries in the U.S. mining industry, as reported to the Mine Safety and Health Administration (MSHA) from 2011 - 2017. Hand and finger injuries occur at a rate of 6.53 per 1000 full-time employees, which is nearly double the rate of the next highest affected body part, the back. Most of the hand and finger injuries were classified as cuts/lacerations/punctures (53%) followed by bone fractures/chips (26%). Materials handling and maintenance/repair were common activities at the time of the incident with miscellaneous metals (pipe, wire, guarding) and hand tools as the primary sources of hand and finger injury. Although the information on glove use was limited, leather gloves were most often worn when an injury occurred. When worn, gloves were found to contribute to 20% of the injuries, indicating their potential to protect the hands, but also potentially put the hands at risk. Further research is necessary to determine performance requirements for gloves used in mining operations, specifically those offering cut and puncture resistance.

Surgical Treatment of Radial Nerve Injuries Associated With Humeral Shaft Fracture-A Single Center Experience

Radial nerve injuries are often associated with humeral shaft fractures. The results of treatment of these injuries, by contemporary surgical approaches, remain diverse. In this paper we presented the outcomes and analyzed the patient, clinical, and surgical procedure related characteristics and factors that may influence the outcome overall, in 77 patients treated at Clinic for Neurosurgery, Clinical Center of Serbia during a 20 years period. The nerve injuries were verified by US and EMNG. The majority of patients were treated by neurolysis or sural nerve grafting, while only few were treated by direct suture. The final recovery was evaluated by muscle strength assessment and classified using MRC. We analyzed extension of the wrist, extension of the fingers including the thumb, and abduction of the thumb. There was a significant statistical difference in MRC grade following the treatment. The total rate of useful functional recovery was achieved in 69 (89.61%) out of all studied patients, out of whom 20 (28.99%) achieved excellent recovery, 26 (37.68%) achieved good recovery and 23 (33.33%) achieved fair recovery. Only 8 (10.39%) out of all studied patients achieved poor recovery. The injured nerves, that were preserved in continuity, acquired by a low-energy trauma, and treated earlier than the 6 months were associated with better functional outcome following the surgery. In addition, there was a trend of better functional improvement with aging, keeping in mind that the old were subjected to lower energy trauma. The expectant management followed by surgery of radial nerve injury associated with humeral shaft fracture should be around 3 months, and the surgical nerve repair should not be performed later than the 6 months after injury. The energy of trauma may be a factor predicting patient's final recovery following the treatment.

Anatomy and histomorphology of the flexor digitorum profundus enthesis: functional implications for tissue engineering and surgery

Background

The enthesis possesses morphological adaptations across the soft-hard tissue junction which are not fully restored during surgical avulsion repairs. This loss of anatomical structure, highly related to function, contributes to poor clinical outcomes. Investigating the native macro- and micro-structure of a specific enthesis can provide functional and biomechanical insights to develop specialised, novel tissue-engineered therapeutic options and potentially improve current surgical treatments for avulsion injuries.

Methods

This study examines the anatomy and histomorphology of the flexor digitorum profundus (FDP) enthesis in 96 fresh-frozen human cadaveric fingers, quantitatively and qualitatively analyzing the shape, size, angle of tendon fibres and histological architecture, and explores differences in sex, finger and distance along the enthesis using linear mixed effects models.

Results

Macroscopically, results showed a consistent trapezoidal insertion shape of 29.29 ± 2.35 mm² mean surface area, but with significant morphometric size differences influenced primarily by the smaller dimensions of the little finger. Microscopically, a fibrocartilaginous enthesis was apparent with a 30.05 ± 0.72^o mean angle of inserting tendon fibres, although regional variation in fibrocartilage and the angle change of tendon fibres before insertion existed.

Conclusions

The implication of these findings on native and specific FDP enthesis function is discussed whilst providing recommendations for optimal FDP enthesis recreation for interfacial tissue engineers and hand surgeons. The study emphasizes the importance of region-specific knowledge whilst also describing methods applicable to assessing any soft tissue insertion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04922-1.

Effects of wearing of metacarpal gloves on hand dexterity, function, and perceived comfort: A pilot study

Metacarpal gloves are commonly used in heavy-duty industries such as mining and are typically thicker and bulkier than manufacturing or assembly industrial gloves. This pilot study investigates the impact of wearing metacarpal gloves on hand dexterity, functional capabilities, and perceived comfort. Four types of commercially available metacarpal gloves were selected for evaluation in a randomized controlled trial. Evaluations included turning and placing tests, also grip, pinch, and screwdriver tests, and rating of the perceived level of effort. Dexterity test results showed that metacarpal gloves significantly reduced the ability to perform motor tasks requiring coordination compared to bare hands. Hand functions such as gripping, pinching, and forearm rotations were not significantly affected. However, the perceived level of effort needed to complete those hand functions increased as the metacarpal glove's bulkiness increased. High levels of mechanical protection typically offered by metacarpal gloves can inversely affect hand dexterity and hand exertion.

Cost, profile, and postoperative resource use for surgically managed acute hand and wrist injuries with emergency department presentation

STUDY DESIGN

Retrospective cost-of-illness study.

INTRODUCTION

Injuries to the hand and wrist are common. Most uncomplicated and stable upper extremity injuries recover with conservative management; however, some require surgical intervention. The economic burden on the health care system from such injuries can be considerable.

PURPOSE OF THE STUDY

To estimate the economic implications of surgically managed acute hand and wrist injuries at one urban health care network.

METHODS

Using 33 primary diagnosis ICD-10 codes involving the hand and wrist, 453 consecutive patients from 2014 to 2015 electronic billing records who attended the study setting emergency department and received consequent surgical intervention and outpatient follow-up were identified. Electronic medical records were reviewed to extract demographic data. Costs were calculated from resource use in the emergency department, inpatient, and outpatient settings. Results are presented by demographics, injury type, mechanism of injury, and patient pathway.

RESULTS

Two hundred and twenty-six individuals (n 1⁄4 264 surgeries) were included. The total cost of all injuries was $1,204,606. The median cost per injury for non-compensable cases (n = 191) was $4508 [IQR $3993-$6172] and $5057 [IQR $3957-$6730] for compensable cases (n = 35). The median number of postoperative appointments with a surgeon was 2.00 (IQR 1.00-3.00) for both compensable and non-compensable cases. The number of hand therapy appointments for non-compensable cases and compensable cases was 4 [IQR 2-6] and 2 [IQR 1-3], respectively.

DISCUSSION

Findings of this investigation highlight opportunities for health promotion strategies for reducing avoidable injuries and present considerations for reducing cost burden by addressing high fail to attend (FTA) appointment rates.

CONCLUSION

Surgically managed hand and wrist injuries contribute to a significant financial burden on the health care system. Further research using stringent data collection methods are required to establish epidemiological data and national estimates of cost burden.

Treatment of acute wounds in hand with Calendula officinalis L.: A randomized trial

Most injuries in the hand and fingers, especially on the digital pulps, are suited for healing by secondary intention. Nevertheless, delay in epithelization seems to unfavorably restrict this technique. The purpose of this controlled randomized clinical trial is to analyze by means of photo planimetry the progression of the healing process by secondary intention in acute wounds of the hand using the standardized extract of Calendula officinalis L. (SEC). The cohort of eligible participants included two groups of 20 patients with skin loss in the hand and fingers treated by secondary intention. Control group (CG) used mineral oil and intervention group (IG) received SEC. Wound pictures were captured at each outpatient assessment until epithelization was achieved and measured with ImageJ. Intervention group (IG) and control group (CG) with 19 wounds each, primarily formed by men in their 40's with wounds in their index and ring fingers on the left side, showed homogeneous variables and similar initial wound areas. Epithelization time was shorter and healing speed was faster in IG (IG = 8.6 ± 4.7 days and 9.5 ± 5.8%day versus CG = 13.2 ± 7.4 days and 6.2 ± 2.9%day, ƿ < 0.05), leading to the conclusion that healing by secondary intention in acute wounds of the hand and fingers with SEC led to a faster epithelization.

A Standard Set for Outcome Measurement in Patients With Hand and Wrist Conditions: Consensus by the International Consortium for Health Outcomes Measurement Hand and Wrist Working Group

PURPOSE

To describe the principles, process, and results of creating the International Consortium for Health Outcomes Measurement (ICHOM) standard set for hand and wrist conditions.

METHODS

Following the standardized methods of ICHOM, an international working group of hand surgeons, therapists, and researchers was assembled to develop an evidence-based, patient-centered, standard set of outcome measures for patients with hand and wrist conditions. Multiple systematic reviews were performed to support our choices of outcome domains and tools for hand and wrist conditions. Fourteen video conferences were held between March 2018 and March 2020, and a modified Delphi process was used.

RESULTS

A consensus was reached on 5 measurement tracks: the thumb, finger, wrist, nerve, and severe hand trauma tracks, with a distinction between regular and extended tracks for which specific allocation criteria applied. The standard set contains a selection of outcome tools and predefined time points for outcome measurement. Additionally, we developed a hierarchy for using the tracks when there are multiple conditions, and we selected risk-adjustment, case-mix variables.

CONCLUSIONS

The global implementation of the ICHOM standard set for hand and wrist conditions may facilitate value-based health care for patients with hand and wrist conditions.

CLINICAL RELEVANCE

The ICHOM standard set for hand and wrist conditions can enable clinical decision making, quality improvement, and comparisons between treatments and health care professionals.

Management of acute scaphoid fractures: a pragmatic approach for the non-specialist

Scaphoid fractures are common and can cause significant morbidity if treated incorrectly. Thus, a working knowledge of the initial assessment and management of scaphoid fractures by non-specialists is crucial to allow quick diagnosis and avoid potentially catastrophic complications of scaphoid fracture. This article summarises the anatomy of the scaphoid, discusses methods to assess for scaphoid fractures and delineates management plans (conservative or operative) for fractures of the scaphoid based on location of vascular compromise. This article can also help the clinician predict which fractures may not unite with conservative management and therefore need referral to a specialist orthopaedic surgeon for possible surgery.

[Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective]

Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective Abstract. Neuropathic pain of the wrist and hand can be caused by a multitude of pathologies, such as trauma, iatrogenic damage, local peripheral nerve compression, nerve tumors and systemic diseases. Neuropathic pain can lead to chronification and disability, severely affecting the patients' quality of life and the ability to work. A precise diagnosis is the key to an adequate therapy with satisfactory functional results. An interdisciplinary and multimodal approach is a prerequisite when treating neuropathic pain. This review article provides an insight into the diagnosis and therapy of pathologies associated with neuropathic pain of the wrist and hand.

Application of WALANT technique for repairing finger skin defect with a random skin flap

BACKGROUND

Wide-awake local anesthesia no tourniquet (WALANT) technique has emerged among hand surgeons with other indications. Surgeries involving pedicled flap and revascularization are no longer used as contraindications. The present study aimed to evaluate the feasibility and merits of the WALANT technique in random skin flap surgery.

METHODS

From May 2018 to March 2019, 12 patients with finger skin defects repaired with random skin flaps were reviewed. Abdominal skin flaps or thoracic skin flaps were used to cover the wound. Both the fingers and the donor sites were anesthetized by the WALANT technique. A 40-mL conventional volume consisted of a mixture of epinephrine and lidocaine. A volume of 5 mL was injected at the distal palmar for nerve block, the other 5 mL was injected around the wound for hemostasis, and the remaining was injected at the donor site of flaps for both analgesia and hemostasis. Baseline data with respect to sex, age, side, type of finger, donor sites, flap size, dosage of anesthetics, usage of finger tourniquet, intraoperative and postoperative pain, hemostasis effect, operation time, Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) score, and hospitalization expense, were collected.

RESULTS

All patients tolerated the procedure, and none of them needed sedation. Single finger skin defect in 8 patients and double finger skin defect occurred in 4 patients; 5 patients were repaired by abdominal skin flaps, and 7 patients were repaired by thoracic skin flaps. The good surgical field visibility was 91.7%. All flaps survived adequately, without necrosis, pulling fingers out, and other complications. The average visual analog scale (VAS) score of the maximal pain was 1.1 in fingers vs. 2.1 in donor sites during the operation. On postoperative day one, the average VAS score of the maximal pain in fingers and donor sites was 1.3 and 1.1, respectively. The average hospitalization expense before reimbursement of the whole treatment was 11% less expensive compared to the traditional method. The average QuickDASH score was 9.1.

CONCLUSIONS

Under wide-awake anesthesia, patients have the ability to control their injured upper extremities consciously, avoiding the complications due to pulling flap pedicles. With the merits of safety, painlessness, less bleeding, and effectivity, the WALANT technique in random skin flaps is feasible and a reliable alternative to deal with finger skin defect.

Experimental evaluation of protected and unprotected hands under impact loading

Hand injuries are a significant problem in many industries with relatively high incidence rates and injury severity. Many workers are required to wear impact protective gloves to protect their hands from impact-related hazards. This research presents the results of an experimental quantification of metacarpal gloves performance subjected to controlled impacts. Thirteen cadaveric hands were used to conduct a set of controlled impact tests on protected and unprotected hands. The controlled impacts targeted the proximal interphalangeal (PIP) joints, the metacarpophalangeal (MCP) joints, and the middle section of the metacarpal bones. Two types of metacarpal gloves commonly used in mining and oil and gas operations were selected for the tests. These gloves include different material and protection configurations on the dorsal side of the hand. The performance of selected gloves was quantified using the maximum reaction force to the impact and number of bone fractures. A total of 191 impacts produced 108 fractures, from which 71% corresponded to the unprotected hands and 40% to the protected hands. Depending on the impact position and type of glove used, the effect of protection ranged from no change up to a 23% reduction in peak reaction force.

Hand injury: investigating the accuracy of referrals to a specialist trauma centre

Hand injury is a common presentation in the emergency department (ED). The accurate assessment of hand injuries is essential to ensure optimal management, which may need to include referral to a tertiary trauma centre. However, hand injury assessment can be challenging, particularly in children. A better understanding of the accuracy of hand injury referrals to tertiary care can help improve clinical practice and clinician training. This article reports on a service improvement project that aimed to determine the accuracy of hand injury referrals from EDs and general practices to a tertiary trauma centre. The retrospective investigation found the accuracy of referrals to be high, but also identified areas where hand injury assessment required improvement, one of them being the training of clinicians referring complex cases to tertiary care.

Hand injuries during COVID-19: Lessons from lockdown

The two-month nationwide lockdown implemented in Australia in response to COVID-19 involved restrictions on social gatherings and non-essential services, resulting in marked changes to the distribution of time spent at home and in the workplace. Given the likelihood of future lockdowns, this study aimed to investigate whether the lockdown was associated with an alteration in the pattern of acute hand injuries admitted to Sydney Hospital Hand Unit relative to the same period in 2019, and whether target areas for preventative strategies could be identified.

During the lockdown period in 2020, 332 acute presentations were noted, and in the same period in 2019, 310 cases were noted. The mean patient age was higher in 2020, largely due to a 327% increase in do-it-yourself (DIY) injuries. Workplace injuries increased in 2020 despite a 9.5% reduction in hours-worked, reflecting a redistribution of workers into manual labour jobs with a higher risk for hand injuries. Patients who suffered low-energy injuries at work were also significantly younger in 2020, suggesting this effect was most pronounced in younger age-groups, probably due to the shutdown of hospitality-based industries. Domestic violence-related injuries increased in 2020, highlighting the need to maintain resources to provide support in such cases at subspecialty hand units, which are often largely outpatient-centred. This study, therefore, identified a number of key areas that could be targeted in the event of future lockdowns, including messages regarding safe DIY activities, and more stringent requirements regarding worksite briefing and safety for people commencing labour-based jobs, especially if transferring from another industry.

Clinical study on repair of metacarpal bone defects using titanium alloy implantation and autologous bone grafting

Due to various limitations in the use of autologous bone and allogeneic bone in the repair of bone defects, the use of synthetic bone graft substitute has become a hot topic in orthopedic surgery and repair medicine. A total of 53 patients treated for trauma-induced metacarpal bone defects were recruited. These patients were divided into the TiAl₆V₄ titanium alloy implantation group (group A) and the autologous bone graft group (group B). The symptoms of patients in the two groups were closely observed and followed up. The operation time, time to bone fusion, post-surgical pain [visual analog scale (VAS) scores], hand function recovery [total active flexion scale (TAFS) scores] and complications were compared between the two groups. Following surgery, none of the patients had necrosis of fingers or bone non-union. The recovery was rated as excellent and good in up to 91.6% of patients, indicating high clinical efficacy. Compared with the use of autologous bone grafting as the gold standard (group B), there was no significant difference in the excellent and good recovery rate based on TAFS scores at 16 weeks after surgery (91.7 vs. 89.7%, P>0.05), and there was also no significant difference in the incidence of post-operative complications (33.3 vs. 41.3%, P>0.05). The operation time (82.08±6.64 min), time to bone fusion (7.75±1.73 weeks) and VAS scores at 3 days after surgery were all significantly lower in group A than in group B (P<0.05). The values of group B were 104.69±8.63 min, 9.17±2.78 weeks and [5(5, 6)], respectively. However, the hospitalization cost (22,657.8±1,595.4Ұ) was significantly higher than that in group B (14,808.2±2,291.3Ұ; P<0.05). In conclusion, the use of titanium alloy implantation may avoid new injury to the donor site, reduce the operation time and post-operative pain and accelerate bone fusion. Therefore, this method is worthy of popularization for defective bone reconstruction and recovery in the clinic.

Capturing the costs of acute hand and wrist injuries: Lessons learnt from a prospective longitudinal burden of injury study

Introduction

Given the high incidence of hand and wrist injuries, they are exceptionally costly to the economy. This prospective, longitudinal study aimed to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective.

Methods

A prospective longitudinal design with baseline measures of injury type and severity, and repeated measures of disability, cost, and activity limitations and participation restrictions at six weeks, three months, and six months was selected. Participants were recruited from two large urban Australian public health care services. We sought to establish methods for capturing the burden of acute hand and wrist injury from an individual and societal perspective and compare survey completion by the method of administration.

Results

A total of 206 patients consented to participate in this study, representing 54% of those invited to participate. The survey completion rates were 18% at six weeks, 2.4% at twelve weeks, and 0.004% at six months following injury. From the limited data collected at six weeks, it was noted that nearly half of the patients reported a decrease in usual financial income, 14% reported absenteeism, and 62% reported presenteeism. Participants who elected to have data collected via phone call had the highest survey completion rate ( n = 6/10; 30%) at six-week’s follow-up.

Discussion

The study findings highlight the difficulties of completing longitudinal survey research investigating individual and societal burden with this population. Future research should be carefully designed to encourage participation and retention by considering patient and public involvement in study design, the time burden placed on the participants within and across selected survey time points, providing participants with incentives to participate, and highlighting the relevance and real-world applications of the findings.

Returning to work after a hand injury: Does ethnicity matter?

Background

Hand injuries (HI) are common and may limit participation in work. The objective of this study is to examine the effect of ethnicity and other prognostic variables on return-to-work (RTW) among male manual workers after acute HI.

Methods

A cohort of 178 subjects (90 Arabs, 88 Jews) aged 22 to 65 was studied. Trained bilingual occupational therapists evaluated and interviewed the subjects, using structured validated questionnaires for evaluating personal and environmental factors, body function and structure, and activity limitation and participation restrictions. Employment status 3 months post injury was assessed by a telephone interview. To establish a predictive model for RTW, ethnicity and certain variables of the four domains mentioned above were analyzed using logistic regression analysis.

Results

A significant difference in the rate of RTW between Jews and Arabs was found (45.5% for Jews, 28.9% for Arabs, p = 0.03) three months post HI. In the univariate regression analysis, ethnicity was associated with RTW (OR = 2.05; CI: 1.10–3.81) for Jews vs. Arabs. Using a multivariate analysis, only legal counseling, educational attainment, and the severity of disability were significantly associated with RTW.

Conclusion

RTW three months post HI among manual workers is directly related to variables such as education and legal counseling and only indirectly related to ethnicity. Patients with a lower level of education and those who were engaged in legal counseling need special attention and close guidance in the process of RTW.

Medical and productivity costs after trauma

Background

Well-advised priority setting in prevention and treatment of injuries relies on detailed insight into costs of injury. This study aimed to provide a detailed overview of medical and productivity costs due to injury up to two years post-injury and compare these costs across subgroups for injury severity and age.

Methods

A prospective longitudinal cohort study followed all adult (≥18 years) injury patients admitted to a hospital in Noord-Brabant, the Netherlands. Patients filled out questionnaires 1 week, 1, 3, 6, 12 and 24 months after trauma, including items on health care consumption from the medical consumption questionnaire (iMCQ) and productivity loss from the productivity cost questionnaire (PCQ). Furthermore, injury severity was defined by Injury Severity Score (ISS). Data on diagnostics was retrieved from hospital registries. We calculated medical costs, consisting of in-hospital costs and post-hospital medical costs, and productivity costs due to injury up to two years post-injury.

Results

Approximately 50% (N = 4883) of registered patients provided informed consent, and 3785 filled out at least one questionnaire. In total, the average costs per patient were €12,190. In-hospital costs, post-hospital medical costs and productivity costs contributed €4810, €5110 and €5830, respectively. Total costs per patient increased with injury severity, from €7030 in ISS1-3 to €23,750 in ISS16+ and were lowest for age category 18-24y (€7980), highest for age category 85 years and over (€15,580), and fluctuated over age groups in between.

Conclusion

Both medical costs and productivity costs generally increased with injury severity. Furthermore, productivity costs were found to be a large component of total costs of injury in ISS1-8 and are therefore a potentially interesting area with regard to reducing costs.

Peripheral nerve injuries, pain, and neuroplasticity

INTRODUCTION

Peripheral nerve injuries (PNIs) cause both structural and functional brain changes that may be associated with significant sensorimotor abnormalities and pain.

PURPOSE OF THE STUDY

The aim of this narrative review is to provide hand therapists an overview of PNI-induced neuroplasticity and to explain how the brain changes following PNI, repair, and during rehabilitation.

METHODS

Toward this goal, we review key aspects of neuroplasticity and neuroimaging and discuss sensory testing techniques used to study neuroplasticity in PNI patients.

RESULTS

We describe the specific brain changes that occur during the repair and recovery process of both traumatic (eg, transection) and nontraumatic (eg, compression) nerve injuries. We also explain how these changes contribute to common symptoms including hypoesthesia, hyperalgesia, cold sensitivity, and chronic neurogenic pain. In addition, we describe how maladaptive neuroplasticity as well as psychological and personality characteristics impacts treatment outcome.

DISCUSSION AND CONCLUSION

Greater understanding of the brain's contribution to symptoms in recovering PNI patients could help guide rehabilitation strategies and inform the development of novel techniques to counteract these maladaptive brain changes and ultimately improve outcomes.

Lateral slit delivery of bone marrow stromal cells enhances regeneration in the decellularized allograft flexor tendon

BACKGROUND/OBJECTIVE

Stem cell-based therapy has been applied to accelerate the revitalization of allograft tendon into a viable and functional tendon. Although many authors have proposed different methods to help the seeded stem cell distribution in the decellularized allograft, limited success has been achieved as tendon is a high dense connective tissue. We hypothesized that bone marrow stromal cells (BMSCs), seeded through the lateral slit, can regenerate the decellularized tendon (DCT) graft. The cell proliferation, cell viability, and tendon-specific gene expression are increased with the seeded cell density.

METHODS

Eighty-seven flexor digitorum profundus tendons were equally and randomly divided into 6 treatment groups that were seeded with low-density (2 × 107 cells/mL) and high-density (5 × 107 cells/mL) BMSCs through lateral slits cultured for 2 and 4 weeks, DCT without cells, and fresh live tendons. Tendons were evaluated for cell distribution, cell proliferation, cell viability, gene expression of Collagen I and Collagen III, tenogenic markers, and MMPs.

RESULTS

Histologic evaluation revealed BMSCs distributed from the lateral slit to the whole DCT. BMSCs were proliferated and kept viable in lateral slit decellularized tendon (LSDCT) in both seeded cell density groups after 2 and 4 weeks of culture. However, no significant differences in the cell proliferation between both cell density groups at 2 and 4 weeks of culture were observed. The lowest cell viability was found in the high-density group after 4 weeks of culture. BMSCs in LSDCT showed a significant tendency of higher gene expression of Collagen I, Collagen III, tenascin C, MMP2, MMP9, and MMP13 compared to normal tendons in both cell density groups at 2 and 4 weeks of culture.

CONCLUSION

BMSCs proliferated and remained viable after 2 and 4 weeks of culture with distribution throughout the lateral slits. Lateral slit preparation allows for the effective delivery and maintenance of mesenchymal cells with proliferation and generating a tenogenic behaviour of DCT in both the low and high cell densities in an in vitro model.

THE TRANSLATION POTENTIAL OF THIS ARTICLE

Revitalizing the implanted decellularized allograft is important for clinical application. In this study, we demonstrated that the DCT, with lateral slits, could harbour the seeded stem cell and stimulate proliferation with collagen synthesis. This evidence was presented for clinical application of the lateral slit technique, in DCT grafts, which would repopulate the seeded BMSCs during tendon and ligament reconstruction.

Impact of Patient-Surgeon Relationship on Patient's Return to Work

BACKGROUND

Upper-limb injuries and musculoskeletal disorders represent a major economic burden for both patients and society, largely due to limitations in returning to work. We hypothesized that a positive patient-surgeon relationship may facilitate patients' recovery and lead to a faster return to work.

METHODS

This longitudinal observational study comprised 219 patients, from 8 French hand trauma centers, who were 18 to 55 years of age and were on sick leave from work because of an injury or musculoskeletal disorder of the upper limb. In addition to instruments measuring patients' functional scores and quality of life, the quality of the patient-surgeon relationship was assessed at enrollment using a specific questionnaire (Q-PASREL [Quality of PAtient-Surgeon RELationship]). Six months after enrollment, the return-to-work status was assessed. Logistic and Cox regression models were developed to identify predictors of return to work (yes/no) and the time off from work in days.

RESULTS

Overall, 74% of the patients who returned to work within 6 months after enrollment had a high or medium-high Q-PASREL score, whereas 64% of the patients who were still on sick leave had a low or medium-low Q-PASREL score. The odds of patients with a low or medium-low Q-PASREL score returning to work were, respectively, 95% and 71% lower than the odds of patients with a high score doing so, with a percent difference of 56% (95% confidence interval [CI] = 40% to 71%) for low versus high (odds ratio [OR] = 0.05 [95% CI = 0.02 to 0.13]) and 25% (95% CI = 6% to 44%) for medium-low versus high (OR = 0.29 [95% CI = 0.11 to 0.76]). All Q-PASREL items and scores were significantly associated with return to work.

CONCLUSIONS

Patients with a lower Q-PASREL score and more severe disability were less likely to return to work within 6 months and had a longer time off from work. Efforts to improve the quality of patient-surgeon relationships may minimize the duration of sick leaves and accelerate patient recovery.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Isolation and characterization of turkey bone marrow-derived mesenchymal stem cells

Flexor tendon injury is often associated with suboptimal outcomes and results in substantial digit dysfunction. Stem cells have been isolated from several experimental animals for the growing interest and needs of utilizing cell-based therapies. Recently, turkey has been developed as a new large animal model for flexor tendon research. In the present study, we reported the isolation and characterization of bone marrow-derived mesenchymal stem cells (BMSCs) from 8- to 12-month-old heritage-breed turkeys. The isolated cells demonstrated fibroblast-like morphology, clonogenic capacity, and high proliferation rate. These cells were positive for surface antigens CD90, CD105, and CD44, but were negative for CD45. The multipotency of turkey BMSCs was determined by differentiating cells into osteogenic, adipogenic, chondrogenic, and tenogenic lineages. There was upregulated gene expression of tenogenic markers, including mohawk, tenomodulin, and EGR1 as well as increased collagen synthesis in BMP12 induced cells. The successful isolation and verification of bone marrow-derived MSCs from turkey would provide opportunities of studying cell-based therapies and developing new treatments for tendon injuries using this novel preclinical large animal model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1419-1428, 2019.

Description and cost-analysis of emergency department attendances for hand and wrist injuries

BACKGROUND

Injuries to the hand and wrist are estimated to account for between 10% and 30% of all ED presentations. The economic burden placed on the healthcare system can be extensive and rise sharply with increase in injury severity.

OBJECTIVES

This cost-analysis was performed with the aim of estimating the economic implications of ED attendances for hand and wrist injuries from the perspective of one Australian public health network.

METHODS

Data from two EDs were retrieved from the electronic billing records of one large health network across two financial year periods (2014-2015 and 2015-2016) using ICD-10 codes. All costs that resulted from the treatment of any acute hand or wrist injury across the 2 year period were calculated and are presented by age, sex, injury type and mechanism of injury.

RESULTS

A total of 10 024 individuals presented to the two EDs in the 2 year period, accounting for approximately 5.4% of all presentations. The most common presentations were males (62.2%), people aged 25-34 years (26.9%) and lacerations (31.2%). The total cost in the 2 year study period was $3 959 535.38 ($1 923 852.38 in 2014-2015; $2 035 683.00 in 2015-2016). The mean cost per presentation was $383 (95% CI [$373, $393]) in 2014-2015 and $407 (95% CI [$394, $421]) in 2015-2016.

CONCLUSIONS

Acute hand and wrist injuries contribute to a significant volume of ED presentations each year in one Australian public health network leading to significant expenditure and health resources. Further research into how to best utilise resources and reduce avoidable injuries should be priority areas to reduce the cost of these injuries to the healthcare system and society.

The Role of Health Locus of Control in Pain Intensity Outcome of Conservatively and Operatively Treated Hand Surgery Patients

PURPOSE

Psychological factors have shown to be associated with treatment outcomes in hand injury patients. This study aimed to investigate the role of health locus of control (HLOC) and its dimensions internal, social-external, and fatalistic-external HLOC in treatment outcomes of hand injury patients.

METHOD

One hundred thirty-two consecutive patients of a tertiary center for hand surgery undergoing treatment for acute hand injury or degenerative hand problems were included in this study. Pretreatment levels of depression, anxiety, HLOC, and pain intensity were measured, along with pain intensity levels at 4-month follow-up. Hierarchical regression analyses were calculated to test for moderation effects of the HLOC dimensions on the relationship between pretreatment and follow-up pain intensity.

RESULTS

Controlling for age, gender, treatment modality, source of hand pain, and depressive symptoms, a moderation effect emerged (β = - 0.16, p < 0.05), such that among patients higher in initial pain intensity, those lower in social-external HLOC experienced higher pain intensity at follow-up compared to those with high social-external HLOC. Internal HLOC and fatalistic-external HLOC did not moderate the effect of initial pain intensity on pain intensity at follow-up.

CONCLUSION

Hand injury patients suffering greater initial pain intensity who also had lower versus higher social-external HLOC experienced less favorable treatment outcome. This finding suggests that if patients with high initial pain succeed in transferring perceived health control to professionals and to gain confidence in treatment and clinicians, treatment outcome could be improved in hand surgery.

Patients admitted for treatment of traumatic finger amputations: Characteristics, causes, and prevention

BACKGROUND

The aim of this study was to analyze the epidemiology of patients admitted with finger amputations in the U.S., as well as to evaluate and propose prevention strategies.

METHODS

The National Electronic Injury Surveillance System was queried to obtain data on patients that presented to, and were admitted from US emergency departments for treatment of traumatic finger amputations during the period of 2002-2016. The Haddon Matrix, a framework that can be used to analyze the host, agent, and environmental factors of an injury relative to its timing, was then used to evaluate possible contributing factors of amputation events, and thereby explore plausible prevention interventions.

RESULTS

From 2002 to 2016, approximately 348,719 people were admitted from the ED for traumatic amputations. The majority were Caucasian and were male. The mean age was 42.3 years old. This was significantly older than those who were not admitted. The top five products responsible for amputations in admitted patients were power saws (40.9% of cases), doors (10.3%), lawn mowers (7.4%), snow blowers (4.3%), and bicycles (2.4%). This list included a higher proportion of powered tools than those with finger amputations who were discharged from the ED with a finger amputation.

CONCLUSION

Patients admitted with finger amputations from the ED were older, more likely to be male, and more likely to be victims of powered tools than those that were discharged. Table saws are responsible for a high proportion of the finger amputations that result in hospital admissions. The Haddon Matrix helps us identify factors (host, agent, physical environment, and social environment) to be addressed in prevention strategies. Such approaches might include championing education campaigns, policy measures, and equipment safety features. The effectiveness of such strategies warrants further investigation.

Functional, motor, and sensory assessment instruments upon nerve repair in adult hands: systematic review of psychometric properties

BACKGROUND

Outcome after nerve repair of the hand needs standardized psychometrically robust measures. We aimed to systematically review the psychometric properties of available functional, motor, and sensory assessment instruments after nerve repair.

METHODS

This systematic review of health measurement instruments searched databases from 1966 to 2017. Pairs of raters conducted data extraction and quality assessment using a structured tool for clinical measurement studies. Kappa correlation was used to define the agreement prior to consensus for individual items, and intraclass correlation coefficient (ICC) was used to assess reliability between raters. A narrative synthesis described quality and content of the evidence.

RESULTS

Sixteen studies were included for final critical appraisal scores. Kappa ranged from 0.31 to 0.82 and ICC was 0.81. Motor domain had manual muscle testing with Kappa from 0.72 to 0.93 and a dynamometer ICC reliability between 0.92 and 0.98. Sensory domain had touch threshold Semmes-Weinstein monofilaments (SWM) as the most responsive measure while two-point discrimination (2PD) was the least responsive (effect size 1.2 and 0.1). A stereognosis test, Shape and Texture Identification (STI), had Kappa test-retest reliability of 0.79 and inter-rater reliability of 0.61, with excellent sensibility and specificity. Manual tactile test had moderate to mild correlation with 2PD and SWM. Function domain presented Rosén-Lundborg score with Spearman correlations of 0.83 for total score. Patient-reported outcomes measurements had ICC of 0.85 and internal consistency from 0.88 to 0.96 with Patient-Rated Wrist and Hand Evaluation with higher score for reliability and Spearman correlation between 0.38 and 0.89 for validity.

CONCLUSIONS

Few studies included nerve repair in their sample for the psychometric analysis of outcome measures, so moderate evidence could be confirmed. Manual muscle test and Rotterdam Intrinsic Hand Myometer dynamometer had excellent reliability but insufficient data on validity or responsiveness. Touch threshold testing was more responsive than 2PD test. The locognosia test and STI had limited but positive supporting data related to validity. Rosén-Lundborg score had emerging evidence of reliability and validity as a comprehensive outcome following nerve repair. Few questionnaires were considered reliable and valid to assess cold intolerance. There is no patient-reported outcome measurement following nerve repair that provides comprehensive assessment of symptoms and function by patient perspective.

Epidemiologic shifts for burn injury in Ethiopia from 2001 to 2016: Implications for public health measures

BACKGROUND

The last generation has seen Ethiopia, a low income country with a population of 100 million people, undergo a marked increase in urbanization and development. The effects of these demographic changes on the epidemiology of burn risk and thermal injury in Ethiopia are unknown. This gap constitutes a major barrier to the creation of effective burn prevention programs.

METHODS

Yekatit 12 Hospital in Addis Ababa is the only burn unit in Ethiopia. In this cross sectional retrospective study, we identified and reviewed all admissions due to burn injury at that facility between 1/1/2016 and 12/31/2016. We then compared them to a previously published burn cohort treated at the same facility between 7/1/2001 and 9/31/2002. Chi square was used to compare proportions between the two samples. Continuous covariates are reported as descriptive data due to missing variance data in the 2001-02 publication.

RESULTS

There were a total of 121 subjects in the 2001-02 sample and 176 subjects in the 2016 sample. The 2016 sample was found to have a significantly larger proportion of males (57%) as compared to the 2001-02 sample (36%) (p=0.0003) and a significantly higher proportion of electrical injuries (27%) than the previous cohort (5%) (p<0.0001). No significant differences were seen in mortality rates between the 2016 and 2001-02 cohorts (8% vs 12%, respectively, p=0.29) or in the regions of origin (44% outside Addis Ababa vs 54%, p=0.09) For the 2016 sample, the highest surviving Baux score was 76 while the mean Baux score for survivors was 29.6±20.11.

CONCLUSION

As Ethiopia has become more industrialized over the last 15 years, the demographic pattern of burn injury has changed accordingly as electrical injuries have increased five-fold with males now constituting a majority of burn cases.

The effect of adipose-derived stem cell sheets and CTGF on early flexor tendon healing in a canine model

Intrasynovial tendon injuries are among the most challenging in orthopedics. Despite significant improvements in operative and rehabilitation methods, functional outcomes continue to be limited by adhesions, gap formation, and rupture. Adhesions result from excessive inflammation, whereas tendon gapping and rupture result from inflammation-induced matrix degradation and insufficient regeneration. Therefore, this study used a combined treatment approach to modulate inflammation with adipose-derived mesenchymal stromal cells (ASCs) while stimulating tendon regeneration with connective tissue growth factor (CTGF). ASCs were applied to the repair surface via cell sheets and CTGF was delivered to the repair center via porous sutures. The effect of the combined treatment was assessed fourteen days after repair in a canine flexor tendon injury model. CTGF, either alone or with ASCs, reduced inflammatory (IL1B and IL6) and matrix degrading (MMP3 and MMP13) gene expression, while increasing anti-inflammatory gene (IL4) expression and collagen synthesis compared to control repairs. The combined treatment was more effective than CTGF treatment alone, reducing the inflammatory IFNG and scar-associated COL3A1 gene expression and increasing CD146+ tendon stem/progenitor cells at the tendon surface and interior along the core suture tracks. Therefore, the combined approach is promising in promoting early flexor tendon healing and worthy of further investigation.

Occupational performance problems identified by 507 patients: An insight that can guide occupation-based hand therapy

Introduction

Several barriers challenge the use of occupation-based interventions in hand therapy. An outpatient clinical setting can be prepared in such a way as to address the most common occupational performance problems which might promote an occupation-based intervention. To this end, more knowledge is needed about which problems patients with hand-related disorders consider most important.

Methods

Interviews using the Canadian Occupational Performance Measure (COPM)were conducted with 507 patients. Data were entered into Microsoft Excel in the COPM categories: Self-care, productivity and leisure and analysed using descriptive statistics. Data concerning main problem areas were categorized according to the Taxonomic Code of Occupational Performance (TCOP). The analysis included the number of prioritized occupational performance problems (NPOPP) in each COPM category/subcategory; the NPOPP in each category is relative to gender and age and the most frequent problems.

Results

The total NPOPP was 2384. Problems within productivity and self-care constituted the largest proportion, respectively, 46% and 40%. Gender or age affected the NPOPP in each category to a limited extend. Problems were expressed at all levels in the TCOP, except the lowest level. The most frequently expressed problem was use of utensils when eating.

Conclusion

The problems mostly concern productivity and self-care, regardless of gender or age. Patients consider problems at the levels of occupation, activities, tasks and actions to be important and meaningful to address in their intervention. This study provides useful knowledge that can be applied when preparing a setting to address the most common problems, which could lead to the promotion of occupation-based interventions.

Burden of Hand Maladies in US Emergency Departments

BACKGROUND

Hand conditions commonly present to the emergency department (ED), yet data are lacking regarding the magnitude of hand-related conditions in the emergency setting. The purpose of this study is to describe the burden and quantify the health care resource utilization of hand conditions seen in EDs across the United States.

METHODS

Using the National Emergency Department Sample, we identified all ED encounters by patients at least 18 years of age that were associated with a hand condition in 2009 to 2012. The primary outcomes were prevalence, etiology, and associated health care charges for specific categories of hand conditions.

RESULTS

The final sample included 34.4 million ED encounters associated with a common hand condition generating $180.4 billion in health care charges. The volume of hand-related presentations varied in a predictable and cyclical manner, peaking in July and waning in December of each year. Trauma was the most common etiology (77.5%) predominantly due to falls (26.2%) and lacerations (19.7%). Over 4 years, the volume of ED encounters rose (5% increase, P < .001) and as did the resulting health care charges (24.6% increase, P < .001).

CONCLUSIONS

Our study confirms that hand-related conditions contribute significantly to ED volume and consume a growing quantity of health care resources in the United States. The volume of patients presenting to EDs with hand-related conditions fluctuates cyclically throughout the year. Open wounds are the most common cause of presentation and mostly occur in young adults, followed by joint pain, contusions, and fractures.

Acute hand injury splinting - the good, the bad and the ugly

Injuries to the hand comprise 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. The initial assessment and management of hand injuries is usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In the Department of Orthopaedic Hand Surgery, Morriston Hospital, we regularly observe patients presenting to the specialist hand fracture clinics having had initial management that shows no appreciation for the treatment objectives or the safe positions for splinting. This article aims to provide guidance for frontline staff on the management of hand fractures, with particular emphasis on the appropriate nonoperative care to avoid any unnecessary morbidity.

Neuroprotective Drug for Nerve Trauma Revealed Using Artificial Intelligence

Here we used a systems biology approach and artificial intelligence to identify a neuroprotective agent for the treatment of peripheral nerve root avulsion. Based on accumulated knowledge of the neurodegenerative and neuroprotective processes that occur in motoneurons after root avulsion, we built up protein networks and converted them into mathematical models. Unbiased proteomic data from our preclinical models were used for machine learning algorithms and for restrictions to be imposed on mathematical solutions. Solutions allowed us to identify combinations of repurposed drugs as potential neuroprotective agents and we validated them in our preclinical models. The best one, NeuroHeal, neuroprotected motoneurons, exerted anti-inflammatory properties and promoted functional locomotor recovery. NeuroHeal endorsed the activation of Sirtuin 1, which was essential for its neuroprotective effect. These results support the value of network-centric approaches for drug discovery and demonstrate the efficacy of NeuroHeal as adjuvant treatment with surgical repair for nervous system trauma.

Novice therapists in a developing context: Extending the reach of hand rehabilitation

Introduction

Hand rehabilitation needs in some parts of the world extend beyond the impact of specialised hand therapists. This study aimed to establish what hand rehabilitation services novice occupational therapists in South Africa were providing; the supports and barriers for such services; and, therapists’ perceptions of being equipped for hand rehabilitation.

Methods

A descriptive cross-sectional study was conducted, and an online questionnaire was sent to all occupational therapists in their first year of practice (n = 240). Data were analysed with Stata 12 and IBM SPSS Statistics, version 21.0. Responses to open ended questions were post-coded.

Results

A 43.3% response rate was obtained. Participants (n = 104) treated an average of 20 clients requiring hand rehabilitation per month often without adequate equipment (73%). Central nervous system (91.3%), bone and joint (72.8%) and arthritic conditions (72.4%) were treated most frequently. Most participants felt confident (64%) and competent (79%) in hand rehabilitation.

Conclusion

Participants were undertaking hand rehabilitation that in other contexts is considered to require specialised skills. To ensure quality rehabilitation, supervision and mentoring of novice therapists and appropriate professional development opportunities are required.