Effects of Injury Pattern and Treatment on Case Length and Disposition for Hand Injuries Treated Under a Workers' Compensation Claim

BACKGROUND

In treating occupational hand injuries under workers' compensation, the 2 most important goals are to maximize patient function, ideally to preinjury levels, and permit a timely return to work (RTW). The purpose of this study was to determine factors affecting total case length, that is, the total time from injury until primary closure of a patient's claim, and disposition among patients with hand injuries treated under workers' compensation.

METHODS

All cases treated under workers' compensation by a single fellowship-trained hand surgeon within a single year were retrospectively reviewed. A case is defined as the entire management and treatment of a single patient related to a single occupational injury incident. Independent variables included age, sex, body mass index, comorbidity, occupation, injury pattern, and treatment modality. Dependent variables included treatment duration from injury to case closure and final case disposition (RTW, functional capacity evaluation [FCE], or loss to follow-up [LTFU]). Comparison between groups was accomplished with analysis of variance. Multivariate linear and logistic regression analysis was performed to predict case length and disposition.

RESULTS

In all, 447 cases involving a workers' compensation claim were reviewed. Among these, 75 (16.8%) were LTFU, 24 (5.4%) required an FCE, and 346 (77.4%) an RTW. The RTW cases averaged 138.5 days, whereas those requiring FCE averaged 331.5 days. Compared with average case length, crush injuries (76.8 days. P < .001) and fractures (111.8 days, P = .0224) had significantly shorter time to closure. In a multivariate linear model, cases of soft tissue and nerve injury were associated with longer case lengths, remaining open for an additional 56.8 and 347.1 days, respectively (P < .001). Each treatment modality studied, therapy, injections, and surgery, was associated with an increase in case length.

CONCLUSIONS

Cases requiring FCE were open significantly longer than those resulting in RTW. In addition, injury pattern and treatment modality were associated with significant variations in total case length. These results imply that a specific subset of patients, namely those with soft tissue and nerve injuries, may experience delayed resolution among patients treated under a workers' compensation claim.

Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes

BACKGROUND

Flap-based limb salvage surgery balances the morbidity and complexity of soft tissue transfer against the potential benefit of preserving a functional limb when faced with a traumatized extremity with composite tissue injury. These composite tissue injuries are well suited for multidisciplinary management between orthopaedic and plastic surgeons. Thus, it makes intuitive sense that a collaborative, orthoplastic approach to flap-based limb salvage surgery can result in improved outcomes with decreased risk of flap failure and other complications, raising the question of whether this orthoplastic team approach should be the new standard of care in limb salvage surgery.

QUESTIONS/PURPOSES

(1) Is there an association between increased annual institutional volume and perioperative complications to include free and local flap failure (substantial flap viability loss necessitating return to the operating room for debridement of a major portion or all of the flap or amputation)? (2) Is an integrated orthoplastic collaborative approach to managing combat-related traumatic injuries of the extremities individually associated with a decreased risk of flap failure and overall flap-related complications? (3) What other factors, such as location of injury, injury severity score, and initial inpatient length of stay, were associated with flap necrosis and flap-related complications?

METHODS

We performed a retrospective review of the electronic medical records of all patients who underwent flap-based limb salvage for combat-related extremity trauma in the United States Military Health System's National Capital Region between January 1, 2003 and December 31, 2012. In total, 307 patients underwent 330 flap procedures. Of the 330 flaps, 59% (195) were local or pedicled flaps and 41% (135) were free flaps. Patients were primarily male (99% [303]), with a median (interquartile range) age of 24 years old (IQR 21 to 29), and 87% (267 of 307) of injuries were sustained from a blast mechanism. We collected data on patient demographics, annual case volume involving flap coverage of extremities, mechanism of injury, flap characteristics, perioperative complications, flap failure, flap revision, isolated orthopaedic management versus an integrated orthoplastic approach, and other salvage procedures. For the purposes of this study, orthoplastic management refers to operative management of flap coverage with microvascular surgeons present for soft tissue transfer after initial debridement and fixation by orthopaedic surgery. The orthoplastic management was implemented on a case-by-case basis based on individual injury characteristics and the surgeon's discretion with no formal starting point. When implemented, the orthoplastic team consisted of an orthopaedic surgeon and microvascular-trained hand surgeons and/or plastic surgeons. In all, 77% (254 of 330) of flaps were performed using this model. We considered perioperative flap complications as any complication (such as infection, hematoma, dehiscence, congestion, or necrosis) resulting in return to the operating room for re-evaluation, correction, or partial debridement of the flap. We defined flap failure as a return to the operating room for debridement of a major portion of the flap or amputation secondary to complete or near-complete loss of flap viability. Of the flap procedures, 12% (40 of 330) were classified as a failure and 14% (46 of 330) experienced complications necessitating return to the operating room. Over the study period, free flaps were not more likely to fail than pedicled flaps (11% versus 13%; p = 0.52) or have complications necessitating additional procedures (14% versus 16%; p = 0.65).

RESULTS

Our multiple linear regression model demonstrated that an increased number of free flaps performed in our institution annually in any given year was associated with a lower likelihood of failure per case (r = -0.17; p = 0.03) and lower likelihood of reoperation for each flap (r = -0.34; p < 0.001), after adjusting for injury severity and team type (orthoplastic or orthopaedic only). We observed a similar relationship for pedicled flaps, with increased annual case volume associated with a decreased risk of flap failure and reoperation per case after adjusting for injury severity and team type (r = -0.21; p = 0.003 and r = -0.22; p < 0.001, respectively). Employment of a collaborative orthoplastic team approach was associated with decreased flap failures (odds ratio 0.4 [95% confidence interval 0.2 to 0.9]; p = 0.02). Factors associated with flap failure included a lower extremity flap (OR 2.7 [95% CI 1.3 to 6.2]; p = 0.01) and use of muscle flaps (OR 2.3 [95% CI 1.1 to 5.3]; p = 0.02).

CONCLUSION

Although prior reports of combat-related extremity trauma have described greater salvage success with the use of pedicled flaps, these reports are biased by institutional inexperience with free tissue transfer, the lack of a coordinated multiservice effort, and severity of injury bias (the most severe injuries often result in free tissue transfer). Our institutional experience, alongside a growing body of literature regarding complex extremity trauma in the civilian setting, suggest a benefit to free tissue coverage to treat complex extremity trauma with adequate practice volume and collaboration. We demonstrated that flap failure and flap-related complications are inversely associated with institutional experience regardless of flap type. Additionally, a collaborative orthoplastic approach was associated with decreased flap failures. However, these results must be interpreted with consideration for potential confounding between the increased case volume coinciding with more frequent collaboration between orthopaedic and plastic surgeons. Given these findings, consideration of an orthoplastic approach at high-volume institutions to address soft tissue coverage in complex extremity trauma may lead to decreased flap failure rates.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Characteristics of Thoraco-Abdominal Injuries - A Series of Three Cases

The enlarged number of powerful vehicles in our country led to an increased speed of travel and hence the high number of traffic accidents with severe consequences, even death. Along with polytrauma caused by occupational accidents, these types of traumas require complex and often multidisciplinary surgical therapy against the clock, which places the surgeon in front of situations that are not found in the everyday practice. Injuries involving damage to the thoracic-phreno-abdominal region fall into this specific category that we have chosen to discuss in the present work. We will further present three clinical cases of patients with thoraco-phreno-abdominal injuries produced by different mechanisms. A work-accident wound produced by an angle grinder, causing left thoracoabdominal injuries; a polytrauma caused by a road accident, with a thoraco-phreno abdominal wound produced by a piece of wood that penetrated obliquely through the right thorax, in the 5th and 6th intercostal spaces, crossed the right lower lung lobe, the diaphragm, the 7th liver segment, and stopped in the right posterior costal grid, and a polytrauma following a fall from a height, with a torn diaphragm and mesentery.

Atypical replantation and reconstruction of frozen ear: A case report

RATIONALE

The first successful ear replantation was performed by Pennigton in 1980 in Sydney. At least 84 ear replantations have been described in the literature over a period of 37 years since the first case. The authors have not found any previous case of frozen ear replantation in the literature.

PATIENT CONCERNS

We report the case of a 38-year-old man, who had an injury to the head while working with a machine.

DIAGNOSIS

The patient suffered total traumatic avulsion of the left ear. The ear was wrapped in moistened, sterile gauze and was transported on dry ice. At the time of admission to our department, the amputated ear was frozen to stiff, solid nonelastic matter.

INTERVENTIONS

We attempted replantation. Despite repeated arterial thrombosis during surgery, the ear was successfully replanted with arterial and venous anastomosis.

OUTCOMES

Venous congestion occurred within 9 h of surgery and was treated using leeches. Freezing cold injury developed during reattachment. The radix and proximal parts of the helix exhibited necrosis and so were reconstructed by contralateral conchal cartilage graft, which was wrapped with a local subauricular skin flap. On completion of treatment, a satisfactory shape was achieved, although the replanted and reconstructed left auricle slightly was smaller than the contralateral auricle.

LESSONS LEARNED

Our report confirms that the replantation of a frozen, amputated ear is possible, and we suggest that ear replantation should be the method of choice for the treatment of ear loss even under these conditions.

Inverted internal limiting membrane flap technique and an autologous platelet concentrate to treat an Nd: YAG laser-induced macular hole: A case report

RATIONALE

Nd:YAG laser-induced macular holes (MHs) feature more extensive anatomical defects and worse functional outcomes than idiopathic MHs. Although new treatment options for large refractory MHs have been suggested, the current literature on Nd:YAG laser-induced MHs suggests only conventional pars plana vitrectomy combined with internal limiting membrane (ILM) peeling, which is the same treatment as for idiopathic MHs.

PATIENT CONCERNS

A 40-year-old dermatologist was referred to us because of a sudden decrease in visual acuity following exposure to a floor-tile-reflected single-shot Nd:YAG laser beam while not wearing protective goggles.

DIAGNOSES

An Nd:YAG laser-induced MH was diagnosed based on fundoscopy and optical coherence tomography (OCT).

INTERVENTIONS

Pars plana vitrectomy using an inverted ILM flap technique and autologous platelet concentrate (APC) was performed.

OUTCOMES

Postoperative spectral domain OCT and en-face OCT showed "U-shaped" closure of the MH and a decreased ellipsoid zone defect, while the best-corrected visual acuity improved from 20/500 to 20/25.

LESSONS

The inverted ILM flap technique combined with APC is an effective option to achieve successful MH closure and visual improvement in patients with an Nd:YAG laser-induced MH.

High-pressure injection injuries of the fingers: Long-term follow-up in patients after extensive debridement

High-pressure injection injuries to the fingers resulting from the introduction of a foreign substance, such as oil or paint, through a minor puncture wound are rare but can have serious clinical consequences. The objective of this article was to examine the long-term outcomes after surgical debridement of these injuries. We present a retrospective case series of 8 adults who had a high-pressure injection injury to their hand and underwent surgical debridement in our facility. Data were extracted from our outpatient registry. Assessment included a full physical examination, grip strength, range of motion, two-point discrimination and Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We followed 8 male patients for an average of 12.7 years. Their average age was 37 at time of injury and all had injured their right dominant hand. Seventy-five percent of the injuries were to the index finger. Seven out of the 8 patients returned to their pre-injury occupation, 4 out of 8 patients had reduced range of motion of the affected digit. Injury sequelae adversely affected activities of daily living (ADL) with an average QuickDASH score of 26. Grip strength in the injured hand was reduced by an average of 35% in 6 out of 8 patients compared with the uninjured hand. Sensation was also reduced in the affected digit in 7 out of 8 patients. All patients suffered from some level of neuropathic pain and/or cold intolerance. High pressure injection injury to the fingers is a serious event found amongst industrial laborers. In most patients, this injury will lead to long-term disability along with a negative impact on ADL. However, most patients eventually return to their pre-injury occupation. Extensive, single or repeat debridement of high-pressure injection injuries remains a valid treatment option with good long-term results.

Unusual case of hypotenar Hammer Syndrome and carpal tunnel syndrome association

BACKGROUND AND AIM OF THE WORK

Hypothenar Hammer Syndrome is a relatively rare disease process caused by repetitive stress or injury to the hypothenar eminence leading to chronic injury to the ulnar artery. Our study reports an unusual case.

METHODS

A 57 years old Plumber presented in April 2016 with a history of constant pain and recurrent paresthesia involving the fingers of the right hand for several months, over the previous 1 year, his hand had become more intolerant of exposure to cold temperatures. Angio-RNM and electromyography were performed and showed a severe double compression of ulnar and median nerve and an ulnar artery deformity without thrombosis. Surgery was performed under sedation and axillary anesthesia.

RESULTS

After surgery patient' symptoms immediately improved, and within a few months, his hand had normalized.

CONCLUSION

Hypothenar Hammer Syndrome is a rare disease process which manifests in certain occupations and activities that put undue stress on the hypothenar area. Furthermore, the carpal tunnel syndrome, a pressure damage of the median nerve, caused by repetitive manual tasks with flexion and extension of wrist has been added as well as hypothenar hammer syndrome which are vascular damages of hand caused by shock-type application of force.

Delayed diagnosis of an intraorbital wooden foreign body

A 35-year-old male patient was presented with pain on his right upper eyelid. A piece of wood injured his orbital and supraorbital regions while working at a furniture factory 10 days prior to our hospital admission. It was learned that the patient was discharged following the primary would closure procedure. Subsequent to the craniofacial computed tomography, primary wound closure was performed in the emergency room of previous hospital. In our clinic, a skin suturing on the nasal side of the right eyebrow was inspected and a foreign body (FB) was palpated on the superonasal contiguity of the patients' right globe. A hyperdense FB measuring 30 × 10 × 5 mm in size with smooth margins on superonasal contour of the globe was detected. Superonasal orbitotomy was performed and the FB was completely removed. Finally, visual acuity was 20/20 and a mild residual ptosis was observed.

A case report of a polytrauma patient with penetrating iron rods in thorax and head

INTRODUCTION

Impalement injury is an uncommon presentation, and penetrating chest injuries account for 1% to 13% of thoracic trauma hospital admissions. The vast majority of patients with penetrating thoracic trauma who survive to reach the hospital alive can be managed nonoperatively. Nevertheless, in 10% to 15% of cases, emergency operation is necessary due to the associated hemorrhagic shock and visceral injury.

CASE PRESENTATION

Here, we report on a 39-year-old male, a construction worker, who fell down from a height of a construction site, landing ventrally on a clump of iron rods with 4 projecting heavy metallic rods penetrating into his thorax and head (scalp pierced only). Emergency surgery was taken, and the patient had an uneventful successful outcome.

CONCLUSIONS

After massive thoracic impalement, rapid transportation to a tertiary trauma center with the impaled objects in situ can improve the outcome. Video-assisted thoracic surgery (VATS) is recommended to remove the foreign body under direct vision and to reduce the incidence of missed, potentially fatal vascular or visceral injuries.

Chronic Carpometacarpal Dislocation of the Thumb: A Case Report and Review of the Literature

CASE

We report a case of a chronic, irreducible carpometacarpal (CMC) dislocation of the thumb, which was managed with a trapeziometacarpal arthrodesis.

CONCLUSION

This case demonstrates that arthrodesis is a suitable salvage procedure for chronic, irreducible CMC dislocations of the thumb.

Viable placental allograft as a biological dressing in the clinical management of full-thickness thermal occupational burns: Two case reports

RATIONALE

Occupational burn injuries can be detrimental and difficult to manage. The majority of complex cases are referred and managed at regional burn centers where access to specialized care is available. As an alternative to hospitalization with staged surgical procedures, placental products may be used for outpatient medical management of these common burn injuries, especially if access to a regional burn center is limited or restricted.Fresh amnion has been a treatment of choice in burns for more than 100 years. As a biological covering with a broad scope of potential uses, human placental membranes represent a dressing that is particularly advantageous for burn therapy. Recent advances in tissue-preservation technology have allowed for the commercialization of placental amnion products.

PATIENT CONCERNS

To address several complications associated with burn injuries-contractures, scar formation, and pain-a viable cryopreserved placental membrane (vCPM) (Grafix-PRIME, Osiris Therapeutics, Inc., MD) retaining the anti-inflammatory, anti-fibrotic, and antimicrobial properties of fresh placental tissues was chosen for clinical use in the 2 cases reported, where both patients had restricted access to the regional burn center.

DIAGNOSES

Two cases of work-related extremity burns presented to a local rural hospital for immediate post-injury assessment. The 1 case was of a man who sustained a 55.4 cm full-thickness 3 degree thermal burn with exposed bone and tendon, to the left dorsal forefoot after having an industrial pressure washer caught on his work boot. The 2 case was of a female who sustained a 4.7 cm full-thickness 3 degree crush burn to the dorsum extensor surface of her dominant hand's index finger after applying 80-pounds per square inch of heated pressure from a hydraulic press.

INTERVENTIONS

Both burn patients elected to continue their care at the outpatient-based wound and hyperbaric center, receiving a combination of weekly ad libitum debridement, applications of vCPM, and occupational therapy.

OUTCOMES

Both burns reached timely wound closure, and patients regained full range of motion of the affected limb, allowing for early return to work. The average number of allograft applications was 7.5, allowing both patients to return to work in an average of 63.5 days without adverse events or post-treatment complications.

LESSONS

The incorporation of this product in the treatment of these complex burns prevented amputation in one patient, and skin autografting and potential index finger contracture-formation in the second patient. The incorporation of vCPM in burn management may offer a new approach to outpatient burn management and may mitigate several of the complications seen post burn injury, leading to favorable patient outcomes.

Blunt rectal trauma Case report and literature review

Blunt colorectal traumas are rare clinical entities with a challenging diagnostic and operative management. We describe the case of a 40-year-old man, victim of an accidental fall from a height of four meters who was subsequently diagnosed to have a blunt rectal trauma. A first CT scan showed fracture of the skull and an extensive subcutaneous haematoma of the lower back associated with a fracture of the left transverse processes of lumbar vertebrae. No other visceral abdominal lesions were recognized and patient was admitted to our department for observational studies. After 48 hours from admission the patient presented a subcutaneous emphysema suspicious for hollow viscus injuries. A digital rectal examination detected a laceration both of the posterior rectal wall and the superior anal margin. The patient was successfully managed with spur colostomy, transanal evacuation of the retroperitoneal haematoma and primary repair of both the sphincteric muscle and the rectal wall. As soon as the patient achieved full recovery we performed a reversal colostomy. Diagnosis and management of rectal blunt trauma is still a matter of debate and no definitive recommendation treatments are available. The surgical treatment should be tailored on patient medical conditions and clinicians should maintain a high index of suspicious because a delay in diagnosis can result in higher morbidity and mortality rate.

KEY WORDS

Colorectal blunt injury, Colostomy, Laparoscopy, Trauma.

[The Throwing Shoulder]

Repetitive top-performance of overhead athletes induces a tremendous stress for the throwing shoulder. Throwers reach rotational speed of their arm of more than 7000°/s with joint compression and distraction forces of more than 1000 N. This performance is tributary to adaption of the shoulder muscles and the joint itself. These adaptions may, however lead to two specific problems of the throwing shoulder: 1. The posterosuperior internal impingement of the rotator cuff and labrum between glenoid and humeral head during late cooking phase; 2. A decreased internal rotation of the glenohumeral joint (GIRD) with compensatory problems of the scapula-stabilizing muscles. Precise analysis of kinematics and pathomechanics aims to improve understanding and treatment of those specific problems of the throwing shoulder.

Deep burn of hand and forearm treated by abdominal wall flap. A case report

AIM

Post-traumatic hand and forearm defects always represent a challenge for reconstructive surgeons, especially when multiple structures are involved, because of a high rate of amputation.

MATERIAL OF STUDY

A 21 years old woman arrived to the E.R. with a complex crush-burn trauma of the upper limb caused by an accident with an industrial ironing machine, resulting in a ulnar bone fracture, ulnar artery laceration and a wide burn of the dorsum of the right forearm.

RESULT

We achieved toTAL limb salvage with coverage of the "nobles" structures of the forearm.

DISCUSSION AND CONCLUSIONS

Different reconstructive methods have been used over time to treat these defects focusing the attention on both functional and cosmetic aspects. The abdominal pedicle flap was one of the achiest reconstructive methods for hand and forearm defects. In an era in which microsurgery takes the lion's share, some basic procedure may be helpful, especially in certain cases. In this study the authors reported a case of a young woman with a complex trauma of the right arm resulting from an occupational accident.

System Failure: No Surgeon To Be Found

A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians to treat emergencies.

Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear

The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis for bicipital tendonitis with a superior labral anterior-posterior (SLAP) tear. Patients undergoing primary subpectoral biceps tenodesis for arthroscopically confirmed SLAP tears with signs or findings of bicipital tendonitis were included. An independent observer collected data prospectively as part of a data repository, which was then analyzed retrospectively. Primary outcome measures were the American Shoulder and Elbow Surgeons (ASES) score and pain relief via visual analog scale (VAS). Secondary outcome measures included the Simple Shoulder Test (SST), Constant, Single Assessment Numeric Evaluation (SANE), and Short Form 12 (SF-12) scores. Twenty-eight patients with a mean±SD age of 43.7±13.4 years and a mean±SD follow-up of 2.0±1.0 years met inclusion criteria. Workers' compensation was involved with 43% of cases, and 46% of the included patients were manual laborers. Eight (32%) patients were athletes, and 88% of the athletes were overhead athletes. Intraoperatively, 15 (54%) patients had type I SLAP tears, 10 (36%) had type II SLAP tears, 1 (3%) had a type III SLAP tear, and 2 (7%) had type IV SLAP tears. Significant improvements were seen in the following outcome measures pre- vs postoperatively: ASES score (58±23 vs 89±18; P=.001), SST score (6.3±3.6 vs 10.6±3.3; P=.001), SANE score (54±24 vs 88±25; P=.003), VAS score (3.8±2.0 vs 1.1±1.8; P=.001), SF-12 overall score (35±6 vs 42±6; P=.001), and SF-12 physical component score (39±6 vs 50±10; P=.001). Overall satisfaction was excellent in 80% of patients. Subpectoral biceps tenodesis demonstrates excellent clinical outcomes in select patients with SLAP tears. [Orthopedics. 2015; 38(1):e48-e53.].

Magnetic Resonance Imaging Findings in the Symptomatic Hips of Younger Retired National Football League Players

BACKGROUND

American football players have an increased level of risk for hip injuries because of the high level of contact, biomechanical load, and anatomic strain placed on the hip joint. Many injuries are attributed to soft tissue injury rather than intra-articular lesions. However, because of improved imaging and increased knowledge, physicians are attributing unexplained hip pain to intra-articular lesions with increasing frequency.

PURPOSE

To assess the prevalence of pathologic intra-articular hip lesions in a younger, retired National Football League (NFL) player cohort evaluated for persistent hip pain.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective chart review was performed of magnetic resonance imaging (MRI) on retired NFL players evaluated at an orthopaedic clinic for persistent hip pain. All MRIs were performed at the same location and reviewed by the same independent radiologist. The study included 62 hips; MRI was used to evaluate 27 hips, and MRI arthrogram was used to evaluate 35 hips. Images were assessed for labral tears, chondral lesions, ligamentum teres (LT) tears, bone cysts, osteophytes, loose bodies, trochanteric bursitis, and alpha angle. Player demographics, including position and seasons played, were recorded.

RESULTS

From February 2011 to December 2012, a total of 50 retired players from the NFL (average age, 33 years; range, 27-39 years) received impairment evaluations assessing all symptomatic joints. Thirty-eight (76%) players had hip complaints and underwent a dedicated hip MRI. Twenty-four players (63%) had bilateral hip pain, for a total of 62 hips evaluated. There were 55 (89%) labral tears, 61 (98%) chondral lesions, and 50 (81%) partial or complete LT tears identified on MRI. Additional findings included 3 (5%) hips with osteophytes, 9 (14.5%) with subchondral bone cysts, and 3 (5%) with paralabral cysts. None of the players were found to have trochanteric bursitis or loose bodies. Fifty-eight of 62 alpha angles could be measured, for a mean of 59° (range, 39°-77°). The majority of players were defensive players (63%), while the remainder were offensive players (34%) and 1 special teams player. Position breakdown was as follows: 29% were defensive backs, 16% played the defensive line, 18% were linebackers, 13% were fullbacks, 11% were wide receivers, 5% played the offensive line, and the remaining 8% were kickers, running backs, and quarterbacks.

CONCLUSION

This study demonstrated a high incidence of intra-articular pathologic lesions of the hip in a younger cohort of retired NFL players. The majority of players had bilateral hip pain. The most common finding was chondral lesions, followed by labral tears. Future research is needed to further elucidate incidence and treatment outcomes using prospective studies examining active and retired players with hip-related injuries.

[Work-related musculoskeletal trauma]

The number of labor accident casualties between 2003 and 2012 has ranged from 110,000 to 130,000 per year in Japan. Japan Advanced Trauma Evaluation and Care (JATEC) program was established for major trauma and has been developed in emergency rooms. Surgical intervention to fractures in extremities includes various methods such as internal fixation with plates and screws including locking compression plate system, interlocking nailing system and external fixation. Definitive treatment for spinal cord injury is still unsolved. Cell transplantation therapy using iPS cells is anticipated to be applied clinically. Some problems still remain in the certification criteria for residual disabilities caused by labor accidents. The criteria should be revised at some early date.

A modern-day solution to a 100-year-old problem: the use of a Bespoke Off-loading Brace in the rehabilitation of 'Deck-Slap' and other high-energy lower limb injuries

'Deck-Slap' is an injury pattern first described at the Battle of Jutland; it is still relevant today, with anti-vehicle mines a significant threat to Coalition troops. The effect of a device exploding beneath a vehicle produces a wave of high energy that is rapidly transmitted through the steel floor; this causes significant axial loading of lower limbs often resulting in severe fractures (notably of the calcaneum). Recent advancements in orthopaedic surgery have allowed for limbs that were destined for immediate amputation following significant trauma to be salvaged. However, despite intense rehabilitation, many of these salvaged limbs have subsequently gone on to delayed amputation, as functional outcomes are often poor. Technologically advanced prosthetic devices are available that afford good quality of life and allow for increased activity levels; these devices are, however, expensive to procure and maintain. This report describes a United Kingdom (UK) Armed Forces soldier who suffered a typical 'deck-slap' injury in Afghanistan with subsequent limb salvage. The use of the Bespoke Off-loading Brace (BOB) is discussed. The results presented here indicate that the biomechanical function of a patient with this type of injury improves when wearing the BOB. Further studies are needed to assess long-term clinical outcomes and the functional benefit of the device as a viable and cost-effective alternative to delayed limb amputation.

Recovering from traumatic occupational hand injury following surgery: a biopsychosocial perspective

PURPOSE

Significant differences occur in the return-to-work (RTW) period amongst workers with an acute traumatic occupational hand injury. This study aimed to develop and test a comprehensive multivariate conceptual biopsychosocial model to predict RTW outcome.

METHOD

Patients presenting with an occupational hand injury were interviewed 7-10 days after their injury (N = 192) and again at 4 weeks after their injury (n = 150). Potential determinants from biomedical, work-related, demographic and psychosocial categories were studied simultaneously.

RESULTS

A small sub-set of workers with an acute traumatic hand injury experienced chronic disability beyond 12 weeks. Analyzing the relationship between predictor variables and work absence resulted in the identification of the most important determinants of recovery. During the acute stages of recovery, injury severity, pain, self-efficacy, and living alone were the most important determinants of delayed RTW outcome. At 4 weeks post-injury, locus of control, injury severity, negative affect and living alone were the most important predictors of delayed RTW.

CONCLUSION

A number of prognostic variables were identified that influenced RTW outcome, which offer new and unique contributions to the field. Injury severity was not the most important determinant of RTW outcome; neither were factors identified in previous hand injury research, such as attribution of blame, significant predictors. Factors not examined in previous research, such as negative affect, were more important determinants of delayed RTW.

High-pressure paint gun injection injury to the palm

High-pressure injection injuries often have a misleadingly benign presentation. However, it is important to recognize the potential surgical urgency and long-term sequelae associated with these injuries. We present a case of paint gun injection to the palm and review the literature on high-pressure paint injection injuries. The 3 factors most important for the fate of the limb are material type, injection pressure, and injury site. The immediate use of antibiotics and tetanus prophylaxis, with or without steroids, is indicated. Urgent debridement in the operating room is imperative and can decompress the neurovascular structures and flexor tendon sheath by removing the irritating agents. Reported overall amputation rates have been as high as 30%.

[Mason's lacing cord. Potential danger of severe open ocular injuries]

BACKGROUND

Introduction of new working equipment or the modification of established working routines could induce new trauma mechanisms. In all of theses cases ophthalmologists are not only responsible for ocular treatment they also have to act as assessors. This might include legal aspects, e.g. to validate the circumstances of an accident.

METHODS

We present a new trauma mechanism caused by a mason's lacing cord which was fixed with nails. In addition to two case studies we collected experimental data (maximum tension and maximum elongation of various mason's lacing cords) about the triggering event using standard test conditions.

RESULTS

A tensile force of 96.2 N was needed to achieve maximum elongation of mason's lacing cords. With a cord length of 5 m, an elongation of 0.09 m was enough to cause penetrating injuries (for 10 m cord length the critical elongation was 0.13 m). Under these conditions a nail could be accelerated to a velocity of 18 m/s. This may lead to open eyeball injuries with severe visual loss.

CONCLUSIONS

Nails fixed to elastic mason's lacing cords are potential risk factors for occupational ocular injuries and severe loss of vision. Caution labels should be attached to the work equipment and proper eye protection should be used to prevent severe occupational ocular injuries.

Rotator cuff injuries in professional and recreational athletes

Professional and recreational athletes involved in contact sports and sports with repetitive overhead motion are at increased risk for rotator cuff tears. Shoulder anatomy, pathology, and biomechanics place unique stress on the rotator cuff tendons during sports activity. Athletes demand effective treatment to quickly return to elite competition. A PubMed search assessed treatment options providing expedited recovery time and return to competition. Twelve of 231 articles fit the objective criteria; 90.5% of professional contact athletes, 40% of professional overhead athletes, and 83.3% of recreational athletes fully recovered following rotator cuff tear surgical repair. Prompt surgical treatment for full-thickness rotator cuff tears may be appropriate for contact athletes and recreational overhead athletes. Although professional overhead athletes have low recovery rates, surgical repair of full-thickness rotator cuff tears may still be indicated. The authors propose a treatment algorithm based on the limited literature (mainly level 4 and 5 evidence).

Primary internal fixation and soft-tissue reconstruction in the treatment for an open Lisfranc fracture-dislocation

The importance of anatomical reduction for improved outcome has been recognised in the management of Lisfranc injuries. Operative fixation is indicated in case of dislocation or unstable ligamentous injury, because discongruity of the Lisfranc joint can lead to deleterious functional outcome. Screws are the recommended method of fixation of the medial en middle column, and K-wires are used for stabilisation of the unstable lateral column. Primary arthrodesis can provide advantages in pure ligamentous injury. In the management of complex open Lisfranc fractures, external fixation with K-wires can be used, but often results in a high percentage of arc deformities and functional limitations. In recent years, there is a progressive change from external to internal fixation in primary stabilisation of open fractures. This case report describes the treatment for a grade III open Lisfranc fracture-dislocation by use of primary internal fixation and soft-tissue reconstruction.

Corneal metallic foreign body injuries due to suboptimal ocular protection

Retrospective review of 100 consecutive presentations of metallic corneal foreign body to the Royal Victorian Eye and Ear Hospital emergency department was undertaken between November and December 2009. The majority of the patients (97%) were male with a mean age of 42 ± 13 years (range 19-73 years). The most common mode of injury was grinding (88%). Nearly half (45%) of patients were wearing "safety eye wear" at the time of injury. Combination of 25-gauge needle and burr was the commonest method employed for removal of foreign body. Overall, 88% (n = 88) cases healed with corneal scar at the site of corneal foreign body and 1 case developed bacterial keratitis. Metallic corneal foreign bodies are common presentations to the emergency department and may be related to inadequate implementation of occupational safety measures.