Comparison of the demographic and wound characteristics of non-suicidal and suicidal self-wrist cutting injuries

Patients who commit self-wrist cutting injuries (SWCIs) are a heterogeneous group composed of patients with non-suicidal self-injury (NSSI) and suicide attempt (SA). The purpose of this study was to compare the demographic features and wound characteristics of patients with NSSI and SA.A retrospective review of 300 patients who visited the emergency department (ED) for treatment of SWCIs between January 2011 and December 2015 was performed. Data collected from the electronic medical records included age, sex, the reason for SWCIs, presence of suicidal ideation, concomitant intoxication with alcohol or drugs, past psychiatric history, whether or not the patient received psychiatric counseling at the ED, the principal psychiatric diagnosis, the number and severity of external wounds, and subsequent follow-up at the psychiatric or hand surgery outpatient department (OPD). The patients were divided into the NSSI and SA groups according to the presence of suicidal ideation and other variables were compared between the two groups.There were 138 NSSI patients and 162 SA patients. The NSSI group was younger (33.9 years vs 40.9 years, P < .01), more female-dominant, and more non-compliant with psychiatric treatment than the SA group. Compared with the SA group, fewer NSSI patients had past psychiatric histories (26.1% vs 45.7%, P < .01) and more patients refused psychiatric counseling (30.4% vs 9.9%, P < .01) and follow-up at the psychiatric OPD (8.0% vs 17.3%, P < .01). In contrast, the number (P = .31) and severity (P = .051) of wounds and the rate of follow-up at the hand surgery OPD (P = .43) were not statistically different between the two groups.Although the NSSI and SA groups showed different demographic features and degrees of compliance with psychiatric treatment, wound characteristics were not different between the two groups. Therefore, hand surgeons cannot estimate patients' suicidal intent based on wound characteristics and all patients should be advised to receive psychiatric treatment.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

BACKGROUND

Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking.

QUESTIONS/PURPOSES

(1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures?

METHODS

Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made.

RESULTS

Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138).

CONCLUSIONS

Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Psychometric properties of two questionnaires in the context of total wrist arthroplasty

INTRODUCTION

Patient-rated outcome measures are frequently used to assess the results of total wrist arthroplasty, but their psychometric properties have not yet been evaluated in this group of patients. The purpose of our study was to assess the psychometric properties of the Danish Quick Disabilites of Arm Shoulder and Hand (QuickDASH) and Patient-rated Wrist Evaluation questionnaires in patients with total wrist arthroplasty.

METHODS

In a prospective cohort of 102 cases, we evaluated the QuickDASH. Furthermore, in a cross-sectional study and a test-retest on a subgroup of the patients, we evaluated the Patient-rated Wrist Evaluation.

RESULTS

Internal consistency and reproducibility were very high (Cronbach's alpha 0.96/0.97; Spearman's rho 0.90/ 0.91; intraclass coefficient 0.91/0.92), and there were no floor or ceiling effects. The responsiveness of the QuickDASH was high (standardised response mean 1.06 and effect size 1.07). The construct validity of both scales was confirmed by three a priori formulated hypotheses: a moderate, negative correlation of scores with grip-strength; a moderate, positive correlation with pain and a very weak or no correlation with mobility. Rheumatoid patients scored significantly higher on the QuickDASH than other patients did. The scores of both questionnaires were very closely related.

CONCLUSION

Both questionnaires are valid and equivalent for use in patients with total wrist arthroplasty.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

TRIAL REGISTRATION

not relevant.

Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: secondary analyses from two controlled trials

Most patients are not treated for osteoporosis after their fragility fracture "teachable moment." Among almost 400 consecutive wrist fracture patients, we determined that better-than-average osteoporosis knowledge (adjusted odds = 2.6) and BMD testing (adjusted odds = 6.5) were significant modifiable facilitators of bisphosphonate treatment while male sex, working outside the home, and depression were major barriers.

INTRODUCTION

In the year following fragility fracture, fewer than one quarter of patients are treated for osteoporosis. Although much is known regarding health system and provider barriers and facilitators to osteoporosis treatment, much less is understood about modifiable patient-related factors.

METHODS

Older patients with wrist fracture not treated for osteoporosis were enrolled in trials that compared a multifaceted intervention with usual care controls. Baseline data included a test of patient osteoporosis knowledge. We then determined baseline factors that independently predicted starting bisphosphonate treatment within 1 year.

RESULTS

Three hundred seventy-four patients were enrolled; mean age 64 years, 78 % women, 90 % white, and 54 % with prior fracture. Within 1 year, 86 of 374 (23 %) patients were treated with bisphosphonates. Patients who were treated had better osteoporosis knowledge at baseline (70 % correct vs 57 % for untreated, p < 0.001) than patients who remained untreated; conversely, untreated patients were more likely to be male, still working, and report depression. In fully adjusted models, osteoporosis knowledge was independently associated with starting bisphosphonates (adjusted OR 2.6, 95 %CI 1.3-5.3). Obtaining a BMD test (aOR 6.5, 95 %CI 3.4-12.2) and abnormal BMD results (aOR 34.5, 95 %CI 16.8-70.9) were strongly associated with starting treatment.

CONCLUSIONS

The most important modifiable facilitators of osteoporosis treatment in patients with fracture were knowledge and BMD testing. Specifically targeting these two patient-level factors should improve post-fracture treatment rates.

Validation of the IOF quality of life questionnaire for patients with wrist fracture

INTRODUCTION

Wrist fracture causes pain and decreased physical, social and emotional function. The International Osteoporosis Foundation has developed a specific questionnaire to assess quality of life in patients with wrist fracture. This questionnaire, including 12 questions, was validated in a multicentre study and compared with an osteoporosis-specific questionnaire (Qualeffo-41) and a generic questionnaire (EQ-5D).

METHODS

The study included 105 patients with a recent wrist fracture and 74 sex- and age-matched control subjects. The questionnaire was administered as soon as possible after the fracture, at 6 weeks, 3 months, 6 months and 1 year after the fracture. Test-retest reproducibility, internal consistency and sensitivity to change were assessed.

RESULTS AND DISCUSSION

The results showed adequate repeatability and internal consistency of the International Osteoporosis Foundation (IOF) wrist fracture questionnaire. The discriminatory capacity between patients and control subjects was very high, with significant odds ratios for each question and domain. The IOF-wrist fracture questionnaire domain scores showed significant improvement after 3 and 6 months and some improvement from 6 months up to 1 year. The sensitivity to change was much higher for the IOF-wrist fracture total score than for Qualeffo-41 and EQ-5D.

CONCLUSION

In conclusion, the IOF-wrist fracture questionnaire appears to be a reliable and responsive quality of life questionnaire.

Is health-related quality of life associated with the risk of low-energy wrist fracture: a case-control study

BACKGROUND

Some risk factors for low-energy wrist fracture have been identified. However, self-reported measures such as health-related quality of life (HRQOL) have not been examined as potential risk factors for wrist fracture. The aims of this study were to compare HRQOL prior to a low-energy wrist fracture in elderly patients (>or= 50 years) with HRQOL in age- and sex-matched controls, and to explore the association between HRQOL and wrist fracture after adjusting for known risk factors for fracture such as age, weight, osteoporosis and falls.

METHODS

Patients with a low-energy wrist fracture (n = 181) and age- and sex-matched controls (n = 181) were studied. Shortly after fracture (median 10 days), patients assessed their HRQOL before fracture using the Short Form 36 (SF-36). Statistical tests included t tests and multivariate logistic regression analysis.

RESULTS

Several dimensions of HRQOL were significantly associated with wrist fracture. The direction of the associations with wrist fracture varied between the different sub-dimensions of the SF-36. After controlling for demographic and clinical variables, higher scores on general health (odds ratio (OR) = 1.31, 95% confidence interval (CI) = 1.10-1.56), bodily pain (OR = 1.18, 95% CI = 1.03-1.34) and mental health (OR = 1.39, 95% CI = 1.09-1.79) were related to an increased chance of being a wrist fracture patient rather than a control. In contrast, higher scores on physical role limitation (OR = 0.87, 95% CI = 0.79-0.95) and social function (OR = 0.65, 95% CI 0.53-0.80) decreased this chance. Significant associations with wrist fracture were also found for living alone (OR = 1.91, 95% CI 1.07-3.4), low body mass index (BMI) (OR = 0.92, 95% CI 0.86-0.98), osteoporosis (OR = 3.30, 95% CI 1.67-6.50) and previous falls (OR = 2.01, 95% CI 1.16-3.49).

CONCLUSION

Wrist fracture patients perceive themselves to be as healthy as the controls before fracture. Our data indicate that patients with favourable and unfavourable HRQOL measures may be at increased risk of wrist fracture.

Educational intervention to reduce falls and fear of falling in patients after fragility fracture: results of a controlled pilot study

OBJECTIVES

Falls and fear of falling are a major health problem. We sought to determine the effectiveness of an educational intervention in reducing fear of falling and preventing recurrent falls in community-dwelling patients after a fragility fracture.

METHODS

One hundred two community-dwelling patients aged 50 years or older who fell and sustained a wrist fracture and were treated at Emergency Departments in Edmonton, Alberta, Canada (2001-2002) were allocated to either standardized educational leaflets and post-discharge telephone counseling regarding fall prevention strategies ("intervention") or attention-controls ("controls"). Main outcomes were fear of falling and recurrent falls 3 months after fracture.

RESULTS

Mean age was 67 years and most patients were female (80%). The majority of falls (76%) leading to fracture occurred outdoors. Three months post-fracture, almost half of patients (48%) reported increased fear of falling and 11 of 102 (11%) reported falling again. The intervention did not reduce the fear of falling (43% had increased fear vs. 53% of controls, adjusted P value=0.55) or decrease recurrent falls (17% fell vs. 5% of controls, adjusted P value=0.059) within 3 months of fracture.

CONCLUSIONS

An educational intervention undertaken in the Emergency Department was no more effective than usual care in reducing fear of falling or recurrent falls in community-dwelling patients. Future strategies must address a number of dimensions beyond simple education.

Psychiatric assessment of patients with self-inflicted lacerations to the wrist and forearm admitted to a nonpsychiatric ward: The experience of a regional plastic surgery unit

In 1984, the Department of Health (DoH) recommended that all patients with deliberate self-harm (DSH) must have a mental assessment before discharge. DSH patients, especially those with lacerations to wrist and forearm, are a regular source of admission to plastic surgery units. In Northern Ireland, the regional plastic surgery service is provided at the Ulster Hospital, which does not have an on-site psychiatric department. Consequently, it was often difficult to arrange a psychiatrist assessment for these patients on the ward even when the assessment was required urgently. The objective of this study was to develop and validate a protocol that would ensure that these patients were assessed and followed up for their mental health as recommended by the DoH. In the absence of clear guidelines from the DoH and utilising the existing arrangement between Accident and Emergency (A&E) and the psychiatric services, all referring A&E departments were instructed at the time of referring patients with DSH to wrist and forearm to arrange a psychiatric examination before transferring the patient to the plastic surgery unit. Data were collected retrospectively (August 2002-October 2002) and prospectively (November 2002-October 2003) and comprised demographic features, previous history of self-harm, conduct of the patient in A&E and the ward, length of stay in the hospital and various aspects of psychiatric assessment and follow-up. In total, 42 referrals were made during the period studied. The average age was 28 years with a male to female ratio of 2:1. The average hospital stay was two days. Despite difficulties, our practice was found effective in ensuring psychiatry assessment and follow-up without risking the patient's physical health. The study also highlighted the need for collaboration between plastic surgeons and psychiatrists to improve services in regards to DSH patients.

Understanding and meeting the needs of farmers with amputations

BACKGROUND

Despite the hazardous nature of the occupation, farmers who sustain serious permanently disabling injuries return to the physical labor of production agriculture. It is estimated that amputations account for 11% of all major farm-related injuries.

PURPOSE

This report describes the process of reentry to farm work of farmers across the United States who experienced above-the-wrist traumatic amputations.

SAMPLE

Interviews with 16 farmers revealed the unique features of the work and world view of these workers who labor in the fields.

FINDINGS

The occupational recovery process included questioning, analyzing, and "getting along." Prostheses and formal rehabilitation programs were viewed as minimally helpful. Suggestions and resources that may be helpful for the orthopaedic nurse to assist this high-risk work group are included.

Patterns of self-cutting: a preliminary study on differences in clinical implications between wrist- and arm-cutting using a Japanese juvenile detention center sample

The present study was aimed to clarify the differences in clinical implications between wrist- and arm-cutting. Subjects were 201 delinquent adolescents (178 males and 23 females) who had been admitted to a detention center from February to March 2003. A self-reporting questionnaire and the Adolescent Dissociative Experience Scale (ADES) were given. Traumatic events and other self-injurious behavior were compared among four groups. In total, 33 (16.4%) subjects reported wrist- and/or arm-cutting. Of the females, 60.9% (n = 14) had experienced self cutting behaviors compared to 10.7% of males (n = 19). Subjects were divided into four groups; 'non-cutting' (NC: n = 168, 83.6%), 'wrist-cutting' (WC: n = 5, 2.5%), 'arm-cutting' (AC: n = 19, 9.5%), and 'wrist- and arm-cutting' (WAC: n = 9, 4.5%). WC, AC, and WAC groups reported early separation, bulling in school, and histories of sexual/physical abuse more frequently than NC group. WC and WAC groups reported suicidal ideation and suicide attempts more frequently than NC and AC groups. The ADES scores in AC and WAC groups were significantly higher than in those in NC group (P < 0.001), while the scores in WC were not different from NC groups. WC and WAC groups self-cut due to suicide idea more frequently than the AC group, while AC group self-cut due to anger expression more frequently than WC or WAC groups. Self-cutters experienced early separation, bullying in school, and sexual/physical abuse more frequently than-non-self-cutters. Arm-cutting behavior may predict dissociation, while wrist-cutting may involve with suicidality.

Hand and wrist fractures

The upper extremities provide support, protection, and pleasure in the everyday activities of work, fun, sports, driving, and writing. When an upper extremity sustains an injury, it has a dramatic effect on quality-of-life issues. As professional caregivers, it is important to have a comprehensive understanding of the the effects of upper extremity fractures. The assessment of the patient with an upper extremity should consist of the general health of the patient after a traumatic event, determination of the mechanism of injury, assessment of the fracture site, confirmation of the exact injury, identification of potential complications, and assessment of the patient's social and professional statuses to identify potential problems that might affect treatment and rehabilitation

Hand and wrist fractures

The upper extremities provide support, protection, and pleasure in the everyday activities of work, fun, sports, driving, and writing. When an upper extremity sustains an injury, it has a dramatic effect on quality-of-life issues. As professional caregivers, it is important to have a comprehensive understanding of the effects of upper extremity fractures. The assessment of the patient with an upper extremity should consist of the general health of the patient after a traumatic event, determination of the mechanism of injury, assessment of the fracture site, confirmation of the exact injury, identification of potential complications, and assessment of the patient's social and professional statuses to identify potential problems that might affect treatment and rehabilitation.

Clinicians' recognition of 10 different types of distal radial fractures

This study concerned baseline performance in recognition of 10 different types of distal radial fractures. Verbal tasks of admitting knowing about fractures and Visual tasks were designed for each fracture type. The Verbal task of admitting knowing consisted of a description with the relevant distinctive features of the fracture. The surgical resident was asked whether he admitted knowing the particular fracture described. The Visual task consisted of X-rays for which the subject had to label the fracture or identify its distinctive features. The test was presented to 30 surgical trainees working in five teaching hospitals. On the Verbal task of admitting knowing, scores were statistically significantly higher (68% "yes") than on the Visual task (33% correct). Responses met our criterion of 80% correct for the following fracture types: Colles's, distal forearm, and Smith's fracture. For seven other fracture types (combination radius and scaphoid, radial styloid process, dorsal Barton's, volar Barton's, pilon, chauffeur's, and lunate load fracture), the 80% criterion was not met. Analysis of the incorrect answers on the Visual task indicated that the surgical residents tended to label unknown fracture types as Colles's or Smith's fractures. Furthermore, the residents tended to overestimate their own diagnostic competence (overconfidence bias) for several fracture types. It was concluded that to improve diagnosis, the relevant distinctive features of distal radial fractures should be taught.

The surgeon as a hand patient: the clinical and psychological impact of hand and wrist fractures

To gain insight into the management of patients with hand and wrist injuries, a series of clinical and psychological analyses was performed on 9 surgeons, each of whom underwent operative fixation of a hand or wrist fracture. The results of these analyses suggest that the functional outcome after hand surgery was affected by the surgeons' personality, motivation, and ability to accept and adapt to the injury; the nature of the injury; and the importance of the hand to the surgeons' careers. Surgeons are highly motivated and compulsive individuals who consider their career involvement a major source of identity and self-worth. Most returned to their operative duties ahead of the schedule set by their hand surgeons (average, 25 days after surgery), regarded their injuries as a positive challenge, and changed their lifestyles after injury to protect their hands.

Reflex sympathetic dystrophy/conversion disorder

Both reflex sympathetic dystrophy (RSD) and conversion disorder are difficult to diagnose and treat. The following article depicts a situation in which diagnosis presents a particular challenge and suggests ways of applying both medicine and psychology in the treatment of this complex problem.

A clinical study of 30 wrist cutters

Thirty patients who committed wrist cuttings were divided into four groups according to the patients' psychiatric diagnosis: hysteria group, depression group, adolescent behavioral disorder group and other diagnostic group. In the hysteria group, wrist cutting was considered as an expression of the patients' unconscious intention to seek sympathy for themselves from other people. In the depression group, wrist cutting seemed to be a preliminary rehearsal of suicide. In the adolescent behavioral disorder group, internal conflicts in adolescence or discordance with the patients' parents seemed to be the chief motivations of wrist slashing. The core groups were the hysteria and adolescent behavioral disorder groups, and the peripheral groups were the depression group and others.