Incidence and treatment of hand and wrist injuries in Dutch emergency departments.

PURPOSE: The purpose of this study was to describe the epidemiology, treatment and costs of hand and wrist injuries presenting to the Dutch ED. With increasing medical costs and crowding of emergency departments (ED), a more detailed description of emergency department attendance of hand and wrist injuries and their treatment may help to facilitate more adequate allocation of health care services. METHODS: The Dutch Injury Surveillance System obtained a total of 160,250 hand and wrist injuries. Patient characteristics, incidence rates, type of injury, treatment, and costs were described. RESULTS: The incidence of hand and wrist injuries in the Netherlands in 2016 was 11 per 1000 in males and 8 per 1000 in females. This is about 25% of all injuries presented at the ED. Of all hand injuries, only 3% was directly admitted to the hospital or received emergency surgery. Thirty percent did not need further treatment in the hospital. CONCLUSION: The current data suggest that a substantial proportion of the hand and wrist injuries needed no subsequent specialized treatment. Although the severity of the injury could not be deduced from our data, the data suggest a ground for a more extensive role of primary health care (general) practitioners in the primary triage and treatment of hand and wrist injuries. This may reduce health care cost and help decongest the ED departments. Prospective studies are needed to confirm these preliminary conclusions. LEVEL OF EVIDENCE: III.

Patient-reported outcomes after a distal radius fracture in adults: a 3-4 years follow-up.

Background and purpose - There are few reports on the outcome of distal radius fractures after 1 year. Therefore we investigated the long-term patient-reported functional outcome and health-related quality of life after a distal radius fracture in adults. Patients and methods - We reviewed 823 patients, treated either nonoperatively or operatively in 2012. After a mean follow-up of 3.8 years 285 patients (35%) completed the Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5D. Results - The mean PRWE score was 11. The mean EQ-5D index value was 0.88 and the mean EQ VAS for self-rated health status was 80. Nonoperatively treated type A and type B fractures had lower PRWE scores compared with operatively treated patients, whereas the EQ-5D was similar between groups. The EQ VAS for patients aged 65 and older was statistically significantly lower than that of younger patients. Interpretation - Patients had a good overall long-term functional outcome after a distal radius fracture. Patients with fractures that were possible to treat nonoperatively had less pain and better wrist function after long-term follow-up than patients who needed surgical fixation.

Is there a need for a clinical decision rule in blunt wrist trauma?

BACKGROUND: Blunt wrist trauma is a very common injury in emergency medicine. However, in contrast to other extremity trauma, there is no clinical decision rule for radiography in patients with blunt wrist trauma. OBJECTIVE: The purpose of this study is to describe current practice and to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma. METHODS: All patients with blunt wrist trauma who presented to our Emergency Department (ED) during a 6-month period were included in this study. Basic demographics were analysed and the radiography ratio was determined. The radiography results were compared for different demographic groups. Current practice and the need and feasibility for a decision rule were evaluated using Stiell's checklist for clinical decision rules. RESULTS: A total of 1019 patients with 1032 blunt wrist injuries presented at our ED in a period of 6 months. In 91.4% of patients, radiographs were taken. In 41.6% of those radiographed, a fracture was visible on plain radiography. Fractures were most common in the paediatric and senior age groups. However, even in the lower-risk groups we observed a fracture incidence of about 20%. CONCLUSION: There is no need for a clinical decision rule for radiography in patients with blunt wrist trauma because the fracture ratio is high. Neither does it seem feasible to develop a highly sensitive and efficient decision rule. Therefore, the authors recommend radiography in all patients with blunt wrist trauma presenting to the ED.

Necessity of routine pathological examination after surgical excision of wrist ganglions.

PURPOSE: The value of routine pathological evaluation of ganglion cysts is questionable considering that the pretest odds of a wrist lesion being a ganglion cyst are usually high based on physical examination and surgical findings alone. This study evaluates the necessity of routine pathological examination of specimens derived from surgical removal of wrist ganglion cysts. METHODS: We identified 429 consecutive adult patients who underwent surgical excision of a wrist ganglion with routine pathological examination of the specimen between 1997 and 2008. The rates of concordant, discrepant, and discordant diagnoses were reported with 95% confidence intervals. The odds of a discrepant or discordant diagnosis were calculated. RESULTS: The prevalence of a concordant diagnosis was 98.6% (424 of 429; 95% confidence interval, 97.3% to 99.6%). The prevalence of a discrepant diagnosis was 1.4% (5 of 429; 95% confidence interval, 0.38% to 2.7%), and the prevalence of a discordant diagnosis was zero. The odds ratio was 0.012 for a discrepant diagnosis and zero for a discordant diagnosis. CONCLUSIONS: This study suggests that, in patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision of the ganglion cyst. Discrepant diagnoses are encountered infrequently and discordant diagnoses did not occur. We recommend pathological examination only when the clear gelatinous fluid typical of a ganglion cyst is not encountered at surgery.

Agreement between Initial Classification and Subsequent Reclassification of Fractures of the Distal Radius in a Prospective Cohort Study.

We tested the hypothesis that the original surgeon-investigator classification of a fracture of the distal radius in a prospective cohort study would have moderate agreement with the final classification by the team performing final analysis of the data. The initial post-injury radiographs of 621 patients with distal radius fractures from a multicenter international prospective cohort study were classified according to the Comprehensive Classification of Fractures, first by the treating surgeon-investigator and then by a research team analyzing the data. Correspondence between original and revised classification was evaluated using the Kappa statistic at the type, group and subgroup levels. The agreement between initial and revised classifications decreased from Type (moderate; Κ(type) = 0.60), to Group (moderate; Κ(group) = 0.41), to Subgroup (fair; Κ(subgroup) = 0.33) classifications (all p < 0.05). There was only moderate agreement in the classification of fractures of the distal radius between surgeon-investigators and final evaluators in a prospective multicenter cohort study. Such variations might influence interpretation and comparability of the data. The lack of a reference standard for classification complicates efforts to lessen variability and improve consensus.

Non-operative treatment of non-displaced scaphoid fractures may be preferred.

AIM: To evaluate the outcome of non-displaced scaphoid fractures treated with 6 weeks of cast immobilisation, and to establish whether the benefits of non-operative treatment might outweigh those of early operation. METHODS: A retrospective study analysed 89 consecutive cases of scaphoid fracture treated at our institution between 2004 and 2007. Diagnosis and treatment methods and complication rates were evaluated. RESULTS: Among 71 non-displaced scaphoid fractures, >80% showed clinical consolidation after 6 weeks of cast immobilisation, and the remaining cases after 8-12 weeks. Two cases needed a longer period of cast immobilisation. CONCLUSION: A restricted period of cast immobilisation is usually adequate for the treatment of non-displaced scaphoid fractures.