Hand and Wrist Injuries Associated With Application of Physical Restraints: A Systematic Review.

While handcuffs and zip ties are common methods of physical restraint used by law enforcement, they have been noted to damage soft tissue and bony structures of the hand and wrist. This paper seeks to characterize the safety of physical restraints by summarizing its effects on hand and wrist function and disability. Relevant studies were gathered through an independent double selection and extraction process using 3 electronic databases (EMBASE, MEDLINE, and CINAHL) from database inception to June 19, 2020. A total of 16 studies involving 807 participants were included. Lesion to the superficial branch of the radial nerve was the most commonly reported injury noted in 82% (42/55) of hands examined. A total of 6% (5/77) of examined hands had bony injury, including 3 radial styloid fractures and 2 scaphoid fractures. Both studies on zip ties noted presence of handcuff neuropathy, with 1 case report documenting severe rapidly progressing ischemic monomelic neuropathy. Overall, the use of handcuffs and zip ties is associated with entrapment neuropathies and bony injury to the hand and wrist. Further studies of higher quality evidence are necessary to understand the effects of physical restraint on hand function and disability.

A Simple Physical Exam Maneuver to Distinguish Trigger Digit, Dupuytren's Nodule, and Flexor Sheath Ganglion.

Trigger digit, Dupuytren's disease, and ganglion cysts are 3 common disorders treated by hand surgeons. Despite the varying nature of their pathology, these 3 entities can all present as a mass at the flexor crease in the distal palm. The regional similarity of these presentations can make diagnosis more difficult. In this paper, we describe a simple clinical exam method that can assist in distinguishing between trigger digit, Dupuytren's disease, and flexor sheath ganglion cysts.

The Total Costs of Seismic Retrofits: State of the Art.

This article presents the current state-of-practice with respect to quantifying the total cost to retrofit an existing building. In particular, we combine quantitative, qualitative, and heuristic data to provide a taxonomy for understanding the direct and indirect costs associated with seismic risk mitigation. Much of the literature to date has focused on estimating structural retrofit costs, the costs of retrofitting the structural elements of a building. In contrast, there is very little research or data on the remaining cost components of the total cost. We propose using structural cost as the foundation for approximating the remaining cost components and the total cost itself. To validate our findings, we compare the proposed approximations with actual cost estimates developed by engineering professionals.

A Predictive Modeling Approach to Estimating Seismic Retrofit Costs.

This paper presents a methodology for estimating seismic retrofit costs from historical data. In particular, historical retrofit cost data from FEMA 156 is used to build a generalized linear model (GLM) to predict retrofit costs as a function of building characteristics. While not as accurate as an engineering professional's estimate, this methodology is easy to apply to generate quick estimates and is especially useful for decision makers with large building portfolios. Moreover, the predictive modeling approach provides a measure of uncertainty in terms of prediction error. The paper uses prediction error to compare different modeling choices, including the choice of distribution for costs. Finally, the proposed retrofit cost model is implemented to estimate the cost to retrofit a portfolio of federal buildings. The application illustrates how the choice of distribution affects cost estimates.

Social and Economic Components of Resilient Multi-Hazard Building Design.

In 2017, U.S. damages from natural hazard events exceeded $300B, suggesting that current targets for building performance do not sufficiently mitigate loss. The significant costs borne by individuals, insurers, and government do not include impacts from social disruption, displacement, and subsequent economic and livelihood effects. In 2016, Congress mandated the National Institute of Standards and Technology (NIST) develop a report (NIST SP 1224) describing the research needs, implementation activities, and engineering principles necessary to improve the performance of residential and commercial buildings subjected to natural hazards. An Immediate Occupancy Performance Objective (IOPO) could help preserve building and social functions post event, minimizing physical, social, and economic disaster. The stakeholder-informed NIST report sets forth items needed for multi-hazard building design that can support enhanced resilience decision-making. This paper highlights the social and economic considerations that require additional research, particularly with regard to feasibility and potential impacts from an IOPO. These topics must be considered prior to and throughout the IOPO technical development and community implementation processes to ensure better outcomes after natural hazard events.

Direct and indirect utilities of patients with mild to moderate versus severe carpal tunnel syndrome.

Health utility is a quantitative global measure of patients' health status. This retrospective cohort study aimed to compare health utilities of patients with mild to moderate versus severe carpal tunnel syndrome and determine inter-instrumental agreement. Health utilities of 29 patients with varying severity of carpal tunnel syndrome were measured indirectly by Short-Form Sixth Dimension and EuroQol 5D questionnaire and directly by Chained Standard Gamble and a visual analogue scale. Health utility was 0.69 for Short-Form Sixth Dimension, 0.78 for EuroQol 5D Questionnaire, 0.98 for Chained Standard Gamble, and 0.76 for the visual analogue scale. There was a significant inter-instrumental agreement between three of the instruments, but not the Chained Standard Gamble. The difference in health utilities between patients with mild or moderate versus severe carpal tunnel syndrome was significant only for the EuroQol 5D questionnaire. We conclude based on our results that there are no clear indications on how health utilities can be integrated into decision analysis models and economic evaluation regarding carpal tunnel syndrome of various severities.Level of evidence: IV.

The Epidemiology of Scapholunate Advanced Collapse.

Background: Scapholunate advanced collapse (SLAC) is the most common pattern of wrist arthritis. Sparse data exist regarding the SLAC wrist pattern of arthritis. This study aimed to document the epidemiology of advanced SLAC in terms of patients' sociodemographics and possible association with trauma. Methods: Sixty-one patients with severe SLAC wrist were included. Baseline sociodemographic characteristics were reviewed. To evaluate the relationship to injury, this group of cases was compared with a control group of 61 patients with first carpometacarpal osteoarthritis (CMC OA). The following data were collected for both groups: age, gender, history of traumatic injury, history of manual labor, duration of symptoms, and dominant hand involvement. Pearson chi-square tests for categorical variables and independent samples t test for continuous variables were performed to determine differences between groups. Results: Patients with SLAC wrist were more likely to be male (80.3% vs 31.1%; p<0.001), have a history of a traumatic injury (69.5% vs 25.9%, P < .001), have longer symptom duration (10.3 ± 13.3 vs 3.5 ± 2.5 years, P = .001), be involved in a manual labor job (49.0% vs 20.0%, P = .002), and be younger (53.1 ± 10.4 vs 58.3 ± 9.8; P = .006) compared with patients with CMC OA. There was no difference in dominant hand involvement (49.2% vs 53.3%; P = .571) between the groups. Conclusions: This study identified the characteristics of patients with advanced SLAC wrist. Compared with a control cohort of CMC OA, patients with SLAC wrist were more likely to be male, have a history of a traumatic injury, and be younger.

Secondary Effects of Radiation Therapy to the Hand for Benign Conditions.

Background: Emerging literature introduces radiation therapy for benign hand conditions. However, hand surgeons are wary recommending radiation therapy for nonmalignant conditions. In our practice, we have used radiation therapy for patients who present with infiltrative or recurrent giant cell tumor of the tendon sheath (GCTTS) since 1998. The purpose of this study is to examine the secondary effects of radiation to the hand through the critical lens of a hand surgeon. Methods: A case series of patients who received radiation therapy for GCTTS were reviewed. The Radiation Oncology/Toxicity Grading Late Radiation Morbidity Scoring Schema was used, and patients were questioned about symptoms and examined for physical findings involving their irradiated digits. Results: A total of 8 patients with GCTTS presented for follow-up. The average patient age was 59.1 years, and the average time since radiation therapy was 5.4 years. Patients had an average of 2.3 surgeries on the affected digit prior to receiving radiation therapy. The average Disabilities of the Arm, Shoulder, and Hand score was 8.1. The most common sign of radiation was nail changes. All patients complained of sensibility changes, although only 2 of the 8 patients had abnormal moving 2-point discrimination tests. There were no confirmed recurrences of GCTTS and no skin cancers. Conclusions: Patients who received radiation therapy to the hand report high levels of satisfaction with the therapy. Radiation therapy is tolerated well by these patients and has a low level of morbidity in our population.

Factor Structure of the Disabilities of the Arm, Shoulder and Hand Questionnaire in Upper Extremity Nerve Injury.

BACKGROUND: This study evaluated the validity of the factor structure of the Disabilities of the Arm, Shoulder and Hand questionnaire to assess upper extremity disability in patients with upper extremity nerve injury. METHODS: Data were used from previous cross-sectional studies of patients with upper extremity nerve injuries. Research ethics approval was obtained for secondary data analyses. Descriptive and factor analyses were performed. RESULTS: Patients (n = 242; 170 men and 72 women) with upper extremity nerve injury included distal nerve (n = 131), brachial plexus (n = 88), and single proximal shoulder nerve (n = 23). The mean Disabilities of the Arm, Shoulder and Hand questionnaire score was 47.3 ± 22. For the questionnaire, a three-factor structure had the highest variance and no overlap between factors. The factors related to (1) light effort tasks, (2) greater effort tasks, and (3) work/social activity limitations and pain. Brachial plexus injuries had significantly higher overall questionnaire scores compared to distal and single proximal nerve injuries. The light effort factor scores were significantly lower in single proximal nerve injuries compared with brachial plexus and distal nerve injuries. Nondominant compared to dominant hand involvement revealed no difference in overall questionnaire scores but significantly higher dominant hand scores in the light effort factor (p = 0.001). CONCLUSIONS: In patients with nerve injury, the factor analysis of the Disabilities of the Arm, Shoulder and Hand questionnaire indicated a multifactor construct. These domains should be considered when using the questionnaire and may be helpful to assess disability related to specific tasks in different nerve injuries and with dominant hand involvement.

Stable rates of operative treatment of distal radius fractures in Ontario, Canada: a population-based retrospective cohort study (2004­2013)

Background: Rates of surgical management of distal radius fractures are increasing internationally despite the higher cost and limited outcome evidence to support this shift. This study examines the epidemiology of distal radius fractures and asks if the same shift has occurred in Ontario, Canada (population 13.9 million). Methods: This population-based, retrospective cohort study examined distal radius fractures in people aged 18 years and older over a 10-year period (2004­2013). The incidence analyses were based on the first occurrence of a fracture within a 2-year time period. The number of fractures, age-adjusted incidence rates and frequency of fracture treatment type by year were assessed. We used a Poisson regression with robust standard errors to determine if there was a statistically significant change in the frequency of fracture treatment type over time. Results: There were 25 355 distal radius fractures among Ontarians 18 years of age and older in 2013. Between 2004 and 2013, the age-adjusted incidence rate for people 35 years of age and older was stable, between 2.32 and 2.70 per 1000 population. Rates of cast immobilization remained stable between 82% and 84%. Of those patients treated surgically, the rate of open reduction and internal fixation rose from 7% in 2004 to 13% in 2013 at the expense of other types of surgical management. Conclusion: In Ontario, rates of cast immobilization are stable and there has been a movement toward open reduction and internal fixation among patients treated surgically.

Contexte: Le taux de prise en charge chirurgicale des fractures du radius distal augmente partout dans le monde, malgré le coût supérieur de l'intervention et le manque de données probantes sur les issues. Cette étude se penche sur l'épidémiologie des fractures du radius distal et cherche à savoir si cette augmentation se reflète en Ontario, au Canada (population : 13,9 millions). Méthodes: Cette étude de cohorte rétrospective basée sur la population examinait les fractures du radius distal chez les personnes âgées de 18 ans et plus sur une période de 10 ans (de 2004 à 2013). Les analyses de l'incidence étaient fondées sur la première occurrence de fracture en 2 ans. Le nombre de fractures, le taux d'incidence ajusté en fonction de l'âge et la fréquence annuelle des types de traitement des fractures ont été évalués. Nous avons utilisé une régression de Poisson avec des erreurs types robustes pour déterminer s'il y avait des changements statistiquement significatifs dans la fréquence des types de traitement des fractures au fil du temps. Résultats: Il y a eu 25 355 fractures du radius distal chez les Ontariens de 18 ans et plus en 2013. Entre 2004 et 2013, le taux d'incidence ajusté en fonction de l'âge pour les personnes de 35 ans et plus était stable, entre 2,32 et 2,70 pour 1000 personnes. Le taux d'immobilisation plâtrée est demeuré stable entre 82 % et 84 %. Chez les patients traités par chirurgie, le taux de réduction chirurgicale et de fixation interne est passé de 7 % en 2004 à 13 % en 2013, au détriment des autres types de prise en charge chirurgicale. Conclusion: En Ontario, le taux d'immobilisation plâtrée est demeuré stable et il y a eu une augmentation de la réduction chirurgicale et de la fixation interne chez les patients traités par chirurgie.

Treatment of carpal tunnel syndrome with wrist splinting: study protocol for a randomized placebo-controlled trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is a common cause of pain, weakness, sensory loss, and activity limitations. Currently, the most common initial treatment is use of a rigid splint immobilizing the wrist, usually during night-time, for several weeks. Evidence regarding the efficacy and effect durability of wrist splinting is weak. The treatment is associated with costs and may cause discomfort and limit daily and work activities. No placebo-controlled trials have been performed. METHODS: This is a randomized controlled trial designed to assess the efficacy of a rigid wrist splint compared with soft wrist bandage (placebo) in patients with primary idiopathic CTS. The trial will be conducted at an orthopedic department. Patients, 25 to 65 years old, who seek primary health-care with symptoms of CTS will be screened, and potentially eligible patients will be referred to the study center. Patients who fulfill the trial's eligibility criteria will be invited to participate. A total of 112 patients who provide informed consent will be randomly assigned to treatment with either a rigid wrist splint or a soft bandage to be used initially for 6 weeks at night and, if possible, during the day. The splints and bandages will be fitted with a temperature-monitoring device to measure the total time during which they have actually been worn. The trial participants will complete a questionnaire that includes the 6-item CTS symptoms scale (CTS-6); the 11-item disabilities of the arm, shoulder, and hand (QuickDASH) scale; and the EuroQol 5-dimension (EQ-5D) health status and quality-of-life measure at baseline and at 6, 12, 24, and 52 weeks after treatment start. The participants will undergo physical examination and nerve conduction testing at baseline and at 52 weeks. The trial's primary outcomes are the change in the CTS-6 score from baseline to 12 weeks and the rate of carpal tunnel release surgery at 52 weeks. DISCUSSION: This is the first placebo-controlled randomized trial with electronic monitoring of actual splint use and will provide evidence regarding the efficacy of wrist splinting in patients with CTS. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN81836603 . Registered on May 5, 2018.

Decisional conflict in surgical patients: Should surgeons care?

Summary: Decisional conflict represents a state of uncertainty regarding an action one must take. It is a concept inherent to shared decision-making and can help promote high-quality and patient-centred decisions in surgical care, leading to better outcomes. Specific elements may cause more uncertainty or decisional conflict for patients: lack of knowledge about risks and benefits, poorly defined personal values about the importance of those risks and benefits, perception of a lack of support, unpredictable outcomes, or the impression that an inadequate decision has been made. Decisional conflict can be measured in the surgical setting using the 16-item validated patient-reported Decisional Conflict Scale (DCS). Better understanding of the reasons behind high decisional conflict can help surgeons support high-quality decisions and lead to more satisfactory outcomes and less decisional regret.

Universal Measures of Support Are Needed: A Cross-Sectional Study of Health Literacy in Patients with Dupuytren's Disease.

BACKGROUND: Health literacy represents the degree to which patients can understand and act on health information. The relevance of health literacy to health care delivery, outcomes, and overall surgical care is unambiguous. This study aimed (1) to determine the prevalence of limited health literacy in patients diagnosed with Dupuytren's contracture and (2) to identify independent predictors of limited health literacy. METHODS: This cross-sectional study included patients with Dupuytren's disease and with self-reported English fluency. The Newest Vital Sign, a rapid, validated, and reliable screening tool, was selected to measure health literacy. An exploratory multivariable logistic regression model was used to identify possible predictors of limited health literacy. RESULTS: A total of 185 patients met eligibility criteria and were included. From those, 82 (44 percent) were found to have limited health literacy, defined as a score of 3 or less on the Newest Vital Sign. The domain of prose literacy was most highly scored compared to numeracy and document literacy. Lower household income was associated with a 4.7-fold increase in the odds of having limited health literacy. Being an immigrant also increased the odds of having limited health literacy by a factor of 3.6. Sensitivity analyses and subgroup analyses (based on education, maternal language, and immigration status) corroborated these independent predictor findings. CONCLUSIONS: Limited health literacy is common among patients with Dupuytren's contracture. System level changes are necessary such as the access and integration to clinical care of universal measures of support to promote productive patient-surgeon interactions.

Effect of Forearm Warming Compared to Hand Warming for Cold Intolerance Following Upper Extremity Trauma.

PURPOSE: This study evaluated the effect of forearm or hand warming versus bare hand conditions to improve cold-induced symptoms and skin temperatures in hand trauma patients. METHODS: Adults with symptoms of cold intolerance at least 3 months following hand trauma and age-/sex-matched controls were included. Testing sessions (bare hand, hand warming, forearm warming) were completed in a climate laboratory with continuous temperature monitoring. Outcomes included physical findings (skin temperature) and self-report symptoms (thermal comfort, pain). RESULTS: Eighteen participants (9 hand trauma patients, 9 control subjects) underwent testing. More severe cold intolerance was associated with higher Disabilities of the Arm, Shoulder, and Hand scores. With bare hands, skin temperatures changed significantly from baseline to cold exposure and to rewarming. Hand trauma patients had the lowest skin temperatures with cold exposure in the injured digits (14.3°C ± 3.5°C) compared with the contralateral uninjured (16.9°C ± 4.1°C) digits. Compared with bare hands, wearing gloves significantly increased the minimum temperature during cold exposure and the maximum temperature after rewarming. Patients reported higher pain with cold exposure. All participants reported significantly more comfort with less coldness with forearm and hand warming. CONCLUSIONS: There was cold response variability in hand trauma patients and control subjects. Hand trauma patients had greater changes in skin temperature during cold exposure that improved with glove warming. Continuous temperature monitoring identified subtle physiological changes associated with cold-induced pain and with warming interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Health Literacy Among Surgical Patients: A Systematic Review and Meta-analysis.

Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients' health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7-39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5-39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.

Increasing Community Resilience Through Improved Lifeline Infrastructure Performance.

The concept of community resilience is complex and multidimensional, relying on engineering and other disciplines to help communities break the cycle of destruction and recovery and reduce the impacts of earthquakes and other hazards. This article presents proposed prioritized actions to improve lifeline infrastructure resilience based on an assessment of lifeline infrastructure performance commissioned and funded by the National Institute of Standards and Technology (NIST).

Case-Cohort Studies: Design and Applicability to Hand Surgery.

Observational studies are common research strategies in hand surgery. The case-cohort design offers an efficient and resource-friendly method for risk assessment and outcomes analysis. Case-cohorts remain underrepresented in upper extremity research despite several practical and economic advantages over case-control studies. This report outlines the purpose, utility, and structure of the case-cohort design and offers a sample research question to demonstrate its value to risk estimation for adverse surgical outcomes. The application of well-designed case-cohort studies is advocated in an effort to improve the quality and quantity of observational research evidence in hand and upper extremity surgery.

Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes?

OBJECTIVE: This case-control study was designed to test the hypothesis whether carpal tunnel release (CTR) during fixation of distal radius 23-C2 AO fractures improves outcomes. METHODS: Thirty-five consecutive patients who sustained distal radius fractures of the dominant hand participated in this study. Patients were allocated into two groups: (a) The ORIF + CTR (16 patients (11 males and 5 females)); (b) the ORIF and NOT CTR 19 patients (12 males and 7 females). Patient assessment included visual analogic scale of pain (VAS), the subjective Mayo Wrist Score (MWS), electromyograms (EMG) at 3 month and 6 months from the day of injury and complications. All patients had the same physiotherapy treatment algorithm following surgery. Patient follow up took place at 1 month, 3, 6, and 12 months. RESULTS: A the T12 month follow up point the VAS average was 0.8 (range 0-3) in ORIF + CTR group compared to 1.2 (range 0-3) in the ORIF and NOT CTR. The MWS average was 98.7 (range 95-100) in ORIF + CTR group versus 97.6 (range 95-100) in ORIF no CTR group. There was no statistical significance (p > 0.5) between the two groups during the follow up period. Patients in the sixth month of ORIF + CTR had no suffering of the median nerve, while 31.58% of patients in ORIF and no CTR found to have carpal tunnel syndrome. CONCLUSIONS: Routine release of the transverse carpal ligament at the time of fracture fixation may reduce the incidence of postoperative median nerve dysfunction.

Reliability, Feasibility and Value of Ecography in Clinical-functional Results in Patients Affected by Carpal Tunnel Syndrome: is There a Correlation?

BACKGROUND: The aim of this study was to evaluate how the ultrasound examination in the carpal tunnel diagnosis could contribute to the clinical and neurophysiological evaluation. This was done by evaluating the cross-sectional area (CSA) and its correlation with symptoms and functionality data assessed by the BTQC questionnaire. METHODS: 60 patients were subjected to open CTR for idiopathic carpal tunnel syndrome. The median nerve CSA was assessed both pre-operatively and in follow-up at 4 and 12 weeks. The Boston Carpal Tunnel Questionanaire (BCTQ) was proposed at the same time. RESULTS: BCTQ score significantly improved after 4 weeks, but there was a less significant increase at 12 weeks for both the BCTQ-S and the BCTQ-F. The 4-week CSA, however, did not appear to have markedly improvement, where as the 12-week CSA turned out to be statistically significant. The correlation between BCTQ and CSA shows that post-surgery, the reduction of CSA of the median nerve is correlated with the symptomatic and functional reduction in patients. CONCLUSIONS: The study shows that the symptomatology and the functionality of the hand after surgery for the carpal tunnel resolves quickly. Furthermore, the reduction of the CSA proves to show that the use of ultrasound can help in the evaluation of patients with this state.