Factitious hand disorders: review of 29 years of multidisciplinary care.

PURPOSE: To improve our understanding of factitious hand disorders with a review of our experience over 29 years in a multidisciplinary hand center. METHODS: A retrospective chart review was performed to identify workers' compensation patients treated for factitious hand disorders in the multidisciplinary hand center between January 1981 and September 2010. Multidisciplinary evaluation at this center involved evaluation by hand surgeons, occupational therapists, and psychologists. Data collected include age, sex, race, educational level, clinical presentation, number of diagnostic tests, number of surgeries, time to referral to the multidisciplinary center, direct cost of care, psychological diagnosis, Minnesota Multiphasic Personality Inventory, treatment modalities, and work status. RESULTS: We identified 174 workers' compensation patients with factitious hand disorders. Presentation was used to classify patients into 1 of 4 categories: psychopathological dystonia, factitious edema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation. There were statistically significant differences between the 4 categories in demographics, utilization of medical resources, psychopathology, treatment modalities, and return-to-work status. Patients with factitious wounds were more educated, used more medical resources, demonstrated an angry or hostile profile, and experienced a lower return-to-work rate. Patients with dystonia were less educated, used less medical resources, demonstrated a hypochondriasis or depressed profile, and experienced a higher return-to-work rate. CONCLUSIONS: Treatment of factitious hand disorders remains frustrating and costly due to failure or recurrence after traditional approaches. This review is a large-scale examination of the factitious hand disorder population that demonstrates the unique pathology involved in each of the 4 categories. There is a specific association between the category of hand disorder and the underlying pathology and prognosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

What influences public perceptions of silicone breast implants?

In an effort to determine public attitude regarding breast implants in the wake of what many might consider biased media publicity, surveys of women and men in Milwaukee were made. Questionnaires appropriate to each of four groups [patients with reconstructions (n = 54), mastectomy without reconstruction (n = 14), those with augmentation mammaplasty (n = 26), and the general public (n = 60)] were administered. Some of the findings included the following: Over 98 percent had heard of the controversy; most had received their information from the media, with less than 10 percent referring to a medical journal; only 6 percent felt that the media coverage was objective, while 88 percent felt that the media were biased; almost two-thirds of those in the general population were not aware of any other method of reconstruction; and almost half that same group would have significant hesitancy in having the procedure on themselves or a family member were it indicated. In summary, our findings would substantiate the fact that the media do exert a very significant influence on the public's perception of silicone breast implants. Though most people surveyed generally consider the media biased, they still use them as the primary source for their negative conclusions on the matter. Though the media cannot be viewed as our ally in this matter, we, as a group, might be better served by minimizing conflict, which makes the whole issue less newsworthy.

Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up.

The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12-month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3-month and 6-month evaluations, but 44 percent of the children continued to report symptoms at 12-month follow-up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re-injury, mood disorders, body-image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons.

Analysis of the distribution of cutaneous perforators in cutaneous flaps.

An anatomic and statistical analysis was performed on the distribution of cutaneous perforators that perfuse the scapular, radial forearm, and lateral arm cutaneous flaps. Perforators were categorized as direct, terminal, and intransitive, depending upon perforator origin and termination site relative to the source artery. Statistical cluster analysis of perforator distributions was performed to determine the regions in which cutaneous perforators are consistently found. The scapular and radial forearm flaps could be divided into up to three well-perfused segments. The analysis predicted the possibility of dividing the lateral arm flap into as many as seven segments while maintaining perfusion. Clinical applications of this method for preoperative flap design and elevation as well as final results are shown.

A comparison of upper arm and forearm tourniquet tolerance.

This study examined the use of upper arm and forearm tourniquets for hand surgery. 40 subjects (20 males, 20 females) were randomly assigned to one of four groups: left upper arm, left forearm, right upper arm and right forearm. Tourniquets were applied to these areas. Subjects were asked to rate their discomfort at 10-minute intervals and the total time of tourniquet tolerance was recorded. The results of a three-factor ANOVA revealed no statistically significant differences in either pain rating or tourniquet tolerance between any of the groups. In addition, forearm tourniquets were used in 18 clinical cases. None of the individuals with tourniquet times less than 30 minutes required any medication in order to tolerate this procedure. Of the 13 patients with tourniquet times greater than 30 minutes, ten required medication in order to tolerate the procedure. We conclude that patients tolerate upper arm and forearm tourniquets equally.

Spiral fracture fixation techniques. A biomechanical study.

The mechanical strengths of five common fixation techniques for spiral fractures have been tested. A total of 240 cadaver metacarpals and proximal phalanges were fractured and fixed by either crossed K-wires, interosseous loops, a dorsal mini-plate, a single compression screw or K-wire plus cerclage wire. Specimens were subjected to torsional and cantilever bending tests. A single compression screw provided the best overall fixation for the proximal phalanx. In addition, a single compression screw provided better fixation than any of the other techniques when proximal phalanges and metacarpals were subjected to torsional tests (P < 0.05). In apex dorsal bending tests of metacarpals, the screw provided fixation superior to interosseous wires, crossed K-wires, or dorsal mini-plates (P < 0.05). These results indicate that the use of a single compression screw provides the most satisfactory biomechanical advantage for spiral fracture fixation.

Early psychological aspects of severe hand injury.

We investigated the incidence and nature of psychological symptoms occurring during the first two months after severe hand injuries. 94% of patients had significant symptoms at some point early in rehabilitation, including nightmares (92%), flashbacks (88%), affective lability (84%), preoccupation with phantom limb sensations (13%), concentration/attention problems (12%), cosmetic concerns (10%), fear of death (5%), and denial of amputation (3%). Two months later, flashbacks (63%) remained pronounced. Nightmares (13%), affective lability (48%), concentration/attention problems (5%), fear of death (0%), and denial of amputation (0%) declined markedly, while cosmetic concerns (17%) and preoccupation with phantom limb sensations (17%) increased. Based on these findings, we believe that psychological treatment should often be given as part of the rehabilitation process.

On-site work evaluations: desensitisation for avoidance reactions following severe hand injuries.

This study examined on-site work evaluations as an environmental exposure strategy to promote return to work in 15 recalcitrant patients who had failed to benefit from established methods of reducing post-traumatic stress disorder symptoms. Following the on-site work evaluation, 87% of these patients were able to use visualisation of the work setting to further desensitize themselves and returned to work within the next eight weeks. All 87% have continued to be employed at six and twelve month follow-ups. This approach holds promise for assisting patients with hand injuries who develop post-traumatic stress disorder and fail to respond to traditional psychological strategies.

Psychological adjustment to hand injuries: nursing management.

Traumatic hand injuries can be devastating experiences both physically and psychologically. The plastic surgery nurse who can identify the various responses that routinely occur with hand injured patients is better prepared to normalize their experiences and implement the necessary interventions toward overall rehabilitation. This article will provide an overview of specific characteristics and emotional reactions following hand injuries, factors that influence adjustment, and nursing management that promotes optimal recovery.

Thermal self-regulation for pain control in reflex sympathetic dystrophy syndrome.

Reflex sympathetic dystrophy syndrome is comprised of a variety of changes in vasomotor and trophic responsivity, as well as, stiffness, edema and severe pain. This study examined 20 patients with reflex sympathetic dystrophy syndrome who had failed to respond to a variety of techniques commonly used to treat this disorder. These patients had documented histories of reflex sympathetic dystrophy syndrome ranging from 18 to 60 months. All had been referred for psychological evaluation and provision of pain management. A combination of thermal biofeedback, relaxation training, and supportive psychotherapy were used to reduce subjective pain. The results indicate that patients were able to significantly increase their initial (p less than 0.0001) and postrelaxation (p less than 0.0001) hand temperatures, as well as to significantly reduce their subjective pain ratings (p less than 0.0001). This reduction in pain was maintained at 1-year telephone follow-up, with 14 of the 20 patients returning to work by that time. This intervention was effective as a pain reduction strategy for our patients with reflex sympathetic dystrophy syndrome who had failed to benefit from other treatments.

Treatment of posttraumatic stress disorder after work-related hand trauma.

Posttraumatic stress disorder frequently accompanies severe work-related hand trauma and, when a patient attempts to return to work it can potentially be as debilitating as the hand injury. Four techniques were examined for their effectiveness in the treatment of the symptoms of posttraumatic stress disorder. Confronting and reprocessing of intrusive thoughts, combined with coping skills training, effectively reduced all symptoms except avoidance reactions. An early return to the worksite was useful with those patients who experienced mild avoidance reactions, although many patients were not able to use this. Graded work exposure was a highly successful technique for those patients with moderate avoidance reactions. For those with severe avoidance reactions, on-site job evaluations were used with good success. We believe that actual exposure to the worksite greatly enhances the ability of occupationally hand-injured patients to return to work for their previous employer. An algorithm for treatment is proposed.

Reliability of sensory threshold measurement using a digital vibrogram.

Loss of vibratory sensation has been suggested as an early symptom in the diagnosis of compression neuropathies. The use of a digital vibrogram has recently been examined as a means of evaluating vibratory sensation thresholds over a range of frequencies from 8 to 500 Hz. Although this instrument does yield useful clinical information, little is known about the test-retest reliabilities of the thresholds obtained. To learn more about this, we assessed a total of 76 hands--32 normal and 44 with suspected carpal tunnel syndrome. The average sensory thresholds for onset and cessation of vibratory sensation were obtained. Pearson product-moment correlation coefficients were computed, and demonstrated improvement if an initial practice trial was administered. Our findings suggest that the vibrogram can be a reliable, clinical assessment when an initial practice trial is included as part of the standard administration.

The transverse gracilis musculocutaneous flap.

Through detailed anatomical study and latex injection of 24 cadaver legs, the blood supply to the skin overlying the gracilis muscle was examined. The proximal pedicle entered the gracilis muscle 10 +/- 2 cm below the pubic tubercle. The dissections identified both septocutaneous and musculocutaneous perforators from the proximal gracilis pedicle. These branches had a pronounced tendency to travel in a transverse direction, supplying the cutaneous territory over the adductor longus and sartorius anteriorly and extending for > 5 cm beyond the posterior margin of the gracilis muscle. This information led to a "new" transverse design of the gracilis musculocutaneous flap, such that the vascular perforators are invariably included in the cutaneous portion of the flap. In contrast, the traditional design, because of skin mobility, may allow elevation outside the skin territory of the muscle perforators.

Characteristics of prosthetic mesh and autogenous fascia in abdominal wall reconstruction after prolonged implantation.

This study evaluated two types of prosthetic mesh and autogenous fascia in long-term abdominal wall reconstruction for rats. Marlex mesh, Gore-Tex patch, and autogenous fascia were implanted and left in place for 1 year. Materials were removed and evaluated using tensile strength of the material, tensile strength of the suture line, and adhesions. No change in the tensile strength of any of the materials were found at 1 year follow-up. Tensile strengths were significantly greater for Gore-Tex patch and Marlex mesh than the autogenous fascia. The Marlex mesh, however, had a weak and a strong tensile strength direction. These were significantly different (p < 0.05). Suture line tensile strength was greater for autogenous fascia and Marlex mesh than it was for the Gore-Tex patch, which was significantly weaker (p < 0.05). The greatest number of adhesions were seen in the Marlex mesh group. No significant difference was present in adhesions between Gore-Tex patch and autogenous fascia. In summary, autogenous fascia showed virtually no adhesions and good suture line strength. While it was the weakest of the three materials examined, the strength was still within the normal range and adequate for abdominal wall reconstruction.

Classification system for factitious syndromes in the hand with implications for treatment.

We evaluated 29 patients with factitious disorders in the hand who received Worker's Compensation benefits. Three types of factitious hand disorders based on physical presentation were self-mutilation and wound manipulation, edema, and finger and hand deformities. Two distinct psychological diagnoses present were factitious disorder with physical symptoms and conversion disorder. The Minnesota Multiphasic Personality Inventory revealed two personality profiles: emotionally dependent and angry and hostile. Behavioral treatment was implemented. The emotionally dependent group responded well, with 80% returning to work. The angry and hostile group had a much poorer response, with 21% returning to work. None of the self-multilating patients returned to work. We recommend a combined evaluation by a physician, a psychologist, and a hand therapist to achieve a definitive diagnosis for these disorders. The identification of psychological profiles assists in ascertaining which patients will be responsive to behavioral treatment.

Effects of litigation on maintenance of psychological symptoms after severe hand injury.

Severe psychological symptoms after severe work-related hand injury, manifested as posttraumatic stress disorder, are not significantly potentiated or sustained by concomitant litigation if the patient has had early psychologic intervention. This study does not support assumptions about "accident neurosis" that delays recovery from the psychological sequelae of severe work-related hand injury.

Multidisciplinary management of altered body image in the patient with an ostomy.

Many clinical studies have found patients with ostomies to be a group facing multiple adjustment demands. One of these demands is coping with a significant change in body image. At the Medical College of Wisconsin, a team approach has been initiated; the ET nurse, the psychologist, and the surgeon deal with body image concerns together. Problems requiring counseling have included difficulty with personal acceptance, personal and social body-image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications. This article represents a study employing a methology of selected case presentations. Cases were chosen to outline the types of problems encountered and were selected from referrals made for psychologic intervention by the surgeon and ET nurse. The patients included four women and three men, ranging in age from 22 to 79 years. Data were compiled by examining the records of the surgeon, ET nurse, and psychologist. The primary needs revolved around personal or social acceptance of altered body image. By addressing these needs in a straightforward, time-limited manner, postsurgical counseling was delivered effectively for these patients. In conclusion, we have demonstrated the multidisciplinary approach to be successful in facilitating adaptation to an altered body image.

Psychometric assessment of patients with chronic upper extremity pain attributed to workplace exposure.

Upper extremity pain attributed to workplace exposure is a growing concern in medicine today. This study was undertaken to investigate the psychological findings in patients with chronic upper extremity pain attributed to workplace exposure. Sixty-three consecutive patients were evaluated. All patients underwent a history and physical examination by a hand surgeon and a psychological evaluation by a licensed psychologist, including a Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Physical and psychological findings were then compared. Forty-one patients (65%) showed abnormalities on MMPI-2 examination (t score > 70 = 97% confidence). This result is far above what generally would be expected in medical patients. When physical findings were grouped with psychological findings, 5 distinct groups were identified: 1 patient had normal physical and psychological results, 6 patients had normal physical findings but abnormal psychological assessments, 21 patients had abnormal physical findings but normal psychological assessments, 28 patients had both abnormal physical and psychological findings, and 7 patients had abnormal physical results but invalid MMPI-2 evaluations due to purposeful attempts to deny psychological symptoms. Identification of these groups may have diagnostic, prognostic, and treatment value. In addition, identification of these groups may help clarify several aspects of the debate over the role of psychosocial factors in the development and maintenance of chronic upper extremity pain that patients attribute to workplace exposure.