Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review.

Importance: Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis. Objective: To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants. Data Sources: Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023. Study Selection: The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities. Data Extraction and Synthesis: The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies. Main Outcomes and Measures: Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated. Results: Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0). Conclusions and Relevance: In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.

Dupuytren Disease Infiltrating a Full-Thickness Skin Graft.

Although the role of the skin in the development and propagation of Dupuytren disease remains unclear, dermofasciectomy and full-thickness skin grafting (FTSG) appears to delay recurrence. In 2011, a 71-year-old, left-handed man presented with recurrent Dupuytren disease in the dominant hand. In 1991, he originally underwent a primary dermofasciectomy and FTSG for Dupuytren disease involving the palmar skin. Twenty years later, the left middle finger was drawn into flexion by a recurrent cord, and the old graft and adjacent palmar skin were clinically involved by fibromatosis. We performed a revision dermofasciectomy and FTSG. Microscopic analysis of the excised graft demonstrated dense infiltration of the entire skin graft by Dupuytren disease, with areas of active and burnt-out fibromatosis distinct from hypertrophic scarring. This report of Dupuytren fibromatosis infiltrating a skin graft raises questions about the pathophysiology of Dupuytren disease.

Protocol for a systematic review and network meta-analysis of the use of prophylactic antibiotics in hand trauma surgery.

BACKGROUND: The use of prophylactic antibiotics in surgery is contentious. With the rise in antimicrobial resistance, evidence-based antibiotic use should be followed. This systematic review and network meta-analysis will assess the effectiveness of different antibiotics on the prevention of surgical site infection (SSI) following hand trauma surgery. METHODS AND ANALYSIS: The databases Embase, MEDLINE, CINAHL and CENTRAL, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform will be searched. Abstracts will be screened by two persons independently to identify eligible studies. This systematic review will include both randomised and non-randomised prospective comparative studies in participants with hand and/or wrist injuries requiring surgery; bite injuries will be excluded. The network meta-analysis will compare the use of different prophylactic antibiotics against each other, placebo and/or no antibiotics on the development of SSI within 30 days of surgery (or 90 days if there is an implanted device). The Cochrane risk-of-bias tool 2 will be used to assess the risk of methodological bias in randomised controlled trials, and the Newcastle-Ottowa scale (NOS) will be used to assess the risk of bias in non-randomised studies. A random-effects network meta-analysis will be conducted along with subgroup analyses looking at antibiotic timing, injury type, and operation location. Sensitivity analyses including only low risk-of-bias studies will be conducted, and the confidence in the results will be assessed using Confidence in Network Meta-Analysis (CINEMA). DISCUSSION: This systematic review and network meta-analysis aims to provide an up-to-date synthesis of the studies assessing the use of antibiotics following hand and wrist trauma to enable evidence-based peri-operative prescribing. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023429618.

Statistics for the hand surgeon. Part 2: avoiding common pitfalls.

In this second of a two-part article, we describe some of the common statistical pitfalls encountered in hand surgery research. These include dichotomania, the 'Table 2 fallacy', p-hacking, regression to the mean, overfitting and unaccounted data clustering. We explain the impact of these pitfalls on hand surgery research and describe techniques to avoid them. The aim of this two-part article was to provide a starting point for hand surgeons to refer to when conducting or analysing research and provide resources and references for interested readers to explore.

Statistics for the hand surgeon. Part 1: principles and application to hand surgery research.

Hand surgeons have the potential to improve patient care, both with their own research and by using evidenced-based practice. In this first part of a two-part article, we describe key steps for the analysis of clinical data using quantitative methodology. We aim to describe the principles of medical statistics and their relevance and use in hand surgery, with contemporaneous examples. Hand surgeons seek expertise and guidance in the clinical domain to improve their practice and patient care. Part of this process involves the critical analysis and appraisal of the research of others.

Incidental findings associated with magnetic resonance imaging of the brachial plexus.

OBJECTIVE: The identification and management of incidental findings is becoming increasingly problematic, particularly in relation to brachial plexus imaging because the prevalence is unknown. Therefore, we aimed to estimate the prevalence of incidental findings in symptomatic patients undergoing MRI of the brachial plexus. METHODS: This retrospective cohort study included all children and adults who underwent MRI over a 12-year period, in a tertiary care centre in the UK. An incidental finding was any abnormality which was not a direct injury to or disease-process of the brachial plexus. An "incidentaloma" was defined by the need for further investigation or treatment. Multivariable logistic regression was used to estimate the odds ratio (OR) of an "incidentaloma". To estimate which factors were associated with the incident rate ratio (IRR) of incidental findings, multivariable Poisson regression was used. RESULTS: Overall, 502 scans (72%) reported incidental anomalies. Although the number of MRIs performed per annum increased by 23%, the prevalence of "incidentalomas" remained static (p = 0.766). Musculoskeletal incidental findings were the most prevalent (63%) and when identified, there were a median of 3 incidental anomalies per patient. Overall, 125 (18%) anomalies were "incidentalomas" which required further investigation or treatment. The odds of having further investigation or treatment was strongly related to the frequency of incidental findings [adjusted OR 1.16 (95% CI 1.08, 1.24)] and when a tumour was identified [adjusted OR 2.86 (95% CI 1.81, 4.53)]. The number of incidental findings recorded per scan increased when trainees co-reported with consultants [adjusted IRR 0.36 (95% CI 0.05, 0.67)] and in the presence of a tumour [adjusted IRR 0.39 (95% CI 0.28, 0.49)]. CONCLUSIONS: The prevalence of clinically important incidental findings on brachial plexus MRI is lower than organ-specific imaging, but still 18% of scans identified an 'incidentaloma' which required further investigation or treatment. ADVANCES IN KNOWLEDGE: This cohort study shows that approximately 1 in 5 symptomatic patients undergoing a brachial plexus MRI had a clinically important incidental findings, which required further investigation or treatment. This information can be used to inform patients consenting to clinical or research imaging.

Orbital varix thrombosis: a rare cause of unilateral proptosis.

Orbital varices are thin walled, low flow, distensible veins which may rarely present with periorbital pain, proptosis or visual loss. Most orbital varices may be managed conservatively and only warrant surgery in the presence of recurrent thrombosis, disfiguring proptosis or acute visual loss. This report concerns an 84-year-old Caucasian woman who was admitted following a fall and noted to have isolated proptosis of the right eye, with vertical diplopia. All biochemical and haematological investigations were normal. A CT scan of the orbits demonstrated a serpiginous soft tissue mass within the superior portion of the right orbit, consistent with a thrombosed orbital varix. Conservative management was agreed with prism glasses and ophthalmological follow-up.