Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

Extension-Block Pinning for Unstable Dorsal Proximal Interphalangeal Joint Fracture-Dislocations: A Simple, Percutaneous Technique With Reproducible Outcomes.

BACKGROUND: Proximal interphalangeal (PIP) joint fracture-dislocations can be technically challenging injuries to treat, and no technique has proven to be superior nor lead to predictably good outcomes. We describe our experience of treating unstable dorsal fracture-dislocations of the PIP joint with extension-block pinning (EBP) at our institution over a 22-year period. METHODS: In all, 23 patients with 24 unstable dorsal fracture-dislocations of the PIP joint treated with EBP between January 1998 and October 2020 were identified. All patients underwent closed reduction of the PIP joint and insertion of a Kirschner wire into the proximal phalanx, creating a mechanical block. Range of motion and joint congruity were assessed at final clinic follow-up. Long-term function was assessed via completion of a Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Spearman's correlation coefficient was utilized to assess if any association existed between treatment delay, pin-in-body days, or amount of articular surface involved and QuickDASH score. RESULTS: Mean range of motion at final follow-up was 83.3° and 22 of 24 PIP joints demonstrated a congruent reduction. In all, 15 of the 23 patients completed the QuickDASH questionnaire at a median long-term follow-up of 57.5 months (range: 3-157 months). Average QuickDASH score was 18.8, indicating minimal long-term disability. No statistically significant associations were found between treatment delay, pin-in-body days, or amount of articular surface involved and QuickDASH score. CONCLUSIONS: EBP offers a simple and innovative method to treat a complex injury of the PIP joint. It is technically straightforward and cheap, and produces excellent functional outcomes with minimal long-term disability.

Lion (Panthera leo) movements in a multiuse area of the eastern Panhandle of the Okavango Delta, Botswana.

As global large carnivore populations continue to decline due to human actions, maintaining viable populations beyond protected area (PA) borders is critical. African lions (Panthera leo) ranging beyond PA borders regularly prey on domestic livestock causing humans to retaliate or even preemptively kill lions to minimize impacts of lost livestock. To understand how lions navigate high-conflict areas in human-dominated landscapes, lions were observed and monitored in the eastern Panhandle of the Okavango Delta between October 2014 and December 2016, and five lions were fitted with GPS satellite collars from August 2015 to December 2016. Lion prides and coalitions were small, with all prides having four or fewer females and all coalitions having two or fewer males. Home range size varied between the sexes but was not statistically different (males: x¯ = 584 km2, n = 3; females: x¯ = 319 km2, n = 2). There was considerable spatial overlap in home ranges as nonassociating, neighboring collared individuals utilized high levels of shared space (female-female overlap = 152 km2, representing 41-56% of respective home ranges; male-male overlap = 125-132 km2, representing 16-31% of respective home ranges). However, neighboring lions varied use of shared space temporally as evidenced by low coefficients of association (< 0.08), avoiding potentially costly interactions with neighboring individuals. Highest levels of overlap occurred during the wet and early dry seasons when flood waters minimized the amount of available land area. All collared individuals minimized time in close proximity (< 3 km) to human habitation, but some individuals were able to rely heavily on areas where unmonitored livestock grazed. While most lions exist within PAs, anthropogenic impacts beyond PA boundaries can impact critical populations within PAs. Studying systems beyond park boundaries with high levels of human-lion conflict while also establishing conservation programs that account for both ecological and sociocultural dimensions will better aid lion conservation efforts moving forward.

Higher-Than-Expected Rates of Distal Radioulnar Joint Fixation in Radial Shaft Fractures: Location of Fracture Matters.

BACKGROUND: The purpose of this study was to evaluate rates of distal radioulnar joint (DRUJ) fixation based on location of the radial shaft fracture and risk factors associated with postoperative complications following radial shaft open reduction internal fixation (ORIF). METHODS: Adult patients who underwent isolated radial shaft ORIF from 2014 to 2018 were identified from American College of Surgeons National Surgical Quality Improvement Program database and stratified by fracture location and by the presence or absence of DRUJ fixation. Preoperative patient characteristics and postoperative complications were compared to determine risk factors associated with DRUJ fixation. RESULTS: We identified 1517 patients who underwent isolated radial shaft ORIF, of which 396 (26.1%) underwent DRUJ fixation. Preoperative patient characteristics and postoperative complications were similar between cohorts. Distal radioulnar joint fixation was performed in 50 (30.7%) of 163 distal radial shaft fractures, 191 (21.8%) of 875 midshaft fractures, and 3 (13.0%) of 23 proximal shaft fractures (P = .025). Risk factors for patients readmitted include male sex (odds ratio [OR] = 12.76, P = .009) and older age (OR = 4.99, P = .035). Risk factors for patients with any postoperative complication include dependent functional status (OR = 6.78, P = .02), older age (50-69 vs <50) (OR = 2.73, P = .05), and American Society of Anesthesiologists (ASA) ≥3 (OR = 2.45, P = .047). CONCLUSIONS: The rate of DRUJ fixation in radial shaft ORIF exceeded previously reported rates of concomitant DRUJ injury, especially among distal radial shaft fractures. More distally located radial shaft fractures are significantly associated with higher rates of DRUJ fixation. Male sex is a risk factor for readmission, whereas dependent functional status, older age, and ASA ≥3 are risk factors for postoperative complications.

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery.

Background Carpal tunnel release (CTR) may be concomitantly performed along with distal radius fracture open reduction internal fixation (DRF ORIF) to prevent carpal tunnel syndrome; however, there is little to no literature investigating the rate, risk factors, and complications associated with CTR. Questions/Purposes The purpose was to determine (1) the rate of CTR performed at time of DRF ORIF, (2) factors associated with CTR, and (3) whether CTR was associated with any complications. Patients and Methods In this case-control study, adult patients who underwent DRF ORIF from 2014 to 2018 were identified from a national surgical database. Two cohorts were analyzed, (1) patients with CTR and (2) patients without CTR. Preoperative characteristics and postoperative complications were compared with determine factors associated with CTR. Results Of the 18,466 patients, 769 (4.2%) had CTR. Rates of CTR in patients with intra-articular fractures with two or three fragments were significantly higher than the rate of CTR for patients with extra-articular fractures. Underweight patients underwent CTR at a significantly lower rate compared with overweight and obese patients. The American Society of Anesthesiologists ≥3 was associated with a higher rate of CTR. Male and older patients were less likely to have CTR. Conclusion The rate of CTR at time of DRF ORIF was 4.2%. Intra-articular fractures with multiple fragments were strongly associated with CTR at time of DRF ORIF, while being underweight, elderly, and male were associated with lower rates of CTR. These findings should be considered when developing clinical guidelines to assess the need for CTR in patients undergoing DRF ORIF. This is a retrospective case control study and reflects level of evidence III.

Lions Panthera leo Prefer Killing Certain Cattle Bos taurus Types.

Lion predation on cattle causes severe human-wildlife conflict that results in retaliatory persecution throughout the lion's geographic range. Cattle closely resemble the body size, shape, and herding patterns of preferred lion prey species. We studied cattle depredation patterns in Botswana's Okavango Delta and tested whether lions exhibited specific preferences based on cattle demographic characteristics (sex and age), as well as morphological traits (body mass, horn length, and pelage patterns). We also tested whether human disturbance of kills influenced lion energy intake and whether depredation circumstances influenced loss levels. Lions predominantly killed cattle at night (87.1%) and exhibited no preference for either sex. Overall, bulls and calves were most preferred, whereas heifers were significantly avoided, as were cattle with uniform colour patterns. Cattle with mottled pelage patterns were most preferred, especially among free-roaming herds. Preferences were context-specific, with lions preferring inexperienced calves during enclosure attacks (including multiple cases of surplus killing) and free-roaming bulls and oxen. About 13% of adult cattle had no horns, and these were preferentially targeted by lions, while cattle with short horns were killed in accordance with their availability and long horned cattle were highly avoided. The contemporary morphology of Tswana cattle that resulted from unnatural selective pressures during domestication does not offer effective antipredatory protection. Human disturbance of feeding soon after kills occurred reduced cattle carcass consumption by >40% (or about 30 kg per carcass per lion). Lions killed significantly more cattle in nonfortified enclosures than in the veldt, although this was influenced by surplus killing. Our results suggest that cattle predation by lions is driven by availability and cavalier husbandry practices, coupled with morphological features associated with facilitating easy husbandry. Cattle no longer exhibit the key features that enabled their ancestors to coexist with large predators and are now reliant upon humans to perform critical antipredator activities. Hence, the responsibility for mitigating human-wildlife conflict involving lions and cattle lies with people in either breeding traits that minimise predation or adequately protecting their cattle.

Aberrant positioning of the ulnar nerve found during carpal tunnel release: A case report.

Aberrant positioning of the ulnar nerve volar to the carpal tunnel is a rare anatomic variation. We present the case of a 55-yearold female with unique ulnar nerve anatomy that was discovered intraoperatively during carpal tunnel release. The ulnar nerve was running directly adjacent to the median nerve in the distal forearm and as the median nerve traversed dorsal to the transverse carpal ligament (flexor retinaculum) to enter the carpal tunnel the ulnar nerve continued directly volar to this structure before angling towards Guyon's Canal. The unique ulnar nerve anatomy was successfully identified, carefully dissected and managed with a successful patient outcome. Variations of the anatomy at the level of the carpal tunnel are rare but do exist. Awareness of these anatomic variations and adequate visualization of the ulnar nerve along with the surrounding structures is crucial to avoid iatrogenic injuries during carpal tunnel release.

Regional Variations of Medicare Physician Payments for Hand Surgery Procedures in the United States.

BACKGROUND: Medicare reimbursement is known to exhibit geographic variation for inpatient orthopedic procedures. This study determined whether US geographic variations also exist for commonly performed hand surgeries. METHODS: Using the Medicare Provider Utilization and Payment Data (2012-2013) from Centers for Medicare & Medicaid Services, we analyzed regional physician charges/payments for common outpatient hand surgeries. RESULTS: The most commonly performed procedures in the United States were open carpal tunnel release (n = 21 944), trigger finger release (n = 15 345), endoscopic carpal tunnel release (n = 7106), and basal joint arthroplasty/ligament reconstruction and tendon interposition (n = 2408). A range of average Medicare physician reimbursements existed based on geographic region for basal joint arthroplasty ($669-$571), endoscopic carpal tunnel release ($400-$317), open carpal tunnel release ($325-$261), and trigger finger release ($215-$167). The latter three exhibited statistically significant variation across geographic regions with regard to both charges and physician reimbursement. However, the overall percentage physician reimbursement (70%-79%) to charges was similar across all geographic regions. CONCLUSIONS: In conclusion, further research is warranted to determine why regional or geographic variations in physician payments exist in the United States for commonly performed hand surgeries.

Parsimonious test of dynamic interaction.

In recent years, there have been significant advances in the technology used to collect data on the movement and activity patterns of humans and animals. GPS units, which form the primary source of location data, have become cheaper, more accurate, lighter and less power-hungry, and their accuracy has been further improved with the addition of inertial measurement units. The consequence is a glut of geospatial time series data, recorded at rates that range from one position fix every several hours (to maximize system lifetime) to ten fixes per second (in high dynamic situations). Since data of this quality and volume have only recently become available, the analytical methods to extract behavioral information from raw position data are at an early stage of development. An instance of this lies in the analysis of animal movement patterns. When investigating solitary animals, the timing and location of instances of avoidance and association are important behavioral markers. In this paper, a novel analytical method to detect avoidance and association between individuals is proposed; unlike existing methods, assumptions about the shape of the territories or the nature of individual movement are not needed. Simulations demonstrate that false positives (type I error) are rare (1%-3%), which means that the test rarely suggests that there is an association if there is none.

Screw Fixation Without Bone Grafting for Delayed Unions and Nonunions of Minimally Displaced Scaphoids.

Delayed unions and nonunions of the scaphoid are most often treated by open reduction and internal fixation with bone grafting. We sought to evaluate a large consecutive series of nondisplaced or minimally displaced scaphoid nonunions and delayed unions treated by a compression screw without bone grafting by 2 fellowship trained hand surgeons. A total of 23 patients (19 males, 4 females) were identified who had fractures located at the distal third (2), the waist (18), and the proximal third (3). Of the 23 patients, 19 had a complete follow-up (mean follow-up period, 5.2 months) with evidence of radiographic union. There were no radiographic signs of arthrosis, osteonecrosis of the scaphoid, hardware-related complications, or reported revision surgeries. In conclusion, nonunions and delayed unions in nondisplaced or minimally displaced scaphoids without carpal malalignment can be successfully treated using compression screw fixation without bone grafting.

Mapping black panthers: Macroecological modeling of melanism in leopards (Panthera pardus).

The geographic distribution and habitat association of most mammalian polymorphic phenotypes are still poorly known, hampering assessments of their adaptive significance. Even in the case of the black panther, an iconic melanistic variant of the leopard (Panthera pardus), no map exists describing its distribution. We constructed a large database of verified records sampled across the species' range, and used it to map the geographic occurrence of melanism. We then estimated the potential distribution of melanistic and non-melanistic leopards using niche-modeling algorithms. The overall frequency of melanism was ca. 11%, with a significantly non-random spatial distribution. Distinct habitat types presented significantly different frequencies of melanism, which increased in Asian moist forests and approached zero across most open/dry biomes. Niche modeling indicated that the potential distributions of the two phenotypes were distinct, with significant differences in habitat suitability and rejection of niche equivalency between them. We conclude that melanism in leopards is strongly affected by natural selection, likely driven by efficacy of camouflage and/or thermoregulation in different habitats, along with an effect of moisture that goes beyond its influence on vegetation type. Our results support classical hypotheses of adaptive coloration in animals (e.g. Gloger's rule), and open up new avenues for in-depth evolutionary analyses of melanism in mammals.

Leopard (Panthera pardus) status, distribution, and the research efforts across its range.

The leopard's (Panthera pardus) broad geographic range, remarkable adaptability, and secretive nature have contributed to a misconception that this species might not be severely threatened across its range. We find that not only are several subspecies and regional populations critically endangered but also the overall range loss is greater than the average for terrestrial large carnivores. To assess the leopard's status, we compile 6,000 records at 2,500 locations from over 1,300 sources on its historic (post 1750) and current distribution. We map the species across Africa and Asia, delineating areas where the species is confirmed present, is possibly present, is possibly extinct or is almost certainly extinct. The leopard now occupies 25-37% of its historic range, but this obscures important differences between subspecies. Of the nine recognized subspecies, three (P. p. pardus, fusca, and saxicolor) account for 97% of the leopard's extant range while another three (P. p. orientalis, nimr, and japonensis) have each lost as much as 98% of their historic range. Isolation, small patch sizes, and few remaining patches further threaten the six subspecies that each have less than 100,000 km(2) of extant range. Approximately 17% of extant leopard range is protected, although some endangered subspecies have far less. We found that while leopard research was increasing, research effort was primarily on the subspecies with the most remaining range whereas subspecies that are most in need of urgent attention were neglected.

Basal joint arthroplasty and carpal tunnel release through a single incision: an in vitro study.

PURPOSE: Carpal tunnel syndrome coexists with basal joint arthritis in a large percentage of patients. These 2 conditions are often treated surgically through separate incisions. The purpose of this cadaver study is to show the effect of trapeziectomy and transverse carpal ligament release from the scaphoid tubercle on carpal canal pressures. This technique may permit both problems to be addressed through the same Wagner incision. METHODS: In 4 fresh frozen cadaver limbs pressures in the carpal canal were elevated to 30 mm Hg through a percutaneously placed balloon. Pressures were measured using an 18-gauge sideport needle via a transducer. Trapeziectomy and release of the transverse carpal ligament from the scaphoid were performed in succession through a Wagner incision with canal pressures measured after each step. RESULTS: Carpal canal pressures decreased after trapeziectomy (mean, 7 mm Hg; range, 3-14 mm Hg) but did not return to baseline (0 mm Hg) until complete release of the ligament. CONCLUSIONS: Decompression of the carpal tunnel can be performed effectively through a Wagner incision during basal joint arthroplasty. This cadaver model shows reduction in the canal pressures after trapeziectomy and release of the transverse carpal ligament. This single-incision approach is attractive because it may decrease morbidity compared with a 2-incision approach in patients with concomitant carpal tunnel syndrome and basal joint arthritis.