Occupational hand trauma - Mechanism of injury and transient risk factors in Jerusalem.

INTRODUCTION: Although prevalent, and variable geographically, there is little information on the incidence and risk factors for occupation hand trauma in our health care system. This pilot study was designed to determine the optimal data collection methods for transient risk factors locally METHODS: All adult patients with occupational hand trauma treated at an emergency department (ED) during a three-month period were interviewed, either in person or by phone, using a case crossover designed questionnaire, regarding occupation and exposure to potential transient risk factor. RESULTS: Of 206 patients treated with occupational trauma during the study period, 94 had trauma distal to the elbow (46%). Patient compliance was high - 89% of the patients consented to phone interviews and 83% completed in-person ED interviews. In the 75 patients which participated in the study, several risk factors were found to be significant, including machine maintenance and being distracted, including by a cellular phone. We found lack of job experience, limited training on the job site and reports of previous injuries in these workplaces to be prevelent. DISCUSSION: The risk factors implicated in this study are similar to those reported in previous studies at other locations and are modifiable although this is the first report linking cellular phone use and occupation trauma. This finding should be further examined in a larger group and according to occupational categories. Compliance with the study was high, in person or with phone interviews, making these options viable for further studies. Several minor changes to the questionnaire were suggested although it did conform with the case-crossover study design. According to this study, standard preventive measures may be lacking in Jerusalem and should be implemented more uniformly, including specific workplace safety plans and education and taking into consideration the risk factors documented here.

A global perspective on gun violence injuries.

INTRODUCTION AND DEFINITIONS: Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients. PRE-HOSPITAL CARE: There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents. ACUTE TREATMENT: Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions. DEFINITIVE CARE: The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation. RESOURCES AND ETHICS: There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Insights and trends review: the role of three-dimensional technology in upper extremity surgery.

The use of three-dimensional (3-D) technology in upper extremity surgery has the potential to revolutionize the way that hand and upper limb procedures are planned and performed. 3-D technology can assist in the diagnosis and treatment of conditions, allowing virtual preoperative planning and surgical templating. 3-D printing can allow the production of patient-specific jigs, instruments and implants, allowing surgeons to plan and perform complex procedures with greater precision and accuracy. Previously, cost has been a barrier to the use of 3-D technology, which is now falling rapidly. This review article will discuss the current status of 3-D technology and printing, including its applications, ethics and challenges in hand and upper limb surgery. We have provided case examples to outline how clinicians can incorporate 3-D technology in their clinical practice for congenital deformities, management of acute fracture and malunion and arthroplasty.

Wrist angle measurements in predicting the presence of a displaced scaphoid fracture.

PURPOSE: Early diagnosis and treatment of scaphoid fractures is critical to achieve union and prevent wrist degenerative arthritis. Plain radiographic measurements can guide the early approach to suspected fractures. Specifically, the ability to predict fracture or fracture stability from plain radiographs may allow the traumatologist to expand initial referral to three-dimensional imaging. We evaluated the ability of four measured angles to predict presence of a scaphoid fracture and stability. METHODS: Fifty patients with a scaphoid fracture and 50 patients without fracture were evaluated for the cortical ring sign, scapho-lunate gapping, lateral scapholunate (SL), radio-scaphoid (RS), radio-lunate (RL), and radio-capitate (RC) angles by two-blinded observers. RESULTS: Measurement of an increased SL interval was associated with the presence of a scaphoid fracture as diagnosed on three-dimensional imaging [odds ratio (OR) 3.0, confidence interval (CI) 1.53-5.87, p = < 0.01]. The measured RL angle was associated with fracture displacement (OR 1.13, 95% CI 1.02-1.25, p = 0.02). CONCLUSIONS: Scapholunate gapping on plain radiographs in the context of a clinically suspected scaphoid fracture should increase suspicion for a fracture and may prompt earlier 3-dimensional imaging, while the presence of an abnormal radiolunate angle should increase wariness for instability and can be used in preoperative planning.

Failure Rate and Early Complications of Thumb Carpometacarpal Joint Replacement-A Multicenter Retrospective Study of Two Modern Implant Designs.

Joint replacement arthroplasty for the treatment of thumb osteoarthritis is gaining popularity as recent studies have demonstrated better pinch and grip strength and faster rehabilitation. Our aim was to identify early complications in modern implant designs using a multicenter study. A total of 381 patients who underwent thumb carpometacarpal replacement surgery in six participating hospitals were enrolled. The complications included were fractures, dislocations, infections, tendon and nerve injuries, and complex regional pain syndrome. Major complications were defined as a failure to implant the prosthesis, revision surgery to remove the implant, and any other need for further surgical intervention. The secondary outcomes were any other complications treated non-surgically and the timing of the complications. Eleven procedures failed, and these patients were treated with trapeziectomies. Twelve other patients required repeat surgical interventions. Minor adverse events occurred in 25.4% of the cases, and transient irritation of the superficial radial nerve and De Quervain tendinopathy were the most prevalent complications. Although this cohort depicted the learning curves of multiple surgeons, our study demonstrated low short-term failure rates. An inability to achieve primary stability of the cup in the trapezium was the leading cause of failure. Dislocations and other major complications with modern implants were very few.

Treatment of upper extremity palsies, gunshot wounds and scaphoid nonunion: my preferred approaches.

The article reviews key considerations and our preferred methods in treating upper extremity palsies, gunshot wounds and scaphoid nonunion. For these three difficult conditions, I highlight the importance of a team approach when treating upper extremity neuromuscular disease, flexibility and creativity when treating gunshot wounds, and my personal protocol for dealing with scaphoid fracture nonunions.Level of evidence: V.

Nationwide community based emergency centers reveal scale of hand trauma.

INTRODUCTION: This study describes the characteristics of hand trauma treated in community-based emergency centers (CBECs) in Israel. It was hypothesized that the rate of hand trauma, as well as patient and injury characteristics, would differ from a recent study of patients treated in hospital emergency departments (EDs) in Jerusalem. METHODS: Data on all hand injury patients treated at any of the CBECs belonging to a large nationwide chain in 2017 were retrieved from the electronic medical records of the treatment centers, including demographic and clinical characteristics. RESULTS: Over the course of 2017, 53,574 individuals were treated for forearm, wrist and hand injuries (35% of all trauma patients treated during this period). The majority of the patients were male (62%). Contusions and fractures were common (80%) with a minority of lacerations (10%). Crush injuries and amputations were rare. Dog bites accounted for 1.5% of the injuries under the age of 10. Females were treated more with painkillers and opioids, especially over the age of 65, with variability between centers. Although the rate of fractures was similar between teens and the elderly, the elderly were treated with immobilization less frequently, and were referred to EDs for further care. Hospital referral rates differed significantly between centers. DISCUSSION: A higher rate of hand trauma was found in the CBECs in comparison to the hospital ED report (35% vs. 20% of all trauma patients, respectively). Patients treated at the CBECs, in comparison to the ED, were less often male, less often young adults, and differed in terms of type of injury. In the CBECs there were more contusions, as well as fewer lacerations and open wound injuries. In contrast, dog bites in children were found to be much more prevalent than previously reported. Hospital referral indications, the use of immobilization and pain management were found to vary according to age, gender and treatment center. Due to the high rate of hand trauma in CBECs, specific protocols are needed for these patients. The use of opioids should be specifically addressed, considering recent changes in treatment protocols. Thus, the prevalence and characteristics of hand trauma may be biased in studies based on hospital records.

Blinking Dermatitis: A Case Report.

CASE REPORT: Quincke sign manifested on the wrist of a young healthy man. The patient had self-treated with topical antibiotics and steroids for a second-degree burn, but then developed contact dermatitis followed by cellulitis. He presented to the emergency department with a "blinking" effect of the skin lesion. CONCLUSION: The "blinking" effect is the result of focal subcutaneous arterial dilatation in the zone of subcutaneous inflammation.

Scaphoid fracture displacement is not correlated with the fracture angle.

Classifications of scaphoid fractures associate the angle of the fracture with its stability. To examine this assumption, we measured acute scaphoid fracture angles and inclinations in relation to different scaphoid axes, using fracture displacement as an indicator of instability. We examined the effect of using different axes on the measurements of angles. CT scans of 133 scaphoid fractures were classified according to the location of the fractures. Using a three-dimensional computer model, we computed four scaphoid axes. For each fracture, we then measured the fracture angle and the direction of the fracture inclination in relation to each one of the axes. We found a correlation between displacement and the angles of proximal fractures using one of these axes (the surface principal component analysis axis). No such correlations were found for waist fractures, which were the majority of fractures. There were significant differences between the measurements made with different axes. The findings indicate that the angle of the fracture and the direction of the fracture inclination are minor factors in the displacement of most scaphoid fractures.Level of evidence: III.

Understanding the Patterns of Deformity of Wrist Fractures Using Computer Analysis.

Computer modeling of the wrist has followed other fields in the search for descriptive methods to understand the biomechanics of injury. Using patient-specific 3D computer models, we may better understand the biomechanics of wrist fractures in order to plan better care. We may better estimate fracture morphology and stability and evaluate surgical indications, design more adequate or effective surgical approaches and develop novel methods of therapy. The purpose of this review is to question the actual advances made in the understanding of wrist fractures using computer models.

Musculoskeletal disorders among dental hygienist and students of dental hygiene.

OBJECTIVES: The purpose of the present study was to present an up-to-date report on the prevalence of musculoskeletal complaints in dental hygienists and dental hygiene students in Israel. It examined the areas of the body that were most frequently affected and the intensity of pain in both groups. The possible differences between groups and the likelihood that musculoskeletal symptoms in students can be attributed to their workload. METHOD: A modified version of The Nordic Musculoskeletal Questionnaire (NMQ) was used to assess reports of Musculoskeletal disorders (MSD) in general and in different body areas. A numerical pain scale was administered to evaluate pain intensity. RESULTS: Two hundred and five women participated in the study: 85 experienced dental hygienists, 17 dental hygiene students and 103 students in a non-clinical track (control group). MSD reports were the most common in the neck (60%), upper back (52%) and lower back (61%). This tendency was seen across all three groups. Hygiene students differed significantly from the control group in terms of number of body areas with MSD and for pain intensity. By contrast, no significant differences were found between dental hygienists and hygiene students, CONCLUSIONS: The findings suggest that dental hygienists and students are at high risk of developing MSD. The high prevalence of MSD among hygiene students underscores the need to commence intervention prior to the initiation of fieldwork.

Approach to the Perpendicular Fixation of a Scaphoid Waist Fracture-A Computer Analyzed Cadaver Model.

PURPOSE: In scaphoid fracture screw fixation, the screw is commonly placed along the long axis of the bone, without consideration of the fracture plane. This position is not perpendicular to transverse waist fractures or to the more common horizontal oblique fractures. Our aim was to examine the feasibility and describe possible approaches to, placing a screw perpendicular and in the center of the scaphoid waist fracture. METHODS: Computed tomography of 12 cadaver wrists was performed in 3 positions to examine possible approaches in flexion, neutral, and extension of the wrist. The scans were evaluated using a 3-dimensional model that simulated horizontal oblique (60°) and transverse (90°) fractures. We examined all possible approaches for screw positioning and their deviation from the axis perpendicular to the fracture and in the center of its plane. RESULTS: The preferred approaches for a perpendicular screw in a horizontal oblique fracture were found to be proximal-dorsal in flexion or transtrapezial in the extended or neutral positions (through the volar-radial trapezium). In transverse fractures, the possible approaches were proximal-dorsal or transtrapezial in the flexed or neutral positions and distal in the extended position (volar to volar-radial trapezium). In these approaches, the screw could be placed perpendicularly (deviating by < 10°) and in the center of the fracture in all specimens. CONCLUSIONS: According to this model, it appears feasible to place a perpendicular screw in the center of a horizontal oblique waist fracture using a proximal-dorsal approach in flexion or a transtrapezial approach in neutral or extension positions of the wrist. Palpable landmarks may be used as additional guides to direct these approaches according to the clinical setting. CLINICAL RELEVANCE: Perpendicular screw fixation of horizontal oblique or transverse scaphoid waist fractures is a possible option, if chosen for its biomechanical advantages.

Scaphoid Fracture Patterns-Part One: Three-Dimensional Computed Tomography Analysis.

Objective Using three-dimensional (3D) computed tomography models of acute scaphoid fractures, we looked for differences between volumetric size of the fracture fragments, recognizable groups, or a shared common fracture area. Methods We studied 51 patients with an adequate computed tomography scan of an acute scaphoid fracture using 3D modeling. Fracture surfaces were identified and fragment volumetric size of the fracture fragments was measured. A principal component analysis was used to find groups. Density mapping was used to image probable common fracture areas in the scaphoid. Results Forty-nine of 51 fractures had a similar pattern. It was not possible to identify subgroups based on fracture pattern. The mean volumetric size of the fracture fragments of the proximal (1.45 cm 3 ± 0.49 cm 3 standard deviation [SD]) and distal fracture fragments (1.53 cm 3 ± 0.48 cm 3 SD) was similar. There was a single common fracture area in the middle third of the bone. In the distal third, there were no horizontal fractures through-but only directly proximal to-the tubercle suggesting that these would be best classified as distal waist fractures. Conclusion Acute scaphoid fractures mainly occur in the middle third of the bone and tend to divide the scaphoid in half by volumetric size of the fracture fragments. There were two distinct grouping patterns: fractures through the proximal and middle third were horizontal oblique, whereas fractures of the distal third were vertical oblique. It seems that scaphoid fractures might be classified into proximal pole fractures, a range of waist fractures, and tubercle avulsion fractures. Level of evidence This is a Level IV study.

The epidemiology of wrist and hand injury in two hospitals in Jerusalem: substantial differences between population subgroups.

BACKGROUND: Wrist and hand injuries are common and constitute a major economic burden. General injury prevention programs have failed to demonstrate a decrease in injury rates. We hypothesized that there are differences in injury patterns in culturally diverse subpopulations of a metropolitan area treated within the same medical system, which may partly explain the difficulties associated with injury prevention. METHODS: We conducted a survey of patients admitted to emergency departments of two hospitals in Jerusalem for wrist and hand injuries during a 3 month period. Patients were asked to complete a questionnaire regarding demographic data, injury type and mechanism. Injury type and mechanism were then compared for age, gender, level of education and degree of religiosity. RESULTS: The questionnaire was completed by 799 patients (response rate 62%; 75% male; average age 27). Thirty-one percent reported they were injured at work, 33% at home and 36% during leisure activities. Data analysis showed that several subpopulations were found to be at risk as compared to their corresponding groups and relative proportion in the overall population of the city. These included contusions after falls in non-ultra-Orthodox Jewish women aged 65 years and over, crush injuries in ultra-Orthodox Jews under the age of 10 (53% vs. 14% for non ultra-Orthodox Jews, respectively) and Muslim teens. Muslims were injured more, especially at work, in comparison to their relative proportion in the population as a whole. CONCLUSION: Different subpopulations at risk and different injury patterns of wrist and hand injuries were found in this culturally heterogeneous population. Awareness of these differences may be the first step when designing specific injury prevention programs in a culturally diverse population. A combined effort of community leaders and government agencies is needed to deal with the specific populations at risk, although legislation may be needed to limit some of the risks such as teens and specific work related hazards and exposures.

First clinical experience with a new injectable recombinant human collagen scaffold combined with autologous platelet-rich plasma for the treatment of lateral epicondylar tendinopathy (tennis elbow).

BACKGROUND: Lateral epicondylitis is a tendinopathy of the common extensor origin at the elbow. When traditional conservative treatment fails, more effective therapies are needed. Vergenix Soft Tissue Repair (STR) Matrix (CollPlant Ltd., Ness-Ziona, Israel) is an injectable gel composed of cross-linked bioengineered recombinant human type I collagen combined with autologous platelet-rich plasma (STR/PRP). The complex forms a collagen-fibrin matrix that promotes cell migration and tissue repair. Based on positive outcomes from preclinical trials, this study is the first clinical trial of STR/PRP on tendinopathy. We hypothesized that STR/PRP would be a safe and effective treatment for lateral epicondylar tendinopathy. METHODS: Patients with chronic lateral epicondylitis underwent treatment with STR/PRP. Outcome assessment included grip strength, functional disability, and changes in sonographic tendon appearance for up to 6 months after treatment. RESULTS: The study enrolled 40 patients. No systemic or local severe adverse events were reported. Clinical evaluation revealed an improvement in the mean Patient-Rated Tennis Elbow Evaluation score from 64.8 before treatment and showed a 59% reduction at 6 months. The 12-Item Short-Form Health Survey questionnaire showed improvement from a mean score of 30.7 to 37.7 at the final follow-up. Grip strength increased from 28.8 kg at baseline to 36.8 kg at 6 months. Improvements in sonographic tendon appearance were evident among 68% of patients. CONCLUSION: STR/PRP is a safe treatment that effectively induces clinically significant improvements in elbow symptoms and general well-being as well as objective measures of strength and imaging of the common extensor tendon within 6 months of treatment of elbow tendinopathy recalcitrant to standard treatments.