Reliability, usability and applicability of the ICD-11 beta draft focusing on hand injuries and diseases: results from German field testing.

OBJECTIVE: To test the interrater reliability when using the codes of the 11th revision of the International Classification of Diseases (ICD)-11 beta draft as well as ICD-10 and to explore the usability of the ICD-11 beta draft and the applicability of ICD-11's Supplementary section for functioning assessment in hand injuries and diseases. DESIGN: We conducted a validation study of the ICD-11 beta draft complemented by a single-centre study to collect clinical routine data on functioning. SETTING: German hand surgery clinics. PARTICIPANTS: Twenty-three physicians coded real-life cases containing diagnostic information on hand injuries and diseases. Additionally, clinical information of 100 patients was coded by 6 physicians and a nurse using ICD-11's Supplementary section for functioning assessment. MAIN OUTCOME MEASURES: Physicians coded 210 cases using the ICD-11 beta draft and ICD-10. Krippendorff's alpha was calculated. Clinical routine data was coded using 38 functioning categories. RESULTS: Interrater reliability (Krippendorff's alpha) of 0.67 for ICD-11 coding and 0.71 for ICD-10 coding was obtained, indicating substantial agreement. However, physicians reported a high proportion of problems with ICD-11 coding and slightly fewer problems with ICD-10 coding. The collected data on functioning could be mapped to ICD-11's Supplementary section for functioning assessment. For some data, however, only unspecific codes were available. CONCLUSIONS: Interrater reliability of ICD-10 and ICD-11 was satisfactory. Training material for ICD-11 is needed to further improve reliability and usability. Future users of ICD-11 should be encouraged to use the Supplementary section for functioning assessment to shed light on the problems patients experience in everyday life.

Review of catastrophic hand diagnosis over 15 years in a tertiary hospital: do we make proper use of the term? / Revisión del diagnóstico de mano catastrófica a lo largo de 15 años en un hospital terciario: ¿hacemos un uso adecuado del término?

OBJECTIVE: To describe the characteristics of patients diagnosed with 'catastrophic hand' by the plastic surgery department in a tertiary hospital in the period between 2000-2015, analyse the evolution of the use of the term 'catastrophic hand' and conduct a review of the literature with a view to proposing the optimal definition for said expression. MATERIAL AND METHOD: We conducted a descriptive and retrospective study of patients diagnosed with 'catastrophic hand' who required hospital care by the plastic surgery department of a tertiary hospital in the period between 2000-2015. We conducted a literature review on the use of the term 'catastrophic hand' and we applied the classifications proposed in the publications consulted to our results. RESULTS: The number of 'catastrophic hand' diagnoses was 133. We observed a downward trend in the use of the term over the years. Applying classifications based on the impossibility of recovery of an acceptable hand (presence of three long fingers and thumb) by reconstructive procedures, only 9 out of 133 patients could be considered to have 'catastrophic hands', constituting 6.7% of the total cases. DISCUSSION: The term 'catastrophic hand' has different meanings, and this generates ambiguity. The use of a classification based on the possibility of obtaining an acceptable hand diminishes its use and improves the approach for such injuries. CONCLUSION: We advocate limiting the use of 'catastrophic hand' to cases that meet criteria of 'mutilated hand' and 'metacarpal hand' to avoid indiscriminate use of the term and optimise therapeutic management.

Lumbrical muscle tear: clinical presentation, imaging findings and outcome.

The incidence of lumbrical muscle tear is increasing due to the popularity of climbing sport. We reviewed data from 60 consecutive patients with a positive lumbrical stress test, including clinical examination, ultrasound and clinical outcomes in all patients, and magnetic resonance imaging in 12 patients. Fifty-seven patients were climbers. Lumbrical muscle tears were graded according to the severity of clinical and imaging findings as Grade I-III injuries. Eighteen patients had Grade I injuries (microtrauma), 32 had Grade II injuries (muscle fibre disruption) and 10 had Grade III injuries (musculotendinous disruption). The treatment consisted of adapted functional therapy. All patients completely recovered and were able to return to climbing. The healing period in Grade III injuries was significantly longer than in the patients with Grade I or II injuries ( p < 0.001). We recommend evaluation of specific clinical and imaging findings to grade the injuries and to determine suitable therapy. LEVEL OF EVIDENCE: IV.

Interposition Tendon Graft and Tension in the Repair of Closed Rupture of the Flexor Digitorum Profundus in Zone III or IV.

We report the results of interposition tendon grafts using the ipsilateral palmaris longus tendon in 12 patients with closed flexor digitorum profundus tendon ruptures in zone III or IV of 14 digits between June 2006 and October 2015. Before surgery, 2 patients were diagnosed with closed tendon ruptures that occurred after nonunion of hamate hook fractures. The other 10 patients were diagnosed with spontaneous tendon ruptures of unknown cause. In 2 of the 10 patients with spontaneous tendon rupture, the cause of the rupture was not found. In the other 8 patients, there was rough surface with deficient overlying soft tissue on the radial side of the hamate hook. In all cases, the ruptured flexor digitorum profundus was reconstructed by applying overtension on the tendon graft, causing greater flexion than for the other normal digits. Hamate hook excision was also performed on 10 subjects with abnormalities. Postoperatively, the patients were followed for an average of 22.5 months (range, 12-64 months). At the final follow-up, the mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 5.7 (range, 3.3-8.3). There were excellent results in all 14 digits according to Strickland and Glogovac criteria. The mean total active motion was 167 degrees (range, 160-180 degrees). There were no surgical complications, including infection, adhesions, or tendon rerupture. There were excellent clinical results with the interposition tendon graft using palmaris longus for closed tendon rupture in zone III or IV of the hand. Applying overtension to the grafted tendon appears to be beneficial.

International Classification of Functioning, Disability and Health: development of an assessment set to evaluate functioning based on the Brief ICF Core Set for Hand Conditions - ICF HandA.

Timely identification of patients' problems after disorder or injury of the hand requires a thorough functional assessment. However, the variety of outcome measures available makes it difficult to choose the appropriate instrument. The brief International Classification of Functioning, Disability and Health (Brief ICF Core Set for Hand Conditions) provides a standard for what aspects need to be measured in hand injuries and disorders without specifying how to make the assessment. We developed the ICF-based Assessment Hand (ICF HandA), an assessment set for functioning based on the Brief ICF Core Set for Hand Conditions. First, we performed a literature review and an expert survey to pool outcome measures appropriate to assess functioning in clinical practice. At an interdisciplinary consensus conference experts decided on the outcome measures to be included in the ICF HandA. The ICF HandA provides a consensus on outcome measures and instruments to systematically assess function in patients with hand injuries and disorders.

A Novel Classification System for Injuries After Electronic Cigarette Explosions.

Electronic cigarettes (e-cigarettes) contain lithium batteries that have been known to explode and/or cause fires that have resulted in burn injury. The purpose of this article is to present a case study, review injuries caused by e-cigarettes, and present a novel classification system from the newly emerging patterns of burns. A case study was presented and online media reports for e-cigarette burns were queried with search terms "e-cigarette burns" and "electronic cigarette burns." The reports and injury patterns were tabulated. Analysis was then performed to create a novel classification system based on the distinct injury patterns seen in the study. Two patients were seen at our regional burn center after e-cigarette burns. One had an injury to his thigh and penis that required operative intervention after ignition of this device in his pocket. The second had a facial burn and corneal abrasions when the device exploded while he was inhaling vapor. The Internet search and case studies resulted in 26 cases for evaluation. The burn patterns were divided in direct injury from the device igniting and indirect injury when the device caused a house or car fire. A numerical classification was created: direct injury: type 1 (hand injury) 7 cases, type 2 (face injury) 8 cases, type 3 (waist/groin injury) 11 cases, and type 5a (inhalation injury from using device) 2 cases; indirect injury: type 4 (house fire injury) 7 cases and type 5b (inhalation injury from fire started by the device) 4 cases. Multiple e-cigarette injuries are occurring in the United States and distinct patterns of burns are emerging. The classification system developed in this article will aid in further study and future regulation of these dangerous devices.

Metacarpal-Like and Metacarpal Hand.

The metacarpal-like and metacarpal hand injuries are devastating conditions that render the hand nonfunctional. Although the metacarpal hand is well-studied, the metacarpal-like hand is never addressed. The authors, using the same principles as in the classification and treatment of metacarpal hand, propose an easy to follow treatment algorithm for metacarpal-like hand injury to guide the reconstructive surgeon. For both injuries, microsurgical toe-to-hand transplantation can restore an acceptable level of function if done properly. Meticulous planning is essential for the toe-to-hand surgery to achieve its prime goal of stable tripod pinch with insignificant morbidity at the donor sites.

Hand trauma: A prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements.

BACKGROUND: Hand injuries are common, contributing up to 30% of accident and emergency (A&E) attendances. The aim of this study was to prospectively analyse the pathological demographics of hand injuries in a level 1 trauma centre with a Hand Trauma Unit and direct A&E links, and compare clinical and intra-operative findings. The null hypothesis was that there would be no differences between clinical and intra-operative findings (100% diagnostic concordance). METHODS: Data were prospectively collected for referrals during 2012. Referral diagnosis, additional pathologies found on clinical assessment and intra-operative findings were documented on a live database accessible from both the Hand Unit and associated operating theatres. Odds ratios were calculated using SAS. RESULTS: Injuries (1526) were identified in 1308 patients included in the study. Diagnostic concordance between Hand Unit clinical examination and intra-operative findings was 92.5% ± 2.85% (mean ± SEM); this was lower for flexor tendon injuries (56.3%) because a greater number of additional pathologies were found intra-operatively (2.25 ± 0.10). This 'trend' was noted across multiple referral pathologies including phalangeal fractures (1.28 ± 0.02; 82.9%), lacerations (1.33 ± 0.04; 79.1%), extensor tendon injuries (1.30 ± 0.05; 87.8%) and dislocations (1.18 ± 0.05; 87.8%). Odds ratio analysis indicated a relationship between primary referral diagnoses that were more or less likely to be associated with additional injuries (p < 0.05); referral diagnoses of flexor tendon injuries and lacerations were most likely to be associated with additional injuries. CONCLUSIONS: As hand injuries are a common presentation to A&E departments, greater emphasis should be placed on training clinicians in the management of hand trauma. Our findings, coupled with the presented relevant literature reports, lead us to advocate that A&E departments should move towards a system wherein links to specialist hand trauma services are in place; we hereby present useful data for hospitals implementing such services.

[Primary flexor tendons repair in zone 2]. / Réparation primitive des tendons fléchisseurs en zone 2.

Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.

[Management of zone 1 flexor digitorum profundus tendon injuries]. / Prise en charge des lésions du tendon fléchisseur profond des doigts en zone 1.

Flexor tendons repair in zone 1 is classically considered providing good results with an overall satisfactory finger function. However, the objective functional results after surgical repair of flexor digitorum profundus are sometimes disappointing. The authors describe the different surgical repair techniques available to the operator from so-called "traditional" sutures to newer methods of internal fixation using miniaturized anchor sutures. The management of postoperative procedures, that of failures and old cases are reported.

Malunited fractures in the hand.

Posttraumatic deformity of a tubular bone in the hand after malunion can impact function due to alteration in mobility, strength, or associated pain. Surgical intervention is often indicated, with the surgical options based on both the type and location of the deformity, as well as any associated articular, tendon, or soft tissue constraints. This article provides a management approach based on the deformity classification, location, and any associated conditions.

Clinical use of a combined grasping and locking core suture technique for flexor tendon repair in zone II.

Previous authors have used either a grasping or a locking technique for flexor tendon repair in zone II. A combined (grasping and locking) 10-strand repair was used by the author in 22 adults (n = 28 fingers) with lacerations of both flexor tendons in zone II. The combined repair is known to be strong (mean tensile strength of 164 N), and the technique was used in selected cases who were thought to be at higher risk of rupture either because of excessive digital oedema (in early tendon repairs) or because of tendon retraction (in late primary tendon repairs). The 10-strand repair was bulky and, hence, only the profundus tendon was repaired; and "venting" of the pulley system was done proximal to the repair site as recommended by other authors. Supervised early active mobilisation was done immediately after the operation. At final follow-up, the outcome was calculated using the original Strickland-Glogovac grading system. There were no ruptures and the final outcome was considered excellent in 19 patients (n = 25 fingers), good in two patients (n = 2 fingers), and fair in the remaining patient (n = 1 finger). It was concluded that the bulky 10-strand repair may be used for zone II finger flexor tendon lacerations as long as a profundus-(?) only repair and "venting" of the pulley system are performed.

The recall DASH score--a novel research tool.

The DASH score is a universally accepted method for assessment of hand function. However, there are occasions when a pre-treatment DASH score is unavailable. This study provides a solution to this situation. An initial DASH score was obtained from all patients at the time of their first clinic visit. A second score was obtained at the time of final follow-up asking the patient to "Recall" their pre-treatment status. The two scores were compared with appropriate statistical analysis. Thirty-eight patients were included in the study and scores were obtained at an average time interval of 32 weeks (6-121 weeks). Excellent agreement was noted for the ability of the patient population to recall their scores with a group correlation of 0.86. This proves that the Recall DASH score is an excellent and useful research tool for use in hand surgery.

[Evaluation of hand injury severity]. / Ocena ciezkosci obrazen rak.

Hand Trauma Severity Scale (HTSS) was created on the basis of our study on 1199 patients who were treated because of the hand injuries in the Second Chair of Surgery Jagiellonian University in Krakow in years 1987-2000. (last examination in 2010, follow-up: 11 to 23 years, mean follow-up: 16 years). Hand Trauma Severity Scale (HTSS) has been created based on We looked at the range of injury, likely total length of treatment, final functional result and possible amount of posttraumatic disability. Created HTSS scale was compared to Hand Injury Severity Score (HISS) and their statistically significant correlation (p < 0,001) was found. We have also found statistically significant correlation between the severity evaluated with HTSS and the circumstances of traumas, their direct cause, necessity of hospitalization after primary reconstructive treatment and total length of treatment. Distant results of treatment such as resuming of previously performed work and permanent posttraumatic disability also correlated with the severity of hand injuries measured with scale described in this study.

A new pathway to classification of complex hand injuries: a clinical pilot testing using a new method of assessment.

All existing classifications, which are based on the severity of hand injuries, are being referred to facets of variety of hand injuries in general. A clear picture of all consequences of hand injuries would be apparent, if any kind of injury mechanism and occurrence of an injury would be identified and academically captured. Predictions regarding return to the former occupation and rehabilitation time would be possible with further study; 102 patients with different hand injuries were engaged in a pilot project using a specifically designed assessment sheet to achieve this purpose in the framework of a retrospective clinical testing within 1 year. Data were summarized and demonstrated graphically. Each category showed a picture of prior localization of the injury and its morphology. All categories show specific injury patterns. The choice of categories reflects the mechanisms of injury emphasized in literature. Furthermore, the mean DASH equivalents of one category were compared to the mean Hand Injury Severity Scoring (HISS) scores in order to get an initial idea of information on the degree of severity. A first impression of the potential of this assessment sheet has been obtained with regard to the above. With further study, we could evaluate the assessment sheet and try to create a classification of the grade of severity as well as prognostic values like return to the former occupation and rehabilitation time.

[Classification and treatment of whole hand degloving injury].

OBJECTIVE: To summarize the injury characteristics of the whole hand degloving injury and to explore its classification and treatment. METHODS: Between December 1999 and May 2010, 41 cases of the whole hand degloving injury were admitted for treatment. There were 28 males and 13 females with an average age of 35 years (range, 18-58 years). The causes of injury included mangled injury in 28 cases and crush injury in 13 cases. The interval between injury and surgery was 1-10 hours (mean, 3 hours). According to self-made classification standard for whole hand degloving injury, 11 cases were rated as type I, 5 cases as type II, 4 cases as type III, 8 cases as type IV, and 13 cases as type V. Type I injury was treated by replantation surgery with vascular anastomosis, type II by reconstruction with thumb flap and the second toe containing dorsal skin flap, type III by reconstruction with the second toe containing dorsal skin flap of both feet, type IV by replantation surgery with vascular anastomosis, and type V by reconstruction with thumb flap containing dorsal skin flap (8 cases) or repairing with abdominal flap (5 cases). The size of the dorsal flap was between 9 cm x 6 cm and 17 cm x 11 cm and the dorsal donor site was covered with free skin grafting. RESULTS: After surgery, partial necrosis occurred at fingers in 6 patients with type I injury, and at fingers and palm skin in 6 patients with type IV injury; the flaps, the reconstructed fingers, and replanted skin all survived in the others. The grafted skin at donor sites successfully healed. Forty cases were followed up from 6 months to 7 years (mean, 14 months). The skin color and texture were close to normal hand in the cases undergoing replantation, who had the best function restoration with S2-S4 sensory recovery; the hand function was basically restored with S2-S3 sensory recovery in the cases undergoing finger reconstruction with thumb and toe flaps; and the restoration of the hand function was not satisfactory with S1-S2 sensory recovery in the cases undergoing abdominal flaps. CONCLUSION: Whole hand degloving injury can be classified into different types according to injury degree and this will help choose the clinical treatment plan. The appropriate treatment based on these

[Rollover hands: classification of injuries and therapeutic strategy]. / «Mains de portière¼: classification lésionnelle et stratégie thérapeutique.

UNLABELLED: The term Rollover hands (ROHs) corresponds to a loss of compound tissue from the back of the hand. Our aim was to specify the injuries associated with this type of accident and codify the therapeutic strategy. PATIENTS AND METHOD: Twenty-one ROHs were reviewed with an average follow-up of 38 months. Skin coverage included 15 pedicle flaps (two posterior interosseous, 13 pedicled groin flaps), and three free flaps (two external brachial or one parascapular). RESULTS: We identified: seven stage IA injuries where the extensor apparatus could be directly sutured; Seven stage IB injuries requiring a tendon graft; Stage II, like stage 1B but with bone and joint lesions or damage to the wrist extensors as well, and Stage III for which over 50% of the intrinsic muscles had been destroyed. All patients recovered their grasp. The mean active extension deficit for each finger was -20.9° for the whole digital chain and a 194.4° TAM. Palmo-digital grip strength was 51.3% on the controlateral side, and the mean DASH score was 16.1. DISCUSSION: Our study demonstrates the prognostic value of the proposed classification and importance of restoring high-quality skin covering. Reconstruction of the extensor apparatus must be envisaged once the condition of the bone and joints has become stable. Vascularised tendon grafts may be indicated when early mobilisation allowing restoration of a glliding surface around the tendon is impossible, or for loss of substance of over 5 cm. Damage to the intrinsic muscles is a very poor prognostic factor.

[The Nuremberg Handscore: a new instrument to gain information on subjective assessment of hand burns]. / Der Nürnberger Handscore. Ein neues System zur Erfassung von Verbrennungsfolgen an der Hand.

Follow-up examinations are necessary to reveal consequences of burn injuries of the hand that are suitable for treatment. However, many patients do not attend such a check-up. A standardised protocol like the DASH questionnaire can help to get at least a minimum of information. We have tested a new set of questions among 81 patients who have been treated at our institution between 2006 and 2007 because of severe burns of their hand. A new coefficient could be calculated, which can fulfill the requirements of a scoring system after burn injuries of the hand quite well. It can be easily applied so that we recommend its use whenever it is not possible to perform a regular medical examination.

DASH and sollerman test scores after hand injury from powered wood splitters.

The purpose of the study was to describe the outcome after hand injury from powered wood splitters, and to investigate the relation between injury severity and outcome. Injury severity was rated according to the Hand Injury Severity Scoring System (HISS system) and the Injury Severity Score method. The patients were evaluated with the Disabilities of the Arm Shoulder and Hand outcome questionnaire (DASH), and 26 of the most severely injured patients were evaluated with the Sollerman test. The mean DASH score was moderately elevated at 15, indicating that many of these patients have sequelae. A statistically significant correlation between HISS and DASH scores was found, implying that initial injury severity is of importance for outcome. The mean Sollerman score in the injured hand was 66, which amounts to a significantly impaired hand function.