The Epidemiology of Upper Extremity Nerve Injuries and Associated Cost in the US Emergency Departments.

BACKGROUND: The purpose of our study was to determine the incidence and average cost of nerve injuries in patients presenting with upper extremity trauma. METHODS: The Nationwide Emergency Department Sample database was queried using International Classification of Diseases, Ninth Revision codes specific to peripheral nerve injuries of the upper extremity. Data on the incidence, patient demographics, average number of associated diagnoses, Injury Severity Scale (ISS) score, mechanism of injury, and average cost of care were collected and analyzed. RESULTS: Of 1.58 million upper extremity traumatic injuries, there were 5244 nerve injuries, resulting in an annual incidence of 16.9 per 100,000 persons with an average age of 38.42 years. Ulnar nerve injuries were the most common (3.86 per 100,000) followed by digital nerve (2.96 per 100,000), radial nerve (2.90 per 100,000), and median nerve (2.01 per 100,000). Injuries to the brachial plexus had the highest average ISS score (9.79 ± 0.71) and number of presenting diagnoses (8.85 ± 0.61) while having a lower than average emergency department (ED) cost. Patients with digital nerve injuries had the highest average ED cost ($8931.01 ± $847.03), whereas their ISS score (2.82 ± 0.19) and number of presenting diagnoses (4.92 ± 0.22) were the lowest. The most commonly reported mechanism of injury in this study population was from a laceration (29.2%) followed by blunt injury, fall (14.8%), and being struck (7.20%). Males were 2.14 (2.01-2.28) times more likely to have an injury to an upper extremity nerve and 3.25 (2.79-3.79) times more likely to injure a digital nerve. CONCLUSIONS: While there was a low incidence of upper extremity nerve injuries associated with upper extremity trauma, the ulnar nerve was most frequently injured. Males were twice as likely to sustain a traumatic upper extremity nerve injury, with laceration being the most common mechanism of injury. The average ED cost associated with upper extremity nerve injuries in the United States was determined to be approximately $5779.

Indirect Cost of Traumatic Brachial Plexus Injuries in the United States.

BACKGROUND: Traumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect cost associated with BPI. METHODS: We estimated indirect costs as the sum of (1) short-term wage loss, (2) long-term wage loss, and (3) disability payments. Short-term (6-month) wage loss was the product of missed work days and the average earnings per day. The probability of return to work was derived from a systematic review of the literature, and long-term wage loss and disability payments were estimated. Monte Carlo simulation was used to perform a sensitivity analysis of long-term wage loss by varying age, sex, and return to work simultaneously. Disability benefits were estimated from U.S. Social Security Administration data. All cost estimates are in 2018 U.S. dollars. RESULTS: A systematic review of the literature demonstrated that the patients with BPI had a mean age of 26.4 years, 90.5% were male, and manual labor was the most represented occupation. On the basis on these demographics, our base case was a 26-year-old American man working as a manual laborer prior to BPI, with an annual wage of $36,590. Monte Carlo simulation estimated a short-term wage loss of $22,740, a long-term wage loss of $737,551, and disability benefits of $353,671. The mean total indirect cost of traumatic BPI in the Monte Carlo simulations was $1,113,962 per patient over the post-injury lifetime (median: $801,723, interquartile range: $22,740 to $2,350,979). If the probability of the patient returning to work at a different, lower-paying job was doubled, the per-patient total indirect cost was $867,987. CONCLUSIONS: BPI can have a far-reaching economic impact on both individuals and society. If surgical reconstruction enables patients with a BPI to return to work, the indirect cost of this injury decreases. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample.

OBJECTIVE: Epidemiology in upper extremity peripheral nerve injury (PNI) has not been comprehensively evaluated. The aim of this study was to calculate updated incidence of upper extremity PNIs in the United States and examine clinical trends and costs using a national database. METHODS: The National (Nationwide) Inpatient Sample was used to evaluate patients with upper extremity PNI (International Classification of Diseases, Ninth Revision, Clinical Modification 9534, 9550-9559) in 2001-2013. RESULTS: A weighted total of 170,579 patients experienced upper extremity PNI, representing a mean incidence of 43.8/1 million people annually. Mean (± SEM) age of patients was 38.1 ± 0.05 years, 74.3% of patients were male, and 49.0% were Caucasian. PNIs occurred to the ulnar (17.8%), radial (15.1%), digital (18.0%), median (13.0%), multiple (11.5%), and other (10.1%) nerves and brachial plexus (14.5%). The number of upper extremity PNIs decreased overall. Average care charge was $47,004 ± $185, with an average increase of $4623/year and compound annual growth rate of 9.59%. Although surgical nerve repair and home disposition were common with isolated PNIs, patients with brachial plexus PNIs did not have nerve surgery and were more likely to be discharged to skilled nursing facilities. Multivariate analysis showed that length of stay (ß = 0.677, P = 0.0001) and number of procedures (ß = 0.188, P = 0.0001) most affected total patient charges. CONCLUSIONS: These results suggest an overall decrease in number of PNIs, suggesting lower incidence or frequency of detection; however, the cost of care has increased. Despite advances in nerve repair techniques, nerve surgery rates have not increased, especially for brachial plexus injuries, which may be undertreated.

Litigation relating to conditions affecting the shoulder and elbow: an analysis of claims against the National Health Service.

We present a review of claims made to the NHS Litigation Authority (NHSLA) by patients with conditions affecting the shoulder and elbow, and identify areas of dissatisfaction and potential improvement. Between 1995 and 2012, the NHSLA recorded 811 claims related to the shoulder and elbow, 581 of which were settled. This comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total of £18.2 million was paid out in settled claims. Overall diagnosis, mismanagement and intra-operative nerve injury were the most common reasons for litigation. The highest cost paid out resulted from claims dealing with incorrect, missed or delayed diagnosis, with just under £6 million paid out overall. Fractures and dislocations around the shoulder and elbow were common injuries in this category. All 11 claims following wrong-site surgery that were settled led to successful payouts. This study highlights the diagnoses and procedures that need to be treated with particular vigilance. Having an awareness of the areas that lead to litigation in shoulder and elbow surgery will help to reduce inadvertent risks to patients and prevent dissatisfaction and possible litigation.

Digital nerve injuries: epidemiology, results, costs, and impact on daily life.

Epidemiology, results of treatment, impact on activity of daily living (ADL), and costs for treatment of digital nerve injuries have not been considered consistently. Case notes of patients of 0-99 years of age living in Malmö municipality, Sweden, who presented with a digital nerve injury and were referred to the Department of Hand Surgery in 1995-2005 were analysed retrospectively. The incidence was 6.2/100 000 inhabitants and year. Most commonly men (75%; median age 29 years) were injured. Isolated nerve injuries and concomitant tendon injuries were equally common. The direct costs (hospital stay, operation, outpatient visits, visits to a nurse and/or a hand therapist) for a concomitant tendon injury was almost double compared with an isolated digital nerve injury (6136 EUR [range, 744-29 689 EUR] vs 2653 EUR [range, 468-6949 EUR]). More than 50% of the patients who worked were injured at work and 79% lost time from work (median 59 days [range 3-337]). Permanent nerve dysfunction for the individual patient with ADL problems and subjective complaints of fumbleness, cold sensitivity, and pain occur in the patients despite surgery. It is concluded that digital nerve injuries, often considered as a minor injury and that affect young people at productive age, cause costs, and disability. Focus should be directed against prevention of the injury and to improve nerve regeneration from different aspects.

A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair.

BACKGROUND: Mesh fixation during laparoscopic total extraperitoneal (TEP) inguinal hernia repair is still controversial. Although many surgeons considered it necessary to fix the mesh, some published studies supported elimination of mesh fixation. Therefore, a meta-analysis based on randomized controlled trials (RCTs) was conducted to compare the effectiveness and safety of fixation versus nonfixation of mesh in TEP. METHODS: RCTs were identified from PubMed, Embase, the Cochrane Library, SCI, and the Chinese Biomedical Literature Database (CBM). Two reviewers assessed the quality of the studies and extracted data independently. The methodological quality was evaluated according to the Cochrane Handbook 5.0.2. Statistical analysis was conducted using the Cochrane software RevMan 5.0.21. RESULTS: Six RCTs involving 772 patients were included. The nonfixation group had advantages in length of hospital stay [MD =-0.37, 95% CI (-0.57, -0.17), p = 0.0003], operative time [MD = -4.19, 95% CI (-7.77, -0.61), p = 0.02], and costs. However, there was no statistically significant difference in hernia recurrence [OR = 2.01, 95% CI (0.37, 11.03), p = 0.42], time to return to normal activities [MD = -0.13, 95% CI (-0.45, 0.19), p = 0.43], seroma [OR = 1.25, 95% CI (0.30, 5.18), p = 0.75], and postoperative pain on postoperative day 1 [MD = -0.21, 95% CI (-0.52, 0.10), p = 0.18] and day 7 [MD = -0.11, 95% CI (-0.42, 0.20), p = 0.47]. CONCLUSIONS: Without increasing the risk of early hernia recurrence, the nonfixation of mesh in TEP appears to be a safe alternative that is associated with less costs, shorter operative time, and hospital stay for the selected patients. Further adequately powered RCTs are required to clarify whether mesh fixation is necessary for the patients with different types of hernias and larger hernia defects.