Digital Nerve Injury: Assessment and Treatment.

Undertreated digital nerve injuries may result in sensory deficits and pain. Early recognition and treatment will optimize outcomes, and providers should maintain a high index of suspicion when assessing patients with open wounds. Acute, sharp lacerations may be amenable to direct repair while avulsion injuries or delayed repairs require adequate resection and bridging with nerve autograft, processed nerve allograft, or conduits. Conduits are most appropriate for gaps less than 15 mm, and processed nerve allografts have demonstrated reliable outcomes across longer gaps.

Appropriateness of patients transferred with orthopedic injuries: experience of a level I trauma center.

BACKGROUND: Trauma patients are frequently transferred to a higher level of care for specialized orthopedic care. Many of these transfers are not necessary and waste valuable resources. The purpose of this study was to quantify our own experience and to assess the appropriateness of orthopedic transfers to a level I trauma center emergency department. METHODS: A retrospective review of orthopedic emergency department transfers to a level I trauma center was performed. Data collected included time of transfer, injury severity score (ISS), age, gender, race, orthopedic coverage at transfer institution, and insurance status. Two orthopedic trauma surgeons graded the appropriateness of transfer. A weighted logistic regression model was used to compare dependent and independent variables. RESULTS: A total of 324 patient transfers were reviewed; 65 (20.1%) of them were graded as inappropriate. There was no statistically significant relationship between appropriateness of transfer and age, availability of orthopedic coverage, night/weekend transfer, or insurance status. Regression analysis showed that only ISS (OR 1.130, p = .008) and "polytrauma" (OR 25.39, p < .0001) designation were associated with increased odds ratio of appropriate transfer. The kappa coefficient for inter-rater reliability between the two raters was 0.505 (95% CI, 0.388-0.623) reflecting moderate agreement. CONCLUSION: Inappropriate transfers create a significant medical burden to our health care system using valuable resources. Our study found similar results of inappropriate transfers compared to previous studies. However, we did not find a relationship between insurance status or nights/weekends and transfer appropriateness.

A Preliminary Assessment of the Utility of Large-Caliber Processed Nerve Allografts for the Repair of Upper Extremity Nerve Injuries.

Background: Cabled sensory nerve autografts are the historical gold standard for overcoming gaps in larger diameter nerves as repair utilizing large-diameter autograft risks central graft necrosis. Commercially available processed nerve allograft (PNA) is available in diameters up to 5 mm but represents an acellular 3-dimensional matrix as opposed to viable tissue. The purpose of this study is to specifically evaluate whether similar concerns regarding the use of large-caliber PNA are warranted. Methods: The RANGER Registry is an active database designed to collect injury, repair, safety, and outcomes data for PNAs (Avance® Nerve Graft; AxoGen, Inc, Alachua, Florida) according to an institutional review board-approved protocol. The database was queried for patients presenting with large-caliber nerve allograft repairs in the upper extremity. Identified patients reporting quantitative outcomes with a minimum of 9-month follow-up were included in the data set. Results: The large-caliber PNA subgroup included 13 patients with 15 injuries. The mean ± SD age was 36 ± 22 years. Large-caliber single-stranded repairs included twelve 4- to 5-mm-diameter grafts. Large-caliber cabled repairs included the combined use of 3- to 4-mm and 4- to 5-mm-diameter nerve allografts in 3 repairs. The mean nerve gap was 33 ± 10 mm with a mean follow-up time of 13 months. Available quantitative data reported meaningful recovery of sensory and motor function in 67% and 85% of the repairs, respectively. Conclusion: Although based on a small subset of patients, PNAs of up to 5 mm in diameter appear capable of supporting successful nerve regeneration.

Technical Assessment of Connector-Assisted Nerve Repair.

PURPOSE: Clinical outcomes of nerve repair have not substantially improved over the last several decades. Although clearly a multifactorial problem, basic principles including proper fascicular alignment are not always realized. The use of short conduits as connectors may enhance nerve alignment by entubulating and directing the approximation of nerve ends. METHODS: Ten hand surgeons (5 experienced and 5 inexperienced) performed a series of in vitro human cadaver nerve repairs. Three small-diameter (2 mm), 3 medium-diameter (3-4 mm), and 3 large-diameter (5-6 mm) nerves were repaired (under 10× magnification) utilizing each of 3 techniques: suture-only, connector-only (sutures placed through the ends of the connector), and connector-assisted (alignment sutures at the nerve interface plus connector). Three judges (blinded to who performed the repairs) assessed each repair for fascicular alignment based on predetermined qualitative scales. RESULTS: Across all surgeons, 23 of 30 connector-assisted repairs were judged good or excellent versus 18 of 30 of the suture-only and 13 of 30 of the connector-only repairs. Experienced surgeons in general did better repairs and in particular were more likely to obtain superior alignment for conduit-only repairs (73.3% vs 13.3% good or excellent) and suture-only repairs (73.3% vs 46.7% good or excellent) and were not statistically different for connector-assisted repairs (86.7% vs 66.7% good or excellent) compared with inexperienced surgeons. CONCLUSIONS: In a cadaver nerve model, there was no significant difference in the technical alignment of conduit-assisted repairs between experienced and inexperienced surgeons whereas inexperienced surgeons were more likely to achieve inadequate alignment with suture-only or conduit-only repairs. CLINICAL RELEVANCE: Connector-assisted repairs combining suture-approximation and entubulation may improve the technical alignment of nerve repairs performed, especially by less-experienced surgeons.