Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND: We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution. QUESTIONS/PURPOSES: Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment? METHODS: In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores. RESULTS: Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (ß 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (ß 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (ß -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment. CONCLUSION: Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics. LEVEL OF EVIDENCE: Level III, therapeutic study.

High-Risk Chief Complaints III: Abdomen and Extremities.

Abdominal and extremity complaints are common in the emergency department (ED) and, because of their frequency, clinical vigilance is vital in order not to miss the timely diagnosis of occult or delayed emergencies. Such emergencies, if not timely managed, are sources of significant patient morbidity and mortality and may expose ED physicians to possible litigation. Each patient complaint yields to a nuanced approach in diagnostics and therapeutics that can lead physicians toward the ruling in or out of the correct high-risk diagnosis. This article discusses the approach and risk management of this high-risk subset of abdominal and extremity diagnoses.

Impact of Patient-Surgeon Relationship on Patient's Return to Work.

BACKGROUND: Upper-limb injuries and musculoskeletal disorders represent a major economic burden for both patients and society, largely due to limitations in returning to work. We hypothesized that a positive patient-surgeon relationship may facilitate patients' recovery and lead to a faster return to work. METHODS: This longitudinal observational study comprised 219 patients, from 8 French hand trauma centers, who were 18 to 55 years of age and were on sick leave from work because of an injury or musculoskeletal disorder of the upper limb. In addition to instruments measuring patients' functional scores and quality of life, the quality of the patient-surgeon relationship was assessed at enrollment using a specific questionnaire (Q-PASREL [Quality of PAtient-Surgeon RELationship]). Six months after enrollment, the return-to-work status was assessed. Logistic and Cox regression models were developed to identify predictors of return to work (yes/no) and the time off from work in days. RESULTS: Overall, 74% of the patients who returned to work within 6 months after enrollment had a high or medium-high Q-PASREL score, whereas 64% of the patients who were still on sick leave had a low or medium-low Q-PASREL score. The odds of patients with a low or medium-low Q-PASREL score returning to work were, respectively, 95% and 71% lower than the odds of patients with a high score doing so, with a percent difference of 56% (95% confidence interval [CI] = 40% to 71%) for low versus high (odds ratio [OR] = 0.05 [95% CI = 0.02 to 0.13]) and 25% (95% CI = 6% to 44%) for medium-low versus high (OR = 0.29 [95% CI = 0.11 to 0.76]). All Q-PASREL items and scores were significantly associated with return to work. CONCLUSIONS: Patients with a lower Q-PASREL score and more severe disability were less likely to return to work within 6 months and had a longer time off from work. Efforts to improve the quality of patient-surgeon relationships may minimize the duration of sick leaves and accelerate patient recovery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Gunshot Injuries to the Extremity: Is Immediate General Surgery Presence Needed?

Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSW require frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for a GSW isolated to the extremity is low.

The Youth Throwing Score: Validating Injury Assessment in Young Baseball Players.

BACKGROUND: Epidemic levels of shoulder and elbow injuries have been reported recently in youth and adolescent baseball players. Despite the concerning frequency of these injuries, no instrument has been validated to assess upper extremity injury in this patient population. Purpose/Hypothesis: The purpose of this study was to validate an upper extremity assessment tool specifically designed for young baseball players. We hypothesized that this tool will be both reliable and valid. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: The Youth Throwing Score (YTS) was constructed by an interdisciplinary team of providers and coaches as a tool to assess upper extremity injury in youth and adolescent baseball players (age range, 10-18 years). The psychometric properties of the test were then determined. RESULTS: A total of 223 players completed the final survey. The players' mean age was 14.3 ± 2.7 years. Pilot analysis showed that none of the 14 questions received a mean athlete importance rating less than 3 of 5, and the final survey read at a Flesch-Kincaid level of 4.1, which is appropriate for patients aged 9 years and older. The players self-assigned their injury status, resulting in a mean instrument score of 59.7 ± 8.4 for the 148 players "playing without pain," 42.0 ± 11.5 for the 60 players "playing with pain," and 40.4 ± 10.5 for the 15 players "not playing due to pain." Players playing without pain scored significantly higher than those playing with pain and those not playing due to pain ( P < .001). Psychometric analysis showed a test-retest intraclass correlation coefficient of 0.90 and a Cronbach alpha intra-item reliability coefficient of 0.93, indicating excellent reliability and internal consistency. Pearson correlation coefficients of 0.65, 0.62, and 0.31 were calculated between the YTS and the Pediatric Outcomes Data Collection Instrument sports/physical functioning module, the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, respectively. Injured players scored a mean of 9.4 points higher after treatment ( P < .001), and players who improved in their self-assigned pain categorization scored 16.5 points higher ( P < .001). CONCLUSION: The YTS is the first valid and reliable instrument for assessing young baseball players' upper extremity health.

Predictive value of the DASH tool for predicting return to work of injured workers with musculoskeletal disorders of the upper extremity.

OBJECTIVES: To determine whether the Disabilities of the Arm, Shoulder, and Hand (DASH) tool added to the predictive ability of established prognostic factors, including patient demographic and clinical outcomes, to predict return to work (RTW) in injured workers with musculoskeletal (MSK) disorders of the upper extremity. METHODS: A retrospective cohort study using a population-based database from the Workers' Compensation Board of Alberta (WCB-Alberta) that focused on claimants with upper extremity injuries was used. Besides the DASH, potential predictors included demographic, occupational, clinical and health usage variables. Outcome was receipt of compensation benefits after 3 months. To identify RTW predictors, a purposeful logistic modelling strategy was used. A series of receiver operating curve analyses were performed to determine which model provided the best discriminative ability. RESULTS: The sample included 3036 claimants with upper extremity injuries. The final model for predicting RTW included the total DASH score in addition to other established predictors. The area under the curve for this model was 0.77, which is interpreted as fair discrimination. This model was statistically significantly different than the model of established predictors alone (p<0.001). When comparing the DASH total score versus DASH item 23, a non-significant difference was obtained between the models (p=0.34). CONCLUSIONS: The DASH tool together with other established predictors significantly helped predict RTW after 3 months in participants with upper extremity MSK disorders. An appealing result for clinicians and busy researchers is that DASH item 23 has equal predictive ability to the total DASH score.

Diagnosing fractures: pain intensity and subjective functional impairment are unreliable markers for initial assessment of possible extremity fractures.

OBJECTIVES: The triage of trauma patients is based on patient-given information. The aim of the study was the accuracy of pain intensity, subjective functional impairment, trauma history, and clinical examination in identifying patients with fractures. METHODS: We prospectively asked 436 patients with an extremity trauma whether they believed they had a fracture. Pain intensity and subjective functional impairment were also assessed. The physicians were also asked, based on trauma history and clinical examination. RESULTS: The sensitivity and specificity of patient opinion and of the functional questions for fracture detection were low. The combination of history and clinical examination delivered the best results. There was only a slight difference in pain intensity between patients with and those without fractures. CONCLUSION: Fracture diagnosis based only on patient opinion or subjective functional impairment can be misleading. Pain intensity needs further investigation for its role in fracture detection.

Reliability and validity of the Chinese version of the Short Musculoskeletal Function Assessment questionnaire in patients with skeletal muscle injury of the upper or lower extremities.

BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) questionnaire is one of the most commonly used scales to evaluate functional status and quality of life (QOL) of patients with a broad range of musculoskeletal disorders. However, a Chinese version of the SMFA questionnaire for the psychometric properties of skeletal muscle injury patients in China is still lacking. The current study translated the SMFA into Chinese and assessed its reliability and validity among Chinese patients with skeletal muscle injury of the upper or lower extremities. METHODS: The original SMFA was translated from English into Chinese and culturally adapted according to cross-cultural adaptation guidelines. A multicenter cross-sectional study was conducted, comprising 339 skeletal muscle injury patients (aged 20-75 years) from 4 hospitals. The SMFA, the health survey short form (SF-36) along with a region-specific questionnaire (including the disabilities of the arm, shoulder, and hand questionnaire (DASH), the hip disability and osteoarthritis outcome score (HOOS), the knee injury and osteoarthritis outcome score (KOOS), and the foot function index (FFI)) were completed according to the region of injury. Reliability was estimated from the internal consistency using Cronbach's α and validity was assessed via convergent validity, known-groups comparison, and construct validity. RESULTS: Cronbach's α coefficient was over 0.75 for two subscales and four categories of the SMFA, suggesting that the internal consistency reliability of the SMFA was satisfactory. Known-groups comparison showed that the dysfunction index and the bother index of the SMFA discriminated well between patients who differed in age, gender, injury location, and operation status rather than in subgroups based on the body mass index (BMI). The convergent validity of the SMFA was good, as moderate to excellent correlations were found between the subscales of the SMFA and the four subscales of SF-36 (physical function, role-physical, bodily pain, and social functioning) and the region-specific questionnaires. The construct validity was proved by the presence of a six-factor structure that accounted for 66.85 % of the variance. CONCLUSION: The Chinese version of the SMFA questionnaire is a reliable and valid instrument to measure patient-reported impact of musculoskeletal injuries in the upper or lower extremities.

Feasibility of Using Low-Cost Motion Capture for Automated Screening of Shoulder Motion Limitation after Breast Cancer Surgery.

OBJECTIVE: To determine if a low-cost, automated motion analysis system using Microsoft Kinect could accurately measure shoulder motion and detect motion impairments in women following breast cancer surgery. DESIGN: Descriptive study of motion measured via 2 methods. SETTING: Academic cancer center oncology clinic. PARTICIPANTS: 20 women (mean age = 60 yrs) were assessed for active and passive shoulder motions during a routine post-operative clinic visit (mean = 18 days after surgery) following mastectomy (n = 4) or lumpectomy (n = 16) for breast cancer. INTERVENTIONS: Participants performed 3 repetitions of active and passive shoulder motions on the side of the breast surgery. Arm motion was recorded using motion capture by Kinect for Windows sensor and on video. Goniometric values were determined from video recordings, while motion capture data were transformed to joint angles using 2 methods (body angle and projection angle). MAIN OUTCOME MEASURE: Correlation of motion capture with goniometry and detection of motion limitation. RESULTS: Active shoulder motion measured with low-cost motion capture agreed well with goniometry (r = 0.70-0.80), while passive shoulder motion measurements did not correlate well. Using motion capture, it was possible to reliably identify participants whose range of shoulder motion was reduced by 40% or more. CONCLUSIONS: Low-cost, automated motion analysis may be acceptable to screen for moderate to severe motion impairments in active shoulder motion. Automatic detection of motion limitation may allow quick screening to be performed in an oncologist's office and trigger timely referrals for rehabilitation.

Extremity injuries as predictors of emergency care resource needs among blunt trauma patients in Japan.

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.

Frequency and cost of claims by injury type from a state workers' compensation fund from 1998 through 2008.

OBJECTIVE: To determine which work-related injuries are the most frequent and costly. DESIGN: Secondary analysis of workers' compensation claims data. SETTING: Data were provided by a large, Maryland workers' compensation insurer from 1998 through 2008. PARTICIPANTS: Not applicable. INTERVENTIONS: None. MAIN OUTCOMES MEASURES: For 45 injury types, the number of claims and compensation amount was calculated for total compensation and for medical and indemnity compensation separately. RESULTS: Back and knee injuries were the most frequently occurring single injury types, whereas heart attack and occupational disease were the most expensive in terms of mean compensation. When taking into account both the frequency and cost of injury (mean cost × number occurrences), back, knee, and shoulder injuries were the most expensive single injury types. CONCLUSIONS: Successful prevention and management of back, knee, and shoulder injuries could lead to a substantial reduction in the burden associated with work-related injuries.

Assessment of coincidence and defect sizes in Bankart and Hill-Sachs lesions after anterior shoulder dislocation: a radiological study.

OBJECTIVE: Bankart and Hill-Sachs lesions are often associated with anterior shoulder dislocation. The MRI technique is sensitive in diagnosing both injuries. The aim of this study was to investigate Bankart and Hill-Sachs lesions with MRI to determine the correlation in occurrence and defect sizes of these lesions. METHODS: Between 2006 and 2013, 446 patients were diagnosed with an anterior shoulder dislocation and 105 of these patients were eligible for inclusion in the study. All patients were examined using MRI. Bankart lesions were classified as cartilaginous or bony lesions. Hill-Sachs lesions were graded I-III using a modified Calandra classification. RESULTS: The co-occurrence of injuries was high [odds ratio (OR) = 11.47; 95% confidence interval (CI) = 3.60-36.52; p < 0.001]. Patients older than 29 years more often presented with a bilateral injury (OR = 16.29; 95% CI = 2.71-97.73; p = 0.002). A correlation between a Bankart lesion and the grade of a Hill-Sachs lesion was found (ρ = 0.34; 95% CI = 0.16-0.49; p < 0.001). Bankart lesions co-occurred more often with large Hill-Sachs lesions (O = 1.24; 95% CI = 1.02-1.52; p = 0.033). CONCLUSION: If either lesion is diagnosed, the patient is 11 times more likely to have suffered the associated injury. The size of a Hill-Sachs lesion determines the co-occurrence of cartilaginous or bony Bankart lesions. Age plays a role in determining the type of Bankart lesion as well as the co-occurrence of Bankart and Hill-Sachs lesions. ADVANCES IN KNOWLEDGE: This study is the first to demonstrate the use of high-quality MRI in a reasonably large sample of patients, a positive correlation of Bankart and Hill-Sachs lesions in anterior shoulder dislocations and an association between the defect sizes.

Arm and shoulder conditions, active component, U.S. Armed Forces, 2003-2012.

This analysis estimated the incidence and health care burden of acute and chronic conditions of the arm and shoulder among active component service members of the Armed Forces from 1 January 2003 through 31 December 2012. There were 196,789 diagnosed incident cases of acute arm and shoulder conditions for a rate of 13.7 cases per 1,000 person-years. The annual incidence rates of sprains, the most common acute condition, nearly doubled during the period. Diagnoses of chronic conditions (overall rate of 28.8 per 1,000 person-years) increased 25 percent during the period, mainly associated with a doubling of the incidence of diagnoses of joint pain. Incidence rates of chronic disorders were progressively higher among successively older age groups of service members. The health care burden of all arm and shoulder conditions together steadily increased during the period, as indicated by numbers of health care encounters, individuals affected, and lost work time. The most commonly documented causes associated with acute and chronic conditions are described.

The overutilization of resources in patients with acute upper extremity trauma and infection.

PURPOSE: To compare patients with acute upper extremity injuries and infections presenting initially to the emergency department with patients transferred from outside institutions, and to evaluate triage guidelines for the appropriate transfer of these patients. METHODS: We reviewed the records of 1,172 consecutive patients with acute upper extremity injuries or infections presenting to 2 level 1 trauma centers over 3-month periods. We analyzed demographics, transfer details, injury characteristics, intervention received, follow-up, and complications. Triage guidelines were established by a board of academic upper extremity and emergency physicians and retrospectively applied to patient data. RESULTS: Of 1,172 patients, 155 (13%) arrived via transfer from outside facilities. Transferred patients had more complex injuries by our guidelines, but many did not require level 1 emergent care. The receiving emergency department discharged 26% of the transferred patients without upper extremity specialist evaluation, and 24% of the transferred patients received no procedural intervention at any point. Only 10% went to the operating room emergently. Implementing our guidelines for appropriate triage, we found that 53% of transfers did not require emergent transfer to a level 1 facility. These nonemergent transfers spent an average of 15.2 hours from the time of initial evaluation at the outside facility to discharge from the level 1 emergency department, compared with 3.1 hours in patients who arrived primarily. Retrospectively, our triage guidelines had a 2% undertriage rate and a 3% overtriage rate. CONCLUSIONS: Over half of the patients transferred with upper extremity injuries and infections for specialized evaluation may be transferred unnecessarily. Guidelines for the care and transfer of patients with acute upper extremity injuries or infections may lead to better use of resources. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Early assessment of the efficacy of digital infrared thermal imaging in pediatric extremity trauma.

Young children or those with intellectual disability with trauma to an extremity often undergo radiographs of the whole limb. The objective of the study was to assess the efficacy of digital infrared thermal images (DITI) in pediatric extremity trauma. We hypothesized fractures to be associated with local hyperthermia, detectable with DITI, which could direct focused radiographs. In this exploratory study, patients seen over a 2-month period in a pediatric emergency department for limb trauma were included if an extremity radiograph was taken on the same day. Patients had DITI of symptomatic and contralateral limbs. The warmest area of each image was compared to the site of pain and/or fracture on the radiograph. Fifty-one patients were enrolled. DITI matched 73% of pain sites. Fractures were seen in 11 patients. DITI matched 7 of 11 (64%) fracture sites. DITI performance in pinpointing the site of injury, although suboptimal, is encouraging for further evaluation.

[Cutaneous malignancies in occupationally-induced scars]. / Maligne Hauttumoren in beruflich verursachten Narben.

BACKGROUND: The occurrence of neoplasms in injury scars--as consequence of occupational accidents--may lead to compensation according to the statutory accident insurance regulations. According to newer regulatory attempts in occupational dermatology, certain criteria have to be met before the diagnosis of a neoplasm induced by a scar is accepted and compensation is due. MATERIAL AND METHODS: Based on a retrospective analysis of 217 dermatological claim files between 2007 and 2009 of the IPA (including 22 follow-ups), medical opinions on neoplasms developing in possible occupational scars were re-evaluated using criteria of the German social accident insurance and the Bamberg medical bulletin, part II (Bamberger Merkblatt, BM II) to see how well they qualified for recognition as an occupational or accident-related disorder. RESULTS: Three cases were identified where a neoplasm was suspected of having developed in an occupationally-related scar. One of the insured events entitled for compensation. Following the guidelines of the BM II, this case was approved as an occupational disease secondary to injuries with resultant reduction in earning capacity, whereas the others did not meet the requirements. CONCLUSIONS: Two problems in evaluating malignant tumors in occupational scars are the long latency period and the documentation of a scar. The tumor excision specimen should be histologically re-examined to document the presence of an associated scar.

Course, diagnosis, and treatment of depressive symptomatology in workers following a workplace injury: a prospective cohort study.

OBJECTIVES: To estimate prevalence, incidence, and course of depressive symptoms and prevalence of mental health treatment following a workplace injury, and to estimate the association between depressive symptoms and return-to-work (RTW) trajectories. METHOD: In a prospective cohort study, workers filing a lost-time compensation claim for a work-related musculoskeletal disorder of the back or upper extremity were interviewed 1 month (n = 599) and 6 months (n = 430) postinjury. A high level of depressive symptoms was defined as 16 or more on the self-reported Center for Epidemiologic Studies-Depression (CES-D) Scale. The following estimates are reported: prevalence of high depressive symptom levels at 1 and 6 months postinjury; incidence, resolution, and persistence of high depressive symptom levels between 1 and 6 months; and prevalence of self-reported mental health treatment and depression diagnosis at 6 months postinjury. RESULTS: Prevalence of high depressive symptom levels at 1 month and 6 months postinjury were 42.9% (95% CI 38.9% to 46.9%) and 26.5% (95% CI 22.3% to 30.7%), respectively. Among participants reporting high depressive symptom levels at 1 month postinjury, 47.2% (95% CI 39.9% to 54.5%) experienced a persistence of symptoms 6 months postinjury. By 6 months, 38.6% of workers who never returned to work or had work disability recurrences had high depressive symptom levels, compared with 17.7% of those with a sustained RTW trajectory. At 6-month follow-up, 12.9% (95% CI 5.8% to 20.1%) of participants with persistently high depressive symptom levels self-reported a depression diagnosis since injury and 23.8% (95% CI 14.7% to 32.9%) were receiving depression treatment. CONCLUSIONS: Depressive symptoms are pervasive in workers with musculoskeletal injuries, but transient for some, and seldom diagnosed as depression or treated.

Epidemiology of work-related upper extremity disorders: understanding prevalence and outcomes to impact provider performances using a practice management reporting tool.

In 2001, the number of repeated trauma cases accounted for 4% of total workplace injuries and 65% of all occupational illnesses, with work-related upper extremity disorders accounting for most cases. Because chronic disability leads to the highest cost, systematic evaluation of this growing occupational condition is needed. This article sheds light on work-related upper extremity disorders by understanding the prevalence and pattern for these diagnoses, their impact on outcomes influenced by age, gender and geography on metrics such as utilization, duration, disability status, and costs. To assess these types of outcomes measurements, a good reporting and management system must be in place to allow for ongoing evaluation and analysis of data and in the construction of intervention programs to improve provider performances and, ultimately, patient outcomes.

Rheumatic diseases that can be confused with work-related upper extremity disorders.

Rheumatic illnesses are a common cause for musculoskeletal complaints in the general population. All ages can be affected, including people in the prime of their working years. Secondary problems, such as entrapment neuropathies, enthesopathies, and Raynaud's syndrome, can be associated with various inflammatory arthritides. A detailed history and physical are the most important tools in screening for potential inflammatory disease in workers with upper extremity complaints.

Worker's compensation litigation of the upper extremity claim.

This article presents an overview of the issues presented to physicians and lawyers in evaluating, treating, litigating, and concluding an upper extremity workers' compensation claim. This analysis includes a review of the unique considerations involved in the workers' compensation patient/claimant, a general examination of workers' compensation law, and the interplay between litigation and the medical management of the patient.