The diagnostic value of ultrasonography and magnetic resonance imaging in missed hand tendon injuries.

BACKGROUND: Patients with hand tendon injuries may present to the hand surgery clinic in the late stage after being examined in emergency departments. Even if an approximate idea has been obtained in physical examination of these patients, diagnostic imaging is usually requested for reconstructive approach, correct planning of surgical incisions and medicolegal reasons. The primary purpose of this study was to determine the overall accuracy of Ultrasonography (USG) and Magnetic Resonance Imaging (MRI) in patients with late presentation of a tendon injury. METHODS: The surgical findings and imaging reports of 60 patients (32 females, 28 males) who underwent surgical exploration, late secondary tendon repair or reconstruction with a diagnosis of late-presenting tendon injury in our clinic were evaluated. Comparisons were made of 47 preoperative USG images (18-874 days) and 28 MRI (19-717 days) results for 39 extensor and 21 flexor tendon injuries. The imaging reports were interpreted as partial rupture, complete rupture, healed tendon and adhesion formation and these were compared with the surgical reports in terms of accuracy. RESULTS: In extensor tendon injuries, the sensitivity and accuracy values were both 84% for USG and 44% and 47% for MRI, respec-tively. In flexor tendon injuries, the sensitivity and accuracy values were 100% for MRI and 50% and 53%, respectively, for USG. Of the 4 sensory nerve injuries, 4 were missed on USG and 1 on MRI. The results obtained with USG and MRI in the late-presenting patients in this study were lower than those reported in previous USG and MRI studies in the literature. CONCLUSION: Scar formation with tendon healing causes a change in anatomy, which could prevent accurate evaluation. There-fore, it would be beneficial for surgeons to start evaluating their patients with easily accessible ultrasonography; thus, surgical morbid-ity should be reduced.

Facet Inclinations and Interfacet Angle of the Distal Radius on Posteroanterior Radiographs: Clinical Associations With 3 Carpal Pathologies.

PURPOSE: The radiographic interfacet angle (IFA), scaphoid facet inclination (SFI), and lunate facet inclination (LFI) of the distal radius were measured in patients with 3 distinct wrist pathologies to determine whether there is an association between these radiographic measurements and these conditions. METHODS: Posteroanterior wrist radiographs were compiled from patients with 3 types of common wrist pathologies (scaphoid waist fracture [n = 54], scapholunate [SL] dissociation [n = 23], and dorsal ganglion [n = 51]). The patients were all Caucasians aged 20 to 45 years who met strict radiographic criteria. The IFA, SFI, and LFI values of these patients were compared with those obtained from 400 normal wrist radiographs of subjects who met the same selection criteria. RESULTS: In men with a scaphoid waist fracture, the IFA and SFI were significantly greater than in normal men, whereas the LFI was significantly lower. In the SL dissociation group, for all patients and for subgroups stratified according to sex, the IFA and SFI were significantly lower than in the normal matched groups. In the dorsal ganglion group, differences were found in the IFA and SFI for women, but not for men. CONCLUSIONS: The facet orientations of the distal radius in patients with scaphoid fracture, SL dissociation, and dorsal ganglion differed from those in the normal population. The IFA alone is most likely to be associated with all 3 pathologies. The SFI and LFI are less likely to be associated with patients with carpal pathologies. CLINICAL RELEVANCE: Patients with a greater IFA may be susceptible to scaphoid fractures when they fall on an overstretched hand. Patients with a smaller IFA may be susceptible to SL dissociation when they fall on an overstretched hand.

First Preliminary Clinical Experiences Using Hyperspectral Imaging for Burn Depth Assessment of Hand Burns.

The accurate assessment of burn wounds is challenging but crucial for correct diagnosis and following therapy. The most frequent technique to evaluate burn wounds remains the clinical assessment, often subjective depending on the experience of the physician. Hyperspectral imaging (HIS) is intended to improve on this subjective diagnosis by accurate and objective analyses of perfusion parameters. The purpose of this study was to analyze the ability of technical burn depth assessment and to investigate a link between a certain value to burn depth versus the value of healthy skin references. One hundred and eighteen HSI analyses were included in this study between July 2017 and July 2019. We analyzed 74 recordings with dorsal hand burns and 44 recordings of healthy skin on the dorsal hand as control group. HSI recordings' investigation was performed with special interest to wound center, intermediate zone, and wound margin. The results indicate that a differentiation between burned tissue and healthy skin was feasible and also significant in almost all HSI analysis parameters (P < .05). No significant distinction between superficial and deep partial thickness burns could be determined. However, in the wound center, we recorded smaller values with a more pronounced tissue damage. Our preliminary results demonstrate that HSI can distinguish between normal and burned hands. However, as currently used, HSI could not accurately determine the depth of indeterminate burns.

Outcomes for Hand Burns Treated With Autologous Skin Cell Suspension in 20% TBSA and Smaller Injuries.

In order to address the confounder of TBSA on burn outcomes, we sought to analyze our experience with the use of autologous skin cell suspensions (ASCS) in a cohort of subjects with hand burns whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with 2:1 meshed autograft for the treatment of hand burn injuries would provide comparable outcomes to hand burns treated with sheet or minimally meshed autograft alone. A retrospective review was conducted for all deep partial and full-thickness hand burns treated with split-thickness autograft (STAG) at our urban verified burn center between April 2018 and September 2020. The exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) vs those treated with STAG alone (ASCS(-)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(-) subjects had 1:1, piecrust, or unmeshed sheet graft alone. Outcomes measured included demographics, time to wound closure, proportion returning to work (RTW), and length of time to RTW. Mann-Whitney U test was used for comparisons of continuous variables and Fisher's exact test for categorical variables. Values are reported as medians and 25th and 75th interquartile ranges. Fifty-one subjects fit the study criteria (ASCS(+) n = 31, ASCS(-) n = 20). The ASCS(+) group was significantly older than the ASCS(-) cohort (44 [32-54] vs 32 years [27.5-37], P = .009) with larger %TBSA burns (15% [9.5-17] vs 2% [1-4], P < .0001) and larger size hand burns (190 [120-349.5] vs 126 cm2 [73.5-182], P = .015). Comparable results were seen between ASCS(+) and ASCS(-), respectively, for time to wound closure (9 [7-13] vs 11.5 days [6.75-14], P = .63), proportion RTW (61% vs 70%, P = .56), and days for RTW among those returning (35 [28.5-57] vs 33 [20.25-59], P = .52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(-) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure, proportion of RTW, and time to return to work as subjects treated with 1:1 or piecrust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

Comparison of three different methods to estimate the burden of disease of burn injuries in Western Australia in 2011-2018.

BACKGROUND: Priority setting and resource allocation in health care, surveillance and interventions is based increasingly on burden of disease. Several methods exist to calculate the non-fatal burden of disease of burns expressed in years lived with disability (YLDs). The aim of this study was to assess the burden of disease due to burns in Western Australia 2011-2018 and compare YLD outcomes between three existing methods. METHODS: Data from the Burns Service of Western Australia was used. Three existing methods to assess YLDs were compared: the Global Burden of Disease (GBD) method, a method dedicated to assess injury YLDs (Injury-VIBES), and a method dedicated to assess burns YLDs (INTEGRIS-burns). RESULTS: Incidence data from 2,866 burn patients were used. Non-fatal burden of disease estimates differed substantially between the different methods. Estimates for 2011-2018 ranged between 610 and 1,085 YLDs per 100.000 based on the Injury-VIBES method; between 209 and 324 YLDs based on the INTEGRIS-burns method; and between 89 and 120 YLDs based on the GBD method. YLDs per case were three to nine times higher when the Injury-VIBES method was applied compared to the other methods. Also trends in time differed widely through application of the different methods. There was a strong increase in YLDs over the years when the Injury-VIBES method was applied, a slight increase when the INTEGRIS-burns method was applied and a stable pattern when the GBD method was applied. CONCLUSION: This study showed that the choice for a specific method heavily influences the non-fatal burden of disease expressed in YLDs, both in terms of annual estimates as well as in trends over time. By addressing the methodological limitations evident in previously published calculations of the non-fatal burden of disease, the INTEGRIS-burns seems to present a method to provide the most robust estimates to date, as it is the only method adapted to the nature of burn injuries and their recovery.

BPBSAM: Body part-specific burn severity assessment model.

BACKGROUND AND OBJECTIVE: Burns are a serious health problem leading to several thousand deaths annually, and despite the growth of science and technology, automated burns diagnosis still remains a major challenge. Researchers have been exploring visual images-based automated approaches for burn diagnosis. Noting that the impact of a burn on a particular body part can be related to the skin thickness factor, we propose a deep convolutional neural network based body part-specific burns severity assessment model (BPBSAM). METHOD: Considering skin anatomy, BPBSAM estimates burn severity using body part-specific support vector machines trained with CNN features extracted from burnt body part images. Thus BPBSAM first identifies the body part of the burn images using a convolutional neural network in training of which the challenge of limited availability of burnt body part images is successfully addressed by using available larger-size datasets of non-burn images of different body parts considered (face, hand, back, and inner forearm). We prepared a rich labelled burn images datasets: BI & UBI and trained several deep learning models with existing models as pipeline for body part classification and feature extraction for severity estimation. RESULTS: The proposed novel BPBSAM method classified the severity of burn from color images of burn injury with an overall average F1 score of 77.8% and accuracy of 84.85% for the test BI dataset and 87.2% and 91.53% for the UBI dataset, respectively. For burn images body part classification, the average accuracy of around 93% is achieved, and for burn severity assessment, the proposed BPBSAM outperformed the generic method in terms of overall average accuracy by 10.61%, 4.55%, and 3.03% with pipelines ResNet50, VGG16, and VGG19, respectively. CONCLUSIONS: The main contributions of this work along with burn images labelled datasets creation is that the proposed customized body part-specific burn severity assessment model can significantly improve the performance in spite of having small burn images dataset. This highly innovative customized body part-specific approach could also be used to deal with the burn region segmentation problem. Moreover, fine tuning on pre-trained non-burn body part images network has proven to be robust and reliable.

The clinical anatomy of crucifixion.

Crucifixion was a widely used form of execution for capital crimes in antiquity. Civilizations and empires perfected the technique, leading to centuries of discussions, controversies, and questions, many of which concerned the death of Jesus Christ. To this day, much remains to be discovered in both religious and scientific realms. However, the aim of this study is to discuss such facts as are known from the medical perspectives of clinical anatomists. Nails/spikes were driven through the hands/wrists and feet of five adult cadavers, and the cadavers were then dissected to observe the anatomical structures that had been injured or placed at risk for injury. While many historical and archeological facts remain to be discovered, we hope that this cadaveric study will enhance our modern understanding of ancient practices from a medical and anatomical perspective. Clin. Anat. 32:12-21, 2019. © 2019 Wiley Periodicals, Inc.

Fatal and Nonfatal Rip Saw Injuries.

This paper deals with a fatal stab wound suffered by a 29-year-old man and nonfatal injuries of 35-year-old and 67-year-old saw operators. Rip saw is a machine that is specially designed for making a rip cut, a cut made parallel to the direction of the wood grain. Rip-saw-related injuries mostly occur when a person is struck by the cutting material, which usually involves splinters of irregular shape and diameter. When the splinter strikes the body diagonally, the injuries may include abrasions, lacerations, and cut wounds; in situations where the victim is struck directly, the most common injuries are oval- or star-shaped stab wounds with a varying width of abrasions around the wounds. Therefore, such injuries may come across as injuries produced by a knife-like instrument, which is an added difficulty in the interpretation of such injuries.

Outline of Hand and Wrist Injuries Presenting to an Emergency of a Tertiary Care Centre in Nepal.

BACKGROUND: Hand and wrist injuries are getting commoner with increasing incidence of injuries and accidents. This study aims to identify the prevalence and pattern of hand and wrist injuries presenting to the emergency department of a tertiary care center of Nepal. METHODS: The study was conducted through review of electronic data of the patient in the emergency department database for the period of 1 Nov 2005 till 31 Oct 2015.Data was extracted in Microsoft Excel 2007 andanalyzed to measure incidence and pattern of the hand and wrist injuries. RESULTS: There were2899 number of patients with hand and wrist injuries during the period. Most were males (80%) and commonest age group was 20-29 years. Majority of the injuries were due to road traffic accident (n=786, 27.11%), fall injury (n=696, 24.09%), cut injury with sharps (n=404, 13.94%) and machinery injury (n=319, 11%). The commonest presenting injuries were hand fractures (n=1820, 62.8%) followed by distal radius fracture (n=613, 21.1%), crush injury of hand (n=409, 14.1%), and cut injury (n= 406, 14%). Almost half, 48.84 % cases were discharged from the emergency department with preliminary or definitive management. CONCLUSIONS: Hand and wrist injuries constitute a substantial number of casesseen and managed in the emergency department.Therefore, public health measures should be taken to reduce RTI, fall injury and occupational accidents. Andit is of paramount importance that emergency care giver attends these injuries properly and timely and establishes a good referral system as and when necessary.

A third of referrals are unnecessary: Critical review of burn outpatient clinic data.

OBJECTIVES: The purpose of this study was to establish patterns in types of burns referred to the Outpatient Clinic (OP) at Vancouver General Hospital (VGH). METHODS: A 2-year retrospective chart review was conducted of patients presenting to the OP Clinic from June 1, 2016 - June 1, 2018. Data collected included: patient demographics, depth of burn, Total Body Surface Area (TBSA), anatomical location of burn, geographical location of referral, and operative versus non-operative management. RESULTS: The OP Clinic served 470 patients for burn injuries with a total of 1852 visits. Of these, 20% were follow-up visits post-admission, and 73.6% were primary referrals from the emergency department (ED) or elsewhere. The vast majority (69.6%) of burns were less than 5% TBSA. Half involved the hands (50.9%), and half were superficial dermal in depth (45.1%). A third of patients attended only one appointment with the OP Clinic before discharge and 15% did not receive any treatment. CONCLUSIONS: The results of our study demonstrate gaps in current provincial referral guidelines leading to a significant number of "unnecessary referrals." Further research could correlate the results to current provincial referral guidelines to estimate their current efficacy in practical use.

A Self-Inflicted Gunshot Wound With an Unusual Hand Injury.

Self-inflicted gunshot wounds are a common cause of firearm-related deaths. The appearance and location of the entry wound, other concomitant findings at autopsy, and correlation with the scene and circumstances are critical in determining the manner of death. A case of a 72-year-old man with a self-inflicted gunshot wound with an unusual injury pattern is described. There was a contact range gunshot entry in the right temple, and an exit wound was seen in the left parietal region. There was a re-entry with an associated exit wound on the left hand.

[Treatment Options for Inveterate Injuries of Deep Finger Flexors - Primary Transplantation with Tendon Graft]. / Moznosti osetrení u zastaralých poranení hlubokých flexoru prstu ruky ­ primární transplantace slachovým stepem.

Injuries of the flexor finger apparatus are very common. Primarily, it is routinely treated by suture of the tendon. Isolated deep flexor injuries, when the flexion restriction only reaches the DIP joint, are sometimes overlooked by the surgeon or by the patients themselves, especially if the deep flexor is injured, after a closed rupture or cutaneous injury with a small skin wound. The patient is then sent to a department specializing in hand surgery after a few weeks. Subsequent shortening of the tendon apparatus makes flexor suture more difficult or sometimes even impossible. Many ways of suturing the tendons and subsequent treatment are described. The treatment results vary immensely. It depends on the mechanism of injury, injury zone, the suture suture technique used, time that has elapsed since primary treatment, surgeon experience and subsequent postoperative and rehabilitative care. One of them is reconstruction of the flexor apparatus by primary transplantation of an autologous tendon graft. Most commonly, the tendon graft is taken from the palmaris longusfrom the same hand. The tendon graft can subsitute the entire area of zones I and II. The tendon suture is made in the palm proximal to the A1 pulley outside the tendon sheath in the area where the muscular belly of thelumbricalis is located on the tendon of the deep flexor. The distal end is reinserted to the base of the distal phalanx. The primary use of the autologous tendon graft can be used in the reconstruction of obsolete deep-flexor injuries in Zone II, but also in primary treatments. This type of treatment has a number of advantages. Performing the reinforcement of the tendon at the base of the distal phalanxand the suture in the palm of the hand completely eliminates the complications caused by the tendon suture in zone II. There is no injury to the tendon sheath, or the need for intersection of the tendons. The transplanted tendon is smaller in diameter than the deep flexor, so it can also be used for older injuries when the tendon sheath is in partially missing. It removes painful palmar resistance by restoring the right position and a tension of tendon of lumbricalis and the tendon of the deep flexor. This type of reconstruction allows immediate active or semi-rehabilitation of the hand and fingers. Key words:tendon, injury, hand, transplantation, surgery, flexor, reconstruction, rupture, treatment.

Venous super-drained posterior interosseous artery flap for dorsal hand defects.

BACKGROUND: Posterior interosseous artery flap PIAF is one of the most preferred reconstructive options for upper extremity defects. As a reverse flap, venous congestion is always a threatening factor. In this report authors aimed to present their experience with venous super-drained posterior interosseous artery flap VS-PIAF. METHODS: Between January 2013 to September 17, 2017 patients were treated with VS-PIAF. Tumor excision, trauma, traffic accident, burn contracture release, and industrial injuries were the causes of defects. Defects were located on the dorsum of the hand, first web space, ulnar and radial side of the hand, and the palm. All the defects were reconstructed with a VS-PIAF, which a distal superficial end-to-end venous anastomosis was added to overcome venous congestion problems. RESULTS: The flap sizes were between 5 × 7 cm and 8 × 12 cm. All the flaps have survived completely without any early or late complications. No venous problems were seen. The donor areas were healed uneventfully. The mean follow-up time was 15.3 months. The results of reconstructions were satisfactory, no functional restrictions was seen. CONCLUSION: The major drawback of PIAF is venous congestion problems that can be manageable with adding a distal superficial end-to-end venous anastomose. VS-PIAF is a robust, much safer and easy-to-learn reconstructive method for upper extremity defects.

Isolated ulnopalmar dislocation of the fifth carpometacarpal joint.

Dislocations of the carpometacarpal (CMC) joints are uncommon and are frequently missed on standard radiographs of the hand. Dislocations could be dorsal or palmar; dorsal dislocations are seen more frequently. Palmar dislocations can be either ulnopalmar or radiopalmar. Stable CMC dislocations could be successfully treated conservatively, while unstable dislocations are mostly treated operatively. The purpose of this report is to present a patient with an isolated ulnopalmar dislocation of the fifth CMC joint, satisfactorily treated with closed reduction and casting.

A Soft Casting Technique for Managing Pediatric Hand and Foot Burns.

Hand and foot burns in children are difficult to dress. The authors have developed a soft casting technique to manage burns to these areas. The aim of this study is to report the outcomes using weekly dressing changes with a soft casting technique to manage pediatric hand and foot burns in the outpatient setting. A retrospective chart review was performed on children with burns to the hands or feet, who underwent dressing changes with a soft casting technique at the Children's Hospital Colorado Burn Center. Soft casting was performed by placing antibiotic ointment-impregnated nonadherent gauze over the burn wound(s), wrapping the extremity using rolled gauze, applying soft cast pad, plaster, soft cast tape, and an elastic bandage. This was changed weekly. Two hundred ninety-eight children with hand burns had a mean age of 16.8 ± 2 months. Two hundred forty-eight children had partial thickness burn injuries (83%), 50 had full thickness burn injuries (17%), and the mean total body surface area (TBSA) was 1 ± 2.4%. The mean time to heal was 10.1 ± 1.7 days for all subjects. Sixty-six children with foot burns were identified with a mean age of 24 ± 2.6 months. Forty-six children had partial thickness injuries (70%), 20 had full thickness burn injuries (30%), and the mean TBSA was 2.3 ± 2.9%. The mean time to heal was 14.1 ± 2.2 days for all subjects. Weekly dressing changes using a soft casting technique are effective for the outpatient management of pediatric hand and foot burns. This method avoids costly inpatient hospital care, reduces the number of painful dressing changes, and allows children to heal in their own environment.

Hand burns surface area: A rule of thumb.

INTRODUCTION: Rapid estimation of acute hand burns is important for communication, standardisation of assessment, rehabilitation and research. Use of an individual's own thumbprint area as a fraction of their total hand surface area was evaluated to assess potential utility in hand burn evaluation. MATERIALS AND METHODS: Ten health professionals used an ink-covered dominant thumb pulp to cover the surfaces of their own non-dominant hand using the contralateral thumb. Thumbprints were assessed on the web spaces, sides of digits and dorsum and palm beyond the distal wrist crease. Hand surface area was estimated using the Banerjee and Sen method, and thumbprint ellipse area calculated to assess correlation. RESULTS: Mean estimated total hand surface area was 390.0cm2±SD 51.5 (328.3-469.0), mean thumbprint ellipse area was 5.5cm2±SD 1.3 (3.7-8.4), and mean estimated print number was 73.5±SD 11.0 (range 53.1-87.8, 95% CI 6.8). The mean observed number of thumbprints on one hand was 80.1±SD 5.9 (range 70.0-88.0, 95% CI 3.7), χ2=0.009. The combined mean of digital prints was 42, comprising a mean of two prints each on volar, dorsal, radial and ulnar digit surfaces, except volar middle and ring (3 prints each). Palmar prints were 15 (11-19), dorsal 15 (11-19), ulnar palm border 3, first web space 2, and second, third and fourth web spaces one each. Using the surface of the palm alone, excluding digits, as 0.5% of total body surface area, the area of one thumbprint was approximated as 1/30th of 1%. CONCLUSIONS: We have demonstrated how thumbprint area serves as a simple method for evaluating hand burn surface area.

"Defense" type wounds in suicide.

"Defense" type wounds are sustained when a victim is attempting to ward off an attacker, or a weapon. A 39-year-old woman is reported who was found deceased with incised wounds to the dorsa of both hands that resembled defense wounds. Examination of the flexor surfaces of both wrists, however, revealed horizontal incised wounds typical of self-infliction. Perfusion of the subclavian arteries produced leakage of water from peripheral veins within wounds on both hands and the right wrist. Death was due to exsanguination from incised wounds of the hands and right wrist; manner suicide. This case demonstrates the difficulties that may arise in differentiating self-inflicted from assaultive wounds. On occasion suicidal sharp force injuries may be multiple and in atypical locations. In these circumstances a high index of suspicion for homicide must be maintained.