The Critical Portions of Carpal Tunnel Surgery: A Comparison Between Opinions of Surgeons and the General Public.

PURPOSE: Attending surgeons must participate in critical and key portions of procedures and otherwise be immediately available. However, surgeon-defined standards of the critical and key portions of surgery have been questioned, potentially affecting trainee graduated responsibility. This study compares the opinions of surgeons and the general public regarding what constitutes the critical portions of carpal tunnel release (CTR). METHODS: A survey was devised inquiring about the appropriateness of surgical trainee execution of each step of CTR. Surgeons who perform CTR were queried (n = 112) and 32 (29%) responded. The survey was modified to compare responses from a sample of 184 nonmedical respondents (NMRs). The NMRs were excluded if they indicated having a career in health care. RESULTS: Of the surgeon respondents, 94% (n = 30) had completed hand fellowship training, 53% (n = 17) declared themselves academic or affiliated with academia, and 53% (n = 17) utilized concurrent operating rooms. The NMR average age was 35.3 ± 10.3 years, 40% were female (n = 73), and they represented various regions of the United States including an assortment of socioeconomic and ethnic groups. Surgeons demonstrated significantly more hesitation with trainees performing surgical steps. Academic surgeons were significantly more comfortable having trainees performing surgical steps than nonacademic surgeons. Critical portions of CTR as agreed upon by surgeons and NMRs included incision, dissection, transverse carpal ligament division, and inspection of the median nerve for injury/complete release. CONCLUSIONS: Surgeons are significantly less comfortable with trainee performance of CTR steps than the general public. Surgeons who regularly work with trainees are more accepting of trainee involvement than those who do not. CLINICAL RELEVANCE: Understanding the opinions of surgeons as well as NMRs with respect to surgical trainee participation in the operating room is important to optimize the informed consent process as well as influence hospital policies that affect graduated surgical trainee autonomy.

Human and other mammalian bite injuries of the hand: evaluation and management.

The hand is the most common site for bite injuries. Because of specific characteristics of hand anatomy, bite mechanics, and organisms found in human and animal saliva, even small wounds can lead to aggressive infections. Failure to recognize and treat hand bites can result in significant morbidity. Human and animal bites most commonly lead to polymicrobial bacterial infections with a mixture of aerobic and anaerobic organisms. Pasteurella species are commonly found in dog and cat bite wounds, and Eikenella is characteristic of human wounds. Staphylococcus, Streptococcus, and anaerobic bacterial species are common to all mammals. Although public health measures in developed countries have been highly effective at reducing rabies transmission, dog bites remain the most common source of rabies infection worldwide. Human bites can transmit HIV, hepatitis B, or hepatitis C, especially when contaminated blood is exposed to an open wound. Appropriate management of any mammal bite requires recognition, early wound cleansing, evaluation of injured structures, and infection prophylaxis. Structural repair is performed as indicated by the severity and contamination of the injury, and wounds may require delayed closure. Wound infections typically require débridement, empiric antibiotics, and delayed repair or reconstruction.

Dorsal Wrist Spanning Plate Fixation for Treatment of Radiocarpal Fracture-Dislocations.

Background: Radiocarpal dislocations are rare injuries that result from high-energy forces across the wrist with the hallmark finding of radiocarpal ligament disruption. Published treatment methods are comprehensive with moderate-to-good outcomes. The purpose of this study was to review the treatment of radiocarpal dislocations with a dorsal wrist spanning plate. Methods: A retrospective review was conducted analyzing the radiographic and clinical outcomes of patients treated for a radiocarpal dislocation using a dorsal wrist spanning plate over a 10-year period. Outcomes assessed included radiographic joint incongruity and arthrosis, wrist range of motion, grip strength, Visual Analogue Scale (VAS) score, surgical complications, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results: Thirteen patients were treated with a dorsal wrist spanning plate for radiocarpal dislocation with a mean follow-up of 615 days from the time of initial surgery. Six patients (46%) had associated distal radioulnar joint instability. The mean wrist range of motion at the final follow-up was: flexion 39°, extension 44°, pronation 79°, and supination 84°. One patient (8%) developed ulnar translation of the carpus, and 11 patients (85%) developed radiographic posttraumatic wrist arthrosis. Mean VAS and DASH scores were 4 and 18, respectively. Conclusions: Acute treatment with a dorsal wrist spanning plate in this series resulted in comparable outcomes to what have been previously reported in the literature. The dorsal wrist spanning plate offers the surgeon a reliable method of stabilization, with minimal additional surgical trauma to the wrist, while avoiding the potential for infections that develop with other treatment methods.

Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections.

BACKGROUND: Hospital transfer decisions regarding pyogenic flexor tenosynovitis (PFT) are made difficult by emergency department presentations similar to other finger infections, with pain, redness, and functional limitation. Our objectives were to: (1) determine diagnostic sensitivity and specificity of Kanavel signs; and (2) identify existing factors most predictive of PFT during initial presentation. METHODS: Adult patients who underwent surgical consultation for concern of PFT over a 5-year period were identified retrospectively. Bivariate screening identified clinical criteria for differentiation, and multivariate logistic regression was performed to control for confounding. We then created a prediction algorithm for diagnosis of PFT. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. RESULTS: Patients with PFT differed significantly from those with non-PFT finger infections in regard to the 4 Kanavel signs, duration of symptoms less than 5 days, and erythrocyte sedimentation rate. Sensitivity of the Kanavel signs ranged from 91.4% to 97.1%. Specificity ranged from 51.3% to 69.2%. Logistic regression identified independent predictors for PFT as tenderness along the flexor tendon sheath, pain with passive extension, and duration of symptoms less than 5 days. A prediction algorithm incorporating these 3 factors showed an area under the ROC curve of 0.91 (95% confidence interval, 0.840-0.979). CONCLUSIONS: Kanavel signs have high sensitivity for detecting PFT but have poor specificity on an individual basis. Clinical prediction algorithms that combine the relevant factors may be helpful in the development of clinical prediction tools and educational materials for optimization of emergency hand care systems. Further prospective study is needed.