Feedback to Patients About Patient-reported Outcomes Does Not Improve Empowerment or Satisfaction.

BACKGROUND: Although patient-reported outcome measures (PROMs) are helpful to define whether an intervention has improved a patient's status in ways the patient feels are important, they may also serve an empowering educational role; specifically, sharing a patient's scores might help the patient understand his or her progress during treatment. However, whether sharing PROM scores in this way improves the sense of empowerment or satisfaction with the process of care has not been well explored. Also, less is known whether specific demographic factors or coping strategies are associated with empowerment. QUESTIONS/PURPOSES: We asked the following: (1) Does giving patients feedback on their PROM scores improve a patient's sense of empowerment or satisfaction? (2) Do demographic factors, duration of disability, or self-efficacy correlate with patient empowerment? METHODS: In this prospective cohort study, we assigned patients with osteoarthritis of the knee or hip sequentially such that the first 70 patients did not receive the intervention and the next 72 did. Patients enrolled in the control cohort were managed according to standard care, whereas patients enrolled in the intervention cohort completed web-based questionnaires measuring their physical function and pain. After filling out the questionnaires, a printout with the scores was given to the patients providing feedback about their physical function and pain. The primary outcome measure was patient empowerment, as measured by the Patient Activation Measure. Secondary outcomes were patient satisfaction, as measured by an 11-point Likert scale and Patient Doctor Relation Questionnaire. Independent variables were demographic factors and coping, measured by the Pain Self-efficacy Questionnaire. Bivariate and multivariable analyses were performed to determine the influence of the feedback. Although no minimum clinically important differences have been defined for the patient empowerment or satisfaction scales, we believe that differences smaller than 10% are unlikely to be clinically important, even if they are statistically significant. RESULTS: Although the group that received PROM feedback had higher scores for empowerment than the group that did not, the effect size was small and likely not to have been clinically important (2.8 ± 0.85 versus 3.1 ± 0.811; mean difference -0.31; 95% confidence interval, 2.8-3.1; p = 0.037). With the numbers available, there were no differences between the group given PROM feedback and the group that did not receive such feedback in terms of satisfaction scores (8.6 ± 1.4 versus 8.8 ± 1.2; mean difference -0.19; p = 0.39). After controlling for demographic factors such as level of education and duration of complaint, we found that the group that received PROM feedback and who had a higher level of self-efficacy had higher scores for empowerment than the group that did not, although the effect size was small. CONCLUSIONS: PROM feedback did not have a clinically important impact on empowerment or satisfaction. This might indicate that counseling based on PROMs during a single visit may be ineffective. The most important positive finding is that more effective coping strategies are associated with greater patient empowerment. LEVEL OF EVIDENCE: Level II, therapeutic study.

The Prevalence of Unanticipated Hamate Hook Abnormalities in Computed Tomography Scans: A Retrospective Study.

BACKGROUND: It is possible that some hamate hook fractures are not diagnosed or treated, thereby affecting the study of their natural history. Study of the prevalence of incidental hamate hook fractures, nonunions, and other abnormalities on computed tomography (CT) ordered for another reason could document a subset of undiagnosed and untreated hamate hook fractures which might change our understanding about the natural history. METHODS: Reports of 2489 hand, wrist, and forearm CT scans for hamate hook abnormalities were searched. We excluded 19 patients with anticipated hamate fractures and 1 patient that had a hamate hook excision. Twenty-eight patients had an unanticipated hamate hook abnormality. RESULTS: There was a significant difference in the prevalence of incidental hamate hook abnormalities by sex but not by age. Among the 28 unexpected hamate hook abnormalities, there were 16 fractures of the base (12 acute, 1 nonunion, and 3 of uncertain age), 5 acute oblique fractures, and 7 tip abnormalities/ossicles. The patient with an incidental nonunion had a CT scan for wrist pain and was diagnosed with gout. All fractures involved a direct blow to the hand (distal radius or scaphoid fracture, or crush injury). The 7 patients with a hamate tip abnormality had a CT scan for a distal radius or metacarpal fracture, crush injury or wrist pain. Five acute fractures were treated operatively with excision and the other 23 fractures were treated nonoperatively. CONCLUSION: Hamate fractures can be diagnosed incidental to other hand and wrist problems on CT.

Association Between Opioid Intake and Disability After Surgical Management of Ankle Fractures.

BACKGROUND: Opioid-centric pain management strategies have created an epidemic of prescription opioid abuse. This study assesses whether opioid intake is associated with disability, satisfaction with treatment, and pain at the time of suture removal and at 5 to 8 months after suture removal following open reduction and internal fixation of ankle fractures. METHODS: We enrolled 102 adult patients in the study at the time of suture removal, 59 of whom were available for follow-up at 5 to 8 months. At the time of suture removal, we recorded opioid use; trauma-related factors; and scores on measures of disability, pain, and treatment satisfaction. Patients who were available for follow-up completed the disability, pain, and treatment satisfaction measures at 5 to 8 months and their opioid use at that time was recorded. RESULTS: No association was found between opioid intake and disability at the time of suture removal. No association was found between opioid intake and satisfaction with treatment or satisfaction with pain management at the time of suture removal. At 5 to 8 months after suture removal, no variables were associated with opioid intake. The psychologic measures of pain anxiety and catastrophic thinking were the factors most consistently associated with disability, treatment satisfaction, satisfaction with pain management, pain at rest, and pain with activity at both of the time points. CONCLUSION: Patients with ankle fractures may be able to use fewer opioids than are currently prescribed and experience levels of disability and treatment satisfaction comparable with those of patients who take greater amounts of opioids, independent of injury characteristics. LEVEL OF EVIDENCE: Prognostic level II.

Patient Complaints Emphasize Non-Technical Aspects of Care at a Tertiary Referral Hospital.

BACKGROUND: Patient concerns represent opportunities for improvement in orthopaedic care. This study's objective is to identify the nature and prevalence of unsolicited patient complaints regarding orthopaedic care at a tertiary referral hospital. The primary null hypothesis that there are no demographic factors associated with complaint types was tested. Secondarily we determined if the overall complaint number and types differed by year. METHODS: Complaints to the hospital ombudsperson by orthopaedic patients between January 1997 and June 2013 were reviewed. All 1118 complaints were categorized: access and availability, humaneness and disrespect, communication, expectations of care and treatment, distrust, billing and research. RESULTS: Patients between 40 and 60 years of age filed the most complaints in all categories except distrust (more common in patients over age 80) and research. Women were slightly more likely to address access and availability, humaneness, disrespect, and billing compared to men. The overall number of complaints peaked in 1999. The most common issue was access and availability followed by communication, and humaneness/disrespect. CONCLUSION: Half of concerns voiced by patients addressed interpersonal issues. The largest category was related to access and availability. Quality improvement efforts can address technology to improve access and availability as well as empathy and communication strategies.

The Correlation Between a Numerical Rating Scale of Patient Satisfaction With Current Management of an Upper Extremity Disorder and a General Measure of Satisfaction With the Medical Visit.

Background: Patient satisfaction is used as an indicator of quality of care, but the measures currently available are lengthy and cumbersome and may not be feasible in orthopedic surgical practices. We set out to assess the relationship between the Medical Interview Satisfaction Scale (MISS-21) and a numerical rating scale (NRS) of patient satisfaction with current management of an orthopedic upper extremity condition. Methods: In this cross-sectional study, 86 patients from the practices of 2 hand surgeons were included during an initial or follow-up visit. Questionnaires assessing demographics, upper extremity specific disability, pain during rest and activity, satisfaction with the medical visits (MISS-21), and satisfaction with current management of an orthopedic upper extremity condition (NRS satisfaction) were completed. Results: Eighty-six patients completed all questionnaires. A small correlation of .21 (P = .050) was found between the MISS-21 and the NRS satisfaction. In bivariate analysis, NRS pain at rest and during activity had small correlations with the MISS-21 (-.29, P = .05 and -.23, P = .034) and with NRS satisfaction (-.27, P = .011 and -0.27, P = 0.012). Quick Disability of Arm, Shoulder and Hand (QuickDASH) had a small correlation with NRS satisfaction (-0.023, P ≤ 0.001), but did not correlate with MISS-21. Conclusions: Although there is small overlap about the 2 satisfaction measures, a complex patient satisfaction questionnaire consisting of multiple facets of patient satisfaction like MISS-21 is not replaceable by 1 simple NRS patient satisfaction question.

Assessment of Decisional Conflict about the Treatment of Trigger Finger, Comparing Patients and Physicians.

BACKGROUND: As an early step in the development of a decision aid for idiopathic trigger finger (TF) we were interested in the level of decisional conflict experienced by patients and hand surgeons. This study tested the null hypothesis that there is no difference in decisional conflict between patients with one or more idiopathic trigger fingers and hand surgeons. Secondary analyses address the differences between patients and surgeons regarding the influence of the DCS-subcategories on the level of decisional conflict, as well as the influence of patient and physician demographics, the level of self-efficacy, and satisfaction with care on decisional conflict. METHODS: One hundred and five hand surgeon-members of the Science of Variation Group (SOVG) and 84 patients with idiopathic TF completed the survey regarding the Decisional Conflict Scale. Patients also filled out the Pain Self-efficacy Questionnaire (PSEQ) and the Patient Doctor Relationship Questionnaire (PDRQ-9). RESULTS: On average, patients had decisional conflict comparable to physicians, but by specific category patients felt less informed and supported than physicians. The only factors associated with greater decisional conflict was the relationship between the patient and doctor. CONCLUSIONS: There is a low, but measurable level of decisional conflict among patients and surgeons regarding idiopathic trigger finger. Studies testing the ability of decision aids to reduce decisional conflict and improve patient empowerment and satisfaction with care are merited.

Factors associated with pain intensity and physical limitations after lateral ankle sprains.

BACKGROUND: Swelling, tenderness, and ecchymosis don't correlate with time to functional recovery in patients with a lateral ankle sprain. It is established that psychosocial factors such as symptoms of depression and low pain self-efficacy correlate with pain intensity and magnitude of limitations in patients with musculoskeletal disorders. OBJECTIVE: We studied the correlation between pain self-efficacy or symptoms of depression and (1) ankle specific limitations and (2) pain intensity in patients with a lateral ankle sprain. Further we explored the correlation between estimation of sprain severity (grade) and (3) pain intensity or magnitude of ankle specific limitations. DESIGN: Eighty-four patients with a lateral ankle sprain prospectively completed the Pain Self Efficacy Questionnaire, the Olerud Molander Ankle Score, Ordinal scale of Pain and the Patient Health Questionnaire-2 at enrollment and the Olerud Molander Ankle Score and the Ordinal scale of Pain three weeks after the injury. Factors associated with higher ankle specific limitations and symptoms were investigated in bivariable and multivariable analysis. RESULTS: When accounting for confounding factors, greater self-efficacy (p=0.01) and older age (p<0.01) were significantly associated with greater ankle specific symptoms and limitations three weeks after the injury and explained 22% of the variability in ankle specific limitations and symptoms. There was no correlation between the grade of the sprain and pain intensity or ankle specific limitations or symptoms. CONCLUSIONS: Psychosocial factors (adaptiveness in response to pain in particular) explain more of the variation in symptoms and limitations after ankle sprain than the degree of pathophysiology. The influence of adaptive illness descriptions and recovery strategies based on methods for improving self-efficacy (i.e. cognitive behavioral therapy) might enhance and speed recovery from ankle injuries and merit additional investigation. LEVEL OF EVIDENCE: Level 2 prospective cohort study.

Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain.

BACKGROUND: Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. We therefore asked the following questions: 1) Which demographic factors and psychological comorbidities are associated with change from an initial diagnosis of nonspecific arm pain to eventual identification of discrete pathophysiology that corresponds with symptoms? 2) What is the percentage of patients eventually diagnosed with discrete pathophysiology, what are those pathologies, and do they account for the symptoms? METHODS: We evaluated 634 patients with an isolated diagnosis of nonspecific upper extremity pain to see if discrete pathophysiology was diagnosed on subsequent visits to the same hand surgeon, a different hand surgeon, or any physician within our health system for the same pain. RESULTS: There were too few patients with discrete pathophysiology at follow-up to address the primary study question. Definite discrete pathophysiology that corresponded with the symptoms was identified in subsequent evaluations by the index surgeon in one patient (0.16% of all patients) and cured with surgery (nodular fasciitis). Subsequent doctors identified possible discrete pathophysiology in one patient and speculative pathophysiology in four patients and the index surgeon identified possible discrete pathophysiology in four patients, but the five discrete diagnoses accounted for only a fraction of the symptoms. CONCLUSION: Nonspecific diagnoses are not harmful. Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

Progression of Heterotopic Ossification around the Elbow after Trauma.

BACKGROUND: This study addresses the null hypothesis that there is no expansion of heterotopic ossification (HO) in the elbow beyond what can be seen early on. METHODS: The area of HO was measured on lateral radiographs of 38 consecutive patients that had operative treatment of HO between 2000 and 2013. Measurements from radiographs obtained between 3 to 7 weeks were compared to measurements from radiographs made 3 months or more after injury. RESULTS: There was no significant difference between the average area of HO on the first (median 2.8 square centimeters, Q1: 1.5, Q3: 5.1) and later radiographs (median of 2.8 square centimeters, Q1: 1.4, Q3: 5.0) (P = 0.99). CONCLUSION: According to our results the area of HO does not expand beyond what can be seen early in the disease process.

Do patients prefer optional follow-up for simple upper extremity fractures: A pilot study.

INTRODUCTION: We aimed to evaluate the results of offering patients optional follow-up for simple upper extremity fractures. Specifically this study tested if there is a difference in (1) upper extremity disability, (2) return to work, and (3) satisfaction with delivered care at 2-6 months after enrollment between patients who choose and do not choose a return visit for an adequately aligned metacarpal, distal radius, or radial head fracture. Additionally we assessed if there was a difference in overall evaluation of the visit at enrollment between those patients and what factors were associated with returning after initially choosing not to schedule a follow-up visit. PATIENTS AND METHODS: We prospectively enrolled all adult patients (n=120) with adequately aligned metacarpal fractures, non-or minimally displaced distal radius fractures, and isolated non- or minimally displaced radial head fractures of whom 82 (68%) were available at 2-6 months after enrollment. Subjects chose to have a scheduled (n=56) or optional (n=64) return visit. Subsequently, we recorded patient demographics and overall evaluation of the visit. Between two and six months after enrollment we measured QuickDASH, satisfaction with care, and current employment status. RESULTS: Accounting for potential differences in baseline characteristics by multivariable analysis, return choice was not associated with QuickDASH (ß regression coefficient [ß] -0.53, 95% confidence interval [CI] -7.4 to 6.4, standard error [SE] 3.5, P=0.88), return to work (odds ratio [OR] -1.3, 95%CI -3.5 to 0.95, SE 1.1, P=0.26), satisfaction with care (ß -0.084, 95%CI -0.51 to 0.35, SE 0.22, P=0.70), or overall evaluation of the initial visit (ß 0.18, 95%CI -0.38 to 0.73, SE 0.28, P=0.53). Of the 64 people choosing optional follow-up, 11 patients returned (17%). The only factor independently associated with returning after initially not choosing to return was greater disability at enrollment (OR 1.05, 95%CI 1.0050-1.098, SE 0.024, P=0.029). CONCLUSIONS: A majority of patients prefer optional follow-up for simple upper extremity fractures with a good prognosis. Hand surgeons can consider offering patients with low-risk hand fractures an optional second visit. Eliminating unnecessary visits, tests and imaging could lower the cost of care. LEVEL OF EVIDENCE: Therapeutic level II.

Is Social Support Associated With Upper Extremity Disability?

BACKGROUND: Pain intensity and disability correlate with psychosocial factors such as depression and pain interference (the degree to which pain interferes with activities of daily living) as much or more than pathophysiology in upper extremity illness. However, other factors like emotional support (perception of being cared for and valued as a person), instrumental support (perception of availability of tangible assistance when needed), positive psychosocial impact (perception and focus on the positive side of a difficult situation, sometimes characterized as posttraumatic growth, benefit-finding, or meaning making), also might be associated with disability in patients with upper extremity orthopaedic illness. This is the first published study, to our knowledge, addressing the potential association of emotional support, instrumental support, and positive psychosocial illness impact with disability in patients with upper extremity illness. QUESTIONS/PURPOSES: We asked: (1) Is there a correlation between the QuickDASH and the Patient-reported Outcomes Measurement Information System (PROMIS(®)) emotional support Computer Adaptive Testing (CAT)? (2) Is there a correlation between the QuickDASH and PROMIS(®) instrumental support CAT? (3) Is there a correlation between the QuickDASH and PROMIS(®) positive psychosocial illness impact CAT? (4) Among the PROMIS(®) measures of depression, emotional support, instrumental support, positive illness impact, and pain interference, which accounts for the most variance in QuickDASH scores? METHODS: One hundred ninety-three patients with upper extremity illness (55% women; average age, 51 ± 18 years) of 213 approached (91% recruitment rate) completed the QuickDASH, and five different PROMIS(®) CATs: pain interference (the degree to which pain interferes with accomplishing one's goals), depression, emotional support, psychosocial illness impact, and instrumental support. We recruited patients from the practice of three surgeons in hand service of the department of orthopaedic surgery at a major urban university hospital. RESULTS: Pearson Product Moment Correlations showed that emotional support (r = -0.18; p = 0.014) and instrumental support (r = -0.19; p = 0.008) were weakly and inversely associated with the QuickDASH), while positive psychosocial illness impact was moderately and inversely associated with the QuickDASH (r = -0.36; p < 0.001). In multivariable analyses, pain interference, but not the social support measures, was the only psychosocial factor associated with the QuickDASH and alone explained 66% of variance. CONCLUSIONS: Emotional support, instrumental support and positive psychosocial illness impact are all individually associated with disability to a small degree, but pain interference (the degree to which pain interferes with accomplishing one's goals) has the strongest influence on magnitude of disability. LEVEL OF EVIDENCE: Level 1, prognostic study.

The effect of a decision aid on informed decision-making in the era of non-invasive prenatal testing: a randomised controlled trial.

Early in pregnancy women and their partners face the complex decision on whether or not to participate in prenatal testing for fetal chromosomal abnormalities. Several studies show that the majority of pregnant women currently do not make informed decisions regarding prenatal testing. As the range of prenatal tests is expanding due to the development of new techniques such as non-invasive prenatal testing (NIPT), autonomous reproductive decision-making is increasingly challenging. In this study, a randomised controlled trial was conducted to evaluate the effect of a web-based multimedia decision aid on decision-making regarding prenatal testing. The decision aid provided both written and audiovisual information on prenatal tests currently available, that is, prenatal screening by first-trimester combined testing, NIPT and invasive diagnostic testing through chorionic villus sampling or amniocentesis. Furthermore, it contained values clarification exercises encouraging pregnant women to reflect on the potential harms and benefits of having prenatal tests performed. The use of the decision aid improved informed decision-making regarding prenatal testing. Of pregnant women allocated to the intervention group (n=130) 82.3% made an informed choice compared with 66.4% of women in the control group (n=131), P=0.004. As the vast majority of pregnant women made decisions consistent with their attitudes towards having prenatal testing performed, this improvement in informed decision-making could be attributed mainly to an increase in decision-relevant knowledge. This study shows that the implementation of a web-based multimedia decision aid directly facilitates the ultimate goal of prenatal testing for fetal chromosomal abnormalities, which is enabling informed autonomous reproductive choice.

Assessment of Decisional Conflict about the Treatment of carpal tunnel syndrome, Comparing Patients and Physicians.

BACKGROUND: As part of the process of developing a decision aid for carpal tunnel syndrome (CTS) according to the Ottawa Decision Support Framework, we were interested in the level of 'decisional conflict' of hand surgeons and patients with CTS. This study addresses the null hypothesis that there is no difference between surgeon and patient decisional conflict with respect to test and treatment options for CTS. Secondary analyses assess the impact of patient and physician demographics and the strength of the patient-physician relationship on decisional conflict. METHODS: One-hundred-twenty-three observers of the Science of Variation Group (SOVG) and 84 patients with carpal tunnel syndrome completed a survey regarding the Decisional Conflict Scale. Patients also filled out the Pain Self-efficacy Questionnaire (PSEQ) and the Patient Doctor Relationship Questionnaire (PDRQ-9). RESULTS: On average, patients had significantly greater decision conflict and scored higher on most subscales of the decisional conflict scale than hand surgeons. Factors associated with greater decision conflict were specific hand surgeon, less self-efficacy (confidence that one can achieve one's goals in spite of pain), and higher PDRQ (relationship between patient and doctor). Surgeons from Europe have--on average--significantly more decision conflict than surgeons in the United States of America. CONCLUSIONS: Patients with CTS have more decision conflict than hand surgeons. Decision aids might help narrow this gap in decisional conflict.

Factors Associated With Met Expectations in Patients With Hand and Upper Extremity Disorders: A Pilot Study.

PURPOSE: The degree to which patients' expectations are met during an office visit consistently correlates with patients' satisfaction, whereas the relationship between previsit expectations and satisfaction varies. OBJECTIVE: The aim of this pilot study was to preliminarily assess the relationship of psychosocial factors, pain intensity, and magnitude of disability to previsit expectations, met expectations, and satisfaction with medical care in patients with hand and upper extremity conditions in a surgical outpatient clinic. METHODS: A cohort of 85 outpatients with upper extremity illnesses indicated their previsit expectations (Patients Intention Questionnaire), degree to which these expectations were met (Expectations Met Questionnaire), level of depressive symptoms (Patient Health Questionnaire-2), confidence about the ability to achieve one's goals in spite of pain (Pain Self-Efficacy Questionnaire), pain intensity (Numerical Rating Scale for pain), disability (Disabilities of the Arm Shoulder and Hand, short version; QuickDASH), and satisfaction with the medical visit (Medical Interview Satisfaction Scale). RESULTS: Higher previsit expectations were associated with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and fewer years of education. Patients in the low and moderate met expectations categories had significantly more symptoms of depression, fewer years of education, and more pain compared to those in the high-met expectations category. Fewer years of education and higher pain intensity predicted higher previsit expectations and explained 19% of variance. CONCLUSION: Psychosocial factors affect both previsit expectations and met expectations during an outpatient visit to a hand surgeon. Met expectations, but not previsit expectations, affect satisfaction. LEVEL OF EVIDENCE: Prognostic, level II.

Facing the decision about the treatment of hip or knee osteoarthritis: What are patients' needs?

PURPOSE: There is an increasing interest in modern orthopaedic practice to empower patients to participate in shared decision-making. Decision aids are thought to be helpful in this process. Before creating decision aids for patients with osteoarthritis in the knee or hip, the goal was to identify the needs of patients and physicians when deciding about the treatment. Specifically, this study tested the null hypothesis that there is no significant difference in decisional conflict between patients with knee or hip osteoarthritis and orthopaedic surgeons. METHODS: Thirty-three orthopaedic surgeons and 172 patients with either knee or hip osteoarthritis were surveyed. Patients entered their demographic information and completed the Knee Injury and Osteoarthritis Outcome Score/Hip Disability and Osteoarthritis Outcome Score, the Assessment of Needs survey based on the Ottawa Decision Support Framework, the Decisional Conflict Scale, the Pain Self-Efficacy Questionnaire, the Patient-Doctor Relationship Questionnaire-9, the Pain Anxiety Symptoms Scale and the Patient Health Questionnaire. Physicians entered their demographic and professional information and completed the Assessment of Needs survey based on the Ottawa Decision Support Framework and the Decisional Conflict Scale. RESULTS: The results showed that there was a significant difference (P < 0.01) between patients [mean (SD), 33 (19)] and physicians [mean (SD), 24 (14)], regarding decisional conflict about the treatment of knee and hip osteoarthritis. It also showed that patients' decisional conflict was associated with the patient-doctor relationship, and there was a need for information and clearness of one's values for risks and benefits. CONCLUSION: Patients had a higher magnitude of decisional conflict than physicians and that the level of decisional conflict was positively influenced by the patient-doctor relationship. Patients had high needs regarding information and clearness of one's values for risks and benefits. LEVEL OF EVIDENCE: II.

Quantitative three-dimensional computed tomography analysis of glenoid fracture patterns according to the AO/OTA classification.

HYPOTHESIS/BACKGROUND: This study measures the characteristics of glenoid fractures to determine if the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification captures the most common fracture patterns. The primary null hypothesis was that surface area and degree of fragmentation do not differ among the different fracture types. Secondarily, we tested if there was a relationship between high- vs. low-energy trauma and fracture classification. METHODS: Three-dimensional models were created for a consecutive series of 53 fractures. The fracture classifications, the number of fragments, and the fragmented articular surface area were related to the type of injury. The difference of articular surface size and number of fragments among classification groups was analyzed with the Kruskal-Wallis test. RESULTS: There is a significant difference in fractured articular surface area among classification groups. Compared with transverse and multifragmented fractures, both anterior and posterior fractures involved significantly less of the articular surface area. High-energy trauma is associated with transverse and multifragmented fractures in 93% of the cases. It is associated with a greater number of fracture fragments and fracture of a larger percentage of the glenoid surface area, with a mean fractured surface of 60% for high-energy fractures and 25% for low-energy injuries. DISCUSSION/CONCLUSION: Quantitative 3-dimensional CT analysis confirms that the current AO/OTA classification adequately characterizes and discriminates glenoid fracture patterns. The classification groups are related to the fragmented articular surface area and the number of fragments. Also, the mechanism of injury is related to the classification group, which supports the clinical relevance of the classification.

Acute Median Neuropathy and Carpal Tunnel Release in Perilunate Injuries Can We Predict Who Gets a Median Neuropathy?

UNLABELLED: This study addressed the following null hypotheses: 1) There are no demographic differences between patients with perilunate dislocation (PLD) or fracture-dislocation (PLFD); 2) There are no factors associated with the development of median nerve symptoms in the setting of a PLD or PLFD; and 3) There are no factors associated with carpal tunnel release. Using a retrospective search of a prospective trauma database, we identified all patients who had sustained a radiologically confirmed PLD or PLFD over a 10-year period at two trauma centers. From the medical records we identified median nerve symptoms and carpal tunnel release in addition to demographic and injury characteristics. Among the 71 patients treated for PLD or PLFD, acute median neuropathy was diagnosed in 33 patients (47 %). The only significant difference between PLD and PLFD was a younger age with PLFD. No demographic or injury factors were associated with symptoms of median neuropathy. Carpal tunnel release surgery during the initial operative management was related to the presence of median nerve symptoms and the trauma center. We report a high incidence of acute median neuropathy accompanying perilunate injuries. As there are no demographic or injury factors associated with symptoms of median neuropathy; all patients with PLD/PLFD merit equally high vigilance for acute median neuropathy. LEVEL OF EVIDENCE: Level III, prognostic study.

The effect of feedback regarding coping strategies and illness behavior on hand surgery patient satisfaction and communication: a randomized controlled trial.

BACKGROUND: Patients and surgeons can feel uncomfortable discussing coping strategies, psychological distress, and stressful circumstances. It has been suggested that patient-reported outcome measures (PROMs) facilitate the discussion of factors associated with increased symptoms and disability. This study assessed the effect of providing feedback to patients regarding their coping strategy and illness behavior on patient satisfaction and patient-physician communication in orthopedic surgery. METHODS: In a prospective study, 136 orthopedic patients were randomly assigned to either receive feedback about the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference computer-adaptive test (CAT) prior to the visit with the hand surgeon or not. The primary outcome was patient satisfaction with the consultation and secondary outcomes involved patient-physician communication. Bivariate and multivariable analyses were performed to determine the influence of the feedback on patient satisfaction and communication. RESULTS: There was no significant difference in patient satisfaction between patients who received feedback and patients who did not (P = 0.70). Feedback was associated with more frequent discussion of coping strategies (P = 0.045) in bivariate analysis but was not independently associated: in multivariable analysis, only PROMIS Pain Interference CAT and age were identified as independent predictors (odds ratio (OR) 1.1; 95 % confidence interval (CI) 1.0-1.1, P = 0.013, and OR 0.97, 95 % CI 0.94-0.99, P = 0.032, respectively). No factors were associated with discussion of stressors. Discussion of circumstances was independently associated with increased PROMIS Pain Interference CAT, marital status, and work status. CONCLUSION: We found that feedback regarding coping strategies and illness behavior using the PROMIS Pain Interference CAT did not affect patient satisfaction. Although feedback was associated with increased discussion of illness behavior in bivariate analysis, less effective coping strategies and personal factors (age, marital status, and work status) were more important factors.

Internet self-diagnosis in hand surgery.

BACKGROUND: Some Internet sites have programs that attempt to help patients find their diagnosis based on symptoms. This study tested the null hypothesis that there are no factors associated with correspondence between online diagnosis and the hand surgeon's diagnosis in an outpatient hand and upper extremity surgeons' office. METHODS: Eighty-six outpatients were prospectively enrolled and used WebMD® symptom checker to guess their diagnosis. We collected demographic information, hours spent on the Internet per week, and the following questionnaires: Pain Catastrophizing Scale (PCS) and Center of Epidemiologic Studies Depression scale (C-ESD). RESULTS: Thirty-three percent of online diagnoses matched the final diagnosis of the hand surgeon. Factors associated with an online diagnosis corresponding to the hand surgeon's diagnosis included sex (women) and patients who studied their symptoms online prior to the visit. The best multivariable model included sex, more years of education, and prior use of the Internet to research their medical condition and explained 15 % of the variation in correspondence of diagnosis. CONCLUSIONS: The majority of online diagnoses for hand and upper extremity conditions do not correspond with the diagnosis of the treating hand surgeon. Psychological factors do not influence the correspondence of online diagnosis with the hand surgeon's diagnosis. LEVEL OF EVIDENCE: Prognostic, level II.

Quantitative 3-dimensional CT analyses of fractures of the middle phalanx base.

BACKGROUND: Quantitative 3-dimensional computed tomography (3DCT) analyses can provide a more detailed understanding of fracture morphology. For fracture-dislocation of the proximal interphalangeal joint, the extent of fragmentation of the volar lip of the middle phalanx-a factor that might influence treatment-is not always apparent from radiographs. We hypothesized that there is no correlation between number of fracture fragments and the percentage of articular surface area involved in intra-articular fractures of the base of the middle phalanx using quantitative 3DCT analyses. METHODS: We used 13 computed tomography scans with a slice thickness of 1.25 mm or less to create 3-dimensional models of 15 intra-articular fractures of the base of the middle phalanx in 13 patients. We resized 3-dimensional models of a non-fractured middle phalanx of the same hand to fit the fractured middle phalanx in order to approximate the size and shape of the fractured middle phalanx in its pre-injury state. We created a heatmap to demonstrate the location of the fractured articular surface. RESULTS: With the number of scans available, we did not find a significant correlation between the percentage of articular surface area involved and the number of fracture fragments. The median percentage of articular surface area involved was 46 % (range, 21-90 %). The heatmap demonstrated that the radio-volar side of the articular surface seems to be more involved than the ulnar-volar side in intra-articular fractures of the base of the middle phalanx. CONCLUSION: Quantitative 3DCT analysis of fracture fragments provides useful information that could facilitate surgery and analysis of complex fractures of the base of the middle phalanx. LEVEL OF EVIDENCE: IV, Basic Science Study, Anatomic Study, Imaging.