The Capitate-to-Axis-of-Radius Distance (CARD): A New Radiographic Measurement for Wrist and Carpal Alignment in the Sagittal Plane.

PURPOSE: To determine the reliability of a new radiographic index evaluating sagittal radiocarpal alignment, the capitate-to-axis-of-radius distance (CARD). A secondary purpose was to validate this index by comparing values between normal wrists and those with distal radial fractures (DRFs) and rheumatoid arthritis (RA). METHODS: The CARD is defined as the perpendicular distance from the center of the capitate head to the axis of the radius. Inter- and intraobserver reliability was tested. Cronbach alpha was calculated, and 2 methods of measurement were compared. The superior one (volar border of radial shaft) was used in the second part of the study. The normal CARD was then compared with unilateral DRFs with dorsal displacement DRF (n = 25) and RA (n = 25). Correlations between the CARD and other radiographic parameters (dorsal angulation, radial inclination, and ulnar variance) were calculated as well as between the CARD and the severity of disease or fracture displacement (mild/moderate/severe). RESULTS: The CARD showed excellent intra- and interobserver reliability. The volar radius measurement method was superior to the midaxis method and was, therefore, used for the second portion of the study. The mean CARD for normal, fractured, and RA wrists was significantly different (2.2 ± 2.5 mm, 15.7 ± 6.5 mm and 0.2 ± 4.4 mm, respectively). There was a strong side-to-side correlation in normal wrists (r = 0.77) and a significant correlation between the CARD (mm) and the severity of deformity (RA, r = -0.7; DRF, r = 0.8). CONCLUSION: The CARD is a reproducible, easy-to-use measurement of sagittal carpal alignment with a strong side-to-side correlation. The CARD increases with dorsal angulation of the distal radius and decreases as severity of deformity with RA increases. CLINICAL RELEVANCE: The correlation of the CARD with severity of deformity in DRFs and RA makes it a useful method of assessing deformities in the sagittal plane. The normal wrist can be used as a comparison when evaluating the CARD in the setting of unilateral wrist disease.

Diagnostic criteria for adverse health effects in the environs of wind turbines.

In an effort to address climate change, governments have pursued policies that seek to reduce greenhouse gases. Alternative energy, including wind power, has been proposed by some as the preferred approach. Few would debate the need to reduce air pollution, but the means of achieving this reduction is important not only for efficiency but also for health protection. The topic of adverse health effects in the environs of industrial wind turbines (AHE/IWT) has proven to be controversial and can present physicians with challenges regarding the management of an exposure to IWT. Rural physicians in particular must be aware of the possibility of people presenting to their practices with a variety of sometimes confusing complaints. An earlier version of the diagnostic criteria for AHE/IWT was published in August 2011. A revised case definition and a model for a study to establish a confirmed diagnosis is proposed.

A quantitative definition of scaphoid union: determining the inter-rater reliability of two techniques.

BACKGROUND: Despite extensive literature supporting the use of computerized tomography (CT) scans in evaluating scaphoid fractures, there has not been a consensus on the methodology for defining and quantifying union. The purpose of this study was to test the inter-observer reliability of two methods of quantifying scaphoid union. METHODS: The CT scans of 50 non-operatively treated scaphoid fractures were reviewed by four blinded observers. Each was asked to classify union into one of three categories, united, partially united, or tenuously united, based on their general impression. Each reviewer then carefully analyzed each CT slice and quantified union based on two methods, the mean percentage union and the weighted mean percentage union. The estimated percentage of scaphoid union for each scan was recorded, and inter-observer reliability for both methods was assessed using a Bland-Altman plot to calculate the 95% limits of agreement. Kappa statistic was used to measure the degree of agreement for the categorical assessment of union. RESULTS: There was very little difference in the percentage of union calculated between the two methods (mean difference between the two methods was 1.2 ± 4.1%), with each reviewer demonstrating excellent agreement between the two methods based on the Bland-Altman plot. The kappa score indicated very good agreement (Κ = 0.80) between the consultant hand surgeon and the musculoskeletal radiologist, and good agreement (Κ = 0.62) between the consultant hand surgeon and the hand fellow for the categorical assessment of union. CONCLUSIONS: This study describes two methods of quantifying and defining scaphoid union, both with a high inter-rater reliability. This indicates that either method can be reliably used, making it an important tool for both for clinical use and research purposes in future studies of scaphoid fractures, particularly those which are using union or time to union as their endpoint. LEVEL OF EVIDENCE: Diagnostic, level III.

Validity and responsiveness of presenteeism scales in chronic work-related upper-extremity disorders.

BACKGROUND: The Work Limitations Questionnaire-25 (WLQ-25) and the Work Instability Scale for Rheumatoid Arthritis (RA-WIS) have been used to measure at-work disability related to musculoskeletal disorders. However, a recent systematic review has shown that important psychometric properties still needed to be evaluated. OBJECTIVE: The purpose of this study was to establish the validity and responsiveness of the WLQ-25 and RA-WIS in people with chronic work-related upper-extremity disorders. DESIGN: Two-hundred six participants with chronic upper-extremity disorders who attended a specialty clinic operated by the Workplace Safety & Insurance Board of Ontario were evaluated at their initial visit and 6 months later. METHODS: Questionnaires completed at each evaluation were: the WLQ-25, the RA-WIS, the QuickDASH, the pain subscale of the Shoulder Pain and Disability Questionnaire, and the Chronic Pain Grade Questionnaire. At the 6-month evaluation, participants completed a global rating of change question. Known-group and construct convergent validity were assessed using analysis of variance and Pearson correlations, and standardized response means (SRMs) were used to assess responsiveness. Clinically important differences (CIDs) also were determined. RESULTS: The WLQ-25 and RA-WIS had low to moderate correlations with pain and disability scales (.28

A qualitative evaluation of scaphoid remodeling in bone-grafted scaphoid nonunions.

The purpose of this case series is to identify and illustrate the phenomenon of scaphoid remodeling in skeletally mature subjects following bone grafting for scaphoid nonunion. Nine patients with scaphoid nonunions were treated with interpositional bone grafting (with iliac crest bone graft) and K-wire fixation. The mean length of follow-up was 28.6 ± 9 months. Radiographs and CT scans were reviewed and assessed for degree of union and a qualitative assessment of scaphoid architecture. Following surgery, there was marked distortion of the scaphoid. Once healed, the contour of the scaphoid was still significantly distorted in all nine patients. Remodeling then became evident along the articular surfaces between 8 and 12 months. By 3 years, the scaphoid was completely recontoured and the normal architecture was completely restored in all nine patients. We conclude that the articular surface of the scaphoid remodels over time in skeletally mature subjects.

Predictors of time lost from work following a distal radius fracture.

STUDY DESIGN: Prospective Cohort. OBJECTIVE: to describe time lost from work following a distal radius fracture. METHOD: A cohort of 227 workers with distal radius fracture was enrolled at a baseline visit to the hand clinic where injury, patient characteristics, and occupational demand were recorded. Patients were followed up at 2, 3, 6, and 12 months and self-reported time lost from work, disability (PRWE, DASH), and health (SF-36). Impairments of grip strength, wrist motion and dexterity were measured at 2 and 3 months post-fracture. Measurements of fracture displacement and post-treatment anatomic position were obtained from available radiographs (n = 101). Bivariate/stepwise multiple linear regression and ANOVA were used to explore factors that affect work loss. RESULTS: The average number of weeks lost from work was 9.2 (SD = 9.7; range = 0-52, median = 8); although 21% of participants reported no lost time. Post-treatment or follow-up radiographic measures were not related to time lost from work. Self-reported disability and occupational demands were the strongest predictors of time lost. Models with self-reported disability produced higher R2 than those with physical impairment (40% vs. 29%), although some independent effects of both were evident (R2 = 43%). Significant bivariate predictors like educational level and worker's compensation were excluded in multivariate models that included occupational demand. CONCLUSIONS: Work loss following DRF is highly variable and cannot be accurately predicted solely on the basis of clinical variables. Patients who have high self-reported pain/disability and occupational demand at baseline are at risk of prolonged work loss.

Public reporting makes accountability possible.

This paper reviews the meta-analysis of Brown, Bhimani and MacLeod and finds it an important contribution to the literature on performance reporting (PR) in healthcare. Of 1,053 papers identified in their search, only 62 met their criteria for inclusion in the review. The authors used a Knowledge, Attitudes and Behaviour (KAB) model for their analysis. Of the 63 papers reviewed, most related to individual consumers and groups of providers, fewer related to groups of consumers and individual providers. The principal findings were that there is a shortfall in the literature on PR to 2004 and limited evidence that PR is having any impact on KAB of consumers or providers. They appropriately conclude that there is a need for the development of a conceptual model and thereby the requirement that the goal of placing PR "within a context that focuses attention and that supports action" may be achieved. In general, the conclusions are defensible and, given the lack of impact of PR they have demonstrated, their work should stimulate response and action within healthcare systems. Finally, this paper concludes by proposing six characteristics of successful PR--clear definition of context and goals, objective and verifiable indicators, transparent and useable information, equitability in scope, engaging the continuum of care, and integrating measures of cost-utility.

Public policy, human consequences: the gap between biomedicine and psychosocial reality.

Despite evidence-based research demonstrating the high prevalence rates of emotional distress, medical systems continue to focus their attention on biomedical aspects of treatment leaving a significant gap in patient care. This paper reflects on values and policy and suggests that we are unlikely to change health care systems unless we routinely address comprehensive aspects of the patient's experience. If we do not measure indicators of emotional distress, we risk not responding to this significant aspect of the cancer experience. The key message to health care providers here is: what we measure is what we act upon.