Bilateral Preiser Disease in a Patient with Sickle Cell Anemia.

Preiser disease is a rare condition of avascular necrosis of the scaphoid occurring in the absence scaphoid fracture or trauma. While the etiology of Preiser disease remains unknown, it has been associated with steroid use, chemotherapy, and infrequently with systemic diseases. No reports have associated Preiser disease with hemoglobinopathy. Due to the rarity of Preiser disease, management remains controversial and evidence is limited. Here, we describe the case of a 32-year-old right-hand dominant male with sickle cell anemia and a 4-year history of bilateral wrist pain. Radiographs and gadolinium-enhanced magnetic resonance imaging revealed bilateral Preiser disease. He was successfully managed with a 1,2 intercompartmental supraretinicaular artery vascularized bone graft to the right scaphoid.

Anatomical Study of the Innervation of Triangular Fibrocartilage Complex and Distal Radioulnar and Radiocarpal Joints: Implications for Denervation.

PURPOSE: Open and percutaneous denervation is an emerging technique for joint pain. This study investigated the course and distribution of the articular branches innervating the triangular fibrocartilage complex (TFCC), distal radioulnar joint (DRUJ), and radiocarpal joint (RCJ) relative to bony and soft tissue landmarks to guide wrist denervation procedures. METHODS: Fourteen formalin-embalmed specimens were serially dissected to expose the origin, course, and distribution of articular branches innervating the TFCC, DRUJ, and RCJ. Bony and soft tissue landmarks to localize each articular branch were documented and visualized on a 3-dimensional reconstruction of the bones of the distal forearm and hand. RESULTS: The TFCC was innervated by articular branches from the posterior interosseus nerve (10 of 14 specimens), dorsal cutaneous branch of the ulnar nerve (14 of 14 specimens), palmar cutaneous branch of the ulnar nerve (12 of 14 specimens), and medial antebrachial cutaneous nerve (9 of 14 specimens). The DRUJ was innervated by the posterior interosseus nerve (9 of 14 specimens) and anterior interosseus nerve (14 of 14 specimens). The RCJ was innervated by the posterior interosseus nerve (14 of 14 specimens), superficial branch of the radial nerve (5 of 14 specimens), lateral antebrachial cutaneous nerve (14 of 14 specimens), and palmar cutaneous branch of the median nerve (10 of 14 specimens). CONCLUSIONS: Multiple nerves were found to innervate the TFCC, DRUJ, and RCJ. The relationship of anatomical landmarks to specific articular branches supplying the TFCC, DRUJ, and RCJ can inform selective denervation procedures based on the structural origin of pain. CLINICAL RELEVANCE: The detailed documentation of the spatial relationship of the nerve supply to the wrist provides clinicians with the anatomical basis to optimize current, and develop new denervation protocols to manage chronic wrist pain.

"Uninformed" Consent: Patient Recollection From Surgical Consent in Hand Surgery-A Quality Improvement Initiative.

Background: Informed surgical consent is necessary and routine; however, it can have significant inadequacies. Our purpose was to investigate patient recollection of the surgical consent process and evaluate adequacy from the patient's perspective. Methods: A quality improvement framework was used. Two patient surveys capturing information recall and satisfaction of the consent process were administered in 5 consecutive hand clinics. All patients who previously underwent elective hand surgery were included. Results: There was exceptionally low recall of the risks and benefits of surgery in 103 consecutive patients who underwent hand surgery. Patients under age 35 had slightly better recall of surgical risks. Unexpected postoperative events affected patient perceptions of the consent process. Conclusions: Patients who have undergone elective hand surgery have poor recollection of the information discussed during the surgical consent process, and therefore the process is lacking. Surgeons may falsely assume that the consent process is sound because it is erroneously perceived as being sufficient by most patients.

Cost-Effectiveness Analysis of Motion-Preserving Operations for Wrist Arthritis.

BACKGROUND: The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective? METHODS: A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime. RESULTS: The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion. CONCLUSIONS: The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.

Outcomes of Secondary Combined Proximal Interphalangeal Joint Release and Zone II Flexor Tenolysis.

Background: Tendon adhesions and capsular contractures following trauma to the proximal interphalangeal joint (PIPJ) may significantly reduce hand function. Traditional, staged surgical management prioritizes restoration of PIPJ passive range of motion with joint release prior to restoration of active range of motion (AROM) with tenolysis. This is expensive and burdensome for patients. Our objective was to evaluate functional outcomes of combined PIPJ release and zone II flexor tenolysis. Methods: We retrospectively reviewed patients who underwent combined PIPJ release and flexor tenolysis. Replantation and tendon graft cases were excluded. Data were collected on pre- and postoperative AROM, total active motion (TAM), tip to distal palmar crease (DPC) distance, and grip strength. Functional outcomes were graded using the Boyes, American Society for Surgery of the Hand, and modified Strickland scores. Results: Twelve patients (9 men and 3 women, median age = 40 years) with a total of 15 digits underwent combined PIPJ release and flexor tenolysis a median of 10.1 months after injury. At a median follow-up of 4.0 months, there were significant improvements in median PIPJ AROM (15° to 70°), TAM (105° to 223°), tip to DPC distance (6.0 to 2.0 cm), and grip strength (35% to 54% of unaffected hand). Modified Strickland score was good in 46% of digits and excellent in 38%. There were no tendon ruptures, surgical site infections, or devascularized digits. Conclusion: Proximal interphalangeal joint stiffness is a challenging complication of hand trauma. Although a complete return to premorbid range of motion and function is rarely attained with surgery, improved outcomes may be consistently achieved with secondary combined PIPJ release and zone II flexor tenolysis.

Influence of psychological factors on patient-reported upper extremity disability.

Disability reflects physical impairment and the influence of psychosocial factors. We investigated the relationship between disability and psychosocial factors in patients with upper extremity pathology. Ninety-two patients at a hand clinic were evaluated to assess disability, pain intensity, health status and psychosocial factors (pain catastrophizing, depression). Statistical analyses evaluated the relationships among disability and patient and psychosocial factors. Moderate levels of disability from all types of pathology were reported and associated with pain catastrophizing, pain and depression. Health status Short Form 36 domains were not correlated with disability as determined by Disabilities of the Arm, Shoulder and Hand (DASH) scores. A strong correlation was found between DASH and QuickDASH scores, but the QuickDASH scored significantly higher by 4 points. Pain catastrophizing was the strongest predictor of disability and explained 59% and 63% of variation in disability scores. Independent of pathology, those patients experiencing psychosocial issues, as well as demographic factors (i.e. employment status and age), were more likely to have disability with hand conditions and surgical procedures. We conclude from this study that psychological factors affect patient-reported outcomes. Level of evidence: IV.

Utility of Specialized Imaging for Diagnosis of Chronic Wrist Pain.

Background Patients with chronic wrist pain often undergo imaging (such as magnetic resonance imaging [MRI], computed tomography [CT], or ultrasound [US]) prior to specialist assessment. Questions Is specialized wrist imaging performed prior to expert consultation necessary? Are there demographic differences between patients who do or do not receive preconsultation imaging? Patients and Methods A total of 115 patients referred to a tertiary hand center for chronic wrist pain and assessed by a hand surgeon were included. At initial consultation, surgeons were blinded to referral information and previous imaging results. The specialist performed a history, physical examination and reviewed X-rays. They established a clinical diagnosis and whether any additional investigations were needed. Prior MRI, CT, and/or US results were then reviewed and the specialists' clinical diagnosis was compared with the blinded referral diagnosis. Preconsultation imaging was categorized as having no value for diagnosis/management, some value, or high value. Results A total of 82 patients had imaging prior to specialist referral (69 MRIs, 11 CTs, and 16 ultrasounds). The majority of additional imaging (73%) was classified as unnecessary, including 77% of the MRIs and 100% of the ultrasounds. Of all the investigations performed, two CT scans were labeled highly valuable clinical aids. Older patients and those with radial-sided pain were less likely to receive preconsultation imaging. Six patients required further imaging after consultation. Conclusion Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain and few patients require additional imaging. Level of Evidence This is a Level III study.

Stable rates of operative treatment of distal radius fractures in Ontario, Canada: a population-based retrospective cohort study (2004­2013)

Background: Rates of surgical management of distal radius fractures are increasing internationally despite the higher cost and limited outcome evidence to support this shift. This study examines the epidemiology of distal radius fractures and asks if the same shift has occurred in Ontario, Canada (population 13.9 million). Methods: This population-based, retrospective cohort study examined distal radius fractures in people aged 18 years and older over a 10-year period (2004­2013). The incidence analyses were based on the first occurrence of a fracture within a 2-year time period. The number of fractures, age-adjusted incidence rates and frequency of fracture treatment type by year were assessed. We used a Poisson regression with robust standard errors to determine if there was a statistically significant change in the frequency of fracture treatment type over time. Results: There were 25 355 distal radius fractures among Ontarians 18 years of age and older in 2013. Between 2004 and 2013, the age-adjusted incidence rate for people 35 years of age and older was stable, between 2.32 and 2.70 per 1000 population. Rates of cast immobilization remained stable between 82% and 84%. Of those patients treated surgically, the rate of open reduction and internal fixation rose from 7% in 2004 to 13% in 2013 at the expense of other types of surgical management. Conclusion: In Ontario, rates of cast immobilization are stable and there has been a movement toward open reduction and internal fixation among patients treated surgically.

Contexte: Le taux de prise en charge chirurgicale des fractures du radius distal augmente partout dans le monde, malgré le coût supérieur de l'intervention et le manque de données probantes sur les issues. Cette étude se penche sur l'épidémiologie des fractures du radius distal et cherche à savoir si cette augmentation se reflète en Ontario, au Canada (population : 13,9 millions). Méthodes: Cette étude de cohorte rétrospective basée sur la population examinait les fractures du radius distal chez les personnes âgées de 18 ans et plus sur une période de 10 ans (de 2004 à 2013). Les analyses de l'incidence étaient fondées sur la première occurrence de fracture en 2 ans. Le nombre de fractures, le taux d'incidence ajusté en fonction de l'âge et la fréquence annuelle des types de traitement des fractures ont été évalués. Nous avons utilisé une régression de Poisson avec des erreurs types robustes pour déterminer s'il y avait des changements statistiquement significatifs dans la fréquence des types de traitement des fractures au fil du temps. Résultats: Il y a eu 25 355 fractures du radius distal chez les Ontariens de 18 ans et plus en 2013. Entre 2004 et 2013, le taux d'incidence ajusté en fonction de l'âge pour les personnes de 35 ans et plus était stable, entre 2,32 et 2,70 pour 1000 personnes. Le taux d'immobilisation plâtrée est demeuré stable entre 82 % et 84 %. Chez les patients traités par chirurgie, le taux de réduction chirurgicale et de fixation interne est passé de 7 % en 2004 à 13 % en 2013, au détriment des autres types de prise en charge chirurgicale. Conclusion: En Ontario, le taux d'immobilisation plâtrée est demeuré stable et il y a eu une augmentation de la réduction chirurgicale et de la fixation interne chez les patients traités par chirurgie.

How accurate are we? A comparison of resident and staff physician billing knowledge and exposure to billing education during residency training

Background: Practice management is an overlooked and undertaught subject in medical education. Many physicians feel that their exposure to billing education during residency training was inadequate. The purpose of this study was to compare resident and staff physicians in terms of their billing knowledge and exposure to billing education during residency training. Methods: Senior residents and staff physicians completed a scenario-based clinical billing assessment. Posttest surveys were completed to determine exposure to practice management and billing education during training. Results: A total of 16 resident physicians and 17 staff physicians completed the billing assessment. Overall, the billing accuracy of respondents was poor. Staff physicians had a greater percentage of correct billing codes (55.3% v. 37.5%, p < 0.001) and underbilled codes (6.2% v. 3.4%, p = 0.009), with fewer missed billing codes (38.5% v. 59.1%, p < 0.001), compared with resident physicians. The percentage value of correct billings was significantly higher for staff physicians (71.5% v. 56.8%, p = 0.01). In the posttest survey, 100.0% of residents and 79.0% of staff physicians desired more billing education during training. Conclusion: In general, staff physicians billed more accurately than resident physicians, but even experienced staff physicians missed a substantial amount of potential revenue because of billing errors and omissions. The majority of the residents and staff physicians who participated in our study felt that current billing education is both insufficient and ineffective. Incorporating practice management and billing education into residency training is critical to ensure that the next generation of medical trainees possess the financial competence to required to manage a successful medical practice.

Contexte: La gestion médicale est un sujet souvent oublié et trop peu enseigné durant les études de médecine. Beaucoup de médecins ont l'impression que la formation sur la facturation offerte durant leur résidence était insuffisante. L'objectif de cette étude était de comparer les connaissances sur la facturation et l'exposition, durant la résidence, à la formation sur ce sujet des résidents et des médecins membres du personnel. Méthodes: Les résidents seniors et les médecins membres du personnel ont effectué une évaluation de facturation clinique à partir de mises en situation. Ils ont répondu à un sondage après le test pour déterminer leur exposition à la formation sur la gestion médicale et la facturation durant leurs études. Résultats: Au total, 16 médecins résidents et 17 médecins membres du personnel ont fait l'évaluation de facturation. Dans l'ensemble, l'exactitude de leur facturation était faible. Les médecins membres du personnel avaient un pourcentage plus élevé de codes de facturation corrects (55,3 % contre 37,5 %, p < 0,001) et de codes de facturation insuffisants (6,2 % contre 3,4 %, p = 0,009), et avaient moins de codes manquants (38,5 % contre 59,1 %, p < 0,001), comparativement aux médecins résidents. Le pourcentage de facturations correctes était significativement plus élevé chez les médecins membres du personnel (71,5 % contre 56,8 %, p = 0,01). Dans le sondage post-test, 100,0 % des résidents et 79,0 % des médecins membres du personnel désiraient avoir davantage de formation sur la facturation durant les études. Conclusion: En général, les médecins membres du personnel ont produit des factures plus exactes que les médecins résidents, mais même des médecins membres du personnel expérimentés ont perdu des revenus potentiels considérables en raison d'erreurs de facturation et d'omissions. La majorité des résidents et des médecins membres du personnel qui ont participé à l'étude avaient l'impression que la formation actuelle sur la facturation était à la fois insuffisante et inefficace. Il est essentiel d'intégrer la formation sur la gestion médicale et la facturation dans la résidence pour garantir que la prochaine génération de futurs médecins possède les compétences financières nécessaires pour gérer un cabinet prospère.

Decisional conflict in surgical patients: Should surgeons care?

Summary: Decisional conflict represents a state of uncertainty regarding an action one must take. It is a concept inherent to shared decision-making and can help promote high-quality and patient-centred decisions in surgical care, leading to better outcomes. Specific elements may cause more uncertainty or decisional conflict for patients: lack of knowledge about risks and benefits, poorly defined personal values about the importance of those risks and benefits, perception of a lack of support, unpredictable outcomes, or the impression that an inadequate decision has been made. Decisional conflict can be measured in the surgical setting using the 16-item validated patient-reported Decisional Conflict Scale (DCS). Better understanding of the reasons behind high decisional conflict can help surgeons support high-quality decisions and lead to more satisfactory outcomes and less decisional regret.

Universal Measures of Support Are Needed: A Cross-Sectional Study of Health Literacy in Patients with Dupuytren's Disease.

BACKGROUND: Health literacy represents the degree to which patients can understand and act on health information. The relevance of health literacy to health care delivery, outcomes, and overall surgical care is unambiguous. This study aimed (1) to determine the prevalence of limited health literacy in patients diagnosed with Dupuytren's contracture and (2) to identify independent predictors of limited health literacy. METHODS: This cross-sectional study included patients with Dupuytren's disease and with self-reported English fluency. The Newest Vital Sign, a rapid, validated, and reliable screening tool, was selected to measure health literacy. An exploratory multivariable logistic regression model was used to identify possible predictors of limited health literacy. RESULTS: A total of 185 patients met eligibility criteria and were included. From those, 82 (44 percent) were found to have limited health literacy, defined as a score of 3 or less on the Newest Vital Sign. The domain of prose literacy was most highly scored compared to numeracy and document literacy. Lower household income was associated with a 4.7-fold increase in the odds of having limited health literacy. Being an immigrant also increased the odds of having limited health literacy by a factor of 3.6. Sensitivity analyses and subgroup analyses (based on education, maternal language, and immigration status) corroborated these independent predictor findings. CONCLUSIONS: Limited health literacy is common among patients with Dupuytren's contracture. System level changes are necessary such as the access and integration to clinical care of universal measures of support to promote productive patient-surgeon interactions.

Health Literacy Among Surgical Patients: A Systematic Review and Meta-analysis.

Health literacy is the extent to which patients are able to understand and act upon health information. This concept is important for surgeons as their patients have to comprehend the nature, risks and benefits of surgical procedures, adhere to perioperative instructions, and make complex care decisions about interventions. Our review aimed to determine the prevalence of limited health literacy of the surgical patient population. A search of MEDLINE and EMBASE was performed from inception until January 14th 2017 for experimental and observational studies reporting surgical patients' health literacy measurement. Overall pooled proportion of surgical patients with limited health literacy was calculated using a random-effects model and methodologic quality was assessed. A total of 40 studies representing 18,895 surgical patients were included in our quantitative synthesis. Pooled estimate of limited health literacy was 31.7% (95%CI 24.7-39.2%, I2 99.0%). There was low risk of bias among the majority of the 51 studies included in the qualitative synthesis. Statistical heterogeneity could not be fully accounted for by methodologic quality or patient and surgical characteristics. However, some of the heterogeneity was accounted by measurement tool [combined proportions with the REALM and NVS of 35.6 (95%CI 31.5-39.9, I2 73.0%)]. A number of different health literacy measurement tools were used (19 overall). Our review demonstrates a high prevalence of limited health literacy among surgical patients with considerable heterogeneity. Our findings suggest the importance of recognizing and addressing surgical patients with limited health literacy and the need for standardization in measurement tools.

Effect of Forearm Warming Compared to Hand Warming for Cold Intolerance Following Upper Extremity Trauma.

PURPOSE: This study evaluated the effect of forearm or hand warming versus bare hand conditions to improve cold-induced symptoms and skin temperatures in hand trauma patients. METHODS: Adults with symptoms of cold intolerance at least 3 months following hand trauma and age-/sex-matched controls were included. Testing sessions (bare hand, hand warming, forearm warming) were completed in a climate laboratory with continuous temperature monitoring. Outcomes included physical findings (skin temperature) and self-report symptoms (thermal comfort, pain). RESULTS: Eighteen participants (9 hand trauma patients, 9 control subjects) underwent testing. More severe cold intolerance was associated with higher Disabilities of the Arm, Shoulder, and Hand scores. With bare hands, skin temperatures changed significantly from baseline to cold exposure and to rewarming. Hand trauma patients had the lowest skin temperatures with cold exposure in the injured digits (14.3°C ± 3.5°C) compared with the contralateral uninjured (16.9°C ± 4.1°C) digits. Compared with bare hands, wearing gloves significantly increased the minimum temperature during cold exposure and the maximum temperature after rewarming. Patients reported higher pain with cold exposure. All participants reported significantly more comfort with less coldness with forearm and hand warming. CONCLUSIONS: There was cold response variability in hand trauma patients and control subjects. Hand trauma patients had greater changes in skin temperature during cold exposure that improved with glove warming. Continuous temperature monitoring identified subtle physiological changes associated with cold-induced pain and with warming interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Dorsal Wrist Plication for Midcarpal Instability.

PURPOSE: Midcarpal instability (MCI) is a cause of chronic wrist pain for which treatment remains controversial. This study's purpose was to determine the outcome of a treatment algorithm for MCI that included immobilization and surgical interventions. METHODS: We prospectively enrolled 23 consecutive patients (12 males, average age 27 years) with 27 symptomatic wrists. All had generalized wrist pain with an average duration of 22 months. All had MCI and a catch-up clunk that reproduced the symptoms. Initial treatment was full immobilization for 6 weeks. When necessary, recurrence after immobilization was treated with an anatomically based surgical procedure to plicate the dorsal capsule and extrinsic ligaments to stabilize the midcarpal joint. Failure of surgical plication was followed by 4-corner intercarpal arthrodesis when necessary. Patients were observed for instability, grip strength, wrist motion, and Patient-Rated Wrist Evaluation. RESULTS: For 22 wrists there was partial relief of symptoms with full-time cast or orthosis immobilization; however, symptoms quickly returned with mobilization. The other wrists had previously been immobilized and patients refused further nonsurgical care. All patients underwent surgical plication of the dorsum of the wrists. Postoperative follow-up (35 months) showed statistically significant improvements in grip strength and Patient-Rated Wrist Evaluation scores. All patients had improved pain at final follow-up. Most improvement was in female patients aged under 25 years, with hypermobility and without major traumatic or work-related injuries. This contrasted with poorer outcomes in men aged over 25years who had moderate or severe trauma that was mostly work-related. Instability recurred in 2 patients who then had a 4-corner arthrodesis. CONCLUSIONS: Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. Surgical midcarpal capsular plication was less effective in men with posttraumatic instability. The capsular plication procedure was successful in young female patients with ligament laxity and a history of only minor or repetitive trauma and no history of major trauma. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Developing Cognitive Task Analysis-based Educational Videos for Basic Surgical Skills in Plastic Surgery.

OBJECTIVE: To describe the development of cognitive task analysis (CTA)-based multimedia educational videos for surgical trainees in plastic surgery. DESIGN: A needs assessment survey was used to identify 5 plastic surgery skills on which to focus the educational videos. Three plastic surgeons were video-recorded performing each skill while describing the procedure, and were interviewed with probing questions. Three medical student reviewers coded transcripts and categorized each step into "action," "decision," or "assessment," and created a cognitive demands table (CDT) for each skill. The CDTs were combined into 1 table that was reviewed by the surgeons performing each skill to ensure accuracy. The final CDTs were compared against each surgeon's original transcripts. The total number of steps identified, percentage of steps shared, and the average percentage of steps omitted were calculated. SETTING: Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, an urban tertiary care teaching center. PARTICIPANTS: Canadian junior plastic surgery residents (n = 78) were sent a needs assessment survey. Four plastic surgeons and 1 orthopedic surgeon performed the skills. RESULTS: Twenty-eight residents responded to the survey (36%). Subcuticular suturing, horizontal and vertical mattress suturing, hand splinting, digital nerve block, and excisional biopsy had the most number of residents (>80%) rank the skills as being skills that students should be able to perform before entering residency. The number of steps identified through CTA ranged from 12 to 29. Percentage of steps shared by all 3 surgeons for each skill ranged from 30% to 48%, while the average percentage of steps that were omitted by each surgeon ranged from 27% to 40%. CONCLUSIONS: Instructional videos for basic surgical skills may be generated using CTA to help experts provide comprehensive descriptions of a procedure. A CTA-based educational tool may give trainees access to a broader, objective body of knowledge, allowing them to learn decision-making processes before entering the operating room.

An Educational Intervention to Improve Splinting of Common Hand Injuries.

BACKGROUND: Hand trauma is a top presenting complaint to hospital emergency departments (EDs) and can become costly if not treated effectively. The cornerstone for initial management of the traumatized hand is application of a splint. Improving splinting practice could potentially produce tangible benefits in terms of quality of care and costs to society. OBJECTIVES: We sought to determine the following: 1) whether the present standard of ED splinting was appropriate and 2) whether a strategically planned educational intervention could improve the existing care. METHODS: We used a pre- and postprospective educational intervention study design. In the preintervention phase, patients referred to our hand clinic were assessed for injury and splint type. Splinting appropriateness was evaluated according to a predetermined hand surgeons' expert consensus. Next, an educational intervention was targeted at all ED staff at our institution. Postintervention, all patients were again evaluated for splint appropriateness. A follow-up evaluation was performed at 1 year to see the long-term effects of the intervention. RESULTS: The most common mechanism of injury of referred patients was falling (35%), and the most frequent injury was metacarpal fracture (40%). Splint appropriateness increased significantly postintervention from 49% to 69% (p = 0.048). At follow-up after 1 year, splinting appropriateness was 70% (p = 0.041). CONCLUSION: Appropriate hand splinting practice is essential for hand trauma management. Our results show that an educational intervention can successfully improve splinting practice. This quality of care initiative was low-cost and demonstrated persistence at 1 year of follow-up.

Three-Dimensional Modelling inside a Differential Pressure Laminar Flow Bioreactor Filled with Porous Media.

A three-dimensional computational fluid dynamics- (CFD-) model based on a differential pressure laminar flow bioreactor prototype was developed to further examine performance under changing culture conditions. Cell growth inside scaffolds was simulated by decreasing intrinsic permeability values and led to pressure build-up in the upper culture chamber. Pressure release by an integrated bypass system allowed continuation of culture. The specific shape of the bioreactor culture vessel supported a homogenous flow profile and mass flux at the scaffold level at various scaffold permeabilities. Experimental data showed an increase in oxygen concentration measured inside a collagen scaffold seeded with human mesenchymal stem cells when cultured in the perfusion bioreactor after 24 h compared to static culture in a Petri dish (dynamic: 11% O2 versus static: 3% O2). Computational fluid simulation can support design of bioreactor systems for tissue engineering application.

Continuous infraclavicular brachial plexus blockade: effect on survival of replanted digits.

In replantation surgery, the use of continuous brachial plexus blockade (CBPB) is popular as it improves postoperative analgesia and vascular flow. The aim of our study was to determine whether CBPB may affect the odds of survivability of replanted digit(s). A four-year retrospective chart review was performed and various parameters affecting replant survival were examined. Outcome was recorded as successful if the transplanted digit(s) survived six months after discharge. All the independent variables were forced into a regression model without using a specific variable selection algorithm. The data for 146 patients was obtained from our chart review. The success rate of replanted digits in the patients reviewed was 65.8%. The logistic regression model showed a relation between the number of digits injured and replanted digit(s) survival. Our study showed that CBPB has no effect on the survivability of the replanted digit(s) till six months after hospital discharge.

Altered VEGF-A and receptor mRNA expression profiles, and identification of VEGF144 in foetal rat calvaria cells, in coculture with microvascular endothelial cells.

Cellular proliferation and differentiation during angiogenesis and osteogenesis require the communication of different cell types through growth factors and their receptors. Vascular endothelial growth factor (VEGF-A) plays an important role in osteoblast and endothelial cell intercommunication. We have investigated the effect of monocultures and indirect coculture of foetal rat calvarial (FRC) osteoblasts and microvascular endothelial cells (ECs) on nodule formation, proliferation, and mRNA-expression of VEGF-A and its receptors during culturing. Despite increased nodule formation in the presence of dexamethasone (Dex) in monocultures, the number of nodules and alkaline phosphatise activity were decreased in cocultured FRCs. VEGF mRNA expression over the differentiation period showed the expression of most Vegf isoforms is biphasic in both FRCs and ECs, whereas receptor expression was quite variable; however, that of Np-2 in FRCs increased steadily and significantly from 8 h to 14 days after an initial drop in expression. Significant changes in the proportion of Vegfa by Day 14 were noted mainly in the matrix-bound variants Vegf144 and Vegf188 in ECs and osteoblasts, respectively. Less striking results were seen in the expression of the soluble isoforms in either cell type. These results have identified expression of Vegf144 in osteoblasts, suggesting a possible autocrine and/or paracrine role that is affecting osteoblast mineralisation along with Vegf188, as well as possible early roles of these isoforms in initial cell attachment. Further study of VEGF expression in coculture and Vegf144 will lead to better understanding of its role in cell-cell communication and bone development.

The aging hand and the ergonomics of hearing aid controls.

OBJECTIVES: The authors investigated the effects of hand function and aging on the ability to manipulate different hearing instrument controls. Over the past quarter century, hearing aids and hearing aid controls have become increasingly miniaturized. It is important to investigate the aging hand and hearing aid ergonomics because most hearing aid wearers are adults aged 65 years and above, who may have difficulty handling these devices. DESIGN: In Experiment 1, the effect of age on the ability to manipulate two different open-fit behind-the-ear style hearing aids was investigated by comparing the performance of 20 younger (18-25 years of age), 20 young-old (60-70 years of age), and 20 older adults (71-80 years of age). In Experiment 2, ability to manipulate 11 different hearing instrument controls was investigated in 28 older adults who self-reported having arthritis in their hand, wrist, or finger and 28 older adults who did not report arthritis. For both experiments, the relationship between performance on the measures of ability to manipulate the devices and performance on a battery of tests to assess hand function was investigated. RESULTS: In Experiment 1, age-related differences in performance were observed in all the tasks assessing hand function and in the tasks assessing ability to manipulate a hearing aid. In Experiment 2, although minimal differences were observed between the two groups, significant differences were observed depending on the type of hearing instrument control. Performance on several of the objective tests of hand function was associated with the ability to manipulate hearing instruments. CONCLUSIONS: The overall pattern of findings suggest that haptic (touch) sensitivity in the fingertips and manual dexterity, as well as disability, pain, and joint stiffness of the hand, all contribute to the successful operation of a hearing instrument. However, although aging is associated with declining hand function and co-occurring declines in ability to manipulate a hearing instrument, for the sample of individuals in this study, including those who self-reported having arthritis, only minimal declines were observed.