A new measure for end of life planning, preparation, and preferences in Huntington disease: HDQLIFE end of life planning.

BACKGROUND: Huntington disease is a fatal inherited neurodegenerative disease. Because the end result of Huntington disease is death due to Huntington disease-related causes, there is a need for better understanding and caring for individuals at their end of life. AIM: The purpose of this study was to develop a new measure to evaluate end of life planning. DESIGN: We conducted qualitative focus groups, solicited expert input, and completed a literature review to develop a 16-item measure to evaluate important aspects of end of life planning for Huntington disease. Item response theory and differential item functioning analyses were utilized to examine the psychometric properties of items; exploratory factor analysis was used to establish meaningful subscales. PARTICIPANTS: Participants included 508 individuals with pre-manifest or manifest Huntington disease. RESULTS: Item response theory supported the retention of all 16 items on the huntington disease quality of life ("HDQLIFE") end of life planning measure. Exploratory factor analysis supported a four-factor structure: legal planning, financial planning, preferences for hospice care, and preferences for conditions (locations, surroundings, etc.) at the time of death. Although a handful of items exhibited some evidence of differential item functioning, these items were retained due to their relevant clinical content. The final 16-item scale includes an overall total score and four subscale scores that reflect the different end of life planning constructs. CONCLUSIONS: The 16-item HDQLIFE end of life planning measure demonstrates adequate psychometric properties; it may be a useful tool for clinicians to clarify patients' preferences about end of life care.

Displaced scaphoid waist fractures: the use of a week 4 CT scan to predict the likelihood of union with nonoperative treatment.

This study assessed whether nonunion of displaced scaphoid waist fractures with nonoperative treatment could be predicted from 4 week CT scans. Thirty-one patients with unilateral displaced scaphoid waist fractures and adequate follow-up were included. CT scans in the longitudinal axis of the scaphoid with sagittal and coronal slices were done 4 weeks after the index injury. The effects of fracture gap, sclerosis and bone resorption on union were assessed. Fracture union was observed in all 13 displaced fractures with a < 2 mm gap, four of the seven with a gap of 2-3 mm and only four of the 11 with a gap > 3 mm (p = 0.01). Bone resorption involving more than 50% of the fracture cross-section was also associated with nonunion, but sclerosis was not.

Undisplaced scaphoid waist fractures: is 4 weeks' immobilisation in a below-elbow cast sufficient if a week 4 CT scan suggests fracture union?

This prospective study investigated a cohort of 59 scaphoid waist fractures which were treated nonoperatively in a below-elbow plaster cast for 4 weeks and then underwent a Week 4 CT scan to assess displacement and progress to union. Forty-three were classed as undisplaced and 37 of these 43 were also classed as 'united'. All the 37 undisplaced and 'united' fractures united with up to 8 weeks' cast immobilisation, including 26 which were taken out of plaster at 4 weeks and mobilised. We conclude that scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks. Such a treatment policy may reduce the period of disability and time off work associated with nonoperative treatment.

Simple technique for exsanguination of the hand.

Hand surgery is facilitated by the production of a bloodless operative field by exsanguination and the use of a pneumatic tourniquet. Exsanguination can be achieved by a variety of techniques, including elevation alone, use of an Esmarch or crepe bandage, or a Rhys-Davies exsanguinator. We present a simple, effective method of exsanguination of the hand for use in procedures performed under local anaesthesia such as carpal tunnel decompression. No additional equipment is required and therefore there is no risk of transmission of infection. The hand is exsanguinated after surgical preparation and draping, thus minimising the tourniquet time.

A revolution in the management of fractures of the distal radius?

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.

Intramedullary fixation of unstable metacarpal fractures.

Intramedullary stabilization of metacarpal shaft and neck fractures is a relatively simple, cost-effective, and safe technique with good published outcomes (Fig. 9); however definite advantages over other techniques of fracture stabilization, or indeed simple early mobilization in some instances, have not been clearly demonstrated. A recent publication does suggest that the technique is comparable to percutaneous transverse fixation in the context of fifth metacarpal neck fractures.

Changes in scaphoid bone density after acute fracture.

The radiographic density of the proximal fragments of 16 scaphoid fractures was assessed on scaphoid series radiographs taken at 6 to 12 weeks. In addition, dual energy X-ray absorptiometry measurements of bone mineral density in the distal radius and proximal and distal fracture fragments were performed at 1 to 2 weeks and 6 to 12 weeks. Median reductions of 9% and 10% were observed in bone mineral density in the proximal fracture fragment and the distal radius respectively, but these did not correlate with the radiographic density of the proximal fragment. A greater median reduction in bone mineral density (27%) was observed in the distal fracture fragment and more bone loss occurred at this site when there was an apparent increase in the radiographic density of the proximal fragment (median fall of 0.23 g/cm2 versus 0.14 g/cm2). Thus, apparent increased radiographic density of the proximal fragment may be due to increased bone loss from the distal fragment.

Partial union of acute scaphoid fractures.

Sixty-six patients with acute scaphoid fractures were treated non-operatively in a below elbow plaster for 8 to 12 weeks and underwent CT scans along the longitudinal axis of the scaphoid at 12 to 18 weeks. These scans showed that 14 fractures had not united and that 30 had united throughout the whole cross-section of the scaphoid. The other 22 had partially united with bridging trabeculae in some areas of the cross-section. These 22 partial unions were graded as 0% to 24% union (0 cases), 25% to 49% union (5 cases), 50% to 74% union (7 cases), and 75% to 99% union (10 cases). The 12 patients who had less than 75% fracture union were followed-up further and nine underwent another CT scan at 23 to 40 weeks after the initial injury. These showed union across the whole of the cross-section of the fracture in seven cases and 75% to 99% union in the other two cases, who had full and painless wrist function. We conclude that partial union of the scaphoid is a common occurrence but, in most cases, it progresses to full union without the need for prolonged plaster immobilization.

Gadolinium enhanced MR assessment of proximal fragment vascularity in nonunions after scaphoid fracture: does it predict the outcome of reconstructive surgery?

This study investigated whether the outcome of bone graft and internal fixation surgery for nonunion of scaphoid fractures could be predicted by gadolinium-enhanced MR assessments of proximal fragment vascularity. Sixteen established scaphoid fracture nonunions underwent gadolinium-enhanced MR scanning before surgical treatment with bone grafting and internal fixation. No relationship was found between MR enhancement and the outcome of surgery. Union was achieved in eight of the 12 nonunions with more than 50% enhancement, and three of the four with less than 50% enhancement, of the proximal pole. Furthermore, union was achieved in both of the nonunions which had less than 25% enhancement of the proximal pole. We conclude that enhanced MR assessments of the vascularity of the proximal fragment of a scaphoid fracture nonunion do not accurately predict the outcome of reconstructive surgery.

Trapezial space height after trapeziectomy: mechanism of formation and benefits.

Seventy-three thumbs in 67 women with osteoarthritis of the trapeziometacarpal joint were assessed prospectively. The patients were randomly allocated for treatment by either trapeziectomy alone (n = 26) or trapeziectomy with tendon interposition (n = 23) or ligament reconstruction (n = 24). A K-wire was passed through the thumb metacarpal base and across the trapezial space into the distal pole of the scaphoid in all procedures; this held the base of the metacarpal away from the scaphoid for 4 weeks. Standard thumb radiographs were used to calculate the trapezial space ratio before surgery and at 1-year follow-up examination. The trapezial space ratio decreased significantly from a preoperative mean of 0.40 (range, 0.20-0.56) to a mean of 0.18 (range, 0.08-0.30) after trapeziectomy, 0.16 (range, 0.07-0.30) after trapeziectomy with tendon interposition, and 0.20 (range, 0.00-0.33) after trapeziectomy with ligament reconstruction. There was no significant difference between these 1-year follow-up trapezial space ratios, suggesting that the placement of a K-wire across the trapezial void is as effective as tendon interposition or ligament reconstruction in creating a trapezial space in the short term at least. However, the need to create a trapezial space and maintain thumb length is questioned because the trapezial space height did not correlate with thumb strength at 1-year follow-up examination.

Hip abductor strength following total hip arthroplasty: a prospective comparison of the posterior and lateral approach in 100 patients.

We studied the hip abductor strength and Trendelenburg test prospectively in 100 patients undergoing total hip replacement via a lateral or posterior approach. In 49 patients, we used the lateral approach to implant the Charnley total hip replacement, and in 51 patients, the posterior approach to implant the Exeter total hip. Isometric abductor strength was measured with the kinetic communicator device and the Trendelenburg test was recorded preoperatively and at 3 and 12 months postoperatively. Of the original 100 patients, 83 were available for study at 3 months and 73 at 12 months. Hip abductor strength and the Trendelenburg test improved postoperatively in both groups, but we found no difference in hip abductor strength recovery at 3 and 12 months between the lateral approach and the posterior approach. Similarly there was no difference in the Trendelenburg test between the two groups 3 and 12 months following hip replacement.

A rare and serious consequence of a rat bite.

Contact with rat saliva or faeces can lead to infection with Streptobacillus moniliformis and the condition known as 'rat bite fever'. We report a case of septic arthritis of the hip due to this organism following a bite on the finger of a 14-year-old boy from a rat for sale in a pet shop. The case was successfully treated by arthrotomy, drainage and joint lavage followed by administration of penicillin. Septic arthritis of the hip due to S. moniliformis has not been previously described and this case highlights a possible danger of keeping rats as pets.

A comparison of the relative costs of cast treatment and intramedullary nailing for tibial diaphyseal fractures in the UK.

A retrospective study was undertaken to compare the costs of treating tibial diaphyseal fractures non-operatively in a cast or operatively with locked intramedullary nailing. In total 39 patients with isolated closed or grade I open, two-part, displaced tibial diaphyseal fractures were studied. Of these, 18 were treated by manipulation under anaesthesia and cast immobilization, and 21 by closed, reamed, locked intramedullary nailing. A detailed analysis of the cost of treatment of each patient was performed and analysed in terms of the in-hospital costs and the overall costs, taking into account time off work. The mean hospital costs were 2226 pounds for plaster treatment and 3727 pounds for intramedullary nailing (significantly different, p < 0.05). The mean time off work was 9 weeks longer in the plaster group and when the cost of lost production through time off work was added to the hospital costs, the overall costs of plaster treatment and intramedullary nailing were 6810 Pounds and 6592 Pounds (difference not significant). This study suggests that the cost to the hospital of treating these fractures is less with plaster treatment but that the overall cost to the community is no different.

Tibial reconstruction by ipsilateral vascularized fibular transfer.

Between 1979 and 1991 ipsilateral vascularized fibular transposition was performed on eight patients with segmental tibial defects following injury. We report these cases with a minimum follow-up of 2.5 years. All the tibial defects were the result of severe open fractures (Gustilo Grade III) and either bone loss or infected non-union, and ranged in size from 1 to 12 cm. The patients had an average of seven procedures and a delay of 33 months before fibular transfer. The procedure was successful in achieving fracture union in all cases, with an average time to union of 15 months (range, 5-33 months). Shortening of up to 3 cm and some residual ankle stiffness was found, but all patients were ambulating bearing full weight and six had returned to their previous occupation by their final follow-up. Only one patient had significant pain affecting function. This is a successful and relatively simple technique compared to microvascular and bone transport procedures for reconstructing segmental tibial defects with relatively avascular graft beds.

Idiopathic multicentric osteolysis principally affecting the phalanges of the hands and feet.

The case of a 64-year-old man with idiopathic symmetrical osteolysis affecting both hands and feet is presented. The phalanges were principally affected, with relative sparing of the carpus and tarsus. The relevant literature has been reviewed and this reveals that the distribution of osteolysis in this case is unique. We suggest that this case represents a different disease entity, which has not been described previously.