Modified Chinese disabilities of arm, shoulder and hand tool: Validity and reliability for upper extremity injuries.

DESIGN: Clinimetric evaluation study. INTRODUCTION: The Chinese Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire has necessitated the development of a revised version to the specific needs of individuals with upper extremity injuries with the progress of times and lifestyle changes. PURPOSE OF THE STUDY: This research aimed to evaluate the reliability and validity of Modified Chinese Disability of Arm, Shoulder and Hand (MC-DASH) questionnaire in individuals with upper extremity injuries. METHODS: One hundred and one individuals with upper extremity injuries (UEI) were recruited. The function of upper extremity was measured using the electronic version of MC-DASH, and compared against the Chinese Disability of Arm, Shoulder and Hand. The MC-DASH was reassessed within three days in all individuals. We investigated the internal consistency, test-retest reliability, content validity, criterion validity, and construct validity of MC-DASH. RESULTS: The internal consistency was deemed sufficient, as indicated by a Cronbach's alpha of 0.986 and an intraclass correlation coefficient of 0.957. Moreover, the mean total scores of MC-DASH on the first-test and retest were 37.86 and 38.19, respectively (ICC: 0.957, 95 %CI: 0.937-0.971, p < 0.001). Furthermore, the MC-DASH version exhibited satisfactory content validity evidenced by its strong correlation (R= 0.903, p < 0.001) with the Chinese DASH. Three major influencing factors were identified from 37 items. The cumulative variance contribution rate of the MC-DASH questionnaire was 75.76 %, confirming its construct validity. CONCLUSION: The Modified Chinese Disability of Arm, Shoulder and Hand questionnaire has been shown to be a valid, reliable, and practical tool for use in patients with upper extremity injuries.

Upper Extremity Injuries in Rock Climbers: Diagnosis and Management.

Rock climbing places substantial stress on the upper extremities and can lead to unique injuries not common to other sports. With increasing popularity of the sport, hand surgeons are expected to see more patients with these pathologies. An understanding of the sport, accurate diagnoses, and appropriate treatment protocols are critical to maintain climbers' competitive abilities.

The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care.

PURPOSE: Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location. METHODS: We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS. RESULTS: There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay. CONCLUSIONS: The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Defining clinical decision making in the provision of audio-visual outpatient care for acute upper limb trauma services: A review of practice.

The Covid-19 pandemic has accelerated the widespread adoption of technology-enabled care in the NHS.1 Moving into phase two of the response, the continuing use of audio-visual technology is expected, where appropriate, to be integral in the provision of safe, quality patient care.2 A clinical need therefore exists to identify when care can be safely delivered remotely using audio-visual technology and when there is a need for in-person contact.  At Salisbury Foundation Trust (SFT), during phase one of the NHS response to Covid-19, the decision to treat upper limb trauma patients in-person or remotely was made using clinical screening criteria. For many patients, audio-visual appointments offered a practical, time efficient way of accessing their reconstructive team for assessment, advice and post-operative care. However, a subset of patients was identified by the team as requiring at least one in-person consultation to minimize perceived clinical risk and to optimize quality outcomes.  In order to understand more fully the challenges and successes of technology-enabled care to date, a national survey of practice across hand units in the UK was conducted. We present here some of our key findings and propose the need to develop nationally agreed screening criteria to determine how and when technology enabled outpatient care can be used in the management of acute upper limb trauma. The results of this survey forms part of a series of projects currently underway looking at the efficacy of audio-visual care in upper limb trauma, including a multicentre observational study.

Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury.

BACKGROUND: Despite advances in management of extremity vascular injuries, "hard signs" remain the primary criterion to determine need for imaging and urgency of exploration. We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility. METHODS: Extremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management. RESULTS: Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury. Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration. CONCLUSION: Hard signs have limitations in identification and characterization of extremity arterial injuries. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury. LEVEL OF EVIDENCE: Diagnostic, level III.

BET 1: Best Evidence Topic Report: is the hook test sensitive enough to be used to exclude distal biceps tendon rupture?

A shortcut review was carried out to see whether the hook test is sensitive enough for a negative result to exclude complete distal biceps tendon rupture (DBTR) in adults. 3 papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that the hook test is moderately sensitive at detecting complete DBTR when carried out by skilled clinicians in specialist upper limb clinics. As a single test, it is not sensitive enough to be used to exclude complete DBTR.

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND: We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution. QUESTIONS/PURPOSES: Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment? METHODS: In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores. RESULTS: Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (ß 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (ß 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (ß -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment. CONCLUSION: Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics. LEVEL OF EVIDENCE: Level III, therapeutic study.

Misperception of Disease Onset in People with Gradual-Onset Disease of the Upper Extremity.

BACKGROUND: Misperception that an established, gradual-onset disease such as osteoarthritis started when the symptoms were first noticed might lead to testing and treatment choices that are inconsistent with what matters most to a patient. In the present study, the primary null hypothesis was that there are no factors associated with patient-reported symptom duration (in months). The secondary null hypotheses were that there are no factors independently associated with (1) a sudden versus gradual perception of disease onset, (2) an event or injury-related versus age-related perceived cause of disease onset, and (3) the magnitude of physical limitations. METHODS: In this cross-sectional study, 121 patients with an atraumatic, established, gradual-onset condition of the upper extremity completed a demographic questionnaire, measures of mental health (symptoms of depression and anxiety, worst-case thinking, and self-efficacy [the ability to adapt and continue with daily activity] when in pain), measurement of the magnitude of upper extremity-specific limitations, and questions about the perceived course and cause of the disease. RESULTS: The median patient-reported symptom duration was 12 months (interquartile range, 3 to 36 months). Twenty-two patients (18%) perceived their disease as new, and 29 patients (24%) believed that the condition was related to ≥1 event (injury) rather than being time and age-related. In multivariable analysis, patients with Medicare insurance were independently associated with longer reported symptom duration (in months). Greater self-efficacy was associated with longer symptom duration in bivariate, but not multivariable, analysis. No factors were independently associated with a sudden versus gradual onset of symptoms. Hispanic ethnicity and federal, county, or no insurance were independently associated with the perception that the problem was caused by an injury or event. CONCLUSIONS: Approximately 1 in 5 patients misperceived new symptoms as representing a new disease, often as a type of injury. Misperception of the pathology as new had a limited association with unhealthy thoughts and is likely generally responsive to reorientation. We speculate that gentle, strategic reorientation of misperception can protect patients from choices inconsistent with their values.

Patient Transfer for Hand and Upper Extremity Injuries: Diagnostic Accuracy at the Time of Referral.

BACKGROUND: Local health care facilities are often unequipped to treat complex upper extremity injuries, and patients are therefore transferred to designated trauma centers. This study describes the characteristics of patients transferred to a Level I trauma center for hand and upper extremity injuries and to investigate the accuracy of the provided diagnosis at the time of referral. METHODS: Adult patients transferred from outside facilities to the authors' Level I trauma center by means of direct contract with the on-call fellow for the care of hand and upper extremity injuries were identified. Patient- and injury-related information was prospectively collected at the time of referral before patient transfer, and again following diagnostic evaluation by a hand surgeon at the authors' institution. RESULTS: Sixty-three patients were transferred to the authors' hand surgery service from outside facilities after direct contact with the on-call fellow. Most patients were referred by emergency medicine physicians [n = 47 (76 percent)], followed by midlevel emergency department providers (physician assistant or nurse practitioner) [n = 12 (19 percent)] or hand surgeons [n = 3 (5 percent)]. Six patients were transferred directly from a Level I trauma center. Twenty-one transferred patients (33 percent) had an inaccurate diagnosis at the time of referral. Factors associated with an inaccurate diagnosis included trauma level of the referring hospital and diagnoses of infection or dysvascularity. CONCLUSIONS: The diagnostic accuracy for hand injuries transferred from outside facilities by means of provider-to-provider communication is imperfect, and some injuries are misdiagnosed. Hand surgeons should continue to improve the triage and transfer process for patients with acute hand surgery injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

[Diagnosis of upper arm, elbow, and proximal lower arm fractures]. / Frakturdiagnostik an Oberarm, Ellenbogen und proximalem Unterarm.

The complex anatomy of the elbow joint enables a wide range of movement and complex functions in everyday and professional life. Typical injuries of this joint include a variety of different pathologies. Due to overlaying structures in plain radiographs, diagnosis of injuries to the elbow joint places high demands on the treating physicians and often needs further diagnostic imaging. The following article will give an overview of the most common of these injuries and their diagnosis.

High-Risk Chief Complaints III: Abdomen and Extremities.

Abdominal and extremity complaints are common in the emergency department (ED) and, because of their frequency, clinical vigilance is vital in order not to miss the timely diagnosis of occult or delayed emergencies. Such emergencies, if not timely managed, are sources of significant patient morbidity and mortality and may expose ED physicians to possible litigation. Each patient complaint yields to a nuanced approach in diagnostics and therapeutics that can lead physicians toward the ruling in or out of the correct high-risk diagnosis. This article discusses the approach and risk management of this high-risk subset of abdominal and extremity diagnoses.

What Can a Jump Tell Us About Elbow Injuries in Professional Baseball Pitchers?

BACKGROUND: The incidence rate of elbow injuries has been rising in recent years among professional baseball pitchers. Determining valid screening procedures that allow practitioners to identify pitchers at an increased risk of such injuries is therefore of critical importance. PURPOSE: To validate the use of countermovement jump (CMJ) tests as a diagnostic tool for pitcher conditioning. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: More than 500 pitchers at a single professional baseball organization performed preseason CMJ assessments on a force plate before the 2013 to 2018 seasons. Three measurements were extracted from ground-reaction force data during the test: eccentric rate of force development (ERFD), average vertical concentric force (AVCF), and concentric vertical impulse (CVI). Athletic trainers at the organization collected detailed information on elbow and shoulder injury rates as well as workload (pitch count) throughout the rest of the season. Poisson regression models were fit to investigate the dependency of injury rates on CMJ test performance. RESULTS: ERFD, CVI, and AVCF were all significant predictors of elbow injury risk after accounting for pitcher age, weight, and workload. The analysis identified 3 specific indicators of heightened risk based on the results of a CMJ scan: low ERFD, a combination of low AVCF and high CVI, and a combination of high AVCF and low CVI. In contrast, shoulder injury risk was roughly independent of all 3 CMJ test measurements. CONCLUSION: This study supports the hypothesis of the entire kinetic chain's involvement in pitching by establishing a link between CMJ test performance and elbow injury risk in professional baseball pitchers. CMJ assessment may be a powerful addition to injury risk alert and prevention protocols. Pitchers in high-risk groups can be prescribed specific exercise plans to improve movement imbalances.

Common Upper-Extremity Injuries.

Primary care and sports medicine physicians will undoubtedly encounter upper-extremity injuries on a regular basis in their practice. Athletes have injuries most commonly to the shoulder, elbow, wrist, and hand as a result of a fall onto an outstretched arm. This article aims to educate physicians about sports-related upper-extremity injuries. Common mechanisms of injury, classic physical examination, and radiographic findings are reviewed. General guidelines for treatment as well as indications for referral to a sports medicine or orthopedic specialist are included in the discussion.

The Emergency Evaluation and Management of Pediatric Extremity Fractures.

Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.

Clinical Outcomes of Open Subpectoral Biceps Tenodesis with Cortical Button Fixation.

BACKGROUND: Open subpectoral biceps tenodesis (OSBT) with cortical button fixation can deliver acceptable results for long head of the biceps (LHB) pathology with the benefit of smaller bone tunnel diameter and a potential reduced risk of postoperative humeral shaft fracture. However, functional outcomes and complications of a button-only technique with a small diameter tunnel in the subpectoral region have not been studied sufficiently. PURPOSE: We sought to determine whether OSBT with cortical button fixation results in significant functional improvements from preoperative to final follow-up. The secondary purpose was to determine whether there is a lower risk of major postoperative complications. METHODS: A retrospective review of patients who underwent OSBT with cortical button fixation at one institution was conducted with objective measurements and clinical outcomes collected with a minimum of 2 years of follow-up. Surgical data was collected for analysis. Objective measures obtained at follow-up included physical exam, strength testing using a handheld dynamometer, and Long-Head of the Biceps score. Clinical outcomes were measured using the following validated questionnaires preoperatively and postoperatively: American Shoulder and Elbow Surgeons score (ASES), Disabilities of the Arm, Shoulder and Hand score (DASH), and Oxford Shoulder Score (OSS). RESULTS: Sixty-one patients with mean age of 53.1 ± 10.1 years at the time of surgery were enrolled in the study. Mean follow-up time was 42.4 ± 16.9 months (range: 24 to 64 months). The postoperative LHB score was 95.5 ± 6.1 (range: 77 to 100). All functional outcome measures (ASES, DASH, and OSS) demonstrated statistically significant improvements at final follow-up (p < 0.05 for each). At total of 92.5% of patients stated they would have the procedure again if necessary. Mean elbow flexion strength on the operative side measured 98.7% ± 15.9% (range: 74.1% to 142.3%) of the contralateral arm. The mean LHB tendon diameter was 5.7 ± 0.8 mm and mean tunnel diameter was 5.9 ± 0.7 mm. There were no cases of intraoperative or postoperative fracture, infection, or Popeye deformity noted during the follow-up period. CONCLUSION: Subpectoral biceps tenodesis with cortical button fixation is a safe and effective surgical treatment option to relieve pain and restore function.

Factor Structure of the Disabilities of the Arm, Shoulder and Hand Questionnaire in Upper Extremity Nerve Injury.

BACKGROUND: This study evaluated the validity of the factor structure of the Disabilities of the Arm, Shoulder and Hand questionnaire to assess upper extremity disability in patients with upper extremity nerve injury. METHODS: Data were used from previous cross-sectional studies of patients with upper extremity nerve injuries. Research ethics approval was obtained for secondary data analyses. Descriptive and factor analyses were performed. RESULTS: Patients (n = 242; 170 men and 72 women) with upper extremity nerve injury included distal nerve (n = 131), brachial plexus (n = 88), and single proximal shoulder nerve (n = 23). The mean Disabilities of the Arm, Shoulder and Hand questionnaire score was 47.3 ± 22. For the questionnaire, a three-factor structure had the highest variance and no overlap between factors. The factors related to (1) light effort tasks, (2) greater effort tasks, and (3) work/social activity limitations and pain. Brachial plexus injuries had significantly higher overall questionnaire scores compared to distal and single proximal nerve injuries. The light effort factor scores were significantly lower in single proximal nerve injuries compared with brachial plexus and distal nerve injuries. Nondominant compared to dominant hand involvement revealed no difference in overall questionnaire scores but significantly higher dominant hand scores in the light effort factor (p = 0.001). CONCLUSIONS: In patients with nerve injury, the factor analysis of the Disabilities of the Arm, Shoulder and Hand questionnaire indicated a multifactor construct. These domains should be considered when using the questionnaire and may be helpful to assess disability related to specific tasks in different nerve injuries and with dominant hand involvement.

Impact of Patient-Surgeon Relationship on Patient's Return to Work.

BACKGROUND: Upper-limb injuries and musculoskeletal disorders represent a major economic burden for both patients and society, largely due to limitations in returning to work. We hypothesized that a positive patient-surgeon relationship may facilitate patients' recovery and lead to a faster return to work. METHODS: This longitudinal observational study comprised 219 patients, from 8 French hand trauma centers, who were 18 to 55 years of age and were on sick leave from work because of an injury or musculoskeletal disorder of the upper limb. In addition to instruments measuring patients' functional scores and quality of life, the quality of the patient-surgeon relationship was assessed at enrollment using a specific questionnaire (Q-PASREL [Quality of PAtient-Surgeon RELationship]). Six months after enrollment, the return-to-work status was assessed. Logistic and Cox regression models were developed to identify predictors of return to work (yes/no) and the time off from work in days. RESULTS: Overall, 74% of the patients who returned to work within 6 months after enrollment had a high or medium-high Q-PASREL score, whereas 64% of the patients who were still on sick leave had a low or medium-low Q-PASREL score. The odds of patients with a low or medium-low Q-PASREL score returning to work were, respectively, 95% and 71% lower than the odds of patients with a high score doing so, with a percent difference of 56% (95% confidence interval [CI] = 40% to 71%) for low versus high (odds ratio [OR] = 0.05 [95% CI = 0.02 to 0.13]) and 25% (95% CI = 6% to 44%) for medium-low versus high (OR = 0.29 [95% CI = 0.11 to 0.76]). All Q-PASREL items and scores were significantly associated with return to work. CONCLUSIONS: Patients with a lower Q-PASREL score and more severe disability were less likely to return to work within 6 months and had a longer time off from work. Efforts to improve the quality of patient-surgeon relationships may minimize the duration of sick leaves and accelerate patient recovery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma.

BACKGROUND: Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS: This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS: Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS: Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.