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Deep learning algorithms can be used to classify medical images. In distal radius fracture treatment, fracture detection and radiographic assessment of fracture displacement are critical steps. The aim of this study was to use pixel-level annotations of fractures to develop a deep learning model for precise distal radius fracture detection. We randomly divided 3785 consecutive emergency wrist radiograph examinations from six hospitals to a training set (3399 examinations) and test set (386 examinations). The training set was used to develop the deep learning model and the test set to assess its validity. The consensus of three hand surgeons was used as the gold standard for the test set. The area under the ROC curve was 0.97 (CI 0.95-0.98) and 0.95 (CI 0.92-0.98) for examinations without a cast. Fractures were identified with higher accuracy in the postero-anterior radiographs than in the lateral radiographs. Our deep learning model performed well in our multi-hospital and multi-radiograph system manufacturer settings. Thus, segmentation-based deep learning models may provide additional benefit. Further research is needed with algorithm comparison and external validation.
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Aprendizado Profundo , Fraturas do Punho , Humanos , Estudos Retrospectivos , Radiografia , AlgoritmosRESUMO
STUDY DESIGN: Cross-sectional study. INTRODUCTION: There is a lack of information on the measurement properties of patient-reported upper extremity instruments and their association to health-related quality of life (HRQoL). PURPOSE OF THE STUDY: This study aimed to examine and compare the measurement properties and construct validity of the Disabilities of Arm, Shoulder, and Hand (DASH) Instrument and the Michigan Hand Questionnaire (MHQ) using a heterogeneous sample of patients with hand and wrist problems. METHODS: Two hundred fifty consecutive patients visiting a general orthopedic outpatient clinic due to various hand/wrist problems were invited to participate in the study. A total of 193 (77%) participants provided sufficient patient-reported outcome data and were included in the analysis. Participants completed the DASH, the MHQ, the EQ-5D-3L, and pain on a visual analog scale instruments. Grip and key pinch forces were measured. Scale targeting, relatedness of demographics, and construct validity of the DASH and the MHQ were assessed. RESULTS: Both the DASH and the MHQ had good targeting, but the DASH had wider coverage. The convergence between the DASH and the MHQ was high. The DASH was more closely related to HRQoL than the MHQ in terms of EQ-5D scores. DISCUSSION: The DASH instrument appeared to measure hand function and disability from a perspective of HRQoL superior to the MHQ among patients with heterogeneous hand and wrist complaints. CONCLUSION: The DASH performs well in measuring the HRQoL-related hand outcomes while the MHQ might be more specific for the affected hand.
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Avaliação da Deficiência , Inquéritos e Questionários , Extremidade Superior/fisiopatologia , Estudos Transversais , Feminino , Finlândia , Força da Mão/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Escala Visual AnalógicaRESUMO
BACKGROUND: Our aim was to determine whether maternal smoking and offspring's own smoking affect the offspring's risk for carpal tunnel syndrome (CTS). METHOD: The study sample consisted of the Northern Finland Birth Cohort 1966 (N = 8703). Information on maternal smoking was collected from the participants' mothers. At 31 years, information on smoking, body mass index, socioeconomic status, and long-term illnesses were collected, combined with data of CTS diagnoses from the Care Register for Health Care (1997-2016). RESULTS: Maternal smoking was not associated with increased risk of CTS in offspring. Before the age of 31 years, smoking ≤10 pack years (hazard ratio [HR] = 1.54, 95% confidence interval [CI] = 1.11-2.15) and >10 pack years (HR = 1.90; 95% CI = 1.20-3.01) among women, and >10 pack years (HR = 1.89; 95% CI = 1.14-3.12) among men was associated with CTS compared with nonsmokers. CONCLUSIONS: In this birth cohort, offsprings' own smoking was associated with CTS; however, maternal smoking was not.
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Síndrome do Túnel Carpal/etiologia , Mães , Fumar/efeitos adversos , Adulto , Índice de Massa Corporal , Síndrome do Túnel Carpal/fisiopatologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de RiscoRESUMO
Metallic osteosynthesis materials, i.e. implants used in the treatment of fractures and correction of bone position in children have traditionally been subsequently removed in a further operation. The necessity for the removal of orthopedic implants left completely under the skin is arguable and research-based evidence is scarce. Treatment practices vary. We present our literature- and experience-based recommendation on the removal of implants or leaving them in position. The removal of an implant should, however, always be decided on an individual basis.
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Remoção de Dispositivo , Fixação Interna de Fraturas/instrumentação , Fixadores Internos , Próteses e Implantes , Adolescente , Criança , Fraturas Ósseas/cirurgia , Humanos , Metais , Seleção de Pacientes , Adulto JovemRESUMO
The aim of the present study was to explore the incidence of corrective osteotomies after conservatively treated distal radial fracture and the risk for late correction depending on the patient's age. Based on data from the Finnish National Care Register of Health Care, Specialist Care, on all corrective osteotomies carried out in Finland during 2015-2019 in adults aged ≥20 years, we calculated the mean annual incidence rates per 100,000 person-years, standardized with the European Standard Population 2013. Using multivariable logistic regression, we calculated the risk of corrective osteotomies in various age groups. In total, 41,418 distal radial fractures were identified. Of those, 10,577 received surgical treatment in the acute phase. The incidence rate of primary operations for distal radial fractures was 47.9 per 100, 000 person-years. A total of 321 conservatively treated fractures needed corrective osteoteomy, with a surprisingly low mean annual incidence rate of 1.5 per 100,000 person-years. The risk for this was highest in patients in their fourth or fifth decade.Level of evidence: III.
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Fraturas Mal-Unidas , Fraturas do Rádio , Adulto , Humanos , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/cirurgia , Fraturas Mal-Unidas/epidemiologia , Fraturas Mal-Unidas/cirurgia , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Osteotomia , Resultado do TratamentoRESUMO
OBJECTIVES: In this study, we evaluated the amount of public funds spent on the operative treatment of carpal tunnel syndrome (CTS) in Finland in 2011-2015. DESIGN: A registry-based cost burden study. SETTING: The data were collected in primary and secondary care in both private and public hospitals, covering the whole population of Finland. PARTICIPANTS: We collected the total number of patients with new CTS diagnoses and the total number of patients undergoing surgery from the Care Register for Health Care, Finland's national register. INTERVENTIONS: Open carpal tunnel release (OCTR). OUTCOME MEASURES: We collected the costs of the OCTR procedure from diagnosis-related group prices. The Social Insurance Institution of Finland provided the total amount of euros reimbursed for sick leaves. We then combined the average amount of reimbursed sick leave with our estimated cost of the treatment chain to approximate the average cost per patient. RESULTS: The average amount of public funds used for diagnosing and surgically treating new CTS in 2011-2015 in Finland, including reimbursements for sick leaves, was 2759 per patient in 2015 currency. The average direct procedure cost was 1020. We found no clear trend in total cost per patient, but the proportion of surgically treated patients rose from 63.14% to 73.09%. The total annual cost of these treatments was between 18 128 420 and 22 569 973. CONCLUSIONS: The average amount of public funds used to surgically treat one patient with new CTS in 2011-2015 in Finland was 2759, making the total annual burden 20.7 million.
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Síndrome do Túnel Carpal , Sistema de Registros , Licença Médica , Humanos , Finlândia , Síndrome do Túnel Carpal/cirurgia , Síndrome do Túnel Carpal/economia , Licença Médica/economia , Licença Médica/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-IdadeRESUMO
Deep-learning (DL) algorithms have the potential to change medical image classification and diagnostics in the coming decade. Delayed diagnosis and treatment of avascular necrosis (AVN) of the lunate may have a detrimental effect on patient hand function. The aim of this study was to use a segmentation-based DL model to diagnose AVN of the lunate from wrist postero-anterior radiographs. A total of 319 radiographs of the diseased lunate and 1228 control radiographs were gathered from Helsinki University Central Hospital database. Of these, 10% were separated to form a test set for model validation. MRI confirmed the absence of disease. In cases of AVN of the lunate, a hand surgeon at Helsinki University Hospital validated the accurate diagnosis using either MRI or radiography. For detection of AVN, the model had a sensitivity of 93.33% (95% confidence interval (CI) 77.93-99.18%), specificity of 93.28% (95% CI 87.18-97.05%), and accuracy of 93.28% (95% CI 87.99-96.73%). The area under the receiver operating characteristic curve was 0.94 (95% CI 0.88-0.99). Compared to three clinical experts, the DL model had better AUC than one clinical expert and only one expert had higher accuracy than the DL model. The results were otherwise similar between the model and clinical experts. Our DL model performed well and may be a future beneficial tool for screening of AVN of the lunate.
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Background: Electrocautery is an option for skin incision for the neck, abdominal or inguinal surgery, but is not generally used for hand surgery. The aim of this study was to clarify whether electrocautery skin incision would be beneficial in open carpal tunnel release (OCTR). Methods: A total of 16 patients with carpal tunnel syndrome underwent skin incision for OCTR using either a scalpel (n = 9) or a microdissection diathermy needle (n = 7). Postoperative pain was assessed using a visual analogue scale (VAS 0-100 mm) daily from postoperative days 1 till 7. Results: The diathermy group reported higher VAS scores (mean 80 mm) on the first postoperative day versus the scalpel group mean of 35 mm (p < 0.001). We continued measuring pain for 7 days after the surgery and found higher VAS scores for the diathermy group in the first 6 days. Conclusions: The use of electrocautery is associated with greater pain score in the first postoperative 6 days following OCTR. Level of Evidence: Level III (Therapeutic).
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Síndrome do Túnel Carpal , Humanos , Síndrome do Túnel Carpal/cirurgia , Eletrocoagulação , Dor Pós-Operatória/etiologia , PeleRESUMO
OBJECTIVES: The aim of this study was to evaluate the cost of surgical treatment for primary ulnar nerve entrapment (UNE) borne by the public sector in Finland. DESIGN: Registry-based cost description study. SETTING: Primary and secondary care throughout Finland. PARTICIPANTS: We identified all the patients diagnosed with primary UNE in the whole population of Finland from 2011 to 2015 from the Care Register for Health Care. From these patients, we identified those who had undergone ulnar nerve release during the year they were diagnosed or the following year. INTERVENTIONS: Open ulnar nerve release. OUTCOME MEASURES: The primary outcome measure was cost borne by the public sector in 2015 euros. The cost of surgery was based on the diagnosis-related group prices. We calculated the cost of a single visit to a primary care physician, an electroneuromyography examination, a preoperative visit to a hand surgeon and a follow-up appointment by telephone in specialised care for each patient. These unit costs were provided by the Finnish Institute for Health and Welfare and the same costs were used for each patient. We obtained the number of reimbursed sick days and the total amount reimbursed to each patient in euros within the 2 years after diagnosis from the Social Insurance Institution of Finland. RESULTS: During our study period, approximately 1786 primary UNE diagnoses were made yearly, and on average, 876 (49%) of patients received surgical treatment annually. The surgery-related cost per patient averaged at EUR 1341 (43%) and reimbursed sick leaves at EUR 952 (30%) during this period. The annual cost of surgical treatment for UNE borne by the public sector in Finland varied between EUR 3082 and EUR 3213 per patient. CONCLUSIONS: The average cost of surgical treatment for UNE in Finland was EUR 3140 per patient between 2011 and 2015.
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Síndromes de Compressão do Nervo Ulnar , Humanos , Síndromes de Compressão do Nervo Ulnar/cirurgia , Finlândia , Sistema de RegistrosRESUMO
In this survey, we compared the current postoperative practices in the largest replantation units of four Nordic countries. The topics included were indication for surgery, anaesthesia, postoperative monitoring, use of antibiotics, anticoagulation and postoperative intravenous fluids, change of dressings, duration of bed rest and hospital stay, hand therapy and follow-up after discharge. Although there were many similarities between the units in the postoperative protocols, we found a large variety of practices. There is no robust evidence to assess or support or reject most of the strategies in postoperative care. The differences in practice warrant prospective studies in order to establish an evidence-based postoperative protocol for replantation surgery.
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Amputação Traumática , Anestesia , Humanos , Amputação Traumática/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Reimplante/métodosRESUMO
Enchondromas are common benign bone tumors, usually presenting in the hand. They can cause symptoms such as swelling and pain but often go un-noticed. If the tumor expands, it can diminish the bone cortices and predispose the bone to fracture. Diagnosis is based on clinical investigation and radiographic imaging. Despite their typical appearance on radiographs, they can primarily be misdiagnosed or go totally unrecognized in the acute trauma setting. Earlier applications of deep learning models to image classification and pattern recognition suggest that this technique may also be utilized in detecting enchondroma in hand radiographs. We trained a deep learning model with 414 enchondroma radiographs to detect enchondroma from hand radiographs. A separate test set of 131 radiographs (47% with an enchondroma) was used to assess the performance of the trained deep learning model. Enchondroma annotation by three clinical experts served as our ground truth in assessing the deep learning model's performance. Our deep learning model detected 56 enchondromas from the 62 enchondroma radiographs. The area under receiver operator curve was 0.95. The F1 score for area statistical overlapping was 69.5%. Our deep learning model may be a useful tool for radiograph screening and raising suspicion of enchondroma.
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BACKGROUND: Scapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC) are common types of wrist osteoarthritis (OA). Non-operative treatment consists of pain medication, splinting, and avoiding activities that induce pain. However, in case a course of conservative treatment is unsuccessful, operative treatment is needed. The two most conventional operative approaches for SLAC/SNAC OA are four-corner arthrodesis (FCA) and proximal row carpectomy (PRC). Although FCA is the gold-standard operative technique and may lead to superior grip strength, the evident benefit of PRC is that it obviates any need for hardware removal and controlling for bony union. To date, no high-quality randomized controlled trial comparing FCA and PRC exists. As clinical outcomes seem comparable, a trial that assesses patient-reported outcomes, adverse events, and secondary operations may guide clinical decision making between these two procedures. Thus, the aim of this multi-institutional double-blind randomized controlled trial is to study whether PRC is non-inferior to FCA in treating SLAC/SNAC OA. We hypothesize that PRC is non-inferior to FCA with lower economic expanses. METHODS: The trial is designed as a randomized, controlled, patient- and outcome-assessor blinded multicenter, two-armed 1:1 non-inferiority trial. Patients with SLAC/SNAC-induced wrist pain meeting trial inclusion criteria will undergo wrist arthroscopy to further assess eligibility. Each patient eligible for the trial will be randomly assigned to undergo either FCA or PRC. The primary endpoint of this study is the Patient Rated Wrist Evaluation (PRWE) at 1-year after FCA versus PRC. Secondary outcomes include Quick-Disabilities of the Arm, Shoulder and Hand, EQ-5D-5L, pain, grip strength, wrist active range of motion, radiographic evaluation, and adverse events. Trial design, methods, and statistical analysis plan will be presented here. DISCUSSION: We present an RCT design comparing FCA vs PRC for SLAC/SNAC-induced OA. The results of this trial will assist in decision making when planning surgery for SLAC/SNAC. TRIAL REGISTRATION: ClinicalTrials.gov NCT04260165 . Registered February 7, 2020.
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Osteoartrite , Osso Escafoide , Humanos , Punho , Osso Escafoide/diagnóstico por imagem , Osso Escafoide/cirurgia , Articulação do Punho/diagnóstico por imagem , Articulação do Punho/cirurgia , Osteoartrite/cirurgia , Artrodese , Dor , Amplitude de Movimento Articular , Força da Mão , Resultado do Tratamento , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
Dupuytren's contracture forms nodules and fibril bundles causing the fingers to contract. The pathological tissue contains myofibroblasts exhibiting properties of fibrocytes and smooth muscle cell myoblasts. The disease has a clear-cut family predisposition, but its etiology remains unclear. Diabetes, smoking, heavy drinking and mechanical irritation of the palm are regarded as predisposing factors. Dupuytren's contracture is treated surgically in cases with the limitation of extension in the metacarpophalangeal joints over 30 degrees and 20 degrees in the proximal interphalangeal joints.
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Contratura de Dupuytren/cirurgia , Articulações dos Dedos/cirurgia , Consumo de Bebidas Alcoólicas/efeitos adversos , Complicações do Diabetes/fisiopatologia , Contratura de Dupuytren/etiologia , Contratura de Dupuytren/genética , Contratura de Dupuytren/fisiopatologia , Articulações dos Dedos/fisiopatologia , Predisposição Genética para Doença , Humanos , Fatores de Risco , Fumar/efeitos adversosRESUMO
This current Special Issue of JCM will highlight some of the latest studies on carpal tunnel syndrome (CTS) [...].
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Carpal tunnel syndrome (CTS) is the most common median nerve compression neuropathy. Its symptoms and clinical presentation are well known. However, symptoms at median nerve distribution can also be caused by a proximal problem. Pronator syndrome (PS) and anterior interosseous nerve syndrome (AINS) with their typical characteristics have been thought to explain proximal median nerve problems. Still, the literature on proximal median nerve compressions (PMNCs) is conflicting, making this classic split too simple. This review clarifies that PMNCs should be understood as a spectrum of mild to severe nerve lesions along a branching median nerve, thus causing variable symptoms. Clear objective findings are not always present, and therefore, diagnosis should be based on a more thorough understanding of anatomy and clinical testing. Treatment should be planned according to each patient's individual situation. To emphasize the complexity of causes and symptoms, PMNC should be named proximal median nerve syndrome.
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To date, the role of smoking in carpal tunnel syndrome (CTS) is unclear. The aim of this systematic review and meta-analysis was to assess the association between smoking and CTS. The literature searches were conducted in PubMed, Embase, and Scopus, from inception until October 2021. Three reviewers screened the titles, abstracts, and full-text articles and evaluated the methodological quality of the included studies. A random-effects meta-analysis was used, and heterogeneity across studies was examined using I2 statistic. A total of 31 (13 cross-sectional, 10 case-control, and 8 cohort) studies were qualified for meta-analysis. In a meta-analysis of cohort studies, the risk of CTS did not differ between current and never smokers (pooled hazard ratio (HR) 1.09, 95% CI 0.84-1.43), current and past/never smokers (HR 1.07, 95% CI 0.94-1.23), and past and never smokers (HR 1.12, 95% CI 0.83-1.49). Furthermore, a meta-analysis of case control studies found no difference in the risk of CTS between current and never smokers (pooled odds ratio (OR) 0.92, 95% CI 0.56-1.53), current and past/never smokers (OR 1.10, 95% CI 0.51-2.36), and past and never smokers (OR 0.91, 95% CI 0.59-1.39). However, a meta-analysis of cross-sectional studies showed the associations of ever (OR 1.36, 95% CI 1.08-1.72) and current smoking (OR 1.52, 95% CI 1.11-2.09) with CTS. However, the association between ever smoking and CTS disappeared after limiting the meta-analysis to higher quality studies or after adjusting for publication bias. The association between current smoking and CTS also attenuated after limiting the meta-analysis to studies that confirmed CTS by a nerve conduction study or studies with low attrition bias. This meta-analysis does not support an association between smoking and CTS. The association between smoking and CTS observed in cross-sectional studies could be due to biases and/or confounding factors.
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A distal radius fracture (DRF) is one of the most common fractures in emergency units, the treatment of which requires considerable health care resources. We analyzed the incidence rate for DRFs and the incidence rate of operative treatment over a five-year period, 2015-2019, for the entire population of Finland and all ages. Data was obtained from the Finnish National Care Register for Health Care. The results were counted as cases per 100,000 person/years and standardized with the European Standard Population 2013. The mean annual incidence rate of DRF was 204.90 (203.21-206.59) in specialist care and 69.53 (68.55-70.52) in primary care. It peaked among the pediatric population and among elderly women, in whom it was more than four times as common compared to men of the same age. No increase in the incidence rate of DRFs was found. The mean incidence rate of operative treatment was 45.66 (45.66-45.66)/100,000 person/years, 2015-2019; women were more likely to undergo operative treatment. Altogether, 15-18% of DRFs were operated on over the study period. The annual incidence rate of operations seemed to plateau compared to earlier studies in Finland.
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BACKGROUND: Excess body mass is a risk factor for carpal tunnel syndrome (CTS), but the mechanisms of this are unclear. This study aimed to evaluate the association between CTS and personal risk factors of body mass index (BMI), waist circumference and waist-to-hip ratio (WHR). METHODS: The study sample consisted of the Northern Finland Birth Cohort 1966 (n = 9246). At the age of 31 in 1997 and at the age of 46 in 2012, the participants underwent a clinical examination. Cohort A consisted of complete cases with a follow-up from 1997 to 2012 (n = 4701), and Cohort B was followed up from 2012 to 2018 (n = 4548). The data on diagnosed CTS were provided by the Care Register for Health Care until the end of 2018. RESULTS: After an adjustment for confounding factors, BMI was associated with CTS among women (hazard ratio (HR) 1.47, 95% Cl 0.98-2.20 for overweight women and HR 2.22, 95% Cl 1.29-3.83 for obese women) and among both sexes combined (HR 1.35 95% Cl 0.96-1.90 for overweight and HR 1.98 95% Cl 1.22-3.22 for obese participants). Neither waist circumference nor WHR was associated with CTS. CONCLUSIONS: BMI is an independent risk factor for CTS and is more relevant for estimating the increased risk of CTS due to excess body mass than waist circumference or WHR.
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The aim of this study was to describe the epidemiology of nerve injuries of the upper extremity in the whole population of Finland (1998-2016). Data based on diagnosis codes were obtained from the Care Register for Health Care, including cases of median, radial, ulnar, musculocutaneous, axillary and digital nerves. Age- and gender-specific incidence rates, both crude and standardized (for the European normal population in 2011), were calculated. Our study included 13,440 patients with upper extremity nerve injury. The mean standardized annual incidence rate of any upper extremity nerve injury was 18.18 among men and 8.15 among women per 100,000 person-years over the study period. The incidence peaked among men at working age. Nerve injuries occurred most commonly in the fingers and thumb, with 5532 cases and mean standardized incidence rates per 100,000 person-years of 7.84 among men and 2.95 among women. The annual incidence did not change significantly over the study period.Level of evidence: III.
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Traumatismos do Braço , Extremidade Superior , Fatores Etários , Feminino , Finlândia/epidemiologia , Humanos , Incidência , Masculino , Nervo Ulnar , Extremidade Superior/lesõesRESUMO
Ulnar nerve entrapment (UNE) is the second most common entrapment neuropathy in the upper extremity. The aetiology of UNE is multifactorial and is still not fully understood. The aim of the study was to identify occupational risk factors for UNE and to determine whether smoking modifies the effects of work-related factors on UNE. The study population consisted of the Northern Finland Birth Cohort of 1966 (NFBC1966). In total, 6325 individuals active in working life participated at baseline in 1997. Occupational risk factors were evaluated by a questionnaire at baseline. The data on hospitalizations due to UNE were obtained from the Care Register for Health Care between 1997 and 2018. The incidence rate of hospitalization due to UNE was 47.6 cases per 100,000 person-years. After adjusting for confounders, entrepreneurs (Hazard ratio (HR) = 3.68, 95% CI 1.20-11.27), smokers (HR = 2.51, 95% CI 1.43-4.41), workers exposed to temperature changes (HR = 1.72, 95% CI 1.00-2.93), workers with physically demanding jobs (HR = 3.02, 95% CI 1.39-6.58), and workers exposed to hand vibration (HR = 1.94, 95% CI 1.00-3.77) were at an increased risk of hospitalization for UNE. Exposure to work requiring arm elevation increased the risk of hospitalization due to UNE among smokers (HR = 2.62, 95% CI 1.13-6.07), but not among non-smokers. Work-related exposure to vibration and temperature changes, and physically demanding work increase the risk of hospitalization for UNE. Smoking may potentiate the adverse effects of work-related factors on UNE.