The Role of Telemedicine in Prehospital Traumatic Hand Injury Evaluation.

Unnecessary ED visits and transfers to hand clinics raise treatment costs and patient burden at trauma centers. In the present COVID-19 pandemic, needless transfers can increase patients' risk of viral exposure. Therefore, this review analyzes different aspects of the remote diagnosis and triage of traumatic hand injuries. The most common file was photography, with the most common devices being cell phone cameras. Treatment, triage, diagnosis, cost, and time outcomes were assessed, showing concordance between teleconsultation and face-to-face patient evaluations. We conclude that photography and video consultations are feasible surrogates for ED visits in patients with traumatic hand injuries. These technologies should be leveraged to decrease treatment costs and potentially decrease the time to definitive treatment after initial evaluation.

Pyro ban on New Year's Eve 2020/2021 - Analysis of firework-related injuries and their treatments

The majority of firework-related injuries in Germany are found at the turn of the year. With regard to hearing, a distinction is made between blast (BT) and explosion trauma (ET). The study examines the prevalence and characteristics of firework-related injuries over the past 11 years on New Year's Eve and compares these with the effects of the pyro ban 2020/21 imposed due to the COVID-19 pandemic. A retrospective chart review of all patients who presented themselves with the diagnosis blast trauma (H 83.3) or explosion trauma (T 70.8) at the Charité emergency service in the last 11 years from December 28 to January 5 was performed. 267 patients were recorded (78 % male). 1/3 each were assigned to the age group 10-19 and 20-29 years. 21 % of the patients were admitted to the hospital. There was an isolated BT of the ear in 66 %, hand injuries in 12 %, head injuries in 8 % and eye injuries in 4 %. 87 % had ear involvement with hearing loss: 83 % with tinnitus, 5.6 % with ET. The tone audiograms of BT and ET show differences only at 6 kHz, but not at 4 kHz. 8.6 % of the patients underwent surgical interventions. The treatment of a tympanic membrane perforation was carried out by: 54 % splinting vs. 38 % tympanoplasty. Therapy with a glucocorticoid was administered i.v. in 48 % and initiated orally in 17 %. Overall, there was a decrease in injuries of almost 90 % in 2020/21 compared to 2017/18. The use of fireworks leads to increased utilization of health care resources. The ban on the sale of pyrotechnics as well as the introduction of pyro ban zones in 2020 led to a relevant decrease in injuries. 2020 was the only year in which there were no injuries in children / adolescents. The BT of the ear is the most common firework-related injury.

The first COVID-19 lockdownʼs impact on hand injuries at a Danish accident and emergency department

INTRODUCTION. During the lockdown of the COVID-19 pandemic in Denmark in March 2020, the trauma Accidents and Emergency (A&E) Department of Odense University Hospital, Denmark, experienced a marked decline in visits. We had the impression that the decline in visits for non-severe injuries was larger than that for severe injuries. METHODS. We analysed the incident rate ratio (IRR) between the first month of the lockdown with the IRR recorded in the month leading up to the lockdown. We then compared this IRR with the IRR for the equivalent periods of 2019. The outcomes were: diagnoses (or diagnosis groups), activity during injury (ADI), mechanisms of injury, age group and gender. Secondarily, certain specific diagnoses (or diagnosis groups) were analysed by ADI and mechanism of injury. RESULTS. We observed a significant reduction by 30.6% of all hand injuries in 2020. The non-severe injuries had a significant IRR reduction of 58.7% and the severe injuries a reduction of 15.3%, which was non-significant. The IRR in 2020 was significantly lower in 2020 for the age groups: 0-14, 15-17 and 25-49 years. The relative reduction in IRR was markedly larger for men (40.8%) than for women (22.3%), although this difference was not significant. CONCLUSION. We observed a greater reduction in non-severe injuries than in severe injuries compared with 2019. Further studies are needed to fully examine the cause of this phenomenon. The reduction may be caused, in part, by a more restrictive attitude towards seeking medical help at a trauma A&E during the first COVID-19 lockdown.

Phenotypic and Genomic Analysis of Novel, Fastidious, Gram-negative Bacilli Isolated from Clinical Wound Specimens

Background. Animal bites are considered the thirteenth leading cause of nonfatal ED visits. Epidemiology studies have shown a rise in dog bites during the COVID-19 pandemic in the U.S. In Oct. 2020, we received a facultatively anaerobic, non-hemolytic Gram-negative rod (OL1) from a dog bite wound for identification. 16S rRNA gene sequencing showed OL1 was 95.9% identical to Ottowia pentelensis in the family Comamonadaceae. Our historical sequence database revealed 8 additional isolates (OL2-OL9) from hand wounds/abscesses (including 3 dog bites) since 2012 that had > 99.8% identity with OL1. Most other Ottowia sp. have been isolated from industrial and food sources, with no reports from patient samples. As these clinical isolates likely represent a novel Ottowia species, we aimed to characterize them using both phenotypic and genomic approaches. Methods. The OL isolates were tested in API 20 NE panels (8 conventional and 12 assimilation tests) for 4 d. Paired-end genomic DNA libraries (Nextera DNA Flex Library Prep, Illumina) were sequenced as 150 nt reads by Illumina NovaSeq. De novo assembly, annotation, functional prediction, and phylogenetic analyses were performed with Geneious, PATRIC, and web-prediction databases. Strain comparison was done with StrainTypeMer. Results. All 9 OL isolates were negative for indole, urea, arginine, esculin, PNPG, glucose fermentation and carbohydrate assimilation tests. Potassium gluconate assimilation and gelatin hydrolysis were positive for 5 and 4 isolates, respectively. StrainTypeMer showed the isolates from different patients were not closely related, but 2 from the same patient were indistinguishable. The estimated genome size was ~3.1 Mbp, with 66.1% G/C, and ~3523 coding genes. Potential virulence factors (BrkB and MviM), multidrug efflux systems (MdtABC-TolC and Bcr/CflA), and 1-2 intact prophages were identified. Genomic phylogenetic analysis with RAxML showed the OL isolates clustered separately from all known Ottowia spp. Conclusion. These OL isolates are fastidious, Gram-negative bacilli from clinical wound specimens, and are associated with dog bites. Genomic and 16S rRNA gene sequence analysis suggests these isolates constitute a novel species within the family Comamonadaceae.

A rare cause of paediatric wrist pain unmasked by minor trauma

Introduction: A 10 year-old girl was referred to paediatric rheumatology with a six-month history of a painful, swollen left wrist associated with functional limitation and disturbed sleep. She initially had a minor fall, X-rays at the time showed no bony abnormalities. Objectives: Blood tests were normal including inflammatory markers and autoimmune screen. Wrist MRI showed significant synovial thickening and avascular necrosis of the left lunate (figure 1). Methods: Our patient received non-steroidal anti-inflammatories and physiotherapy, but a year later continued to have chronic regional pain with allodynia and hyperalgesia. Despite this, she remains upbeat and continues to live a normal childhood and has coped well with the recent increase in computer usage and typing associated with remote-schooling as a consequence of closures during the COVID-19 pandemic. Results: Kienböck disease;an eponym for avascular necrosis of the lunate bone, is of unknown aetiology and incidence[1]. The proposed trigger is trauma in those with a susceptibility due to natural skeletal and vascular variations[2]. It is the commonest cause of adult aseptic osteonecrosis of the upper extremity, usually in dominant hands of men aged 20-40[3]. Paediatric Kienböck is rare;presenting as pain, stiffness, swelling and reduced power often after an innocuous fall. Diagnostically this is challenging because the mechanism suggests a soft-tissue injury whereas the chronicity mimics Juvenile Idiopathic Arthritis. Radiographic severity is defined by Lichtman classification and used to guide non-curative surgical or conservative management[4]. This aims to relieve pressure on the lunate bone and restore perfusion. Anti-inflammatory medications are offered prior to surgical jointlevelling to reduce pain, swelling and deformity[5]. Conclusion: We emphasise that clinicians consider this rare, destructive pathology in their differential diagnosis for paediatric chronic wrist pain and swelling, especially in those presenting weeks after a seemingly innocuous hand trauma.

Virtual fracture clinic management of little (5th) metacarpal neck fractures;a safe and feasible option?

Aim: To determine the safety and efficacy of a Virtual Fracture Clinic (VFC) in managing little metacarpal neck fractures. Method: Retrospective review of consecutive little MC neck fractures presenting to the ED June-December 2020 and subsequently referred on to VFC. Patient demographics and clinic outcomes were reviewed using electronic patient records and radiographs. Results: Fifty patients were identified (Male:Female 37:13;mean age 26 years, range 3-89 years). Of these, 41/50 were discharged directly following VFC advice, with no adverse event. The remaining 9/50 had a face-to-face Fracture Clinic review due to safeguarding concerns (2), concurrent neck of fourth MC fracture (2), concerns regarding fracture pattern (4), and an unclear indication (1). These 9/50 were discharged after single review, with no adverse events to date. Conclusions: Our data suggest that VFC review of patients with little MC neck fractures is a safe and feasible means of patient care which has the potential to reduce the requirement of face-to-face patient contact during the Covid-19 pandemic and reduce fracture clinic attendance. We suggest the routine incorporation of a Virtual Fracture Clinic for these hand injuries. Further work is needed to formally investigate associated patient satisfaction and the application of this approach to other trauma presentations.

Patient perception on hand trauma management through a plastic surgery trauma clinic

Aim: We assessed patient perceptions of hand trauma management through a plastic surgery trauma clinic. We also assessed effects of educating patients about outcomes of their condition on their desire to have prompt surgery. Method: A prospective survey review was conducted at our plastic surgery trauma clinic. Patients included were those referred due to simple hand trauma. Any patients needing urgent admissions were excluded. An anonymous survey assessing patient perceptions before and after education about delay in surgery was distributed. Results: Of 100 patients, there were mixed expectations regarding trauma clinic;38% (n=38) expect an operation, 32% (n=32) expect no operation and 30% (n=30) expect either option. 90% (n=90) expect surgery within a week (50% n=50) or within a day (40% n=40);10% expect it (n=10) within a few weeks. After educating patients about no negative effects on their condition from surgical delay, 43% (n=17) fewer patients desired surgery within a day, and 8% (n=3) fewer patients desired surgery within a week. 190% (n=19) more patients were willing to have surgery within a few weeks. 79% (n=79) would rather come back at a guaranteed surgical slot than stay in hospital until a slot is available. 72% (n=72) considered knowledge about long-term outcomes associated with surgical delay to influence their decision more than anaesthetic type (12% n=12) and personal circumstances (16% n=16). Conclusions: If appropriate patients are assured that their condition will not be affected by surgical delay, fewer patients may stay in hospital with financial benefits of reduced bed occupancy and reduced covid risks.

Epidemiology of hand traumas during the COVID-19 confinement period.

INTRODUCTION: hand injuries are a common emergency mainly caused by domestic accidents or sport injuries. During the COVID-19 pandemic confinement period, with a cut off in transportation as well as in occupational and physical activities, we observed a decrease in medical and elective surgical activities but emergency cases of upper limb and hand surgery increased. MATERIALS AND METHODS: we conducted a retrospective epidemiological study to analyze two periods between the same dates in 2019 and 2020, for all the duration of the confinement period. We compared the numbers of consultations in the emergency department, elective surgeries, hand and upper limb emergency cases in our center and urgent limb surgeries in the nearby hospital. Then we compared the mechanisms and severity of injuries and the type of surgery. RESULTS: between 2019 and 2020 there was a decrease of consultations in the emergency department in our institution of 52%, a decrease of total elective surgeries of 75%, a decrease in surgeries for urgent peripheral limb injuries of 50%, whereas the hand and upper limb emergency remained stable or even increased by 4% regard to occupational and domestic accidents. There was a significant difference in the mechanism of injury with an increase of domestic accident and a decrease of occupational, road traffic and sport accidents. Severity of the injuries increased, with augmentation of the number of tissues involved and longer expected time of recovery. CONCLUSION: during the confinement period of the COVID-19 pandemic, despite an important reduction of medical activities, the amount and severity of hand emergency cases increased. A specific plan regarding duty shift organization for hand trauma should be maintained regardless of the sanitary situation.