Soft tissue coverage for IIIB fractures: from timing to coverage options.

Open tibia fractures are the most common open long bone injury. Most of these injuries involve a high-energy mechanism. Many standards for management have been created to provide guidance and a baseline for quality. There are several factors that must be considered when determining the timing of coverage for an open fracture with soft tissue compromise. Understanding the available options for soft tissue coverage, including local/rotational flaps and free tissue transfer, will allow for a tailored approach based on the personality of the injury. The aim of this review was to characterize the critical window of treatment based on the current literature and to provide a review of the available soft tissue coverage options.

Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures.

BACKGROUND: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE: Level IV.

An Examination of Complication Rates and Surgery Durations in Elective Hand Surgery During the COVID-19 Pandemic.

Background: The COVID-19 pandemic presented unique challenges to hand surgeons as hospitals worked to adapt to unprecedented demands on resources and personnel. The purpose of this study is to evaluate the impact of COVID-19 on outcomes in elective hand surgery using a large national database. Methods: This is a retrospective review of the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) dataset for patients undergoing elective hand procedures in 2019 and 2020. Demographics, comorbidities, procedural factors, and outcomes were compared between cases occurring in 2019 and 2020. Multivariable regressions were performed to evaluate the association between operative year and 30-day outcomes. Results: A total of 8971 patients were included with a mean age of 52.2 ± 16.7 and 52.8 ± 16.4 years for the 2019 and 2020 cohorts, respectively. Compared to the 2019 cohort, the 2020 cohort demonstrated higher prevalence of obesity (43.3% vs 40.8%, P = 0.019), hypertension requiring medication (32.9% vs 35.0%; P = 0.046), and American Association of Anesthesiologists (ASA) class ≥ 3 (30.4% vs 27.0%; P < 0.001). There were no significant differences in outcomes including 30-day readmissions, reoperation, or complications between cohorts on unadjusted or multivariable analysis. Conclusions: Elective hand cases performed during the pandemic were associated with longer operating times and more frequently involved patients with greater comorbidities. Despite these differences, patients undergoing surgery during the pandemic demonstrated similar outcomes including complications, readmissions, and reoperations compared to those undergoing surgery the year prior, suggesting that even in the setting of a pandemic, performing elective surgery is safe without an increased risk to the patient.

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches.

BACKGROUND: Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes. METHODS: A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD. RESULTS: Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%. CONCLUSION: Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability. LEVEL OF EVIDENCE: I, Systematic Review.

Evaluation of a Fast Method to Measure High-Frequency Audiometry Based on Bayesian Learning.

This study aimed to assess the validity of a high-frequency audiometry tool based on Bayesian learning to provide a reliable, repeatable, automatic, and fast test to clinics. The study involved 85 people (138 ears) who had their high-frequency thresholds measured with three tests: standard audiometry (SA), alternative forced choice (AFC)-based algorithm, and Bayesian active (BA) learning-based algorithm. The results showed median differences within ±5 dB up to 10 kHz when comparing the BA with the other two tests, and median differences within ±10 dB at higher frequencies. The variability increased from lower to higher frequencies. The BA showed lower thresholds compared to the SA at the majority of the frequencies. The results of the different tests were consistent across groups (age, hearing loss, and tinnitus). The data for the BA showed high test-retest reliability (>90%). The time required for the BA was shorter than for the AFC (4 min vs. 13 min). The data suggest that the BA test for high-frequency audiometry could be a good candidate for clinical screening. It would add reliable and significant information without adding too much time to the visit.

Tourniquet Use in Extremity-Based Microsurgery.

BACKGROUND: The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. METHODS: A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. RESULTS: A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. CONCLUSION: Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

Body Mass Index Is Associated With Myocutaneous Free Flap Reliability: Overcoming the Obesity Obstacle With a Proposed Clinical Algorithm to Identify and Manage High-Risk Patients Undergoing Gracilis Free Flap With Skin Paddle Harvest.

INTRODUCTION: The purpose of this study was to evaluate the role of body mass index (BMI) in predicting postoperative complications following myocutaneous free flap transfer. In addition, we sought to identify certain body composition variables that may be used to stratify patients into low- versus high-risk for gracilis myocutaneous free flap with skin paddle failure. METHODS: Using the National Surgical Quality Improvement Program database, we collected data for all patients who underwent myocutaneous free flap transfer from 2015 to 2021. Demographic data, medical history, surgical characteristics, and postoperative outcomes, including complications, reoperations, and readmissions, were collected. Body mass index was correlated with outcome measures to determine its role in predicting myocutaneous free flap reliability. Subsequently, we retrospectively obtained measurements of perigracilis anatomy in patients who underwent computed tomography angiography bilateral lower extremity scans with intravenous contrast at our institution. We compared body composition data with mathematical equations calculating the potential area along the skin of the thigh within which the gracilis perforator may be found. RESULTS: Across the United States, 1549 patients underwent myocutaneous free flap transfer over the 7-year study period. Being in obesity class III (BMI ≥40 kg/m2) was associated with a 4-times greater risk of flap complications necessitating a return to the operating room compared with being within the normal BMI range. In our computed tomography angiography analysis, average perigracilis adipose thickness was 18.3 ± 8.0 mm. Adipose thickness had a strong, positive exponential relationship with the area of skin within which the perforator may be found. CONCLUSIONS: In our study, higher BMI was associated with decreased myocutaneous free flap reliability. Specifically, inner thigh adipose thickness can be used to estimate the area along the skin within which the gracilis perforator may be found. This variable, along with BMI, can be used to identify patients who are considered high-risk for flap failure and who may benefit from additional postoperative monitoring, such as the use of a color flow Doppler probe and more frequent and prolonged skin paddle monitoring.

The Effect of Surgical Timing on Upper Extremity Nerve Repair.

BACKGROUND: The purpose of this study was to evaluate the association between timing of nerve repair and the ability to perform a primary nerve repair versus a bridge repair requiring the use of allograft, autograft, or a conduit in lacerated upper extremity peripheral nerve injuries. METHODS: This is a retrospective case-control study of patients who underwent upper extremity nerve repair for lacerated peripheral nerves identified by Current Procedural Terminology codes. Timing of injury and surgery, as well as other information such as demographic information, mechanism of injury, site of injury, and type of nerve repair, was recorded. The odds of a patient requiring bridge repair based on the duration of time between injury and surgery was evaluated using logistic regression. RESULTS: A total of 403 nerves in 335 patients (mean age 35.87 ± 15.33 years) were included. In all, 241 nerves were primarily repaired and 162 required bridge repair. Patients requiring bridge repair had a greater duration between injury and surgery compared with patients who underwent primary repair. Furthermore, the nerves requiring bridge repair were associated with a greater gap compared with the nerves repaired primarily. Based on logistic regression, each 1-day increase in duration between injury and surgery was associated with a 3% increase in the odds of requiring bridge repair. CONCLUSIONS: There is no defined critical window to achieve a primary nerve repair following injury. This study demonstrated that nerve injuries requiring bridge repair were associated with a significantly greater delay to surgery.

Reducing Tourniquet Pressures in Hand Surgery: Are Lower Pressures as Effective?

Background Pneumatic tourniquets are widely used in hand surgery. Elevated pressures can be associated with complications, and thus, guidelines based on patient-specific tourniquet pressures have been recommended. The primary aim of this study was to determine whether lower tourniquet values based on systolic blood pressure (SBP) could be effectively applied in upper extremity surgery. Methods A prospective case series of 107 consecutive patients undergoing upper extremity surgery with use of a pneumatic tourniquet was performed. Tourniquet pressure used was based on the patient's SBP. The tourniquet was inflated based on our predetermined guidelines: 60 mm Hg was added for SBP < 130 mm Hg, 80 mm Hg for SBP between 131 and 190 mm Hg, and 100 mm Hg for SBP > 191 mm Hg. The outcome measures included intraoperative tourniquet adjustment, surgeon-rated quality of bloodless operative field and complications. Results The mean tourniquet pressure was 183 ± 26 mm Hg with a mean tourniquet time of 34 minutes (range: 2-120 minutes). There were no instances of intraoperative tourniquet adjustment. The surgeon-rated quality of bloodless operative field was excellent in all patients. No complications were associated with the use of a tourniquet. Conclusion Tourniquet inflation pressure based on SBP is an effective method to provide a bloodless surgical field in upper extremity surgery at significantly lower inflation pressures than are the current standards.

A Prospective Analysis of Patient Characteristics Affecting the Outcome of Dorsal Splinting for Soft Tissue Mallet Injuries.

BACKGROUND: Much has been written about the diagnosis and treatment of soft tissue mallet injuries. However, there has been little regarding the characteristics of this injury affecting patients' prognosis. The purpose of this prospective study was to identify factors influencing the outcome of treatment of soft tissue mallet injuries. METHODS: Patients diagnosed with soft tissue mallet injuries were enrolled prospectively in a protocol of dorsal splinting for 6 to 12 weeks, followed by weaning over 2 weeks and then evaluated at 6, 9, and ≥12 months. RESULTS: Thirty-seven patients (38 digits) completed the study. Treatment success was defined as a final extensor lag of <15° and failure as a final extensor lag of ≥15°. Those failing splint treatment were older compared with those successfully treated. Patient compliance was significantly associated with a successful outcome. Factors that did not significantly affect success included time to treatment, initial injury severity, splinting duration, sex, and ligamentous laxity. Disabilities of Arm, Shoulder, and Hand scores >0 were not associated with treatment failure. Radiographic and clinical extension lag were statistically comparable. CONCLUSIONS: This study shows strong association between the success of splint treatment, younger patient age, and compliance with the treatment protocol. Despite this finding, most patients did not report any functional limitations, irrespective of the treatment success. In contrast to prior results, time to treatment and initial extensor lag did not significantly affect treatment success.

The Variable Insertional Anatomy of the Abductor Pollicis Longus: Functional Relevance and Relationship to Adjacent Thumb Extensors.

BACKGROUND: The abductor pollicis longus (APL) is classically described as inserting on the base of the first metacarpal. This study analyzed APL insertional anatomy and quantified the size of various elements of the extensor side of the thumb to determine associations with size and function. METHODS: Twenty-four formalin-preserved upper limbs were dissected. The insertional anatomy of the APL, extensor pollicis brevis, and extensor pollicis longus were characterized, and the capacity of APL tendon slips to perform palmar abduction of the first digit was quantified based on slip size and insertion. RESULTS: The mean number of APL tendon slips observed was 2.3. Abductor pollicis longus insertion sites included the base of the first metacarpal, trapezium, abductor pollicis brevis, and opponens pollicis. Only 4 specimens had a solitary metacarpal slip, while 83% of specimens had insertions onto at least 1 thenar muscle. A total of 62.5% of APL tendons exhibited some form of branching that we categorized into "Y" and "Z" patterns. In assessing palmar abduction capacity, we found that APL tendon slips inserting into the base of the first metacarpal were larger in cross-sectional area than nonmetacarpal slips and reproduced complete palmar abduction of the digit in the absence of nonmetacarpal slips. The abduction capacity of APL tendon slips was not correlated to the cross-sectional area. CONCLUSIONS: There is significant variability in APL tendon slips, branching patterns, and insertional anatomy. These findings provide further understanding of the function of the APL and its surgical implications.

Spatial Anatomy of the Radial Nerve in the Extended Deltopectoral Approach.

The goal of this study was to define safe zones to prevent radial nerve injury in an extended deltopectoral approach. Relative distances of the upper margin (UMRN) and lower margin (LMRN) of the radial nerve to the proximal and distal borders of the pectoralis major and deltoid insertions were measured in 20 cadaveric arms. Four proximal humeral zones were identified (zone I, proximal border of the pectoralis major tendon to the proximal border of the deltoid tendon; zone II, proximal border of the deltoid tendon to the distal border of the pectoralis major tendon; zone III, distal border of the pectoralis major tendon to the distal border of the deltoid tendon; and zone IV, distal to the distal border of the deltoid tendon). On fluoroscopic measurement, mean distances between the UMRN and the proximal border of the pectoralis major tendon and the proximal border of the deltoid tendon were 71.6±2.1 mm and 26.2±2.5 mm, respectively. The incidence of the radial nerve in the spiral groove within each defined zone was as follows: zone I, 0%; zone II, 50%; zones III and IV, 100%. There was a significant association between anatomic zone and radial nerve entry into the spiral groove, χ2(3, N=88)=64.53, P<.001. The proximal border of the pectoralis major tendon to the proximal border of the deltoid tendon (zone I) is a safe location to avoid injury to the radial nerve. We recommend placing cerclage wires proximal to zone I from lateral to medial to avoid entrapment of the radial nerve. [Orthopedics. 2023;46(1):e31-e37.].

Does Time Heal Trauma? 18 Month Follow-Up Study of Syrian Refugees' Mental Health in Iraq's Kurdistan Region.

The findings of longitudinal studies on traumatized refugees have shown that factors related to premigration, migration, and post-migration experiences determine changes in mental health over time. The primary aim of this follow-up study was to examine the potential change in the prevalence rates of probable PTSD and depression among Syrian refugees in Iraq. An unselected group of N = 92 Syrian adult refugees was recruited from Arbat camps in Sulaymaniyah Governorate in Iraq's Kurdistan Region, and then interviewed at two different time points between July 2017 and January 2019. Locally validated instruments were used to assess traumatic events and mental health symptoms. The primary results showed no significant change in the mean scores of PTSD and depression symptoms from the first measurement to the second measurement over the course of 18 months. On the individual level, no reliable change was found for either PTSD or depression symptoms in more than three-quarters of the participants (78.3% and 77.2%, respectively). New adversities and traumatic events that occurred over the 18 months between the interviews were a significant predictor of increasing trauma-related symptoms. After the flight from conflict settings, trauma-related disorders seem to be chronic for the majority of Syrian refugees. Further longitudinal studies are needed in order to identify specific risk factors that lead to maintaining or worsening mental health symptoms over time, and to explore effective therapeutic intervention methods for this traumatized population.

Promising results of captopril in improving knee arthrofibrosis and cartilage status: an animal model study.

PURPOSE: Several cytokines and growth factors start and progress the destruction process of joint hyaline cartilage and fibrosis formation. Captopril is classified as an Angiotensin-converting enzyme inhibitor in which several studies revealed that captopril significantly decreases fibrosis formation in some organs like the liver, heart, and kidney. This study aimed to evaluate the use of captopril in reducing the possibility of arthrofibrosis and osteoarthritis in an animal model. METHOD: In this in-vivo animal model study, the anterior cruciate ligament of 24 rabbits was transected to induce osteoarthritis and arthrofibrosis. The control group contained 11 rabbits and the second group consisted of 13 rabbits. The second group was treated with 10 mg/ kilogram/day captopril through a nasogastric tube. The control group was treated with normal saline in the same way. Cartilage damage and osteoarthritis were evaluated by Osteoarthritis Research Society International (OARSI) scoring system. After 30 days, animals were sacrificed, and arthrofibrosis and cartilage damage were evaluated microscopically and macroscopically. RESULTS: According to macroscopic and microscopic evaluation, captopril dramatically reduced arthrofibrosis formation based on visual scoring and the Masson trichrome staining system. Cartilage damage was lower in the intervention group compared to the control group. CONCLUSIONS: Captopril is an angiotensin-converting enzyme inhibitor that demonstrated to significantly decreases the possibility of arthrofibrosis. Although the beneficial preventive effect of captopril on osteoarthritis was not proved statistically, better results may be obtained if the route of administration or drug dosage is changed.

The mental health of forcibly displaced couples.

Most current research investigating traumatic stress is focused on its effects at the individual level, utilizing the implicit assumption that trauma-related disorders are mutually independent within families and communities. However, there is reason to assume that trauma-related symptoms within couples are influenced by each partner's risk factors and symptoms. Using the actor-partner interdependence model, this study aimed to test whether symptoms of posttraumatic stress disorder (PTSD) and depression were predicted by participants' partner's exposure to traumatic events over and above the influence of the participant's own experiences. For this purpose, we interviewed 687 heterosexual, married Iraqi and Syrian couples in Iraq's Kurdistan region who had been forcefully displaced. We assessed symptoms of PTSD and depression using locally validated scales. Nearly all participants (98.8%) reported exposure to at least one traumatic event, with husbands reporting exposure to a higher number of traumatic events than wives, d = 0.48, p < .001. More than half of the participants met the criteria for a probable PTSD (61.1%) or major depressive disorder diagnosis (60.4%). Within couples, significant actor effects of experienced trauma exposure on personal PTSD and depressive symptoms were observed for both husbands and wives. Further, there were significant partner effects of wives' traumatic experiences on husbands' PTSD and depressive symptoms as well as of husbands' traumatic experiences on wives' PTSD and depressive symptoms. The findings argue for the interdependence of trauma-related symptoms within dyads in a dual-trauma context, suggesting the presence of intracouple transmission of trauma-related symptoms.

Topographic Localization of the Extensor Retinaculum A Cadaveric Study.

PURPOSE: The extensor retinaculum of the wrist, a thickening of the deep forearm fascia, is often used as do- nor graft material for annular pulley reconstructions and bone-retinaculum-bone grafts for ligament reconstructions. The purpose of our study was to identify the relationships between the radial and ulnar styloids, readily recogniz- able topographic landmarks of the wrist, and the anatomic boundaries of the retinaculum. METHODS: The extensor retinacula of 12 preserved, right cadaver wrists (3 male and 9 female) were studied by gross dissection using 3.5-power loupe magnification. The proxi- mal and distal extents of the retinaculum were identified and marked with needles, and their distances from the radial and ulnar styloids measured to determine the lengths of the retinaculum on both sides. RESULTS: The extensor retinaculum on the radial side extended 23.9 ± 2.9 mm proximal to the radial styloid and 5.8 ± 2.6 mm distal to the styloid for a total length of 29.7 ± 3.8 mm. On the ulnar side, the retinaculum extended 2.4 ± 1.4 mm proximal to the ulnar styloid and 17.9 ± 2.6 mm distal to the styloid for a total length of 20.3 ± 2.9 mm. CONCLUSIONS: The extensor retinaculum has a consis- tent relationship with the readily recognized topographic landmarks of the radial and ulnar styloids. The use of the extensor retinaculum as donor material for pulley and liga- ment reconstruction make these findings useful for surgical planning.

Adjunctive Procedures for Median Nerve Decompression in Carpal Tunnel Syndrome An Intraoperative Somatosensory Evoked Potential Study.

The objective of this study was to determine the role of ad- junctive surgical procedures on the median nerve for carpal tunnel syndrome as measured by somatosensory evoked potentials (SEPs) on the nerve. Fifty-five median nerves in 47 patients were studied. In each patient, a base-line SEP was recorded in the operating room prior to incision and then intraoperatively following each of three sequential pro- cedures: division of the transverse carpal ligament, an epi- neurolysis of the nerve, and finally, either an epineurotomy or epineurectomy that we refer to as a "limited internal neu- rolysis" since it did not involve any intraneural dissection of fascicles. Comparison of the baseline mean SEP latency for the median nerve, referred to as N19 (negative polarity = 19 msec), showed a statistically significant improvement following each of the three procedures. The average reduc- tion of latency after ligament release alone was 1.52 msec, and the total improvement in latency from baseline through limited internal neurolysis was 4.72 msec. Our study showed that epineurolysis followed by a limited internal neurolysis using either an epineurotomy or epineurectomy produced a significant electrophysiologic improvement in the median nerve. There was no significant difference when comparing epineurotomy and epineurectomy.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women.

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, Mage (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

Nerve Imaging in the Wrist.

Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.