Advancing the management of upper extremity musculoskeletal conditions: Insights from the field of implementation science.

INTRODUCTION: The development of effective interventions in hand and upper extremity rehabilitation is critically important; yet even the most promising interventions may not successfully be implemented in practice. Occupational and physical therapists who provide specialized hand and upper extremity rehabilitation services ("hand therapists") can face extensive, multi-level barriers when attempting to use research findings in real-world settings, widening the long-standing research-to-practice gap. Concepts from the field of implementation science can be leveraged to address this gap and expedite the application of research discoveries that can maximize treatment outcomes of the musculoskeletal upper extremity client. As the intersection of hand and upper extremity rehabilitation and implementation science draws growing attention, there is a great need for researchers and clinicians to infuse implementation science into the hand and upper extremity rehabilitation research and practice contexts. PURPOSE: The purpose of this article is to define implementation science and synthesize several studies from the hand and upper extremity rehabilitation field that have examined the effect of implementation strategies (eg, chart audit and feedback techniques; implementation teams) on implementation outcomes (eg, acceptability, fidelity). We also present recommendations for how (1) hand and upper extremity rehabilitation researchers can design studies to examine both patient outcomes and implementation outcomes relative to interventions for the musculoskeletal upper extremity and (2) hand and upper extremity rehabilitation specialists and administrators can develop implementation teams to facilitate the use of evidence in practice. CONCLUSION: Collaboration between researchers and clinicians has great potential to advance the entirety of the hand and upper extremity rehabilitation profession, especially when such collaborations are guided by the implementation science field.

Plating of acute humeral diaphyseal fractures through an anterior approach in multiple trauma patients.

OBJECTIVE: We evaluated the clinical and long-term functional outcomes of humeral diaphyseal fractures treated with acute anterior plating in a trauma population. DESIGN: Single-center, retrospective cohort analysis with long-term prospective follow-up. SETTING: Urban, Level I trauma center. PATIENTS: Ninety-six patients with high-energy fractures of the humeral shaft were treated over a 10-year period. INTERVENTION: All patients were treated by a standard surgical protocol of open reduction through an anterior approach with small or large fragment fixation in the supine position. MAIN OUTCOME MEASUREMENTS: Mechanism of injury, time to union, complications, and range of motion during clinical follow-up were obtained. We also prospectively assessed long-term strength, range of motion, and perceptions of disability using the Disabilities of the Arm, Shoulder and Hand questionnaire. RESULTS: Mean time to surgery was 5 days (standard deviation, 11 days); 97.5% of patients achieved union in an average of 16.9 weeks (range, 6-56 weeks). Complications included two postoperative infections, two nonunions, and three implant failures. Long-term follow-up (n = 34) averaged 4.75 years (range, 1.4-10.8 years). On average, no significant differences between the injured and uninjured extremities were seen in range of motion at the shoulder and elbow with the exception of shoulder flexion. A modest loss of upper extremity strength in the injured arm was appreciated. The mean Disabilities of the Arm, Shoulder and Hand score was 25.9 (range, 0-79). CONCLUSIONS: A standard anterior surgical approach with small fragment fixation is a safe and effective treatment for humeral shaft fractures in multiple trauma patients. We show a high union rate and few complications, although a modest loss of function and some perceived disability exists in the long-term.