A three-dimensional computed tomography study of the palmar ulnar corner fragment in distal radial fractures.

Fixing palmar ulnar corner fragments of distal radial fractures can be challenging. We described the palmar ulnar corner fragment morphology in a retrospective cohort study of 40 patients who underwent preoperative wrist computed tomography scans. Palmar ulnar corner fractures were categorized based on articular cross-sectional area, sagittal angulation relative to the radius long axis, palmar cortical length, radioulnar width and associated palmar radiocarpal subluxation. Three types emerged: type 1 fragments involved 37% (SD 10) of the radiocarpal articular surface and were extended in the sagittal plane; type 2 fragments involved 28% (SD 10) of the articular surface and had a long palmar cortex, of which 57% had palmar carpal subluxation; and type 3 fragments involved 13% (SD 2) of the articular surface, had a short palmar cortex and all had palmar carpal subluxation. Understanding palmar ulnar corner fragment morphology may guide optimal reduction and fixation strategy and prevent palmar radiocarpal subluxation, especially in type 3 fractures.Level of evidence IV.

Universal Design in Education (UDE) Across the Life Course: Applying a Systems Framework to Create an Inclusive Experience for All.

The UN Convention on the Rights of Persons with Disabilities (UNCRPD) promotes the realisation of the right of persons with disabilities to education through Article 24 - Education. Universal Design in Education (UDE) fosters a whole systems approach so that the physical and digital environments, the educational services, and the teaching and learning can be easily accessed, understood and used, by the widest range of learners and by all key stakeholders, in a more inclusive environment. The whole systems approach incorporates the entire educational environment, as well as the recognition of the capacity for all learners (including persons with disabilities) to learn, and environments which are fully accessible and inclusive. This paper discusses methods whereby a systems approach can be applied to various aspects of education across the life continuum. It further advocates the inclusion of Universal Design as subject matter in curricula and assessment, to ensure a broader and more widespread adoption across the educational spectrum.

Double and Single True Knot of an Umbilical Cord: A Case Report.

The primary function of the umbilical cord is to transport blood to and from the fetus. It carries deoxygenated blood away from the fetus by two umbilical arteries, and oxygenated blood from the placenta toward the fetus by an umbilical vein. In some cases, the umbilical cord can form a true knot increasing the risk of asphyxia and fetal demise. The umbilical cord may also form a false knot, which is only a kink and will not increase fetal risk of abnormalities. A 40-year-old woman, gravida six, parity three (G6P3), presented to the hospital in active labor after 39.1 weeks of gestation. Six hours after admission a healthy male fetus was delivered with one nuchal cord. The placenta was delivered approximately 3 minutes later. Upon inspection, the presence of a double and a single true knot of the umbilical cord was noted. This case describes a fetus with a double and single true knot of the umbilical cord that was not apparent by ultrasonography.

Establishing the Patient Acceptable Symptom State in a Nonshoulder Hand and Upper Extremity Population for the Disabilities of the Arm, Shoulder, and Hand and Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Tests.

PURPOSE: It is unclear what score thresholds on patient-reported outcomes instruments reflect an acceptable level of upper extremity (UE) function from the perspective of patients undergoing hand surgery. The purpose of this study was to calculate the patient acceptable symptom state (PASS) for the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) UE Computer Adaptive Test (CAT), version 2.0, in a population who underwent hand surgery. METHODS: Adult patients who underwent hand surgery between February 2019 and December 2019 at a single academic tertiary institution were identified. QuickDASH and PROMIS UE CAT version 2.0 scores were collected 1 year after surgery, as were separate symptom- and function-specific anchor questions that queried the acceptability of patients' current state. Threshold values predictive of a patient reporting an acceptable symptom state (PASS[+]) were calculated for both instruments using the 75th percentile score for patients in the PASS(+) group and the Youden Index as determined by receiver operating curve (ROC) analysis. RESULTS: A total of 222 patients were included. QuickDASH and PROMIS UE CAT scores differed significantly between the PASS(+) and PASS(-) groups. The 75th percentile method yielded PASS values of <16 for the QuickDASH and >43 for the PROMIS UE CAT for both anchor questions. The ROC analysis yielded PASS estimates of <15.9 to <20.5 for the QuickDASH and >38.1 to >46.2 for the PROMIS UE CAT, with ranges calculated from differing threshold values for each of the 2 anchor questions. The ROC-based estimates demonstrated high levels of model discrimination (area under the curve ≥ 0.80). CONCLUSIONS: We propose PASS estimates obtained using the 75th percentile and ROC methods. CLINICAL RELEVANCE: Specifically, PASS values in the range of 15.9-20.5 for the QuickDASH and 38.1-46.2 for the PROMIS UE CAT version 2.0 should be used when interpreting outcomes at a population level.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population.

PURPOSE: Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population. METHODS: Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status. RESULTS: There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination. CONCLUSIONS: We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population. CLINICAL RELEVANCE: These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Establishing the Substantial Clinical Benefit in a Non-Shoulder Hand and Upper Extremity Population for the QuickDASH and PROMIS Upper Extremity and Physical Function Computer Adaptive Tests.

PURPOSE: It is unclear what score changes on the abbreviated Disabilities of the Arm, Hand, and Shoulder (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive test (CAT), and PROMIS physical function (PF) CAT represent a substantial improvement. We calculated the substantial clinical benefit (SCB) for these 3 instruments in a non-shoulder hand and upper extremity population. METHODS: Adult patients treated between March 2015 and September 2019 at a single academic tertiary institution were identified. The QuickDASH, PROMIS UE CAT v2.0, and PROMIS PF CAT v2.0 scores were collected using a tablet computer. Responses to the QuickDASH both at baseline and follow-up 6 ± 4 weeks later, and a response to the anchor question "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" were required for inclusion. A second anchor question querying treatment-related improvement was also used. The SCB was calculated using an anchor-based approach comparing the mean change difference between groups reporting no change and a maximal change for both anchor questions. RESULTS: Of 1,119 included participants, the mean age was 48 ± 17 years, 53% were women, and half were recovering from surgery. Score changes between baseline and follow-up were significantly different between groups reporting no improvement and maximal improvement on both anchor questions. The SCB values ranged between 16.9 and 22.8 on the QuickDASH, 5.9 and 7.1 on the UE CAT, and 3.5 and 6.7 on the PF CAT. CONCLUSIONS: These score improvements for the QuickDASH, UE CAT, and PF CAT represent a substantial clinical improvement in a non-shoulder hand and upper extremity population. CLINICAL RELEVANCE: These SCB estimates may assist with the interpretation of outcome scores at a population level.

Recurrent Carpal Tunnel Syndrome Associated with Mycobacterium szulgai Infection: A Case Report.

CASE: We present the case of an otherwise healthy 77-year-old male retired firefighter and recreational pheasant hunter who presented with recurrent symptoms of carpal tunnel syndrome and tenosynovitis because of Mycobacterium szulgai. He was initially treated unsuccessfully for a presumed seronegative rheumatologic flare, followed by surgical diagnosis and treatment including revision carpal tunnel release with tenosynovectomy, and a secondary debridement and wound closure. His symptoms resolved after several months of multidrug antibiotic therapy with only mild residual median nerve deficit. CONCLUSION: Nontuberculous Mycobacterium infections of the upper extremity are extremely rare and challenging to diagnose/treat. This report highlights diagnostic and surgical challenges in this rarely reported infection.

The "Y" Double Spiral Cord: An Anatomic Variant of Dupuytren Disease: A Report of 2 Cases.

CASE: We report 2 cases of a spiral nerve variant that has only 1 previously reported description in the literature. A pretendinous cord was found to branch into a "Y" configuration, extending distally on both the radial and ulnar sides of the same digit, with the radial and ulnar digital nerves spiraling around each limb of the "Y cord". CONCLUSION: Rare spiral nerve variants exist which place the digital neurovascular bundles (NVBs) at risk. Awareness of these variants and adherence to conservative surgical principles allow the surgeon to identify these scenarios intraoperatively and safely dissect the digital NVBs free of pathologic tissue.

Impinging exostoses of the proximal radius: a report of two cases with distinct clinical features.

Owing to the rotatory motion of proximal radius and the closely apposed anatomic structures, cortically based osseous lesions at the level of the proximal forearm may produce symptomatic impingement. While osseous impingement onto the adjacent proximal ulna may result in limited forearm rotation, impingement on the surrounding soft-tissue structures may produce symptoms as well. Here, we describe two cases of symptomatic proximal radius exostosis, each of which produced distinct clinical symptoms. In the first case, impingement on the posterior interosseous nerve produced symptoms of radiating forearm pain and paresthesia resembling radial tunnel syndrome. In the second case, impingement of the exostosis on the distal biceps tendon resulted in painful mechanical snapping with rotation of the forearm. In both cases, symptoms rapidly improved after surgical excision.

Regional differences between superficial and deep lumbar multifidus in patients with chronic lumbar spine pathology.

BACKGROUND: Due to its unique arrangement, the deep and superficial fibers of the multifidus may have differential roles for maintaining spine stabilization and lumbar posture; the superficial multifidus is responsible for lumbar extension and the deep multifidus for intersegmental stability. In patients with chronic lumbar spine pathology, muscle activation patterns have been shown to be attenuated or delayed in the deep, but not superficial, multifidus. This has been interpreted as pain differentially influencing the deep region. However, it is unclear if degenerative changes affecting the composition and function of the multifidus differs between the superficial and deep regions, an alternative explanation for these electrophysiological changes. Therefore, the goal of this study was to investigate macrostructural and microstructural differences between the superficial and deep regions of the multifidus muscle in patients with lumbar spine pathology. METHODS: In 16 patients undergoing lumbar spinal surgery for degenerative conditions, multifidus biopsies were acquired at two distinct locations: 1) the most superficial portion of muscle adjacent to the spinous process and 2) approximately 1 cm lateral to the spinous process and deeper at the spinolaminar border of the affected vertebral level. Structural features related to muscle function were histologically compared between these superficial and deep regions, including tissue composition, fat fraction, fiber cross sectional area, fiber type, regeneration, degeneration, vascularity and inflammation. RESULTS: No significant differences in fat signal fraction, muscle area, fiber cross sectional area, muscle regeneration, muscle degeneration, or vascularization were found between the superficial and deep regions of the multifidus. Total collagen content between the two regions was the same. However, the superficial region of the multifidus was found to have less loose and more dense collagen than the deep region. CONCLUSIONS: The results of our study did not support that the deep region of the multifidus is more degenerated in patients with lumbar spine pathology, as gross degenerative changes in muscle microstructure and macrostructure were the same in the superficial and deep regions of the multifidus. In these patients, the multifidus is not protected in order to maintain mobility and structural stability of the spine.

Corrigendum: Surgical Rates for Crohn's Disease Are Decreasing: A Population-Based Time Trend Analysis and Validation Study.

This corrects the article DOI: 10.1038/ajg.2017.394.

Surgical Rates for Crohn's Disease are Decreasing: A Population-Based Time Trend Analysis and Validation Study.

OBJECTIVES: Temporal changes for intestinal resections for Crohn's disease (CD) are controversial. We validated administrative database codes for CD diagnosis and surgery in hospitalized patients and then evaluated temporal trends in CD surgical resection rates. METHODS: First, we validated International Classification of Disease (ICD)-10-CM coding for CD diagnosis in hospitalized patients and Canadian Classification of Health Intervention coding for surgical resections. Second, we used these validated codes to conduct population-based surveillance between fiscal years 2002 and 2010 to identify adult CD patients undergoing intestinal resection (n=981). Annual surgical rate was calculated by dividing incident surgeries by estimated CD prevalence. Time trend analysis was performed and annual percent change (APC) with 95% confidence intervals (CI) in surgical resection rates were calculated using a generalized linear model assuming a Poisson distribution. RESULTS: In the validation cohort, 101/104 (97.1%) patients undergoing surgery and 191/200 (95.5%) patients admitted without surgery were confirmed to have CD on chart review. Among the 116 administrative database codes for surgical resection, 97.4% were confirmed intestinal resections on chart review. From 2002 to 2010, the overall CD surgical resection rate was 3.8 resections per 100 person-years. During the study period, rate of surgery decreased by 3.5% per year (95% CI: -1.1%, -5.8%), driven by decreasing emergent operations (-10.1% per year (95% CI: -13.4%, -6.7%)) whereas elective surgeries increased by 3.7% per year (95% CI: 0.1%, 7.3%). CONCLUSIONS: Overall surgical resection rates in CD are decreasing, but a paradigm shift has occurred whereby elective operations are now more commonly performed than emergent surgeries.

Universal Design Across the Curriculum: Training for Students and Teachers.

Providing an inclusive educational setting for children with disabilities is essential if they are to truly benefit from mainstream education. Universal design (UD) provides a framework to develop our classrooms, materials and methods to accommodate diverse learners and students with special educational needs without the need to retrofit or remove the student from the classroom. This paper outlines the theory and the approach of two training courses on Universal Design developed for teachers and students.

Clinical Predictors of the Risk of Early Colectomy in Ulcerative Colitis: A Population-based Study.

BACKGROUND: A subset of patients with ulcerative colitis (UC) will require colectomy within a few years of diagnosis. Thus, our aim was to determine the clinical predictors of early colectomy among patients with UC who are hospitalized with an acute flare. METHODS: Using population-based surveillance (1996-2009), all adults (≥18 years) hospitalized for UC within 3 years of diagnosis (n = 489) were identified. The primary outcome was a colectomy within 3 years of diagnosis. All medical charts were reviewed. A logistic regression model evaluated clinical variables that predicted colectomy within 3 years of diagnosis, and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. RESULTS: Among patients admitted to hospital with UC within 3 years of diagnosis, 57.7% underwent colectomy, with the odds of colectomy decreasing by 12% per year. Early colectomy was more likely among patients aged 35 to 64 years versus 18 to 34 years (OR 2.18 [95% CI, 1.27-3.74]), males (OR 2.03 [95% CI, 1.24-3.34]), those with pancolitis (OR 5.38 [95% CI, 3.20-9.06]), and living in rural areas (OR 2.81 [95% CI, 1.49-5.29]). Prescription of infliximab before hospitalization increased odds of surgery (OR 5.12 [95% CI, 1.36-19.30]). CONCLUSIONS: Patients hospitalized for UC have a high risk of early colectomy. This is particularly true in middle-aged men, those living in rural areas, and those without response to infliximab.

Lumbar multifidus muscle degenerates in individuals with chronic degenerative lumbar spine pathology.

Histological and cell-level changes in the lumbar musculature in individuals with chronic lumbar spine degenerative conditions are not well characterized. Although prior literature supports evidence of changes in fiber type and size, little information exists describing the tissue quality and biology of pathological features of muscle in this population. The purpose of this study was to quantify multifidus tissue composition and structure, inflammation, vascularity, and degeneration in individuals with chronic degenerative lumbar spine pathology. Human multifidus biopsies were acquired from 22 consecutive patients undergoing surgery for chronic degenerative lumbar spine pathology. Relative fractions of muscle, adipose, and extracellular matrix were quantified along with muscle fiber type and cross-sectional area (CSA) and markers of inflammation, vascularity, satellite cell density, and muscle degeneration. On average, multifidus biopsies contained 48.5% muscle, 11.7% adipose tissue, and 26.1% collagen tissue. Elevated inflammatory cell counts (48.5 ± 30.0 macrophages/mm2 ) and decreased vascularity (275.6 ± 69.4 vessels/mm2 ) were also observed compared to normative values. Satellite cell densities were on average 13 ± 9 cells per every 100 muscle fibers. Large fiber CSA (3,996.0 ± 1,909.2 µm2 ) and a predominance of type I fibers (61.8 ± 18.0%) were observed in addition to evidence of pathological degeneration-regeneration cycling (18.8 ± 9.4% centrally nucleated fibers, and 55.2 ± 24.2% of muscle regions containing degeneration). High levels of muscle degeneration, inflammation, and decreased vascularity were commonly seen in human multifidus biopsies of individuals with lumbar spine pathology in comparison to normative data. Evidence of active muscle degeneration suggests that changes in muscle tissue are more complex than simple atrophy. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2700-2706, 2017.

Contribution of Lumbar Spine Pathology and Age to Paraspinal Muscle Size and Fatty Infiltration.

STUDY DESIGN: Retrospective chart analysis of 199 individuals aged 18 to 80 years scheduled for lumbar spine surgery. OBJECTIVE: The purpose of this study was to quantify changes in muscle cross-sectional area (CSA) and fat signal fraction (FSF) with age in men and women with lumbar spine pathology and compare them to published normative data. SUMMARY OF BACKGROUND DATA: Pathological changes in lumbar paraspinal muscle are often confounded by age-related decline in muscle size (CSA) and quality (fatty infiltration). Individuals with pathology have been shown to have decreased CSA and fatty infiltration of both the multifidus and erector spinae muscles, but the magnitude of these changes in the context of normal aging is unknown. METHODS: Individuals aged 18 to 80 years who were scheduled for lumbar surgery for diagnoses associated with lumbar spine pain or pathology were included. Muscle CSA and FSF of the multifidus and erector spinae were measured from preoperative T2-weighted magnetic resonance images at the L4 level. Univariate and multiple linear regression analyses were performed for each outcome using age and sex as predictor variables. Statistical comparisons of univariate regression parameters (slope and intercept) to published normative data were also performed. RESULTS: There was no change in CSA with age in either sex (P > 0.05), but women had lower CSAs than men in both muscles (P < 0.0001). There was an increase in FSF with age in erector spinae and multifidus muscles in both sexes (P < 0.0001). Multifidus FSF values were higher in women with lumbar spine pathology than published values for healthy controls (P = 0.03), and slopes tended to be steeper with pathology for both muscles in women (P < 0.08) but not in men (P > 0.31). CONCLUSION: Lumbar muscle fat content, but not CSA, changes with age in individuals with pathology. In women, this increase is more profound than age-related increases in healthy individuals. LEVEL OF EVIDENCE: 3.

Clinical prediction rule to determine the need for repeat ERCP after endoscopic treatment of postsurgical bile leaks.

BACKGROUND AND AIMS: In patients who have undergone ERCP with biliary stenting for postsurgical bile leaks, the optimal method (ERCP or gastroscopy) and timing of stent removal is controversial. We developed a clinical prediction rule to identify cases in which a repeat ERCP is unnecessary. METHODS: Population-based study of all patients who underwent ERCP for management of surgically induced bile leaks between 2000 and 2012. Multivariate and binary recursive partitioning analyses were performed to generate a rule predicting the absence of biliary pathology on repeat endoscopic evaluation. RESULTS: A total of 259 patients were included. On multivariate analysis, postsurgical normal alkaline phosphatase (ALP; OR, 2.26; 95% CI, 1.03-4.99), time from surgery to first ERCP < 8 days (OR, 2.47; 95% CI, 1.15-5.31), and minor leak with no other pathology on initial ERCP (OR, 6.74; 95% CI, 1.75-25.89) were independently associated with the absence of persistent bile leak and other pathology on repeat ERCP. The derived rule included laparoscopic cholecystectomy, normal postsurgical ALP, minor leak with no other pathology on initial ERCP, and an interval from initial to repeat ERCP between 4 and 8 weeks. When all 4 criteria were met, the rule had a sensitivity of 94% (95% CI, 83%-99%) and a negative predictive value of 93% (95% CI, 81%-99%). Optimism-adjusted sensitivity and negative predictive value were 88% (95% CI, 76%-96%) and 86% (95% CI, 73%-96%), respectively. CONCLUSIONS: This clinical decision rule identifies patients who can have their biliary stents removed via gastroscopy, which may improve patient safety and healthcare utilization.

Smoking Is Associated with an Increased Risk for Surgery in Diverticulitis: A Case Control Study.

IMPORTANCE: Cigarette smoking increases the risk of surgery in Crohn's disease. However, the effect of smoking on the need for surgery for diverticulitis is unknown. OBJECTIVE: We evaluated whether smoking was a risk factor for surgery among patients admitted to hospital with acute diverticulitis. DESIGN: We conducted a population-based comparative cohort study of patients admitted to hospital for diverticulitis who were treated with medical versus surgical management. SETTING & PARTICIPANTS: We used the population-based Discharge Abstract Database to identify 176 adults admitted emergently with a diagnosis of diverticulitis between 2009 and 2010 in Calgary. INTERVENTION & MAIN OUTCOME: We performed a medical chart review to confirm the diagnosis of diverticulitis and to extract clinical data. The primary outcome was a partial colectomy during hospitalization. Logistic regression evaluated the association between smoking and surgery after adjusting for potential confounders, including age, sex, comorbidity, and disease severity. RESULTS: A partial colectomy was performed on 35.6% of patients with diverticulitis and 1.3% died. Among diverticulitis patients, 26.8% were current smokers, 31.5% were ex-smokers, and 41.6% never smoked. Compared to non-smokers, current smokers (adjusted odds ratio [OR] 9.02; 95% confidence interval [CI]: 2.47-32.97) and former smokers (adjusted OR 5.41; 95% CI: 1.54-18.96) had increased odds of surgery. CONCLUSION AND RELEVANCE: Smoking is associated with the need for surgical management of diverticulitis.