Medical Malpractice in Nerve Injury of the Upper Extremity.

Background: Medical malpractice accounts for more than $55 billion of annual health care costs. Updated malpractice risk to surgeons and physicians related to upper extremity peripheral nerve injury has not been published. Methods: A comprehensive database analysis of upper extremity nerve injury claims between 1995 and 2014 in the United States was conducted using the Medical Professional Liability Association Data Sharing Project, representing 24 major insurance companies. Results: Nerve injury in the upper extremity accounted for 614 (0.3%) malpractice claims (total of 188 323). Common presenting diagnoses included carpal tunnel syndrome (41%), upper extremity fractures (19%), and traumatic nerve injuries to the shoulder or upper limb (8%). Improper performance (49% of total claims) and claims without evidence of medical error (19%) were the most common malpractice suits. Orthopedic surgeons were the most frequently targeted specialists (42%). In all, 65% of nerve injury claims originated from operative procedures in a hospital, 59% of claims were dismissed or withdrawn prior to trial, and 30% resulted in settlements. Thirty-three percent of claims resulted in an indemnity payment to an injured party, with an average payout of $203 592 per successful suit. Only 8% of claims resulted in a completed trial and verdict, and verdicts were overwhelmingly in favor of the defendant (83%). Conclusions: Most malpractice claims from peripheral nerve injuries in the United States arise from the management of common diagnoses, occur in the operating room, and allege improper performance. Strategies to reduce malpractice risk should emphasize the management of common conditions and patient-physician communication.

Prevalence of Needlestick Injuries, Attitude Changes, and Prevention Practices Over 12 Years in an Urban Academic Hospital Surgery Department.

OBJECTIVE: Needlestick injury prevalence, protection practices, and attitudes were assessed. Current medical students were compared with 2003 data to assess any changes that occurred with engineered safety feature implementation. BACKGROUND: Risk of occupational exposure to bloodborne pathogens is elevated in the operating room particularly with surgeons in training and nurses. METHODS: A cross-sectional survey was distributed to medical students (n = 358) and Department of Surgery staff (n = 247). RESULTS: The survey response rate was 24.8%. Needlestick injuries were reported by 38.7% of respondents (11% high risk), and the most common cause was "careless/accidental." Needlestick injury prevalence increased from medical students to residents and fellows (100%). Thirty-three percent of injured personnel had at least one unreported injury, and the most common reason was "inconvenient/too time consuming." Needlestick injury prevalence and double-glove use in medical students did not differ from 2003, and 25% of fellows reported always wearing double gloves. The true seroconversion rate for bloodborne pathogens was underestimated or unknown. The concern for contracting a bloodborne pathogen significantly decreased (65%) compared to 2003, and there were significantly less medical students with hepatitis B vaccinations (78.3%). Level of concern for contracting a bloodborne pathogen was predictive of needlestick injury. CONCLUSIONS: Needlestick injury and occupational exposure to bloodborne pathogens are significant hazards for surgeons and nurses. Attitudes regarding risk are changing, and the true seroconversion risk is underestimated. Educational efforts focused on needlestick injury prevalence, seroconversion rates, and double-glove perforation rates may be effective in implementing protective strategies.

High Ulnar Nerve Injuries: Nerve Transfers to Restore Function.

Peripheral nerve injuries are challenging problems. Nerve transfers are one of many options available to surgeons caring for these patients, although they do not replace tendon transfers, nerve graft, or primary repair in all patients. Distal nerve transfers for the treatment of high ulnar nerve injuries allow for a shorter reinnervation period and improved ulnar intrinsic recovery, which are critical to function of the hand.

CT evaluation of extra-articular glenoid neck fractures: does the glenoid medialize or does the scapula lateralize?

OBJECTIVES: Medial translation of the glenoid is frequently described as the main mode of displacement after glenoid neck fracture. Indeed, plain radiographs typically show the glenoid medialized relative to the scapular body. However, whether this truly represents medialization of the glenoid relative to the axial skeleton or lateralization of the scapular body remains unclear. The goal of this investigation was to assess the relationship between the glenoid, the scapular body, and the axial skeleton in patients with glenoid neck fractures using computed tomographic data analysis with the contralateral shoulder serving as an internal control. DESIGN: Retrospective radiographic review. SETTING: Two Level I trauma centers. PARTICIPANTS: Eighteen patients (5 women and 13 men; average age, 38.7 years; range, 17-75 years) admitted between January 2000 and March 2006 with isolated extra-articular glenoid neck fractures (OTA 14C1 fractures) and chest computed tomographic scans that included both shoulders. MAIN OUTCOME MEASUREMENTS: Glenoid to midline distance and scapular width. RESULTS: The injured glenoid was lateralized an average of 9.8 mm (range, 8 mm medialized to 23 mm lateralized) (P < 0.001). Relative to the uninjured side, glenoid medialization infrequently occurred (4 of 18 patients) and when present was less than 1 cm (range, 2-8 mm). Lateralization occurred more frequently (14 of 18 patients), with an average displacement of 13.7 mm (range, 1-23 mm). The injured scapula was shortened by an average of 3.3 mm (range, 18 mm shorter to 20 mm longer) (P = 0.09). In 15 of 18 patients, the scapular width was shortened by an average of 5.9 mm (range, 1-18 mm), whereas in only 3 of 18 patients was the injured scapular width longer, an average of 9 mm (range, 1-20 mm). CONCLUSIONS: In patients with glenoid neck fractures, pure medial translation of the glenoid relative to the axial skeleton rarely occurs. Instead, there is typically a component of shortening of the scapula width combined with lateralization of the scapular body.

Thumb size and appearance following reconstruction of radial polydactyly.

PURPOSE: To evaluate thumb size, shape, and appearance after surgical correction of radial polydactyly. METHODS: Thirty-one reconstructed thumbs in 26 children with radial polydactyly were evaluated at an average of 45 months after surgery. The length, girth, nail width, and joint angulation were measured and compared with the contralateral side of patients with unilateral polydactyly and with standard thumb measurements for patients with bilateral involvement. A surgeon, therapist, and caregiver each subjectively assessed the aesthetic outcome, using a visual analog scale (VAS); raters also provided the principal reasons for their assessment of the altered appearance. RESULTS: The average length of the reconstructed thumb relative to the index finger proximal phalanx was 81%; that of the unaffected, contralateral thumb was 80%. The girth of the reconstructed thumb relative to the index finger was 102%; that of the contralateral thumb was 103%. Thumbnail width in proportion to index fingernail width was significantly decreased in the reconstructed thumbs, at 111% (compared with the contralateral value of 136%). The VAS scores averaged 7.7; the most common reason cited for decreased VAS score was an angulated thumb. Lower VAS scores were associated with Wassel type VI and VII thumbs and with increased interphalangeal, but not metacarpophalangeal, joint angulation. CONCLUSIONS: Thumb polydactyly reconstruction typically provides a satisfactory thumb appearance. The primary issues affecting appearance after reconstruction are reduced nail width, interphalangeal joint angulation, and presence of type VI and VII radial polydactyly.