Congenital thumb anomalies and the consequences for daily life: patients' long-term experience after corrective surgery. A qualitative study.

PURPOSE: The aim of the study was to explore patients' long-term experience of a congenital hand problem, and the consequences for daily life. METHOD: Fifteen participants with a median age 24 years (17-55 years), born with thumb hypoplasia/aplasia or thumb duplication were interviewed using a semi-structured interview guide. The interviews were subjected to qualitative content analysis. RESULTS: Although the mobility and strength in the thumb/hand(s) varied within the group, hand function was generally described as good. Compensatory strategies were used to overcome practical obstacles. The emotional reactions to being visibly different from peers in early life varied from total acceptance and a sense of pride in being special, to deep distress and social withdrawal. Support from parents, teachers and others was important in facing emotional challenges and practical consequences. CONCLUSION: The present study highlights the importance of healthcare professionals addressing appearance-related concerns which may have long-term emotional and social consequences for patients born with a thumb anomaly. Implications for Rehabilitation Appearance-related concerns and need for emotional support should be fully considered throughout the rehabilitation process to prevent distress and social withdrawal. Effective problem-solving strategies, such as compensation, change in occupational performance and support from others may reduce activity limitations and participation restriction.

Long-term results of syndactyly correction by the trilobed flap technique focusing on hand function and quality of life.

UNLABELLED: Syndactyly is usually corrected surgically during the first years of life. The trilobed flap, a surgical method that does not require skin grafting, was developed in the 1990s and the short-term results were comparable with previously reported techniques. Here we report on long-term outcomes, focusing on how children perceive their hand function and quality of life when they grow up. A total of 19 patients (29 web spaces) were operated on between 1990 and 2000, and followed-up 16 years later with questionnaires and clinical tests. The patients reported low QuickDASH scores, normal sensibility and dexterity, and minor cold intolerance. Only two reoperations, due to early web creep, were needed. The condition minimally affected the choice of occupations, leisure activities and perceptions of appearance. The trilobed flap technique for release of syndactyly provides a good long-term outcome with good hand function and minimal impact on the quality of life. LEVEL OF EVIDENCE: IV.

Injury to the human median and ulnar nerves in the forearm--analysis of costs for treatment and rehabilitation of 69 patients in southern Sweden.

This study analysed the costs of median and ulnar nerve injuries in the forearm in humans and factors affecting such costs. The costs within the health-care sector and costs of lost production were calculated in 69 patients with an injury to the median and/or ulnar nerve in the forearm, usually caused by glass, a knife, or a razorblade. Factors associated with the variation in costs and outcome were analysed. The total median costs for an employed person with a median and an ulnar nerve injury were EUR 51,238 and EUR 31,186, respectively, and 87% of the total costs were due to loss of production. All costs were higher for patients with concomitant tendon injuries (4 tendons). The costs within the health-care sector were also higher for patients who changed work after the injury and if both nerves were injured. Outcome was dependent on age and repair method.

Hand injuries in young children.

Four hundred and fifty five young children (0-6 years old) were treated for hand injuries between 1996 and 2000. Boys (61%) were injured more often and a higher number of injuries occurred during May and September. Fingertip injuries were the most common injuries (37%), and were often caused by jamming in doors at home. Fractures were caused by falls and punches and tendon/nerve injuries by sharp objects. The incidence of hand injuries increased from 20.4/10,000/year in 1996 to 45.3/10,000/year in 2000. Only 4% of the children had complex injuries but these placed a high demand on resources. The incidence of injuries was not higher amongst children from immigrant families.

What determines the costs of repair and rehabilitation of flexor tendon injuries in zone II? A multiple regression analysis of data from southern Sweden.

The epidemiology and costs of repair and rehabilitation of zone II flexor tendon injuries in 135 patients from the southern part of Sweden were analysed. The little finger was most frequently injured (43%), usually with a knife (46%), and 30% of the injuries were work related. Total median costs within the health-care sector for the injuries were SEK 48,500 (1 EURO=9.23 SEK, 4/1/2002). Costs in other sectors were SEK 93,000. Active mobilization or mobilization with rubber band traction increased costs within the health-care sector (SEK 7400 or SEK 6000, respectively) but improved range of movement (5-7%). Immobilization had a higher complication rate (rupture or need for secondary procedures), which in itself increased total costs by 57%. Non-linear effects were found between age and costs within the health-care sector and the outcome.

Epidemiology of amputations and severe injuries of the hand.

In a prospective population-based study, all open hand, wrist, and forearm injuries that were treated during a 10-year period, at hospitals and emergency wards in three Norwegian cities with 225,000 inhabitants, were registered. Injury severity was graded using the abbreviated injury scale (AIS). For moderate injuries (AIS 2) overall incidence (95% CI) was 59 (56-62), incidence among males 92 (86-98), and among females 28 (25-31) per 100,000 person-years. For severe injuries (AIS > or = 3), overall incidence (95% CI) was 7.5 (6.3-8.6), incidence among males 11.1 (9.1-13.1), and among females 4.0 (2.8-5.2) per 100,000 person-years. In a second study, all upper extremity amputation and devascularization injuries were referred during a 9-year period to the only replantation center in a southern Swedish region where 1.6 million inhabitants were analyzed. The incidence rate (95% CI) for upper extremity amputation or devascularization injuries potentially requiring replantation or revascularization was 1.9 (1.7-2.1), incidence among males 3.3 (2.9-3.7), and among females 0.5 (0.4-0.7) per 100,000 person-years.

Multifocal neurilemomas in the same upper extremity. Case report.

Multifocal neurilemomas in different nerves of the same upper extremity are rare. A 36-year-old woman presented with five neurilemomas involving the main trunks of the median and radial nerve and digital nerves of her left upper extremity. These were excised and she recovered without complications. Fifteen years later she presented with several recurrences which were removed, and two years after that she required a further operation to excise tumours. At the time of writing she has at least five tumours on different nerves of her left arm but these are causing her no problems.

Asthma but not smoking-related airflow limitation is associated with a high fat diet in men: results from the population study "Men born in 1914", Malmö, Sweden.

The purpose of this study was to investigate whether there is an association between asthma and the intake of food with pro-oxidant or antioxidant activity (fat, alcohol, iron, zinc, and vitamins A and C), and to analyse whether any such association is specific to asthma or is found in airflow limitation in general. This study deals with 478 men, who were randomly selected from all the men born in Malmö in 1914. They were investigated using spirometry and their medical, occupational and dietary history was recorded in 1982-1983, at the age of 68 yrs, as part of the cohort study "Men born in 1914". Asthma was defined as a past or present physician's or nurse's diagnosis of asthma and airflow limitation was defined as a forced expiratory volume in one second/vital capacity ratio (FEV1/VC) of less than 70%. The relative risk of having asthma or airflow limitation as related to dietary intake at the age of 68 yrs was analysed after adjustments for smoking history and body mass index. Asthma was reported in 21 men and was not related to smoking history. Asthma was more common in men with a high fat intake (relative risk of asthma 1.74 for a 10% increase in fat intake, 95% confidence interval for the relative risk 1.13-2.68). The consumption of alcohol was higher for current smokers than ex-smokers and nonsmokers, and the intake of carbohydrates, vitamin C and iron was lower. Airflow limitation without asthma was present in 156 men and was related to smoking but not to dietary intake. Men with asthma had a significantly higher intake of fat than men without asthma. This difference appeared to be specific to asthma and was not found in airflow limitation in general.

Alcohol consumption modifies the total lung capacity in smokers.

Smoking-related airflow obstruction can develop with or without emphysema. Moderate alcohol consumption has been suggested to diminish the risk of centrilobular emphysema caused by smoking. Our aim was to study the influence of total energy and nutrient (protein, fat, carbohydrate and alcohol) intake on smoking-related emphysema. Lung function and nutrient intake including alcohol consumption were recorded at age of 68 years in 478 men as part of the population study 'Men Born in 1914' in Malmö, Sweden. In nonsmokers (n = 88) and ex-smokers (n = 223), there were no significant relationships between energy and nutrient intake and lung function. In smokers (n = 167), men in the highest and lowest quintile of total lung capacity (TLC) differed in alcohol intake (p = 0.004) but not in intake of total energy or other nutrients. In smokers with a forced expiratory volume in 1 s/vital capacity ratio of below 70% (n = 81), alcohol intake was positively correlated with TLC (r = 0.31; p = 0.006) after adjustment for smoking and body mass index. We conclude that in men with smoking-related airway obstruction, emphysema defined as large TLC was associated with high alcohol consumption but not with the intake of total energy or other nutrients.

Nitrogen dead space in heavy smokers aged 44-58 years.

Functional and alveolar dead spaces for nitrogen (VDF and VDalv) were calculated in a population of 20 male and 20 female heavy smokers and compared to data from static and forced spirometry (functional residual capacity [FRC], residual volume [RV], lung clearance index [LCI] and volume of trapped gas [VTG]) obtained with the same multiple-breath nitrogen wash-out as the dead spaces, and to variables considered sensitive to small airways disease measured with a single-breath nitrogen elimination (closing volume in per cent of vital capacity [CV%], closing capacity in per cent of total lung capacity [CC%] and slope index [SI]). Both nitrogen dead spaces increased with tidal volume in smokers as well as in healthy non-smokers. The majority of smokers were outside the predicted mean +2 SD for VTG (75%), CC and VDalv (70%) and SI (65%). The following variables were less sensitive for disclosing abnormality: CV (55%), RV (53%), LCI (38%) and forced expired volume in the first second (FEV1, 33%). If high sensitivity is considered preferable in epidemiological studies, the nitrogen dead spaces are equally as sensitive as the better of earlier described tests, and significantly superior to LCI and FEV1. Being tests that measure alveolar distribution of inhaled gas, they are probably sensitive to small airways disease.

Multiple breath nitrogen dead space.

Ventilatory efficiency for eliminating CO2 is expressed by the physiological dead space, VD phys = (1-PE CO2/Pa CO2) x VT, where PE is the mixed exhaled and Pa the arterial CO2-tension and VT the tidal volume. We used data from the multiple breath N2-wash-out with oxygen for calculating a functional dead space for nitrogen. VDF N2 = (1-FEN2/FidN2) x VT.FEN2 is the mixed exhaled N2-fraction and FidN2 the calculated mean alveolar N2-fraction during a wash-out with the same number of breaths to reach 2% N2 in end tidal air, but having completely even distribution. FidN2 is shown to be 0.20 +/- 0.01 for wash-outs using 20-150 breaths. The method was applied to wash-outs from 21 healthy volunteers, 18 patients with chronic obstructive lung disease and two subjects with acute bronchospasm. VDF was well related to VD phys CO2 (r = 0.78) but higher than the latter. In subjects with lung disease VDF was inversely related to the degree of obstruction expressed by forced expiratory volume in one second per cent of vital capacity (r = 0.85). The subjects with bronchospasm had very high VD/VTF in relation to their FEV%. If airway dead space predicted from height and sex is subtracted from VDF, the resulting alveolar dead space will be a good expression for uneven gas distribution in the lungs. We also deduced a direct mathematical relation between lung clearance index and VD/VTF. The documented good reproducibility of LCI is thus also valid for VD/VTF, while the latter better expresses ventilatory efficiency.