Factors affecting time off work in patients with traumatic hand injuries-A bio-psycho-social perspective.

Hand injuries are common and can result in a long time off work. To analyse and identify factors affecting time of work, a holistic view on patients is needed. World Health Organization's International Classification of Functioning, Disability and Health (ICF) with its bio-psycho-social perspective provides such a holistic view. The purpose of this study is to analyse time off work in patients with traumatic hand injuries and to identify factors affecting time off work from a bio-psycho-social perspective. We used factors derived from the ICF Core Set for Hand Conditions to predict time off work by applying Cox regression analyses and Kaplan-Meier method using data of a multicentre prospective study in nine German Level 1 hand trauma centres. In total, 231 study participants with a broad range of hand injuries were included. From these, 178 patients (77%) returned to work within 200 days. Impairments in mobility of joint functions and sensory functions related to temperature and other stimuli as well as higher hand strain at work led to extended time off work. Gender, fine hand use and employment status additionally influenced time off work in sub-models. Our results demonstrate that a bio-psycho-social perspective is recommended when investigating time off work.

International Classification of Functioning, Disability and Health: development of an assessment set to evaluate functioning based on the Brief ICF Core Set for Hand Conditions - ICF HandA.

Timely identification of patients' problems after disorder or injury of the hand requires a thorough functional assessment. However, the variety of outcome measures available makes it difficult to choose the appropriate instrument. The brief International Classification of Functioning, Disability and Health (Brief ICF Core Set for Hand Conditions) provides a standard for what aspects need to be measured in hand injuries and disorders without specifying how to make the assessment. We developed the ICF-based Assessment Hand (ICF HandA), an assessment set for functioning based on the Brief ICF Core Set for Hand Conditions. First, we performed a literature review and an expert survey to pool outcome measures appropriate to assess functioning in clinical practice. At an interdisciplinary consensus conference experts decided on the outcome measures to be included in the ICF HandA. The ICF HandA provides a consensus on outcome measures and instruments to systematically assess function in patients with hand injuries and disorders.

The nitric acid burn trauma of the skin.

Nitric acid burn traumata often occur in the chemical industry. A few publications addressing this topic can be found in the medical database, and there are no reports about these traumata in children. A total of 24 patients, average 16.6 years of age, suffering from nitric acid traumata were treated. Wound with I degrees burns received open therapy with panthenol-containing creams. Wound of II degrees and higher were initially treated by irrigation with sterile isotonic saline solution and then by covering with silver-sulphadiazine dressing. Treatment was changed on the second day to fluid-absorbent foam bandages for superficial wounds (up to IIa degrees depth) and occlusive, antiseptic moist bandages in combination with enzymatic substances for IIb degrees -III degrees burns. After the delayed demarcation, necrectomy and mesh-graft transplantation were performed. All wounds healed adequately. Chemical burn traumata with nitric acid lead to specific yellow- to brown-stained wounds with slower accumulation of eschar and slower demarcation compared with thermal burns. Remaining wound eschar induced no systemic inflammation reaction. After demarcation, skin transplantation can be performed on the wounds, as is commonly done. The distinguishing feature of nitric-acid-induced chemical burns is the difficulty in differentiation and classification of burn depth. An immediate lavage should be followed by silver sulphadiazine treatment. Thereafter, fluid-absorbent foam bandages or occlusive, antiseptic moist bandages should be used according to the burn depth. Slow demarcation caused a delay in performing surgical treatments.

[Surgical indication for injuries to the palmar plate of the PIP joint]. / Operationsindikation bei Verletzungen der palmaren Platte des Mittelgelenks.

Injuries to the proximal interphalangeal (PIP) joint are often discounted as trivial although they can lead to instability and even more frequently to contracture of the PIP joint. Distortion and hyperextension traumata are the most common causes of PIP joint injuries of the hand and frequently occur in conjunction with sports-related injuries. Treatment concepts demonstrate considerable agreement. There is consensus of opinion that the predominant proportion of injuries can be assigned to conservative therapy.The basic diagnostic evaluation of the injured finger consists in X-rays taken in two planes. The examiner must always compare the stability of the PIP joint with the uninjured side. During functional assessment of the joint's stability a distinction can be made between active and passive stability.Injuries of the palmar plate with and without small bone fragments that do not exhibit subluxation after repositioning and X-ray control are immobilized during the phase of acute pain in a palmar splint in the intrinsic plus position for a maximum of 5 days. Thereafter the patient independently performs movement exercises.

[Neuropathy of the median nerve caused by intraneural haematoma after carpal tunnel release in an anticoagulated patient]. / Neuropathie des Nervus medianus durch intraneurale Blutung bei einem antikoagulierten Patienten nach Karpaltunnelspaltung.

We report about the sudden onset of a median nerve neuropathy in an anticoagulated patient eight weeks after uneventful carpal tunnel release. Several differential diagnosis have to be considered: compression syndrome as well as iatrogenic damage of the median nerve due to the preliminary procedure or even concomitant disease can generate symptoms of peripheral neuropathy. We diagnosed an intraneural haematoma through surgical exploration. This rare complication of oral anticoagulation therapy occurred spontaneously and was treated successfully by interfascicular neurolysis.

[Long-term results following denervation of the wrist in patients with stages II and III SLAC-/SNAC-wrist]. / Langzeitergebnisse nach Handgelenkdenervation bei fortgeschrittenem karpalem Kollaps (SLAC-/SNAC-Wrist Stadium II und III).

INTRODUCTION: Mid-carpal arthrodesis, proximal row carpectomy and wrist arthrodesis are commonly cited in the literature as successful methods for pain reduction in patients with advanced carpal collapse (SLAC-/SNAC-wrist stages II and III). However, studies of isolated wrist denervation in patients who still possess good wrist mobility appear to be an underrepresented topic, especially in the German literature. PURPOSE: Based on follow-up results, it was possible to establish to what extent patients benefit long-term from isolated wrist denervation, whilst retaining wrist mobility. PATIENTS AND METHOD: 46 patients (6 female, 40 male) with a diagnosis of SLAC-wrist (n = 10) or SNAC-wrist (n = 36) stages II and III underwent wrist denervation of points 1 - 4, 6, 9 and 10 according to Wilhelm, between 1990 and 2001, following a positive denervation test. No previous reconstructive wrist surgery had been performed on any of the patients, whose average age at the time of denervation was 47 years. In 29 cases the dominant hand was affected, and in 22 cases the symptoms could be classified as post-traumatic. Post-operative follow-up was possible in 32 out of 46 cases (70 %), and occurred on average 6.3 years post-denervation (range 2.3 to 14 years). RESULTS: Twelve out of 32 patients (32 %) reported to be pain-free at follow-up, with a post-operative period ranging from 2.3 to 11.4 years (average 6.2 years). Six patients (18.75 %) continued to experience pain when load-bearing, which remained unchanged over a period of several years. Three patients (9 %) reported pain after stress, five patients (15.6 %) the recurrence of severe pain, which developed on average 3.8 years post-operatively. Two patients (6.25 %) experienced no analgesic benefits following wrist denervation, and four patients underwent wrist arthrodesis on average 13.5 months post-denervation, due to remaining or additional symptoms. Nineteen out of 32 patients subjectively reported a significant improvement following wrist denervation. Reassessment of range of movement post-denervation showed a reduction of 8.1 % in wrist extension/flexion, and 20 % in radio/ulna-abduction. Compared to the unaffected side, this represented an average loss of 28 % wrist extension/flexion, and 33.5 % radio/ulna-abduction. An average 51 % increase in hand strength could be shown at follow-up, leaving an average 30 % deficit compared to the unaffected hand. Evaluation of these results using the Krimmer score showed a good - very good outcome in 20 of the 32 patients (62.5 %); six patients were found to have a satisfactory outcome, and six patients a poor outcome. Subjective measures of pain (obtained using visual analogue scales) showed a reduction from 68.13 pre-operatively to 25.63 post-operatively. The DASH assessment (parts A and B) attained an average post-operative value of 17.1. CONCLUSION: Denervation of the wrist in patients with SLAC-/SNAC-wrist stages II and III can achieve a long-term elimination or reduction of pain, whilst improving hand strength, and having only a minimal impact on wrist range of movement. Wrist denervation should therefore be given preference over wrist arthrodesis, midcarpal arthrodesis or proximal row carpectomy in patients with good wrist mobility.

[The superior gluteal artery perforator flap (S-GAP-Flap)]. / Der "Superior Gluteal Artery Perforator Flap" (S-GAP-Flap).

Superior gluteal artery perforator flap for breast reconstruction with autologous tissue (S-GAP-flap): With the introduction of perforator flaps for breast reconstruction with autologous tissue the gluteal region became again investigated as a possible donor site. With the S-GAP-flap breast reconstruction from the gluteal region is possible utilising skin and fat without muscle sacrifice. 52 S-GAP-flaps for autologous breast reconstruction with a flap loss rate of 7.7 % were performed at the Department of Plastic and Hand surgery, Behandlungszentrum Vogtareuth, Germany from 1997 till 2002. Although there is an obvious learning curve also with this free tissue transfer, the S-GAP-flap is a reliable alternative in autologous breast reconstruction, when tissue from the lower abdomen is not available.

Callus distraction in the hand skeleton.

From 1992 to 1996, 27 patients with traumatic amputations or malformations underwent lengthening of thumb and fingers. A total of 36 procedures were carried out. In several cases, deepening of the web space or bone transplantations proved to be necessary to improve general function or to compensate for missing bone structure. Complications included pin-track infections, necrosis of bone, non-union and scarring. Overall the results indicate that distraction of the thumb and fingers is a feasible operative technique leading to a promising improvement of function.

[Comparison of various evaluation measures for assessment of treatment success after scaphoid injuries]. / Vergleich verschiedener Bewertungsmassstäbe zur Beurteilung des Behandlungserfolges nach Kahnbeinverletzungen.

Different evaluation scores have been developed in order to assess treatment outcome of carpal injuries. The available scores are not comparable and differ in type and number of parameters. This is a retrospective study of 100 patients who presented with a fracture or a pseudarthrosis of the scaphoid from 1983 to 1997. The Cooney and the Meine scores were compared with our own score. While the Cooney score and the newly developed score show an equal distribution of results in all categories, the score of Meine led to an overall better outcome assessment. The comparative evaluation of the different scores shows that the combination of only a few well defined parameters is sufficient for assessing the treatment outcome of carpal injuries.

[Persistent scaphoid pseudarthrosis after surgical treatment: results of repeated bone transplantation]. / Persistierende Kahnbeinpseudarthrose nach operativer Behandlung: Ergebnisse der erneuten Knochenspanplastik.

From 1984 to 1993, 30 patients with persistent scaphoid non-union despite bone grafting procedures underwent additional reconstructive surgery. Twenty-five patients were followed-up between one and eleven years after revision with a mean follow-up time of 4.8 years. Fifteen patients had bone graft procedures alone, ten patients had additional internal fixation with the Herbert screw or Ender plate. At follow-up, scaphoid union was achieved in 16 patients (64%), 19 patients had arthritic changes of the radiocarpal joint. Only patients with scaphoid union showed satisfactory functional results. Five patients with failed revision surgery needed further operations for chronic wrist pain, including three wrist arthrodeses.

[Surgical treatment of scaphoid pseudarthrosis--long term outcome with the Herbert screws]. / Die operative Behandlung der Kahnbeinpseudarthrose--Langzeitergebnisse mit der Herbert-Schraube.

Between 1984 and 1993, 131 scaphoid nonunions were treated with iliac crest bone grafting and the Herbert-screw. 105 patients were followed between one and ten years with an average followup period of 4.5 years. Bony union was achieved in 93 patients with improvement of range of motion and grip strength. In 14 patients with DISI-instability, the angulation deformity was incompletely corrected with an average reduction of the scapho-lunate angle of eleven degrees. Limited athritic changes at the radial styloid were noted in 58%, intercarpal in 25% of the patients. Most frequent reasons for persistent nonunion were technical problems with the Herbert-screw.