Motorcycle crashes and upper extremity trauma.

OBJECTIVES: Upper extremity injuries following motorcycle crashes (MCC) incur increased healthcare costs and rehabilitation needs. We aim to characterize the epidemiology of MCC upper extremity injuries and identify factors that influence the severity of and cost of care for upper extremity injuries. METHODS: We performed a retrospective cohort analysis of 571 patients with upper extremity injuries after MCC at a level 1 trauma center from 2002 to 2013. We collected data pertaining to demographics, helmet use, toxicology, bony injury, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), hospital length of stay (LOS), and cost. Continuous variables were compared using t-test or Wilcoxon rank test, depending on data distribution, and dichotomous variables were compared using Pearson's chi-squared or Fisher's exact tests. Regression models were used to evaluate the effect of intoxication or helmets on injury location, severity, cost of care, and LOS. RESULTS: The incidence of MCC upper extremity injury was 47.5%, with hand and forearm fractures the most common injuries (25.5% and 24.7% of total injuries). Intoxicated patients were more likely to have a high cost of care (p = 0.012), extended LOS (p = 0.038), plastic surgery involvement in their care (p = 0.038), but fewer upper extremity bony injuries (p = 0.019). Non-helmeted patients sustained less upper extremity bony injuries (p < 0.001) and upper extremity soft tissue injuries (p = 0.001), yet more severe injuries (ISS ≥ 30, p = 0.006 and GCS < 9, p < 0.01) than helmeted patients. CONCLUSION: Upper extremity injuries are common in motorcyclists. Despite vital protection for the brain and maxillofacial injury, helmeted MCC patients have an increased incidence of upper extremity injuries compared to non-helmeted patients, but overall have less severe injuries. Intoxicated patients have fewer upper extremity bony injuries, but the higher cost of care, and extended LOS. Therefore, even with the increased risk of injury helmets may expose to the upper extremity, helmets reduced overall morbidity and mortality. In addition to mandatory helmet laws, we advocate for further development of safety equipment focusing specifically on the prevention of upper extremity injuries.

The Effect of Insurance Type on Patient Access to Carpal Tunnel Release Under the Affordable Care Act.

PURPOSE: To assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to hand surgeons for carpal tunnel syndrome (CTS). METHODS: The research team called 240 hand surgeons in 8 states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for her fictitious mother to be evaluated for CTS and possible surgical management through carpal tunnel release (CTR). Each office was called 3 times to assess the responses for Medicaid, Medicare, or Blue Cross Blue Shield. From each call, we recorded whether an appointment was given and whether there were barriers to an appointment, such as the need for a referral. RESULTS: Twenty percent of offices scheduled an appointment for a patient with Medicaid, compared with 89% for Medicare and 97% for Blue Cross Blue Shield. Patients with Medicaid had an easier time scheduling appointments (28% vs 13%) and experienced fewer requests for referrals (25% vs 67%) in states with expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement for CTR was significantly correlated with the incidence of successful appointments. Although the difference in Medicaid and Medicare reimbursements for CTR was small, the appointment success incidence for Medicare was approximately 5 times higher. CONCLUSIONS: Despite the passage of the Affordable Care Act, patients with Medicaid have reduced access to surgical care for CTS and more complex barriers to receiving an appointment. Although Medicaid was accepted at a higher rate in states with expanded Medicaid eligibility, a more robust strategy for increasing access to care may be helpful for patients with Medicaid. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Assessment of pronator quadratus repair integrity following volar plate fixation for distal radius fractures: a prospective clinical cohort study.

PURPOSE: To assess prospectively the integrity of pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures and to compare the clinical and radiographic outcomes of durable versus failed repairs in 24 subjects. In addition, by grading the degree of PQ injury, an attempt was made to correlate failure of repair with the PQ injury severity. METHODS: The extent of PQ injury was graded for each fracture. After fracture fixation, the PQ muscle was repaired along its radial and distal borders. Radiopaque hemoclips were attached to each side of the PQ repair, 2 radially and 2 distally. The distance between these markers at time 0 versus x-rays taken at approximately 2 weeks, 6 weeks, and 3 months was recorded. Clip displacement of 1 cm or more compared to time 0 indicated repair failure. RESULTS: One of 24 repairs (4%) failed at 3 months. No statistical difference was noted between the type of PQ injury and wrist flexion/extension, pronation/supination, and grip strength. CONCLUSIONS: Pronator quadratus repairs after volar plate fracture fixation are generally durable. They withstand forces that occur at the distal radius during the healing process with a 4% failure rate. No correlation was shown between type of PQ injury and radiographic failure of the repair.

Trigger finger: etiology, evaluation, and treatment.

Trigger finger is a common finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. Although it can occur in anyone, it is seen more frequently in the diabetic population and in women, typically in the fifth to sixth decade of life. The diagnosis is usually fairly straightforward, as most patients complain of clicking or locking of the finger, but other pathological processes such as fracture, tumor, or other traumatic soft tissue injuries must be excluded. Treatment modalities, including splinting, corticosteroid injection, or surgical release, are very effective and are tailored to the severity and duration of symptoms.

Arthritis of the base of the thumb.

The purpose of this article is to outline the pathophysiology and epidemiology of arthritis of the base of the thumb. The usual presentation and diagnosis will be discussed along with the current conservative treatment options. Surgical treatment options are determined by the stage of the arthritis as well as the demands of the patient. The current standard surgical treatment options will be reviewed along with their results in the literature.

Microarray gene analysis and expression profiles of Dupuytren's contracture.

Dupuytren's disease, although not altogether uncommon, has eluded scientists who have sought to explain the cause of this palmar fibroproliferative disorder. It can lead to severe limitations of hand function if left untreated. This study is the first broad genetic survey using microarray technology to find gene products that are overexpressed or underexpressed in diseased tissues. The authors found 23 genes with levels that differ consistently from control levels. Nine were selected for further verification using reverse transcription-polymerase chain reaction. These genes hold potential promise in explaining some of the demographic trends seen with disease, such as correlation with alcoholism and the striking predisposition for the male gender.