Infections.

Seemingly minor hand infections can have devastating consequences. The occupational health professional must be capable of early recognition and prompt intervention to avoid permanent sequelae to the patient.

Replantation and revascularization of the digits in a community microsurgical practice.

One-hundred and twenty-seven digits in Verdan zones I and II, and 24 thumbs in 106 patients were reviewed from 1979 to 1995. Patients were all followed for a minimum of 5 months to assess early results and complications, and to determine if a short course (minimum 3 days) of dextran 40 anticoagulation adversely affected digit survival. The total survival rate was 88 percent. Digits with only a single artery and vein repaired had a significantly higher rate of failure (p > .05). Index and small fingers also showed a trend toward lower survival. Vein grafts were used in 22 percent of cases. No vascular problems were noted after 5 days. Variables not affecting survival were: presence of a joint fusion, type of fixation, level of injury, number of digits, mechanism of injury, and use of vein grafts. The average hospital stay for the group was 6.5 days (+/-SD 3.3). No complications were seen with dextran use. A total of 51 complications were seen overall and the non-union rate was 10 percent. Community-based replantation and revascularization can be performed with early results equivalent to prior published studies. Complications are to be expected and demand expeditious treatment. Functional recovery of severed digits remains the benchmark for success in these injuries, however, lost digits never work.

Carpal tunnel syndrome. Effects of litigation on utilization of health care and physician workload.

We performed a study consisting of two parts to investigate the impact of litigation on patient recovery and physician workload. We received 556 replies from a questionnaire sent to hand surgeons and discovered that 98.20% of them felt that litigation increased the subjective complaints of patients. Most of these physicians (89.75%) also felt that litigation led to a worse result from treatment. Second, we undertook a retrospective chart review of 447 patients to see if there was a correlation between litigation, patient utilization of health care and physician workload. We found that workers' compensation patients with pending litigation went to the doctor's office more. They also had more letters, phone calls, and forms associated with their care, had more nerve conduction studies performed, and took longer to be discharged from care than patients with non-work-related carpal tunnel syndrome as well as workers' compensation patients who did not have pending litigation. These results indicated that litigation does affect patient utilization of health care and increases the workload on the physician.

Upper extremity disorders: a literature review to determine work-relatedness.

The objective of this review is to establish whether the medical literature validates a causal relationship between upper extremity disorders and work activities. Selected articles were reviewed using a Diagnostic Medical Criteria. Articles meeting this criteria were further reviewed for validity. Only 14 of 52 reviewed articles were felt to encompass medical criteria. However, these articles also contained what appear to be major validity flaws. Very little of the written material dealing with the issue of work-related upper extremity conditions incorporates what are felt to be sound medical diagnostic criteria in the definition and identification of these conditions. None of the reviewed studies have established a causal relationship between distinct medical entities and work activities. Further research using well constructed studies that incorporate reliable epidemiologic and accepted diagnostic criteria is needed. In this manner, the best of the medical and epidemiologic fields can be applied to solving these problems.

Fracture subluxation of proximal interphalangeal joint treated by palmar plate advancement.

A modified technique of palmar plate advancement (PPA) was used to treat certain patients, most with failed previous treatment, with fracture subluxation of the proximal interphalangeal joint. The modification of the original technique consisted of using two sutures to attach the palmar plate and tying them deep to the skin on the dorsum. This allowed consistent maintenance of reduction, and there were no infections. The results of 11 of 23 patients who were treated with this technique and followed from 2 to 9 years postoperatively are reported. The indications for PPA in this injury are discussed.

Acute scaphoid fracture with scapholunate gap.

Disruptive forces from wrist trauma are thought to fracture bone or disrupt ligaments. Two cases are presented to demonstrate the simultaneous occurrence of acute scaphoid fracture and scapholunate gap. Recommended treatment in acute cases is open reduction and internal fixation of the fracture and open stabilization of the scaphoid. In chronic cases, we recommend open reduction and internal fixation with bone graft to the scaphoid nonunion combined with fusion of the scaphoid-trapezium-trapezoid joint.

Acquired Madelung-like deformity in a gymnast.

High-level gymnastic training may cause clinical and radiographic changes in the wrist. A case is reported demonstrating bilateral closure of the ulnar side of the distal radius epiphyseal plate in a patient with a history of high-level gymnastic training. Cumulative microtrauma to the ulnar side of the distal radius epiphyseal plate may cause premature closure leading to a Madelung-like deformity.

Arthroplasty of the ulnar carpometacarpal joints.

Fracture-dislocation of the ulnar carpometacarpal (CMC) joints may result in malunion or arthropathy when it is missed or inadequately treated. Partial resection arthroplasty of the ulnar CMC joints was done in 16 patients to treat malunion subsequent to dorsal fracture-dislocation. This procedure is recommended as a reliable means of treatment that preserves the important motion on the ulnar side of the hand.

Scapholunate gap with scaphoid nonunion.

Ten of 64 patients reviewed with scaphoid nonunion were found to have scapholunate gaps (SLG). A roentgenographic study of the entire group who were symptomatic, but had no prior surgery, showed the SLG. The SLG indicated severe ligamentous injury and instability, and was always associated with the presence of Doral Intercalated Segment Instability (DISI) and an increased scapholunate angle. Instability was progressive and associated with the early onset of arthritis. In the entire group of nonunions, high frequency of arthritis occurred with a predictable sequence of radioscaphoid and midcarpal degenerative changes. Terminal wrist arthritis in scaphoid nonunion developed in the scapholunate articulation, as a manifestation of rotary subluxation of the distal scaphoid fragment.

Degenerative change in symptomatic scaphoid nonunion.

A retrospective radiographic analysis of 64 patients with symptomatic scaphoid nonunions without previous surgical treatment was accomplished. The results showed a high frequency of degenerative changes occurring in a predictable sequence. For nonunions of 4 years duration, 75% of patients had radioscaphoid changes, and for those of 9 years duration 60% of the patients had midcarpal changes. The pattern of arthritis in scaphoid nonunion is that of scapholunate advanced collapse (SLAC) wrist resulting from rotary subluxation of the distal scaphoid fragment. The radius-proximal scaphoid fragment joint and the radiolunate joint were consistently spared from degenerative changes, even with severe arthritis. Instability was progressive and associated with an earlier onset of arthritis. Patients with symptomatic scaphoid nonunions appear to have a significant likelihood of arthritis developing.

The lumbar puncture. Patterns of use in clinical practice.

The records of 195 patients who had undergone lumbar puncture (LP) before or after the introduction of computerized axial tomography (CT) were reviewed. Twenty percent of the patients had potentially important spinal fluid abnormalities. The LP changed the diagnosis in 10% of the patients and changed therapy in 10% of the patients. It contributed to the patient's care in 32% of the patients prior to the introduction of the CT and in 48% of the patients after the introduction of the CT (p less than 0.05). Introduction of the CT was associated with a 35% decrease in the frequency of the LP (p less than 0.05). We found that fungal and AFB cultures did not appear to be indicated in most patients. We conclude that use of the LP has improved since the introduction of the CT. Further improvement is still possible, however.