Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury.

BACKGROUND: Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking. QUESTIONS/PURPOSES: (1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures? METHODS: Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made. RESULTS: Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138). CONCLUSIONS: Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery. LEVEL OF EVIDENCE: Level III, diagnostic study.

Long-Term Health-Related Quality of Life Outcomes in Digital Replantation versus Revision Amputation.

Background Earlier, digit viability judged the success of digital replantation. Now, utility health-related quality of life (HRQOL) measures can better assess the impact of digital replantation. Methods Overall, 264 digital injury patients were sent a regimen of utility measures: Disabilities of the Arm, Shoulder and Hand (DASH) score, European Quality of Life 5 Dimensions, visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). Overall, 51 patients responded completely to all of these-36 replantation patients and 15 revision amputation patients. The utility results of these patients were stratified between replantation versus revision amputation; dominant hand replantation versus nondominant hand replantation; and dominant hand revision amputation versus nondominant hand revision amputation. Results The mean VAS score of replant (0.84) and revision amputation (0.75) groups was significantly different (p = 0.05). The mean DASH score of dominant hand replantations (29.72) and nondominant hand replantations (17.97) was significantly different (p = 0.027). The dominant hand revision amputation had higher anxiety levels in comparison to nondominant hand revision amputation (p = 0.027). Patients with two or more digits replanted showed a significant decrease in VAS, TTO, and SG scores in comparison to patients who only had one digit replanted (p = 0.009, 0.001, and 0.001, respectively). Conclusions This study suggests that HRQOL can offer better indices for outcomes of digital replantation. This shows some specific replantation cohorts have a significantly better quality of life when compared with their specific correlating revision amputation cohort. These findings can be employed to further refine indications and contraindications to replantation and help predict the quality of life outcomes.

Open Finger Fractures: Incidence, Patterns of Injury and the Influence of Social Deprivation.

BACKGROUND: This study investigates the patterns and epidemiology of open finger fractures. There is little good data about these injuries. METHODS: Data were collected prospectively in a single trauma unit serving a well-defined population. RESULTS: Over a 15 year period 1090 open finger fractures were treated in 1014 patients. These made up the vast majority of open fractures treated in the trauma unit during this period. The incidence of open finger fractures was 14.0 per 100,000 patients per year. Deprivation did not influence the incidence of open finger fractures but did affect treatment choices for women. Most open finger fractures resulted from crush injuries or falls and required only simple operative treatments: debridement, lavage and early mobilization. CONCLUSIONS: Open finger fractures formed the majority of the workload of open fractures at our trauma centre but usually required simple treatments only. Social deprivation was not shown to influence the patterns or epidemiology of these injuries but did affect treatment choices for women.

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views.

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatisation of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatisation. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

Functional and aesthetic outcomes of the fingertips after nail lengthening using the eponychial flap.

INTRODUCTION: Eponychial flap technique is able to lengthen the visible nail and allow the preservation of the nail complex following fingertip amputations with nail bed involvement. The study assessed the functional and aesthetic outcomes of the reconstructed fingertips using the eponychial flap. METHODS: Eponychial flaps were performed in 11 fingertip amputations. Two-point discrimination, light touch, Purdue dexterity test, and pinch power of the reconstructed digits were examined. Patient-reported outcomes including subjective pain, Michigan Hand Outcome Questionnaire, and visual analog scale for appearance were documented. For comparison, nine patients with similar fingertip amputations treated by stump revision and nail bed ablation were included. RESULTS: The average length of the visible nail beds of the injured digits was 33.3% compared with the contralateral normal nail beds. The eponychial flap could lengthen the nail beds by an average of 32.4% of the length of the contralateral side. The mean follow-up was 26 months. Patients treated using the eponychial flap had greater pinch power of the reconstructed digits, higher satisfaction, and better aesthetic results when compared with patients receiving stump revision and nail bed ablation. There were no significant differences between two groups in sensation and Purdue dexterity test. Patient satisfaction was correlated with the reconstructed nail length. CONCLUSION: The eponychial flap is a simple and safe technique that can restore the functional and aesthetic fingertip in selected distal phalanx amputations. The aesthetics, pinch power, and patient satisfaction are significantly better with fingernail preservation and elongation using the eponychial flap.

Replantation vs revision amputation in single digit zone II amputations.

The objective of this study was to compare the functional outcomes of zone II amputations treated with either replantation or revision amputation at our institution to better aid patients in their decision making process regarding these treatment options. We conducted a comparative retrospective study. All cases of single digit amputations received at our replantation center between 2007 and 2011 were screened for single digit zone II injuries. These patients were stratified based on the treatment received: replantation vs revision amputation. Patients were called and invited to participate in the research project. Those who accepted to enter the study were asked to complete the Quick-DASH, the Beck Depression Inventory-short form, and a custom made questionnaire. There were seventeen patients with single digit zone II replantation and fourteen patients with similar injuries who underwent revision amputation and agreed to take part in the study. Our data revealed that the duration of sick leave, occupation after injury, professional and social reintegration, discontinued activities, and self-confidence were not statistically different between the two groups. The average hospital stay and the follow-up period of replanted individuals were longer. The replantation group did not have higher levels of pain or cold intolerance, and the global functional and esthetic satisfaction levels were similar between the two groups. Also, Beck Depression Inventory and Quick-DASH scores were not statistically different. Yet, significantly more patients in the replantation group would opt to repeat the replantation than revised patients would opt for revision amputation. From a functional viewpoint, our study suggests that revision amputation is not superior to replantation in zone II single digit amputations. This is valuable information that should be given to patients when deciding on the treatment process and to insure a proper informed consent.

Determinants of disability after fingertip injuries.

BACKGROUND: Psychological factors, such as depression, catastrophic thinking, and self-efficacy, account for more of the variation in upper extremity disability than motion and other impairments, but their influence in the setting of hand trauma is less well studied. OBJECTIVE: The aim of this study was to determine which factors account for variation in disability 1 month after fingertip injuries. METHODS: We enrolled 82 patients with finger injuries distal to the proximal interphalangeal joint, and 70 patients completed the study. Questionnaires and measurements were taken at the initial visit and approximately 1 month later. Patients completed the short version of the Disabilities of the Arm Shoulder and Hand questionnaire, the pain self-efficacy questionnaire, and the Patient Health Questionnaire to assess depressive symptoms. Bivariate and multivariable analyses determined factors associated with QuickDASH scores. RESULTS: The mean disabilities of the arm shoulder and hand questionnaire score was 35 at the initial visit (the U.S. norm is 10) and 17 approximately 1 month later. The best model explained 54% of the variation in disabilities of the arm shoulder and hand questionnaire 1 month after injury and included symptoms of depression (Patient Health Questionnaire; partial R2 0.43) and injury mechanism (saw injury compared with sport injury; partial R2 0.14). The criterion symptoms of depression was also the factor most strongly associated with both pain intensity and time off work. CONCLUSIONS: In patients with fingertip injury, symptoms of depression account for most of the variability in hand and arm-specific disability, pain intensity, and days to return to work. Identification and treatment of symptoms of depression might facilitate recovery from fingertip injuries.

[Replantation and reconstruction vs terminalization in the treatment of amputation of the digits]. / Porównanie wyników replantacji lub rekonstrukcji i terminalizacji w leczeniu amputacji palców rak.

MATERIAL AND METHODS: This study records the outcomes of the treatment of 21 patients, 19 men and two women, who sustained an amputation of the total of 35 digits (27 fingers and eight thumbs). Eleven patients received replantation or reconstruction maintaining the length of the digit, whereas ten had their digits terminalized. RESULTS: The results were assessed at a mean of 5 years after injury. Patients with finger stumps had stronger grip than those with replanted digits (72% vs 48% of strength of the healthy hand). Hand function as assessed by quickDASH score (29 vs 33), quality of life as assessed by SF-36 score (63 vs 67) and number of patients experiencing cold sensitivity (7 vs 7) were similar in both groups. Patients after terminalization returned to work significantly earlier than those after replantation or reconstruction (6 vs 12 months). CONCLUSIONS: These results show that - considering function of the hand - replantation or advanced reconstruction offers the patient less benefit than simple terminalization.

The influence of job satisfaction, burnout, pain, and worker's compensation status on disability after finger injuries.

PURPOSE: Motivation, job satisfaction, burnout, and secondary gain are factors that can influence return to work and disability after orthopedic injuries. The current study evaluated the separate effects of job satisfaction, burnout, and secondary gain on arm-specific disability after a finger injury. METHODS: Ninety-three employed patients with finger injuries were enrolled in this prospective study, and 51 completed the follow-up. Burnout (measured with Shirom-Melamed's Burnout Measure), job satisfaction (measured with the Job Descriptive Index questionnaire), and demographics were assessed at the initial visit. After 6 months, arm-specific disability was measured with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and general health status was measured with the Short Form-36 (SF-36) survey, mental component summary (MCS) and physical component summary (PCS). RESULTS: In the 51 patients with complete follow-up, the mean DASH score was 12, the mean SF-36 PCS was 48, the mean SF-36 MCS was 49, and the mean pain rating was 2.1. In multivariable analysis, pain and worker's compensation status explained 52% of the variability in DASH scores (pain alone accounted for 49%); pain accounted for 14% of the variability in SF-36 PCS scores; and worker's compensation accounted for 11% of the variation in the SF-36 MCS scores. CONCLUSIONS: The majority of variation in the SF-36 PCS and MCS scores remained unaccounted for by the models, but pain and worker's compensation were more important than job burnout or job satisfaction. Pain and worker's compensation were also significant predictors of the DASH. CLINICAL RELEVANCE: Worker's compensation and pain were more important than job satisfaction and burnout in explaining variations in arm-specific disability in patients with finger injuries.

Anger scale and anger types of patients with fifth metacarpal neck fracture.

OBJECTIVE: The aim of this study was to investigate aggressive and angry behavior in patients with fifth metacarpal neck fracture and to analyze the anger management style of these patients and their response to psychological support. METHODS: This study included 30 patients (mean age: 24.8 years) who presented to the emergency room with fractures of the fifth metacarpal neck and 30 healthy control subjects (mean age: 28.7 years). All subjects were evaluated with the Spielberger state-trait anger scale and the 30 subjects with the fifth metacarpal neck fractures completed the Turkish version of Barratt impulsiveness scale and semi-structured data form to assess anger level before the trauma and willingness to receive psychological support. RESULTS: In the metacarpal fracture group, 60% of injuries were caused by hitting the hand against a wall and 40% by hitting the hand in a fight. The non-planning impulsiveness score of Barratt impulsiveness scale was higher in the injured group. There was no significant difference between the Spielberger state-trait anger scores of the injured and control groups. High scores in the subsection that measures impulsiveness that requires attention were found in 82% of patients. CONCLUSION: Impulsive anger behavior is a common cause for fractures of the fifth metacarpal neck. Patients with these types of injuries often have difficulty controlling and directing their anger and often refuse psychiatric support. We believe that the hand surgeon should focus on the psycho-social problems of patients, and if necessary patients should be treated by a psychiatrist to prevent late psychopathologies for health promotion.

Patient-specific prosthetic fingers by remote collaboration--a case study.

The concealment of amputation through prosthesis usage can shield an amputee from social stigma and help improve the emotional healing process especially at the early stages of hand or finger loss. However, the traditional techniques in prosthesis fabrication defy this as the patients need numerous visits to the clinics for measurements, fitting and follow-ups. This paper presents a method for constructing a prosthetic finger through online collaboration with the designer. The main input from the amputee comes from the Computer Tomography (CT) data in the region of the affected and the non-affected fingers. These data are sent over the internet and the prosthesis is constructed using visualization, computer-aided design and manufacturing tools. The finished product is then shipped to the patient. A case study with a single patient having an amputated ring finger at the proximal interphalangeal joint shows that the proposed method has a potential to address the patient's psychosocial concerns and minimize the exposure of the finger loss to the public.

Patient experience of distraction splinting for complex finger fracture dislocations.

The study design is qualitative phenomenological and grounded theory. Intraarticular fractures of the finger joints can severely limit function due to stiffness and pain. Distraction with early movement is thought to deliver the best results and this has been used to treat these types of injuries at The Alfred Hospital for eight years. Qualitative data from patient interviews were used to describe patients' own experiences of treatment with distraction splinting and identify key issues in patient adherence. The key finding was a disconnect between perceived complexity of injury and treatment. Those who adhered with the treatment regime felt that they were well informed of the reasoning behind it. The hand surgery and therapy team must be aware of the patient experience of complex finger injuries and should ensure patients are well supported with education about their injury and treatment. Early preemptive pain control may help optimize adherence to the splint and exercise regime. Findings can be applied to other acute conditions requiring cumbersome splinting and potentially uncomfortable early exercise routines.

Finger prosthesis: the art of reconstruction.

Hand deformities affect aesthetics function of hand severely compromised and also cause psychological disturbances. This report describes the fabrication of a silicone finger prosthesis for a patient after an accident at work. The finger prosthesis was retained by a vacuum effect on the stump. The silicone material Silastic-MDX 44210 was used to provide function and aesthetics. The finger prosthesis offered psychological, functional and rehabilitative advantages for the patient. Restoring the natural appearance with the prosthesis eliminated the trauma generated by the dysfunction and represented an efficient psychological therapy.

Self-inflicted finger injury in individuals with spinal cord injury: an analysis of 5 cases.

OBJECTIVE: To describe the occurrence of finger autophagia in 5 persons with traumatic spinal cord injury and to present a discussion of putative causes and potential treatments. BACKGROUND: Minor self-mutilating actions, such as nail biting and hair pulling, are common in humans and usually benign. In some circumstances, these behaviors are associated with obsessive-compulsive personality traits. In humans, self-injurious biting behaviors are well described in the setting of mental retardation and psychosis and in persons with Lesch-Nyhan syndrome. Rare cases of human autophagia in persons with intact cognition have been reported, most commonly in the setting of acquired nervous system lesions. After spinal cord injury, it has been suggested that this behavior constitutes a human variant of animal autotomy and a response to neuropathic pain. DESIGN: Case presentation narrative. MAIN OUTCOME MEASURES: Photographic and radiological study, administration of Yale-Brown Obsessive-Compulsive Scale (YBOCS). FINDINGS: In 5 patients with complete tetraplegia, pain in the hands was present in only one instance. The severity of autoamputation varied from minor to extreme. In all cases, damage was confined to analgesic body parts. In 3 cases, autophagia behavior was discovered in progress. Treatments included pharmacotherapy, counseling, and behavioral therapy, with mixed results. All patients were intelligent, willing to discuss their issues, and able to identify conditions of stress and isolation in their lives. Mild preinjury obsessive-compulsive behaviors, such as nail biting, were universal. On the YBOCS, only 1 patient scored in a range indicative of mild obsessive-compulsive symptomatology. CONCLUSIONS: This group exhibited heterogeneous medical, social, and cultural characteristics. A link between pain and self-injurious behavior could not be demonstrated. This behavior may be viewed as an extreme variant of nail biting, with potential ominous complications. Treatment strategies have been employed with mixed results.

Self-amputation of a healthy hand: a case of body integrity identity disorder.

A case report is presented of self-amputation of a healthy hand. We have reviewed the literature and seek to broaden the scope of understanding of Body Integrity Identity Disorder. This rare condition can constitute a pitfall for the unsuspecting hand surgeon.

Toe-to-hand transplantation surgery.

This article discusses toe-to-hand transplantation. The purpose of this article is to familiarize nurses with this procedure. In many cases, the actions taken initially and postoperatively may have a direct effect on the success or failure of the surgery. Two different procedures are discussed. The first procedure is replantation or revascularization of amputated digits in which time is of the essence and is usually performed right after the initial injury. The second procedure is the toe-to-hand transfer, which is an elective procedure in which there is less emphasis on time. This procedure occurs a few months after the initial accident.