Use of digital images to aid in the decision-making for acute upper extremity trauma referral.

UNLABELLED: This study evaluated the use of digital smartphone images in the decision-making for acute upper extremity trauma referrals. Surgeons (n = 15) were presented with ten upper limb trauma scenarios for consideration of immediate transfer. Based on verbal history and with additional images, participants were asked questions regarding diagnosis, injured tissues, recommended management and diagnostic and treatment confidence. Statistical analyses evaluated confidence level changes and relationships between confidence levels and independent variables. Confidence levels for diagnosis and treatment were increased with the provision of smartphone images, and this was statistically significant. The decision to transfer was changed in 22%. The photographs were more useful for amputation versus non-amputation injuries (diagnosis and treatment) and hand versus forearm injuries (diagnosis), and these differences reached statistical significance. Smartphone digital images were shown to be useful for decision-making in acute upper extremity trauma referrals. This improved communication may have implications for health cost savings and patient burden by minimizing unnecessary acute transfers. LEVEL OF EVIDENCE: Diagnostic Level III.

Resurfacing of colour-mismatched free flaps on the face with split-thickness skin grafts from the scalp.

Free-tissue transfer is commonly used in micro-vascular head and neck reconstruction. In a significant proportion of cases, the reconstruction involves the placement of a conspicuous, colour-mismatched skin paddle on the face. This article presents our experience in resurfacing of free flaps on the face in seven patients, using split-thickness skin grafts harvested from the scalp. All patients had a noticeable improvement in colour match. This relatively minor procedure can significantly improve aesthetic outcome and merits consideration in appropriate patients.

Patient outcome following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion.

This study reports patient outcome following a thoracodorsal to musculocutaneous nerve transfer. We retrospectively reviewed the charts of six patients who had undergone transfer of the thoracodorsal nerve to the musculocutaneous nerve for reconstruction of elbow flexion. The mean age was 47 years (standard deviation: 24 years; range: 17-72 years). The mean time from injury to surgery was 3 months (standard deviation: 2 months; range: 1-5 months). In all cases, the biceps muscle was successfully reinnervated; in one case the Medical Research Council (MRC) muscle grade was grade 5, in four cases it was grade 4, and in one case it was grade 2. No patients complained of functional weakness with shoulder adduction and/or internal rotation. In the majority of cases, transfer of the thoracodorsal nerve to the musculocutaneous nerve provides excellent recovery of elbow flexion.

Current approach to cubital tunnel syndrome.

The choice for surgical treatment of cubital tunnel syndrome is no clearer today than when it was reviewed 10 years ago. There continue to be no significant prospective randomized trials to adequately compare the different surgical techniques. Even if such a trial were performed, most hand surgeons would probably continue to be skeptical. In the end, each surgeon must rely on his or her own personal experience or judgment. Based on the authors' experience in the treatment of cubital tunnel syndrome, they are confident that anterior transmuscular transposition of the ulnar nerve obtains the best results when the preoperative algorithm is properly applied and early postoperative physical therapy is instituted.

Clinical outcome following nerve allograft transplantation.

The clinical outcome of seven patients who underwent reconstruction of long upper- and lower-extremity peripheral nerve gaps with interposition peripheral nerve allografts is reported. Patients were selected for transplantation when the nerve gaps exceeded the length that could be reconstructed with available autograft tissue. Before transplantation, cadaveric allografts were harvested and preserved for 7 days in University of Wisconsin Cold Storage Solution at 5 degrees C. In the interim, patients were started on an immunosuppressive regimen consisting of either cyclosporin A or tacrolimus (FK506), azathioprine, and prednisone. Immunosuppression was discontinued 6 months after regeneration across the allograft(s) was evident. Six patients demonstrated return of motor function and sensation in the affected limb, and one patient experienced rejection of the allograft secondary to subtherapeutic immunosuppression. In addition to providing the ability to restore nerve continuity in severe extremity injuries, successful nerve allografting protocols have direct applicability to composite tissue transplantation.

Evaluation of hand sensibility: a review.

Many assessment devices and measures have been described to evaluate sensibility, with little consensus on the optimal measurement tool. The purpose of this paper is to review the assessment methods and devices used in the evaluation of hand sensibility. Consideration is given to the characteristics of each measurement tool, the information necessary for complete patient evaluation, and the battery of valid and reliable measurements that provide the most complete and accurate patient assessment.

Outcome following implantation of a peripheral nerve stimulator in patients with chronic nerve pain.

This study evaluated the usefulness of the implanted peripheral nerve stimulator in patients with pain following injury to a peripheral nerve. The patient sample (n = 17) consisted of 7 men and 10 women with a mean age of 48 years (SD = 18 years). The mean follow-up time since implantation of the stimulator was 21 months (SD = 15 months). Workers' compensation and/or litigation were involved in 11 cases. Peripheral nerve stimulators were placed in the upper extremity in 12 patients and in the lower extremity in 5 patients. Pain relief following implantation was rated as excellent by five patients, good by six patients, fair by four patients, and poor by two patients. A statistically significant decrease in reported pain level was found postoperatively (p < 0.0003). There was no statistically significant difference in postoperative pain level between men and women (p = 0.30), between cases involving workers' compensation or litigation and those not involving these issues (p = 1.0), or between patients who received an upper-extremity implant and those who received a lower-extremity implant (p = 0.56). Of the 12 patients who were unable to work before the operation, 6 returned to work after the operation. In conclusion, peripheral nerve stimulators can be useful in decreasing pain in carefully selected patients with severe neurogenic pain.

Subjective recovery of nerve graft donor site.

Nerve graft procedures require the use of a donor nerve to supply the graft material. This results in an area of numbness in a less critical region. The purpose of this study was to assess donor site recovery using patient subjective evaluation. Thirty-one patients (mean age, 38 years) who were at least 2 years past a nerve graft procedure participated in the telephone survey. The mean time since surgery was 65 months. Donor nerves from the lower extremity were utilized in 16 patients and from the upper extremity in 15 patients. The subjective patient evaluations indicated low levels of pain, numbness, and cold sensitivity in the donor nerve sensory distribution. Patient factors, including workers' compensation and legal involvement, did not have a significant effect on recovery at the donor site. Function and daily activity were not affected significantly by donor site factors. Satisfaction with nerve graft recovery was related significantly to reported patient satisfaction of the donor site (p = 0.002).