Health insurance coverage of the unemployed: COBRA and the potential effects of Kassebaum-Kennedy.

We use the April 1993 Current Population Survey to examine the health insurance coverage decisions of the unemployed and to simulate the potential effects of the new Kassebaum-Kennedy legislation. After controlling for demographic characteristics, COBRA eligibility raises the probability of health insurance coverage by 0.095, while eligibility for spouse employer insurance increases the likelihood of coverage by 0.318, and eligibility for both increases the likelihood of coverage by 0.341. In our simulations, we find that had Kassebaum-Kennedy been in effect in April 1993, 9.0 percent of the unemployed would be eligible to take up coverage, and the coverage rate of the unemployed would have been increased by 0.85 percent to 1.5 percent from 41.6 percent. Our estimates of the effect of Kassebaum-Kennedy on health insurance coverage are much lower than those reported by the Government Accounting Office prior to the passage of the legislation.

Roping injuries in the hand: mechanism of injury and functional results.

Twenty-two patients with roping injuries to 38 digits, including 19 patients injured while team roping, are discussed. Ten digits in nine patients were successfully revascularized or replanted. Seven digits in three patients failed after initial success. One patient is included in both categories. The failure rate is 41 percent for all 17 digits. Average follow-up is 18 months. The dominant hand was injured in 83 percent of team roping injuries; the thumb is the most commonly injured digit. Average interphalangeal motion for thumb replants is zero; for revascularizations, it is 47 degrees. There was 43 percent return of pinch strength for thumb replants compared to 83 percent return for a single thumb revascularization. The most common mechanism of injury was catching the roping thumb in the "thumb up" position during dallying. There are good motion and pinch strength with thumb revascularizations provided tendons and the interphalangeal joint are intact. Reconstruction of the flexor pollicis longus in the replanted thumb gave poor results. Primary tenodesis or arthrodesis is recommended.

Palmar arthroplasty for the treatment of the stiff swan-neck deformity.

Palmar arthroplasty for the treatment of the stiff swan-neck deformity in rheumatoid arthritis is designed to correct the mechanical block to flexion that is caused by palmar plate adhesions (which obliterate the retrocondylar recess) and by collateral ligament contracture and adhesions. This procedure can be performed at the same time as correction of the primary cause of proximal interphalangeal joint (PIP) hyperextension (e.g., intrinsic tightness or flexor tenosynovitis) and can also be supplemented with superficialis tenodesis to minimize recurrent hyperextension. Postoperative flexor dynamic traction, which is started at 24 to 48 hours and continued for a minimum of 3 to 4 weeks, is critical to the maintenance of motion. Arthroplasty in 47 PIP joints in 14 hands of 9 patients demonstrate an increase in motion from +20 degrees hyperextension and 9.5 degrees flexion to -7 degrees extension and 72 degrees flexion postoperatively.

Rehabilitation following electrical injury to the upper extremity.

This review emphasizes two of the difficult problems associated with electrical injury to the hand and forearm. Early wound closure to preserve important vascular, nerve, and tendon structures in the hand must be considered, recognizing the tendency for continued necrosis of tissue in this type of injury. Tissue fibrosis, even in areas of the hand not grossly injured, may develop, progressively compromising function. Five patients are presented to illustrate the early care and rehabilitation of these patients.

Volar fracture-dislocation of the carpometacarpal joint of the index finger treated by delayed open reduction.

Isolated volar fracture dislocation of the carpometacarpal joint of the index finger is a rare injury and has apparently not previously been reported. We are presenting a case treated by delayed open reduction and internal fixation. Satisfactory but not anatomic reduction was obtained. The literature and anatomic factors are discussed.

Hemophilus influenzae cellulitis of the hand.

Hemophilus influenzae type b cellulitis of the hand is a rare infection presenting mainly in the 2-month to 3-year age group. Three proven cases and one clinical case are reported, and the bacteriology and management are discussed. Most of these infections respond to ampicillin and/or chloramphenicol. One must include H. influenzae type b in the differential diagnosis of cellulitis of the hand in this age group and specify this possibility on all cultures so that appropriate identification of the organism can be made.

Recovery of function following replantation and revascularization of amputated hand parts.

One hundred patients with replantation or revascularization of 149 hand units were studied with respect to return of function. Criteria for assessment included level and mechanism of injury, age, active range of motion, two-point discrimination sensibility ratings, grip and pinch strength, cold intolerance, and return to previous employment. Survival rate for replantation was 79% and for revascularization 97%. In the 38 replantation patients 80% underwent secondary operations, the most common being flexor tendon reconstruction. Most digits regained two-point discrimination of better than 10 mm; normal two-point discrimination was achieved in 40% of digits in this group; total active motion of 84% of fingers was rated poor. In the 62 revascularizations motion of 28% was rated poor, of 29% rated excellent. Restoration of tendon and joint function was aided by early and aggressive flexor tendon reconstruction and early digital motion; selected patients had primary insertion of silastic rods when there was expectation of a poor result due to tendon or soft-tissue damage. Isolated index amputations should not be replanted except in children or young adults. Revascularization should rarely be used when there is index tendon and bone involvement.

Wounds of the hand contaminated by human or animal saliva.

A prospective and retrospective evaluation of 75 patients with hand wounds contaminated by human saliva (35) or animal saliva (40) demonstrates that a program of outpatient management can be sufficient for optimal care in many patients. This series challenges the proposition that hospitalization, radiographs, and surgical debridement are necessary for most such wounds. Sixty-seven per cent did not have surgical intervention and no complications resulted. Ninety-two per cent received antibiotics. Radiographs were obtained only when bony injury or entry into a joint was suspected. Delay in seeking treatment until obvious signs of infection or pain are present is common. Literature review details the anatomic factors important in the natural history and control of these infections, and the changes with respect to modes of treatment for these potentially dangerous wounds. The injury is caused by bites with the hand extended or, in fight-bite wounds, with the metacarpal-phalangeal and interphalangeal joints flexed, allowing deeper penetration and then sealing of the wound when the first is opened. Staphylococcus and Streptococcus are the organisms most frequently found in human bites, and in animal bites; Pasteurella multocida should be considered in dog and cat bites.

High-pressure injection injuries of the hand.

One hundred twenty-seven case reports of high-pressure injection injuries have been analyzed, and five patients of our own are reported. The injury usually occurs to young, working males, most often to their nondominant index finger. Without proper surgical intervention, the injected part often progresses to necrosis, debilitating fibrosis, and stiffness. The pathology is that of inflammation and foreign body granulomatous formation. Damage results from impact, ischemia resulting from vascular compression, chemical inflammation, and secondary infection. Recommended treatment has traditionally been early surgical decompression, removal of injected material, and antibiotics. There is some evidence that anti-inflammatory medication is of value. In the patients treated early with steroids and proper antibiotics, infection has not been a problem. We feel that treatment of these injuries should include: 1) Immediate, high-dose, parenteral steroids followed by high-dose oral steroids in tapered doses. Our present regimen consists of initial doses of hydrocortisone sodium succinate 100 mg intravenously every 6 hours until it appears that swelling and erythema have maximized and begun to diminish, then changing to oral prednisone 25 mg twice daily. Prednisone is then slowly tapered in 5- to 10-mg increments per day until stopped. If swelling, pain, and erythema begin to worsen, high-dose steroids are resumed and tapered again. 2) Extensive and complete surgical decompression and drainage of the injured part. 3) Appropriate broad-spectrum antibiotic coverage.