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).

Nerve transfers. New options for reconstruction following nerve injury.

Surgical reconstruction of proximal level nerve repair or long nerve grafts have provided less than optimal results, presenting the opportunity for investigation of alternate reconstructive techniques. Good motor function following an injury to a motor nerve requires a maximal number of motor axons reaching the motor end plate within a critical time period. Nerve transfers eliminate the need for a nerve graft by allowing a direct end to end nerve repair without tension. This article reviews surgical options using nerve transfers for patients with upper and lower extremity nerve injuries.

Utility of vibration thresholds in patients with brachial plexus nerve compression.

The diagnosis of brachial plexus nerve compression is controversial due to the subjective nature of patient symptoms and the lack of objective, quantifiable tests. It has been hypothesized that quantitative sensory evaluation of sensory threshold is the most sensitive method of evaluating nerve compression, particularly in the early stages. This study evaluated the sensitivity and specificity of vibration thresholds for detection of brachial plexus nerve compression. A multiple-frequency vibrometer was used to evaluate 40 control subjects and 35 patients with brachial plexus nerve compression. Calculated sensitivity values were modest (0.49 at 63, 250, and 500 cps) with high specificity values (0.98 at 8 cps) for individual frequencies using a fifth percentile criterion. The low sensitivity values indicate that this instrument is not adequate as a screening device.

Multiple nerve entrapment syndromes in office workers.

Reports of nerve compression syndromes have been increasing in frequency. The authors discuss evaluation, management, and surgical repair of these multifactorial disorders.

Evaluation of hand sensibility with single and double latex gloves.

The purpose of this study was to examine hand sensibility of surgeons wearing single and double latex gloves. Evaluation of hand sensibility, including cutaneous pressure thresholds, moving two-point discrimination, and static two-point discrimination, was performed on 25 surgeons (mean age 45 years). The dominant hand index finger was assessed with no glove, single glove, and double glove. The majority of surgeons had a moving and static two-point discrimination of 2 or 3 mm. The lowest cutaneous pressure thresholds were found when measured with no gloves and increased with single and double gloves. Statistically significant differences in cutaneous pressure thresholds using Semmes-Weinstein monofilaments were found for gloves versus no gloves (p < 0.0003) and single versus double gloves (p = 0.0003). Statistically significant differences in moving two-point discrimination were found for no gloves versus double gloves (p = 0.05) and single versus double gloves (p = 0.02). In conclusion, we found significant differences in hand sensation when measured with single and double gloves.

Surgeons' concern and practices of protection against bloodborne pathogens.

OBJECTIVE: To evaluate surgeons' concern regarding risk awareness and behavioral methods of protection against bloodborne pathogen transmission during surgery. METHODS: A 29-item questionnaire was sent to 914 surgeons from two universities and two surgical societies. RESULTS: The questionnaire was returned by 768 active surgeons. Slight or moderate concern about contracting human immunodeficiency virus (HIV) was reported by most surgeons; 8% reported extreme concern and 4% reported no concern. In total, 605 surgeons reported having been vaccinated against hepatitis B; surgeons in practice <7 years were most likely to be vaccinated. Most surgeons did not routinely use double gloves: 92 of 768 surgeons reported that they always use double gloves when performing surgery, and 83 reported that they usually use double gloves. There was a statistically significantly higher proportion of surgeons who always or usually use double gloves who also had hepatitis B vaccinations. Most surgeons incorrectly estimated the seroconversion rates with exposure to a patient with HIV (66% incorrect), hepatitis B (88% incorrect), or hepatitis C (84% incorrect). Most surgeons never or rarely report needle-stick injuries, and only 17% always report needle-stick injuries. CONCLUSIONS: Most surgeons underestimate the risk of bloodborne pathogens and do not routinely use double gloves.

Nerve injury in repetitive motion disorders.

Nerve compression in repetitive motion disorders is being recognized with increasing frequency. The pathophysiology of chronic nerve compression spans a broad spectrum beginning with subperineurial edema and progressing to axonal degeneration. These changes depend on the amount and duration of the compressive forces. Certain postures or positions in the upper extremity will increase pressures around certain nerves increasing pressure exposure. Evaluation of these patients with chronic nerve compression should include examination at all levels of potential entrapment in the upper extremity to identify all sites of compression.

Pain responses in patients with upper-extremity disorders.

The purpose of this study was to evaluate the relationship between pain response factors and upper-extremity disorders associated with work-related compensable disorders. In this retrospective study, the charts of 113 patients were examined. Compensation was not found to have any statistically significant association with pain levels. The degree of functional overlay in these patients, indicated by pain questionnaire scores, differed only slightly between compensated and noncompensated patients and indicated no significant difference between the 2 groups, except that the compensated group used a higher number of descriptors to describe their pain (p = .0143). These results indicate that compensation affects the verbalization of pain but does not affect the degree of pain experienced. Working status was found to be significantly correlated with a better ability to cope with stress at home, suggesting that employment status may be a more important factor than compensation status in the presentation of these patients.

Evaluation of cutaneous vibration thresholds in medical transcriptionists.

This study was designed to determine whether vibration thresholds of transcriptionists varied significantly from the thresholds of individuals not exposed to keyboard activities. Using a multifrequency vibrometer, we obtained vibration threshold values from 31 medical transcriptionists who perform work on computer keyboards and compared them to values obtained from 40 control subjects. Thresholds tended to become more abnormal at higher frequencies, although this difference was statistically significant only at frequencies of 125 Hz, 250 Hz, and 500 Hz in the index and small fingers. Vibration thresholds were not found to increase significantly with age or years of occupation. Vibration thresholds were significantly increased in medical transcriptionists at the higher frequencies, suggesting subtle neural dysfunction.