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Although intraoperative educational videos have become increasingly popular, comparatively few videos teach clinical reasoning for surgical procedures. The objectives of this study were to develop an engaging online video-based module to teach decision-making for cubital tunnel surgery, including supercharge nerve transfer, using a multimedia learning framework; and evaluate its effectiveness and use for continuing professional development.The educational module consisted of a prelecture knowledge assessment, choice of two self-guided video lectures (7 minutes and 28 minutes), and a postlecture knowledge assessment. An additional assessment examined knowledge retention 3 months after module completion. Surgeon surveys were administered after each knowledge assessment.A total of 279 surgeons participated in the educational module (75 percent practicing surgeons, 25 percent trainees), 112 surgeons completed the postlecture assessment, and 71 surgeons completed the knowledge retention assessment. Median score on the prelecture assessment was five out of 10 (interquartile range, four to seven). Scores improved by three points (10-point scale; p0.0001) in the postlecture assessment. Median score on the knowledge retention assessment was eight out of 10 (interquartile range, six to nine), with participants maintaining a two-point increase from their prelecture score ( p = 0.0002). Among surgeons completing this assessment, 68 percent reported that the module had changed their management of cubital tunnel syndrome.This study introduces a framework for the development of online multimedia modules for surgical education. It also underscores a demand among surgeons for easily accessible, reusable educational resources. Similar video-based modules may be developed to address this demand to facilitate continuing professional development in surgery.

PurposeTo describe the principles, process, and results of creating the International Consortium for Health Outcomes Measurement (ICHOM) standard set for hand and wrist conditions.MethodsFollowing the standardized methods of ICHOM, an international working group of hand surgeons, therapists, and researchers was assembled to develop an evidence-based, patient-centered, standard set of outcome measures for patients with hand and wrist conditions. Multiple systematic reviews were performed to support our choices of outcome domains and tools for hand and wrist conditions. Fourteen video conferences were held between March 2018 and March 2020, and a modified Delphi process was used.ResultsA consensus was reached on 5 measurement tracks: the thumb, finger, wrist, nerve, and severe hand trauma tracks, with a distinction between regular and extended tracks for which specific allocation criteria applied. The standard set contains a selection of outcome tools and predefined time points for outcome measurement. Additionally, we developed a hierarchy for using the tracks when there are multiple conditions, and we selected risk-adjustment, case-mix variables.ConclusionsThe global implementation of the ICHOM standard set for hand and wrist conditions may facilitate value-based health care for patients with hand and wrist conditions.Clinical relevanceThe ICHOM standard set for hand and wrist conditions can enable clinical decision making, quality improvement, and comparisons between treatments and health care professionals.

Systematic scoping review The purpose of this study was to understand the barriers to accessing upper extremity (UE) reconstructive surgery among those living with tetraplegia, and to identify gaps in knowledge. Using standardized scoping review methods, a literature search was conducted using four databases and 1069 articles were procured. Two independent reviewers systematically screened the articles in two phases. Retrieved articles underwent thematic analysis using a constructivist grounded theory methodology. The reviewed articles (n = 25) were published between 2002 and 2019, and study designs included: cross-sectional (64%), retrospective (16%), and review articles (8%). Common barriers to UE reconstruction were categorized into factors related to patients, providers, and systems. These general domains included lack of awareness of UE reconstruction and its benefits among people with tetraplegia and providers, poor interdisciplinary working relationships, and a lack of specialized centers that provide these reconstructive surgeries. Specific patient-related barriers related to intrinsic (coping skills, trust, fear) and extrinsic (support network, finances, postoperative course) factors that influenced decision-making. There are many barriers that prevent individuals with tetraplegia from accessing surgery at different levels of the healthcare system. Establishing specialized centers with strong interdisciplinary working relationships and raising awareness about the advantages and disadvantages of UE reconstruction through peer networks may help to improve accessibility. Using a value-based, patient-centered approach by exploring how individuals with SCI weigh each decision factor when considering surgery may help providers develop treatment options that better align with their goals.

Although aromatase inhibitors are the first-line treatment in postmenopausal women with hormone receptor-positive breast cancer, there is increasing evidence that they can induce carpal tunnel syndrome and stenosing tenosynovitis. This systematic review summarizes the risk factors, incidence, and management for patients with aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis compared to tamoxifen or placebo.A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review of PubMed/MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials was conducted (to March 19, 2020), supplemented with Google Scholar, Plastic and Reconstructive Surgery, and The Journal of Hand Surgery. Two reviewers independently completed the primary and secondary screens and the quality appraisal.This study reviewed 577 abstracts and included 19 studies. Risk factors for aromatase inhibitor-induced carpal tunnel syndrome or stenosing tenosynovitis included hormone replacement therapy before trial entry, history of musculoskeletal symptoms, age younger than 60 years, prior chemotherapy, and body mass index greater than 25 kg/m2. The incidence can be increased up to 10 times compared to tamoxifen. Patient discontinuation of aromatase inhibitor treatment because of carpal tunnel syndrome and stenosing tenosynovitis was reported. Nonsurgical management led to complete resolution of carpal tunnel syndrome symptoms in up to 67 percent of cases. Although most aromatase inhibitor-induced stenosing tenosynovitis original studies were low quality, all recommended surgical release for symptom resolution.This study provides current knowledge of the associated risk factors, management options, and quality of literature for aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis. Early recognition can prevent self-discontinuation of an aromatase inhibitor and long-term sequelae of poorly treated carpal tunnel syndrome and stenosing tenosynovitis.

Nerve transfer (NT) surgery can improve function in people with cervical spinal cord injury (SCI). However, the impact of donor nerve deficits remains unclear. The purpose of this study was to quantify donor deficits experienced by individuals with cervical SCI following NT.This prospective single-arm, comparative study included people with SCI undergoing upper extremity NTs. Myometry was used to assess muscle strength at baseline and follow-up. The Spinal Cord Independence Measure was used to measure the ability to perform activities of daily living.Ten individuals underwent 20 NTs to restore elbow extension (donor, posterior deltoid; n = 2), hand opening (donor, supinator; n = 7), and hand closing (donor, brachialis; n = 11). Shoulder abduction strength decreased (-5.6% at early and -4.5% late follow-up) in the elbow extension NT. Wrist extension strength decreased at early (-46.9% ± 30.3) and increased by late (76.4% ± 154.0) follow-up in the hand opening NT. No statistically significant change in elbow flexion strength was noted in the hand closing NT. Spinal Cord Independence Measure scores did not change significantly between baseline and early postoperative follow-up; they improved at late follow-up.Use of expendable donor nerves with redundant function to perform NT surgery has relatively little impact on strength or capacity to perform activities of daily living, even in the unique and highly vulnerable SCI population. Early, temporary loss in wrist extension strength can be seen after the supinator to posterior interosseous nerve transfer. This study offers quantitative data about possible diminution of donor function after NT, enabling hand surgeons to better counsel individuals contemplating upper extremity reconstruction.Prognostic I.

This study evaluated the validity of the factor structure of the Disabilities of the Arm, Shoulder and Hand questionnaire to assess upper extremity disability in patients with upper extremity nerve injury.Data were used from previous cross-sectional studies of patients with upper extremity nerve injuries. Research ethics approval was obtained for secondary data analyses. Descriptive and factor analyses were performed.Patients (n = 242; 170 men and 72 women) with upper extremity nerve injury included distal nerve (n = 131), brachial plexus (n = 88), and single proximal shoulder nerve (n = 23). The mean Disabilities of the Arm, Shoulder and Hand questionnaire score was 47.3 ± 22. For the questionnaire, a three-factor structure had the highest variance and no overlap between factors. The factors related to (1) light effort tasks, (2) greater effort tasks, and (3) work/social activity limitations and pain. Brachial plexus injuries had significantly higher overall questionnaire scores compared to distal and single proximal nerve injuries. The light effort factor scores were significantly lower in single proximal nerve injuries compared with brachial plexus and distal nerve injuries. Nondominant compared to dominant hand involvement revealed no difference in overall questionnaire scores but significantly higher dominant hand scores in the light effort factor (p = 0.001).In patients with nerve injury, the factor analysis of the Disabilities of the Arm, Shoulder and Hand questionnaire indicated a multifactor construct. These domains should be considered when using the questionnaire and may be helpful to assess disability related to specific tasks in different nerve injuries and with dominant hand involvement.

Study Design Prospective cohort. Introduction Successful nonoperative treatment of mallet finger injuries requires compliance to prolonged immobilization and understandable educational materials. Purpose of the Study This study evaluated the use of written and online video education tools after mallet finger injury. Methods After ethics board approval and informed consent, adults with an acute mallet finger injury referred to hand therapy were included. Standard nonoperative treatment was instituted with orthotic immobilization and verbal instructions, in addition to an education pamphlet and an online video link. A questionnaire regarding the educational materials was administered at the follow-up appointment. Results There were 61 patients (mean age, 42 ± 14 years). The middle (n = 21) and ring (n = 22) fingers were most commonly injured. All patients were fluent in English. Written instructions (n = 57) were used by more patients than the videos (n = 30). Comparing patients who viewed the video with those who did not, there were no differences (P > .05) in demographics (sex, age, education, work status, and second language). Both written and video instructions were reported as helpful; mean helpful score for the video was significantly (P = .03) higher than written instructions. Most patients preferred having written and video instructions, and both were easy to understand and convenient. Discussion In our study of patients with acute mallet finger injuries, written and video instructions were utilized and both were reported as helpful. Conclusions This study provides evidence of the usefulness of online videos as an educational aid and the opportunity for future investigations to improve patient access to education materials.

The aim of this study was to review the literature to determine the prevalence of cold sensitivity in upper extremity nerve compression syndromes and the impact of treating nerve compression syndromes on cold sensitivity.Following a standardized scoping review protocol, this study included interventional and observational study designs assessing patients with cold sensitivity and upper extremity nerve compression syndromes. Review articles, case reports, and small case series (n5) were excluded. The abstracts and eligible full texts were screened by 2 independent reviewers. Data were extracted and reported according to PRISMA extension for scoping reviews statement.Three databases were searched (Ovid MEDLINE, Ovid EMBASE, and CINAHL on EBSCO); 274 references were reviewed. Fifteen studies from the database search and 8 studies from the reference search were eligible for this review (n = 23). Two interventional and 21 observational studies were identified. The most common method for assessing cold sensitivity was cold pain threshold testing (n = 12), followed by subjective patient reporting (n = 4). The Cold Intolerance Symptom Severity questionnaire was the most common validated patient-reported outcome questionnaire used in the studies (n = 3). Cold sensitivity was most commonly reported in carpal tunnel syndrome (96% of the studies). The prevalence of cold sensitivity in nerve compression syndromes ranged from 20% to 69%. Nerve decompression improved the severity of cold sensitivity in 5 of 6 studies where cold sensitivity was studied.There is heterogenicity in the studies assessing cold sensitivity in nerve compression syndromes. Despite moderate prevalence in patients with carpal tunnel syndrome, cold sensitivity is understudied. Within the limitations of eligible studies reviewed, surgical decompression improved the severity of cold sensitivity in some studies.Therapeutic IV.

Needlestick injury prevalence, protection practices, and attitudes were assessed. Current medical students were compared with 2003 data to assess any changes that occurred with engineered safety feature implementation.Risk of occupational exposure to bloodborne pathogens is elevated in the operating room particularly with surgeons in training and nurses.A cross-sectional survey was distributed to medical students (n = 358) and Department of Surgery staff (n = 247).The survey response rate was 24.8%. Needlestick injuries were reported by 38.7% of respondents (11% high risk), and the most common cause was "careless/accidental." Needlestick injury prevalence increased from medical students to residents and fellows (100%). Thirty-three percent of injured personnel had at least one unreported injury, and the most common reason was "inconvenient/too time consuming." Needlestick injury prevalence and double-glove use in medical students did not differ from 2003, and 25% of fellows reported always wearing double gloves. The true seroconversion rate for bloodborne pathogens was underestimated or unknown. The concern for contracting a bloodborne pathogen significantly decreased (65%) compared to 2003, and there were significantly less medical students with hepatitis B vaccinations (78.3%). Level of concern for contracting a bloodborne pathogen was predictive of needlestick injury.Needlestick injury and occupational exposure to bloodborne pathogens are significant hazards for surgeons and nurses. Attitudes regarding risk are changing, and the true seroconversion risk is underestimated. Educational efforts focused on needlestick injury prevalence, seroconversion rates, and double-glove perforation rates may be effective in implementing protective strategies.

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

Background: Upper extremity transplantation has been performed to improve quality of life, the benefit which must be traded off for the risk created by life-long immunosuppression. We believe the process of decision analysis is well suited to improve our understanding of these trade-offs. Method: We created a decision tree to include a branch point to illustrate the expected recovery of useful function in the transplant, using the best estimates for utility and probability that exist. Results: Our model revealed that when the probability of achieving a good result, graded as Chen level one or two is greater than 73%, transplantation is preferred over no transplantation. The decision is sensitive to the probability of major complications and the utility of a transplanted limb with minimal function. Conclusions: The results of this analysis show that under some circumstances given a high probability of satisfactory functional recovery, unilateral hand transplantation can be justified.

Ensuring that distal interphalangeal joint extension is maintained is an important but challenging part of the treatment process. These authors describe a simple approach to ensuring distal interphalangeal joint extension for these patients . – V ictoria P riganc , PhD, OTR, CHT, CLT , Practice Forum Editor

Purpose To describe the population-based rates of immediate breast reconstruction (IBR) for all women undergoing mastectomy for treatment or prophylaxis of breast cancer in the past decade, and to evaluate geographic, institutional, and patient factors that influence use in the publically funded Canadian health care system. Methods This population-based retrospective cohort study used administrative data that included 28,176 women who underwent mastectomy (25,141 mastectomy alone and 3,035 IBR) between April 1, 2002, and March 31, 2012, in Ontario, Canada. We evaluated factors associated with IBR by using a multivariable logistic regression model with the generalized estimating equation approach. Results The population-based, age-adjusted IBR rate increased from 5.1 procedures to 8.7 in 100,000 adult women (43.7%; P < .001), and the increase was greatest for prophylactic mastectomy or therapeutic mastectomy for in situ breast cancer (78.6%; P < .001). Women who lived in neighborhoods with higher median income had significantly increased odds of IBR compared with mastectomy alone (odds ratio [OR], 1.71; 95% CI, 1.47 to 2.00), and immigrant women had significantly lower odds (OR, 0.59; 95% CI, 0.44 to 0.78). A patient had nearly twice the odds of receiving IBR when she was treated at a teaching hospital (OR, 1.84; 95% CI, 1.1 to 3.06) or at a hospital with two or more available plastic surgeons (OR, 2.01; 95% CI, 1.53 to 2.65). Patients who received IBR traveled significantly farther compared with those who received mastectomy alone (OR, 1.04; 95% CI, 1.02 to 1.05 for every 10 km increase). Conclusion IBR is available to select patients with favorable clinical and demographic characteristics who travel farther to undergo surgery at teaching hospitals with two or more available plastic surgeons.

BACKGROUND: Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP).METHODS: This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods.RESULTS: There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance.CONCLUSIONS: Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Purpose This study evaluated the validity of the Patient Specific Functional Scale (PSFS) in patients with upper extremity nerve injury. Methods Following Research Ethics Boards (REB) approval, we included English-speaking adults, with greater than 6 months after an upper extremity nerve injury. Patient reported questionnaires included: PSFS, 36-item short-form health survey (SF-36), Disabilities of the Arm, Shoulder and Hand (DASH), McGill Pain Questionnaire, Pain Catastrophizing Scale (PCS) and Pain Disability Index (PDI). Statistical analyses evaluated the relationships among the outcome measures and the independent variables (age, gender, nerve injured, time since injury, work status, worker's compensation/litigation). Linear regression was used to evaluate the variables that predicted the PSFS. Results There were 157 patients (53 women, 104 men); median time since injury of 14 months. The mean ± SD scores were: PSFS 3.1 ± 2.3, DASH 44 ± 22, PCS 16 ± 15, pain intensity 4.2 ± 3.0, pain rating index 13 ± 11, PDI 28.3 ± 17.6 and SF-36 component scores physical (41.8 ± 8.7) mental (45.9 ± 12.6). There were moderate correlations between the PSFS and the DASH, and the SF-36 physical role domain. The PSFS was significantly lower in brachial plexus injuries. The final model explained 20.7 % of the variance and independent variables were DASH, nerve injured and age. Conclusion This study provides evidence of construct validity of the PSFS for patients with upper extremity nerve injury. The PSFS is a valid method to assess functional limitations identified by the individual and can be completed in a shorter period of time than the DASH.

Background: The anterolateral thigh flap was described by Song et al. in 1984. Although more usually used as a free flap, it also has remarkable versatility as a pedicled flap. There are, however, no well-established guidelines that exist to define the extent of defects that can be reconstructed using this flap. In this article, the authors evaluate their experience with consecutive cases of the pedicled anterolateral thigh flap in complex abdominal and pelvic reconstruction. Methods: A retrospective review of medical records and photographic archives was performed looking at 28 proximally pedicled anterolateral thigh flaps in 27 patients. Results: The authors identified the arcs of rotation achieved, the types of defects reconstructed, points of surgical technique that enhanced their results, and some pitfalls of this flap. Useful points of surgical technique identified included suprafascial flap harvesting, extended harvesting of fascia, utilization of fascia to protect the pedicle, harvesting as a composite flap with the vastus lateralis, prudent preservation of large perforators that transgress the lateral aspect of the rectus femoris, synergistic use with a sartorius "switch," complete flap deepithelialization to fill dead space, and simple conversion to a free flap when pedicle length is inadequate. Pitfalls identified included the increased risk of pedicle avulsion in the morbidly obese, the risk of atherosclerotic plaque embolization in an atheromatous pedicle, and the potential inadequacy of thigh fascia for reconstituting abdominal wall integrity. Conclusions: This versatile flap has a wide arc of rotation. Multiple surgical modifications can be employed to tailor the flap to individual patient needs.

Purpose: The purpose of this review was to present an analysis of the literature of the outcome studies reported in patients following traumatic upper-extremity (UE) nerve injuries (excluding amputation), to assess the presence of an association between neuropathic pain and outcome in patients following traumatic UE nerve injuries, and to provide recommendations for inclusion of more comprehensive outcome measures by clinicians who treat these patients. Summary of Key Points: A Medline and CINAHL literature search retrieved 48 articles. This review identified very few studies of patients with peripheral nerve injury that reported neuropathic pain. When pain was reported, visual analogue or numeric rating scales were most frequently used; standardized questionnaires measuring pain or psychosocial function were rarely administered. Recent evidence shows substantial long-term disability and pain in patients following peripheral nerve injury. Recommendation: To better understand neuropathic pain in patients following peripheral nerve injury, future outcome studies should include valid, reliable measures of physical impairment, pain, disability, health-related quality of life, and psychosocial functioning.

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.

Purpose This study evaluated patient-reported outcome and the factors associated with disability after an upper extremity nerve injury. We hypothesized that patients at least 6 months after injury would report considerable disability and that pain would be the strongest predictor of the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Methods After research ethics board approval, the medical charts of patients with these inclusion criteria were reviewed: adults; presenting to a nerve surgeon; 6 months or greater after nerve injury. Patients completed the DASH questionnaire and the Short Form-36 (SF-36) as a routine part of the initial evaluation. These data were reviewed retrospectively to determine predictors of the DASH score. Results There were 84 patients (mean age, 39 years; SD, 14 years) with brachial plexus (n = 27) and peripheral nerve (n = 57) injuries. The mean time after injury was 38 months (SD, 47). For all SF-36 domains, the mean values of the nerve-injured patients were significantly lower than the normative data, indicating a lower health status. The mean DASH score was 52 (SD, 22) of 100. Significantly more disability was associated with more SF-36 bodily pain and with brachial plexus injuries. In the final regression model, SF-36 bodily pain, age, and nerve injured were significant predictors of the DASH score. SF-36 bodily pain accounted for 35% of the variance. Conclusions Substantial long-term disability (high DASH scores) was found in patients after nerve injury that was predicted by higher pain, older age, and brachial plexus injury. Further investigation of this pain and the associated factors may provide the opportunity for improved health-related quality of life. Type of study/level of evidence Prognostic II.

Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution’s 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction ( P < 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.

Workers' musculoskeletal disorders are often pain-based and elude specific diagnoses; yet diagnosis or classification is the cornerstone to researching and managing these disorders. Clinicians are skilled in pattern recognition and use it in their daily practice. The purpose of this study was to use the clinical reasoning of experienced clinicians to recognize patterns of signs and symptoms and thus create a classification system.Two hundred and forty-two workers consented to a standardized physical assessment and to completing a questionnaire. Each physical assessment finding was dichotomized (normal versus abnormal), and the results were graphically displayed on body diagrams. At two different workshops, groups of experienced researchers or clinicians were led through an exercise of pattern recognition (clustering and naming of clusters) to arrive at a classification system. Interobserver reliability was assessed (8 observers, 40 workers), and the classification system was revised to improve reliability.The initial classification system had good face validity but low interobserver reliability (kappa0.3). Revisions were made that resulted in a proposed triaxial classification system. The signs and symptoms axes quantified the areas in the involved upper limbs. The proposed third axis described the likelihood of a specific clinical diagnosis being made and the degree of certainty. The interobserver reliability improved to approximately 0.70.This triaxial classification system for musculoskeletal disorders is based on clinically observable findings. Further testing and application in other populations is required. This classification system could be useful for both clinicians and epidemiologists.

Neoplasms located in the lateral skull base region present a challenge for evaluation and management due to their difficult anatomic location and the complex reconstruction that is required following extensive tumor resection. Repair following tumor ablation requires a watertight dural seal, obliteration of the dead space, and coverage with vascularized soft tissue. Advances in radiologic imaging, diagnostic pathology, and surgical techniques and a multidisciplinary team for tumor ablation and reconstruction have significantly improved the treatment of these patients, minimized the occurrence of postoperative complications, and maximized patient outcome and quality of life. In this article, we present our experience in the reconstruction of extensive lateral skull base defects after tumor ablation.

This study evaluated patient-reported outcome of the donor site in patients following head and neck cancer reconstruction. Patients who had undergone cancer reconstruction using either an anterolateral thigh or a radial forearm free flap and who were at least 6 months postsurgery were included and contacted by telephone. There were 37 patients (mean age 61 years, standard deviation 16 years) with 18 anterolateral thigh flaps and 19 radial forearm flaps. The majority of patients were not bothered by scar appearance, light touch, numbness or pain. Significantly more females (P = 0.038) and more patients with radial forearm flaps (P = 0.045) were bothered by the cold at the donor site and more females reported that the shape of the operated extremity was different (P = 0.009). Donor site morbidity is not significant following a radial forearm or anterolateral thigh free flap and the reconstruction should be based upon individual patient factors and surgeon expertise. © 2007 Wiley-Liss, Inc. Microsurgery, 2007.

This study evaluated donor-site morbidity (retrospective chart review and followup questionnaire) in patients following reconstruction using an anterolateral thigh free flap. Twenty-one flaps were performed in 20 consecutive patients (mean age: 45.0 +/- 3.8 years). Primary wound closure was obtained in 52.4 percent. The perforators were intramuscular in 68 percent and septocutaneous in 32 percent. The early complications included infection (n = 2), wound dehiscence (n = 2), delayed healing (n = 8), and seroma (n = 1). Wound healing took 4.5 +/- 0.7 weeks, and leg weakness resolved completely (n = 13) by 6.6 +/- 2.0 weeks. More chronic complications (n = 19) included weakness (n = 5), pain/tightness (n = 6), contour deformity (n = 14), muscle herniation (n = 6), and unsatisfactory scar appearance (n = 6). No statistically significant differences existed in aesthetics or healing between wound-closure groups, nor in pain or weakness between perforator groups. Pain and weakness were significantly related to sacrifice of the deep fascia from the thigh through its elevation in the flap.

Objective: This study reports three cases of ulnar neuropathy after trampoline injuries in children. Methods: A chart review was performed on children who sustained an ulnar nerve injury from a trampoline accident. In all cases, surgical intervention was required. Results: Injuries included upper-extremity fractures in two cases and an upper-extremity laceration in one case. All cases required surgical exploration with internal neurolysis and ulnar nerve transposition. Nerve grafts were used in two cases and an additional nerve transfer was used in one case. All patients had return of intrinsic hand function and sensation after surgery. Conclusion: Children should be followed for evolution of ulnar nerve neuropathy after upper-extremity injury with consideration for electrical studies and surgical exploration if there is no improvement after 3 months.

Background Work-related upper limb disorders have come under increasing scrutiny and become a frustrating problem. Methods A unifying hypothesis to explain the multiplicity of symptoms with work related neuromuscular disorders is outlined. This multifactorial problem includes physical, individual, and psychosocial factors. Abnormal postures and positions may compress nerves or may alter muscle length resulting in secondary compressive forces on nerves or in muscle imbalances. Evaluation should identify all nerve compression levels and muscle imbalance in the arm and cervicoscapular region. Management must include patient education, postural correction, and an exercise program to address the multiple nerve compression levels and muscle imbalance. Results and Conclusions The etiology of work related neuromusculoskeletal disorders is multifactorial and successful management must address all contributing factors. Appropriate conservative management will relieve symptoms in most patients. Surgery should be reserved for those few patients with evidence of a specific diagnosis who have failed conservative management. Am. J. Ind. Med. 41:343–352, 2002. © 2002 Wiley-Liss, Inc.

Proximal ulnar nerve injuries can result in loss of intrinsic muscle function of the hand, and distal nerve transfers provide nerve coaptation close to the target muscle. This retrospective chart review evaluated patient outcome following a distal nerve transfer of the anterior interosseous nerve (AIN) to the deep motor branch of the ulnar nerve. There were eight patient charts reviewed, three women, and five men. The mean patient age was 38 years (standard deviation: 22 years). The mean time from injury to surgery was 3 months (standard deviation: 3 months), and mean postoperative follow-up time was 18 months (standard deviation: 11 months). All patients had reinnervation of the ulnar nerve intrinsic hand muscles with improved postoperative lateral pinch and grip strength. One patient had a secondary tendon transfer. No functional deficit in performing tasks in pronation was reported. The distal nerve transfer of the AIN to the deep motor branch of the ulnar nerve provides good reinnervation of the ulnar-nerve-innervated intrinsic muscles of the hand.

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.

We report the case of a 59-year-old woman who developed an arteriovenous fistula in her right buttock following a right inferior gluteal artery perforator flap for breast reconstruction.

A 17-year-old patient presented with a long thoracic nerve palsy following an idiopathic onset of weakness to the serratus anterior muscle. With no evidence of recovery 3.5 months following onset of serratus anterior weakness, the patient underwent a thoracodorsal to long thoracic nerve transfer to reinnervate the serratus anterior muscle. Follow-up examination 6.5 years following the nerve transfer revealed no scapular winging, full range of motion of the shoulder and no reported functional shoulder restriction. We conclude that a thoracodorsal to long thoracic nerve transfer results in good functional recovery of the serratus anterior muscle.

Evaluation of hand sensibility using measures of threshold and tactile discrimination are standard assessment methods following nerve injury. Many of the available sensory measures for the quantification of hand sensibility lack verification of intertester reliability. Intertester reliability of vibration threshold, cutaneous pressure threshold, two-point discrimination, object identification, and texture identification was established. The intraclass correlation coefficient ranged from 0.96 to 0.99 for all variables except texture identification (r = 0.77). Comparisons were made between the sensory measures and each functional measure. The strongest correlational relationship was between two-point identification and object identification. Based on the results of this study, evaluation of hand sensibility may be attained with measurement of vibration and cutaneous pressure threshold, two-point discrimination, and object identification.

Object This study examines common peroneal nerve decompression and its effect on nerve function. Methods Fifty-one peroneal nerve decompressions were retrospectively reviewed. All patients were evaluated preoperatively and postoperatively for motor and sensory function of the peroneal nerve as well as for pain. Results Postoperatively, 40 (83%) of 48 patients who had preoperative motor weakness had improvement in motor function. Likewise, 23 (49%) of 47 patients who had sensory disturbances and 26 (84%) of 31 patients who had preoperative pain improved after surgical decompression of the peroneal nerve. Conclusions Common peroneal nerve decompression is a useful procedure to improve sensation and strength as well as to decrease pain.

This study evaluated the recipient and donor site complications associated with breast reconstruction using a deep inferior epigastric artery perforator flap (DIEAP) flap compared with a free TRAM flap. The charts of 108 patients who underwent breast reconstruction using these techniques were reviewed. There were 130 flaps. Patients with free TRAM flaps had a significantly longer hospital stay (P = 0.003). There were significantly more cases of fat necrosis in the unilateral DIEAP flaps (P = 0.001). In patients who were overweight or obese (body mass index >25 kg/m2), there were significantly more breast complications (P = 0.006). There were more cases of abdominal flap necrosis at the donor site in smokers (P = 0.018) and the diabetic patients (P = 0.013). This study suggests that postoperative complications are related to patient comorbidities, and personal factors and should be considered when selecting the most appropriate reconstructive option.

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.

This study reports the relationship between three clinical tests in the diagnosis of carpal tunnel syndrome and the stages of nerve compression. Assessments of 158 patients with carpal tunnel syndrome were reviewed retrospectively. 77% of patients had at least one of the clinical signs present. The incidence of positive pressure-provocative and Phalen’s tests were similar and more likely to occur in combination than separately. Tinel’s sign was more likely to be positive in the later stages of nerve compression. Our results suggest that the presence or absence of a provocative test is dependent upon the severity of the nerve compression.