Journal of Hand Surgery-American Volume最新文献

Deliberate self-harm (DSH), including self-injurious behavior and nonsuicidal self-injury, presents substantial challenges to health care providers because of its prevalence, association with psychiatric conditions, and potential progression to suicide.^1,2 Hand surgeons are often among the first subspecialists to encounter these patients, particularly in emergency and outpatient settings, where upper-extremity injuries are common. This article explores the critical role of hand surgeons in identifying, managing, and preventing DSH-related injuries, emphasizing a multidisciplinary approach. Early recognition of DSH is vital, as many patients display subtle signs, such as scars on the upper extremities or discrepancies in reported injury mechanisms. Suicide screening tools, such as the Ask Suicide Screening Questions toolkit, enable rapid and effective identification of at risk individuals to guide subsequent care. In the emergency setting, hand surgeons must balance surgical intervention with the need for psychiatric evaluation, leveraging a multidisciplinary team to address underlying mental health conditions. Similarly, in outpatient clinics, hand surgeons have a unique opportunity to screen for DSH, initiate mental health referrals, and establish follow-up care with the help of existing clinical staff and social workers. Addressing misconceptions, such as the belief that discussing suicide may "implant" the idea or that surgical intervention reinforces self-harm for the average patient, is essential to improving care pathways. These misconceptions also deter hand surgeons from asking about DSH and suicidal thoughts. By expanding their role to include mental health considerations, hand surgeons can reduce recurrence rates, improve functional outcomes, and potentially save lives. We provide a comprehensive framework for integrating suicide prevention strategies and mental health resources into hand surgery practice, underscoring the critical impact of hand surgeons in managing this vulnerable patient population.

Purpose: There is a lack of comprehensive data concerning the prevalence of surgically treated peripheral nerve injuries (PNIs) and associated financial burden within the United States. Our purpose was to determine incidence of operatively managed major mixed upper-extremity PNIs and to quantify direct payments for PNI surgical intervention.

Methods: We analyzed administrative data from the Merative MarketScan Commercial Database and the Multi-State Medicaid Database from 2016 to 2022, focusing on adults aged 18-64 with surgically managed PNIs. Incidence, demographics, and direct payments within the first year postsurgery were examined. We used descriptive statistics to summarize payment data and the Mann-Kendall test to assess trends in annual incidence rates from 2016 to 2022.

Results: There were 5,735 patients and 2,917 patients in the commercial and Medicaid databases, respectively, who met inclusion criteria. The incidence of surgically managed PNIs in the commercial insurance population remained relatively stable, averaging 3.73 per 100,000 individuals annually. In the Medicaid population, incidence increased from 2.8 to 4.4 per 100,000 insured individuals between 2016 and 2022. Among patients with 365 days of continuous enrollment, mean total payments over 1 year were $31,840.55 in the commercial data set and $27,517.00 in the Medicaid data set. At 30, 90, and 180 days, mean total payments were $16,759.69, $20,367.30, and $24,537.40 for commercially insured patients as well as $10,443.09, $13,892.63, and $17,536.23 for Medicaid patients, respectively; these payments represent interval-specific averages, not cumulative payments.

Conclusions: The incidence of surgically treated PNIs is stable in the commercially insured but is rising in the Medicaid-insured population. Of the patients who remained insured in the year after injury, there were ongoing direct payments, highlighting the persistent claims-based financial footprint associated with PNI. These estimates reflect only direct payments and do not assess cost-effectiveness or broader societal costs but serve as a foundation for future investigations.

Type of study/level of evidence: Economic/Decision Analysis IV.

Purpose: Bennett fractures are inherently unstable intra-articular fractures of the first metacarpal base and are subject to multiple deforming forces. Suboptimal treatment can lead to fracture displacement, malunion, and post-traumatic arthritis of the carpometacarpal joint. The purpose of this study was to evaluate three fixation techniques for the stabilization of Bennett fractures. Our hypothesis was that screw fixation would be stiffer than the other methods.

Methods: Thirty fresh frozen cadaver hands were obtained. Bennett fractures were created by a fellowship-trained hand surgeon. Specimens were then randomized to fixation with one of three techniques: two 1.2 mm (0.047 in) Kirschner wires (K-wires), two 1.2 mm cortical lag screws, or a single 1.7 mm (0.067 in) headless compression screw with a minisuspensory cortical button construct (suture-button/screw). The specimens were loaded in displacement-controlled axial compression until failure. Radiographs were taken before and after testing to compare the final displacement and method of failure. Interfragmentary motion and applied load were recorded. The maximum force and relative motions of the first metacarpal and Bennett fragment were filtered and calculated.

Results: The median force to failure for screw, K-wire, and suture-button/screw were 166.6 N (38.9-590.3), 98.4 N (41.9-444.0), and 97.5 N (24.5-242.6), respectively, with no significant differences between constructs. Similarly, there were no significant differences in median displacement measured in three-dimensional space (5.7 mm (1.6-8.4), 5.7 mm (1.9-11.5), and 6.1 mm (3.9-17.9), respectively, or stiffness (37.2 N/mm (5.6-345.0), 22.8 N/mm (2.0-113.8), and 14.3 N/mm (5.5-285.9), respectively, between the groups.

Conclusions: All three methods of Bennett fracture fixation performed similarly at time zero in this in vitro biomechanical study.

Clinical relevance: The results of the present study may be taken into consideration along with patient factors and fracture characteristics when treating Bennett fractures.

The regionalization of trauma care has resulted in improvement of patient outcomes by triaging complex injuries to tertiary and quaternary hospitals with more resources, greater availability of subspecialty care, and higher case volumes. Undertriage of complex patients is associated with poor patient outcomes and mortality. Conversely, overtriage, defined as the overestimation of injury severity and unnecessary transfer to a higher level of medical care, risks overburdening higher trauma tier hospitals, can create a bottleneck effect of scarce resources and personnel, and may impede access for other critically ill patients. The increasing burden is borne by these trauma centers, which is more concerning, given the current trend of fewer practicing hand surgeons taking hand call. The medical decision to transfer a patient from a local hospital to a higher-tier hospital is a complex, shared decision between providers, and this is generally subject to time constraints with limited information regarding the patient's injuries. Furthermore, previous research has demonstrated that nonmedical factors often considerably influence the decision to transfer, including insurance status, Black race, and presentation to a local emergency department during night or weekend hours. This article discusses a number of ethical concerns that arise in the consideration of interhospital transfers of hand surgery patients and implications for practicing hand surgeons on both the referring and receiving sides. The main focuses of the article include the following: (1) the regionalization of hand trauma care; (2) the harms of undertriage; (3) the practical problems with overtriage; (4) viewing through the lens of principalism; and (5) recommendations for the path forward.

Purpose: Kienböck disease (KD), osteonecrosis of the lunate, has an unclear etiology. While there is a strong and clear association between KD and negative ulnar variance (UV), it is likely not the only mechanical factor. The capitate, which has a large joint surface with the lunate, may play a role in KD pathogenesis. This study investigated the association between capitate morphology and KD. We classified the capitate into three types based on the angle and length ratio of the capitotrapezoid (CT) and scaphocapitate joint lines: type I (short, vertical CT facet), type II (pentagonal with a large, oblique CT facet), and an intermediate type. We hypothesized that type II capitate increases capitate-lunate loading, leading to a higher incidence of KD.

Methods: A case-control study was conducted, including 80 KD patients who underwent surgery between 2019 and 2024 and 467 controls with radiographs from suspected scaphoid fracture cases. Demographic data, UV, and capitate type were analyzed.

Results: The prevalence of type II capitate in the control group was 18%. Patients with KD had considerably higher rates of negative UV (35% vs 7%) and type II capitate (30% vs 18%) compared to the control group. Among 488 non-negative UV patients and 59 negative UV patients, type II capitate remained more common in the KD group (42% vs 17%). Multivariable analysis confirmed negative UV (OR = 9.2, 95% CI: 4.8-17.4) and type II capitate (OR = 2.7, 95% CI: 1.5-5.0) as independent risk factors for KD.

Conclusions: Our study introduces a radiographic classification of capitate morphology and establishes its association with KD. These findings suggest that, beyond negative UV, type II capitate is an associated factor, warranting further research into its mechanical and vascular role in KD pathogenesis.

Type of study/level of evidence: Diagnostic III.