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Background: Previous studies identified limited impairment and disability several years after diaphyseal fractures of both the radius and ulna, although the relationship between impairment and disability was inconsistent. This investigation studied skeletally mature and immature patients more than ten years after injury and addressed the hypotheses that (1) objective measurements of impairment correlate with disability, (2) depression and misinterpretation of nociception correlate with disability, and (3) patients injured when skeletally mature or immature have comparable impairment and disability.Methods: Seventy-one patients with diaphyseal fractures of the radius and ulna were evaluated at an average of twenty-one years after injury. Twenty-five of the thirty-five patients who were skeletally immature at the time of injury were treated nonoperatively, and thirty-one of the thirty-six skeletally mature patients were treated operatively. Objective evaluation included radiographs, functional assessment, and grip strength. Validated questionnaires were used to measure arm-specific disability (the Disabilities of the Arm, Shoulder and Hand [DASH] score), misinterpretation of pain (Pain Catastrophizing Scale [PCS]), and depression (the validated Dutch form of the Center for Epidemiologic Studies-Depression scale [CES-D]).Results: The average DASH score was 8 points (range, 0 to 54); 97% of patients had excellent or satisfactory results according to the criteria of Anderson et al., and 72% reported no pain. Both the forearm rotation and the wrist flexion/extension arc was 91% of that seen on the uninjured side; grip strength was 94%. There were small but significant differences in rotation (151° versus 169°, p = 0.004) and wrist flexion-extension (123° versus 142°, p = 0.002) compared with the results in the uninjured arm. There was no difference in disability between patients who were skeletally mature or immature at the time of injury. Pain, pain catastrophizing (misinterpretation of nociception), and grip strength were the most important predictors of disability.Conclusions: An average of twenty-one years after sustaining diaphyseal fractures of both the radius and the ulna, patients who were skeletally immature or mature at the time of fracture have comparable disability. Disability correlates better with subjective and psychosocial aspects of illness, such as pain and pain catastrophizing, than with objective measurements of impairment.Level Of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The Nucleosome Remodeling and Deacetylase (NURD) complex is a key regulator of cell differentiation that has also been implicated in tumorigenesis. Loss of the NURD subunit Deleted in Oral Cancer 1 (DOC1) is associated with human oral squamous cell carcinomas (OSCCs). Here, we show that restoration of DOC1 expression in OSCC cells leads to a reversal of epithelial-mesenchymal transition (EMT). This is caused by the DOC1-dependent targeting of NURD to repress key transcriptional regulators of EMT. NURD recruitment drives extensive epigenetic reprogramming, including eviction of the SWI/SNF remodeler, formation of inaccessible chromatin, H3K27 deacetylation, and binding of PRC2 and KDM1A, followed by H3K27 methylation and H3K4 demethylation. Strikingly, depletion of SWI/SNF mimics the effects of DOC1 re-expression. Our results suggest that SWI/SNF and NURD function antagonistically to control chromatin state and transcription. We propose that disturbance of this dynamic equilibrium may lead to defects in gene expression that promote oncogenesis., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To identify demographic, injury-related, or psychologic factors associated with finger stiffness at suture removal and 6 weeks after distal radius fracture surgery. We hypothesize that there are no factors associated with distance to palmar crease at suture removal., Design: Prospective cohort study., Setting: Level I Academic Urban Trauma Center., Patients: One hundred sixteen adult patients underwent open reduction and internal fixation of their distal radius fractures; 96 of whom were also available 6 weeks after surgery., Intervention: None., Main Outcome Measurements: At suture removal, we recorded patients' demographics, AO fracture type, carpal tunnel release at the time of surgery, pain catastrophizing scale, Whiteley Index, Patient Health Questionnaire-9, and disabilities of the arm, shoulder, and hand questionnaire, 11-point ordinal measure of pain intensity, distance to palmar crease, and active flexion of the thumb through the small finger. At 6 weeks after surgery, we measured motion, disabilities of the arm, shoulder, and hand, and pain intensity. Prereduction and postsurgery radiographic fracture characteristics were assessed., Results: Female sex, being married, specific surgeons, carpal tunnel release, AO type C fractures, and greater catastrophic thinking were associated with increased distance to palmar crease at suture removal. At 6 weeks, greater catastrophic thinking was the only factor associated with increased distance to palmar crease., Conclusions: Catastrophic thinking was a consistent and major determinant of finger stiffness at suture removal and 6 weeks after injury. Future research should assess if treatments that ameliorate catastrophic thinking can facilitate recovery of finger motion after operative treatment of a distal radius fracture., Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to evaluate surgeon, patient, and radiographic factors influencing the recommendation for operative treatment in distal radius fractures. In a web-based study 252 orthopaedic surgeons from a variety of countries reviewed 30 consecutive sets of radiographs of patients that presented to our emergency department with a fracture of the distal radius. Surgeons were randomly assigned to receive either 'Radiographs only' or 'Radiographs and clinical information'. Surgery was recommended on average 52% of the time whether or not surgeons received clinical information. Female surgeons, surgeons with less than 21 years of experience, and hand surgeons were more likely to recommend operative treatment, but these factors explained only 1% of the variation. Radiographic criteria (intra-articular fractures, ulnar styloid fractures, dorsal comminution, dorsal tilt, and ulnar variance) explained 49% of the variation. The overall agreement on treatment was moderate and slightly higher among surgeons that received radiographs alone. Level of evidence: Level II, therapeutic; not a clinical study., (© The Author(s) 2014.)

Background: Patients in other countries use fewer opioids than patients in the United States with satisfactory pain relief., Objective: This study tested the null hypothesis that opioid intake after orthopedic surgery does not influence satisfaction with pain management., Methods: A total of 232 orthopedic surgical inpatients completed measures of pain self-efficacy and symptoms of depression at enrollment and commonly used measures of pain intensity, satisfaction with pain relief, and satisfaction with hospital staff attention to pain approximately 14 days after surgery. Inpatient opioid intake per 24-hour period was quantified., Results: At a phone evaluation approximately 2 weeks after discharge from the hospital, patients who were always satisfied with their pain relief in hospital and always satisfied with staff attention to pain used significantly less opioids on day 1 compared with patients who were not always satisfied. There were no differences in satisfaction by type of surgery. The final multivariable model for not always satisfied with pain relief included greater opioid use on day 1 (odds ratio = 1.2), and preadmission diagnosis of depression (odds ratio = 2.6). Greater opioid use on day 1 was the only factor associated with less than always satisfied with the staff attention to pain relief (odds ratio = 1.3)., Conclusions: Patients who take more opioids report less satisfaction with pain relief and greater pain intensity. Evidence-based interventions to increase self-efficacy merit additional study for the management of postoperative pain., Level of Evidence: Prognostic, Level 1., (Copyright © 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the effect of preinjury residence on inpatient mortality following hip fracture. This study addressed whether (1) admission from a nursing home residence and (2) admission from another hospital were associated with higher inpatient mortality after a hip fracture., Methods: Using the National Hospital Discharge Survey database, we analyzed an estimated 2 124 388 hip fractures discharges, from 2001 to 2007. Multivariable logistic regression analysis was performed to identify whether admission from a nursing home and admission from another hospital were independent risk factors for inpatient mortality. Our primary null hypothesis is that there is no difference in inpatient mortality rates after hip fracture in patients admitted from a nursing home, compared to other forms of admission. The secondary null hypothesis is that there is no difference in inpatient mortality after hip fracture in patients whose source of admission was another hospital, compared to other sources of admission., Results: Almost 4% of the patients were admitted from a nursing home and 6% from another hospital. The mean age was 79 years and 71% were women. The majority of patients were treated with internal fixation. Admission from a nursing home residence (odds ratio [OR] of 2.1, confidence interval [CI] 1.9-2.3) and prior hospital stay (OR 3.4, CI 3.2-3.7) were associated with a higher risk of inpatient mortality after accounting for other comorbidities and type of treatment., Conclusions: Patients transferred to an acute care hospital from a long-term care facility or another acute care hospital are at particularly high risk of inpatient death. This subset of patients should be considered separately from patients admitted from other sources., Level of Evidence: Prognostic level II.

Surgeons use radiographic measures of deformity to help make treatment decisions in distal radius fractures. Precise threshold values are sometimes offered as a guide to treatment. The purpose was to evaluate if agreement on treatment recommendations would improve if surgeons were provided with radiographs rather than precise numeric radiographic measurements. We randomized 259 surgeons to review the scenarios of 30 consecutive adult patients with a distal radius fracture treated at our emergency department either with radiographs (135 surgeons) or with radiographic measurements (124 surgeons). Interrater reliability was measured with the Fleiss' generalized Kappa. Factors associated with a recommendation for operative treatment were sought in bivariate and multivariable analyses. Surgeons that received measurements only recommended operative treatment significantly more often, but were less likely to agree than surgeons evaluating actual radiographs. Patient factors - radiographic factors in particular - had a greater influence on treatment recommendation than surgeon factors. Agreement on treatment recommendations improved if surgeons were provided with radiographs instead of just measurements. There may be radiographic factors other than measures of deformity that some surgeons use to determine recommendations for surgery.

Introduction: Musculoskeletal injury is a common cause of impairment (pathophysiology), but the correlation of impairment with pain intensity and magnitude of disability is limited. Psychosocial factors explain a large proportion of the variance in disability for various orthopaedic pathologies. The aim of this study is to prospectively assess the relationship between psychological factors and magnitude of disability in a sample of orthopaedic trauma patients in The Netherlands., Material and Methods: One hundred and one adult patients between 1 and 2 months after one or more fractures, tendon or ligament injuries were enrolled. Four eligible patients refused to participate. Thirty-five women and 30 men with an average age of 50 years (range, 22-92 years) completed the follow-up evaluation between 5 and 8 months after their injury and their data was analyzed. The patients completed a measure of disability (the Short Musculoskeletal Function Assessment-Netherlands, SMFA-NL), the Dutch Centre for Epidemiologic Study of Depression-scale (CES-D), the Dutch Impact of Event Scale (SVL), and the Dutch Pain Catastrophizing Scale (PCS) at the time of enrollment and again 5-8 months after injury., Results: There were moderate correlations between symptoms of depression (CES-D, r=0.48, p<0.001) and symptoms of PTSD (SVL, r=0.35, p=0.004) at enrollment and magnitude of disability 5-8 months after trauma. Catastrophic thinking (PCS) at enrollment and magnitude of disability 5-8 months after trauma showed a small correlation (PCS, r=0.26, p=0.034). The Pain Catastrophizing Scale (Beta=0.29; p=0.049), surgery (Beta=0.26; p=0.034), additional surgery (Beta=0.26; p=0.019) and other pain conditions (Beta=0.31; p=0.009) were the significant predictors in the final model (adjusted R-squared=0.35; p<0.001) for greater disability 5-8 months after trauma., Discussion and Conclusions: In The Netherlands, symptoms of depression measured 1-2 months after musculoskeletal trauma correlate with disability 5-8 months after this trauma. The psychological aspects of recovery from musculoskeletal injury merit greater attention., Level of Evidence: Level II, Prognostic study., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The Iliad, composed approximately in the middle of the eighth century bc, constitutes the leading and oldest known example of heroic epic. The Homeric epic presents the conflicts that took place during the last year of the 10-year lasting Trojan War, offering a realistic description of battle wounds. We studied the text of The Iliad in ancient Greek and in the translations in modern Greek and English and searched for all recorded injuries to the pelvis and lower extremities. A total of 16 traumatic injuries of pelvis and lower extremities were described, including 7 fatal wounds, while in 9 cases, the outcome was unknown.The Iliad remains the oldest record of Greek medicine and a unique source of surgical history. To study the vividly reported events is a great experience, particularly for a surgeon.

Cognitive flexibility - the ability to restructure one's knowledge, incorporate new facts, widen perspective, and adapt to the demands of new and unexpected conditions - can help one adapt to illness. The aim of this study was to assess the relationship between cognitive flexibility and hand and upper extremity specific disability in patients presenting to a hand surgeon. Secondarily, we determined predictors of cognitive flexibility and pain. Eighty-nine consecutive outpatients completed the Cognitive flexibility questionnaire (CFS), Short Health Anxiety Inventory-5 (SHAI-5), Pain Self-Efficacy Questionnaire (PSEQ), Disabilities of Arm, Shoulder and Hand, short form (QuickDASH), and Patient Health Questionnaire for Depression-2 (PHQ-2) in a cross-sectional study. CFS did not correlate with disability or pain intensity. Disability correlated with PSEQ (r = -0.66, p < 0.01), PHQ-2 (r = 0.38, p = <0.01), and SHAI-5 (r = 0.33, p < 0.01). Pain intensity correlated with PSEQ (r = -0.51 p < 0.01) and PHQ-2 (r = 0.41 p < 0.01). There was a small correlation between the CFS and PSEQ (r = 0.25, p = 0.02). The best multivariable models for QuickDASH and pain intensity included PSEQ and PHQ and explained 35 % and 28 % of the variability respectively. Upper extremity specific disability and pain intensity are limited more by self-efficacy than cognitive flexibility. Interventions to improve self-efficacy might help patients with upper extremity illness.

Background: The Pain Self-Efficacy Questionnaire (PSEQ) is a validated tool to assess pain self-efficacy and is strongly correlated with disability. Reducing the number of questions of the original PSEQ to screen for self-efficacy will result in more efficient screening and less burden for the patient., Objective: The aim of this study was to prospectively validate the shortened version of the PSEQ., Method: Overall, 249 new and follow-up patients visiting our outpatient orthopedic hand surgery clinic were prospectively enrolled and asked to complete the PSEQ, short version of the Disabilities of the Arm Shoulder and Hand, and 2-question version of the Patient Health Questionnaire (PHQ-2) depression questionnaires. The patients completed the questionnaires in the office and online 2 weeks after their visit. At the follow-up visit, the PSEQ was substituted with the 2-question version of the Pain Self-Efficacy Questionnaire (PSEQ-2). The factors associated with higher short forms of the Disabilities of the Arm, Shoulder and Hand scores were investigated in a bivariate and multivariable analysis. Paired t-test was used to compare the mean values of the short and long questionnaires at enrollment., Results: There was a large correlation (r = 0.90; p < 0.001) between the original PSEQ and the PSEQ-2 at enrollment. The Cronbach α were comparable for the PSEQ and the PSEQ-2 (α = 0.95 compared with α = 0.91). There was a small but statistically significant difference between the average scores of the PSEQ and PSEQ-2 (4.4 vs 4.8; p < 0.001). For the shortened PSEQ, a smaller-but still large-correlation was found with the short forms of the Disabilities of the Arm, Shoulder and Hand (r = 0.71 vs r = 0.61). Both the PSEQ-2 and the PSEQ were the most important predictors of the short forms of the Disabilities of the Arm, Shoulder and Hand scores. A substantial test-retest reliability was found for the PSEQ-2 (0.66)., Conclusion: The PSEQ-2 can be used to quickly assess patients׳ pain self-efficacy., (Copyright © 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The National Hospital Discharge Survey (NHDS) and the Nationwide Inpatient Sample (NIS) collect sample data and publish annual estimates of inpatient care in the United States, and both are commonly used in orthopaedic research. However, there are important differences between the databases, and because of these differences, asking these two databases the same question may result in different answers. The degree to which this is true for arthroplasty-related research has, to our knowledge, not been characterized., Question/purposes: We tested the following null hypotheses: (1) there are no differences between the NHDS and NIS in patient characteristics, comorbidities, and adverse events in patients with hip osteoarthritis treated with THA, and (2) there are no differences between databases in factors associated with inpatient mortality, adverse events, and length of hospital stay after THA., Methods: The NHDS and NIS databases use different methods of data collection and weighting to provide data representative of all nonfederal hospital discharges in the United States. In 2006 the NHDS database contained 203,149 patients with hip arthritis treated with hip arthroplasty, and the NIS database included 193,879 patients. Multivariable analyses for factors associated with inpatient mortality, adverse events, and days of care were constructed for each database., Results: We found that 26 of 42 of the factors in demographics, comorbidities, and adverse events after THA in the NIS and NHDS databases differed more than 10%. Age and days of care were associated with inpatient mortality with the NHDS and the NIS although the effect rates differ more than 10%. The NIS identified seven other factors not identified by the NHDS: wound complications, congestive heart failure, new mental disorder, chronic pulmonary disease, dementia, geographic region Northeast, acute postoperative anemia, and sex, that were associated with inpatient mortality even after controlling for potentially confounding variables. For inpatient adverse events, atrial fibrillation, osteoporosis, and female sex were associated with the NHDS and the NIS although the effect rates differ more than 10%. There were different directions for sources of payment, dementia, congestive heart failure, and geographic region. For longer length of stay, common factors differing more than 10% in effect rate included chronic pulmonary disease, atrial fibrillation, complication not elsewhere classified, congestive heart failure, transfusion, discharge nonroutine compared with routine, acute postoperative anemia, hypertension, wound adverse events, and diabetes mellitus, whereas discrepant factors included geographic region, payment method, dementia, sex, and iatrogenic hypotension., Conclusions: Studies that use large databases intended to be representative of the entire United States population can produce different results, likely related to differences in the databases, such as the number of comorbidities and procedures that can be entered in the database. In other words, analyses of large databases can have limited reliability and should be interpreted with caution., Level of Evidence: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Background: Evidence suggests that when patients have a role in medical decisions they are more satisfied with their health care., Objective: To assess predictors of patient satisfaction, ratings of the provider's informed shared decision-making (ISDM), and disability among patients with orthopedic pain complaints., Research Design: A total of 130 patients with nontraumatic painful conditions of the upper extremity were enrolled. Medical encounters were audio recorded and coded by 2 independent coders. Eight ISDM elements and a total ISDM score were evaluated. Bivariate and multivariable analyses were used to answer the study questions., Measures: Participants completed the Princess Margaret Hospital Patient Satisfaction with their Doctor Questionnaire to measure satisfaction; the Disabilities of Arm, Shoulder and Hand questionnaire; the Patient Health Questionnaire-9 to measure depression; the Whiteley Index to assess heightened illness concerns; and the pain catastrophizing scale to assess coping strategies in response to pain., Results: Less health anxiety, female gender, the ISDM element Identify choice, and any specific diagnosis determined 22% of the variation in satisfaction. Less health anxiety and unemployed unable to work compared with full-time working status were associated with a better rating of shared decision-making on the ISDM. Catastrophic thinking, female gender, symptoms of depression, and any specific diagnosis were associated with greater disability. Catastrophic thinking and symptoms of depression were the greatest contributors to the variation in disability., Conclusions: Psychologic factors are the strongest determinants of patient satisfaction, ratings of shared decision-making on the ISDM, and upper-extremity disability. Health anxiety is the most important factor in ratings of patient satisfaction and ISDM, whereas depression and catastrophizing are salient predictors of disability., Level of Evidence: Prognostic level I., (Copyright © 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Sprain or dislocation of the proximal interphalangeal joint may be a useful example of the counterintuitive aspects of recovery as the prognosis is excellent, but protectiveness in response to discomfort often hinders the stretching exercises that are a key component of the recovery process., Objective: The aim of this study was to investigate the relationship between disability and pain self-efficacy in this context., Methods: A total of 82 patients (54 men and 28 women) were enrolled in this prospective study. Finger motion was measured, and the patients completed measures of upper limb-specific disability (the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), symptoms of depression (Patient Health Questionnaire-9), effective coping strategies in response to pain (the Pain Self-Efficacy Questionnaire), and a pain scale at enrollment., Results: Patients were enrolled a mean of 48 days after injury. The final multivariable model accounting for greater disability included lower self-efficacy, greater symptoms of depression, and gender (women have more disability). Lower self-efficacy was also the strongest predictor of pain intensity and finger stiffness., Conclusions: Effective coping strategies such as self-efficacy facilitate recovery (less disability, pain, and stiffness) after proximal interphalangeal joint sprain/dislocation., Level of Evidence: Prognostic level I., (Copyright © 2014 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine if there was a difference between patients participating in research and those who did not regarding their satisfaction with the medical encounter and their physician., Methods: We prospectively randomized 128 patients to either complete 20 minutes of questionnaires (participate in research) or not. After the visit, all patients rated their satisfaction with their visit and satisfaction with the doctor on an 11-point ordinal satisfaction scales, with 0 being not at all satisfied and 10 being completely satisfied. Average satisfaction scores were analyzed in relation to demographics, questionnaires, and involvement in research., Results: There were no significant differences between patients that did and did not participate in research for satisfaction with the medical encounter or satisfaction with the treating physician. Satisfaction was not associated with marital status, work status, or diagnosis. There was a significant correlation between greater satisfaction and both less education and lower self-efficacy. There was no significant correlation between patient satisfaction and magnitude of disability, pain intensity, or health anxiety., Conclusions: This study demonstrated that patients' participation in research can coexist with patient satisfaction., Type of Study/level of Evidence: Prognostic I., (Copyright © 2014 American Society for Surgery of the Hand. All rights reserved.)

Background: In 2012, Medicare began to tie reimbursements to inpatient complications, unplanned readmissions, and patient satisfaction, including satisfaction with pain management., Questions/purposes: We aimed to identify factors that correlate with (1) pain intensity during a 24-hour period after surgery; (2) less than complete satisfaction with pain control; (3) less than complete satisfaction with staff attention to pain relief while in the hospital; and we also wished (4) to compare inpatient and discharge satisfaction scores., Methods: Ninety-seven inpatients completed measures of pain intensity (numeric rating scale), satisfaction with pain relief, self-efficacy when in pain, and symptoms of depression days after operative fracture repair. The amount of opioid used in oral morphine equivalents taken during the prior 24 hours was calculated. Through initial bivariate and then multivariate analysis, we identified factors that were associated with pain intensity, less than complete satisfaction with pain control, and less than complete satisfaction with staff attention to pain relief., Results: Patients who took more opioids reported greater pain intensity (r = 0.38). No factors representative of greater nociception (fracture type, number of fractures, days from injury to surgery, days from surgery to enrollment, or type of surgery) correlated with greater pain intensity. The best multivariable model for greater pain intensity included: depression or anxiety disorder (p = 0.019), smoking (0.047), and greater opioid intake (p = 0.001). Multivariable analysis for less than ideal satisfaction with pain control included the Pain Self-Efficacy Questionnaire (PSEQ) (odds ratio [OR], 0.95; 95% CI, 0.92-0.99) alone; for less than ideal satisfaction with staff attention to pain control, the PSEQ (OR, 0.96; 95% CI, 0.92-0.99) and opioid medication use before admission (OR, 3.6; 95% CI, 1.1-12) were included., Conclusions: After operative fracture treatment, patients who take more opioids report greater pain intensity and less satisfaction with pain relief. Greater self-efficacy was the best determinant of satisfaction with pain relief. Evidence-based interventions to increase self-efficacy merit additional study for the management of postoperative pain during recovery from a fracture., Level of Evidence: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Background: The effectiveness of night splinting after treatment of mallet finger is unknown. We tested the hypothesis that there is no difference in extensor lag between patients with mallet finger that wear a night splint for an additional month after 6 to 8 weeks of continuous splinting and patients that do not wear a night splint., Methods: Fifty-one patients were enrolled in this randomized controlled trial. At enrollment, range of motion was measured for the injured and contralateral uninjured finger. The follow-up was conducted approximately 4 weeks later in person (41 patients) or by phone (10 patients). Analysis was by intention to treat., Results: There were no significant differences in final extensor lag between patients that did and did not receive a night splint. Among the 41 patients with a final in-person evaluation, the final average extensor lag was 14°, and 34 % (14 of 41 patients) had a lag of 20° or greater. Final extensor lag correlated significantly with age, enrollment distal interphalangeal joint (DIP) flexion and extensor lag, and final DIP flexion, with the latter two accounting for 28 % of the variation in final lag in the final multivariable model (p < 0.001). There were no differences in disability (p = 0.67) or treatment satisfaction (p = 0.48) between patients that did and did not use night splints., Conclusions: Supplemental night splinting does not improve the outcome of mallet finger in terms of extensor lag, disability, or satisfaction with treatment. Patients with worse initial extensor lags should expect worse final lags; residual lags of 20° or greater are commonplace.

Background: This study tests the null hypothesis that, among patients aged 65 and older admitted to a United States hospital with an isolated fracture of the proximal humerus (no other injuries or fractures), there are no differences between operative (fixation or arthroplasty) and nonoperative treatments with respect to inpatient adverse events, inpatient mortality, and discharge to a long-term care facility rates accounting for comorbidities., Methods: Using a large national database representing an estimated 132,005 patients aged 65 and older admitted to a US hospital with an isolated proximal humerus fracture between 2003 and 2007. Sixty-one percent did not have surgery, 22% were treated with open reduction and internal fixation (ORIF), and 17% were treated with arthroplasty., Results: The risk of an in hospital adverse event was 21% overall and was 4.4 times greater with arthroplasty and 2.7 times greater with ORIF compared to nonoperative treatment. The risk of in hospital death was 1.8% overall and was 2.8 times greater with ORIF compared to nonoperative treatment. Patients treated operatively were less likely to be discharged to a long-term facility compared to patients treated nonoperatively., Conclusion: In spite of a tendency to treat the most infirm patients (those that are not discharged to home) nonoperatively, operative treatment (open reduction and internal fixation in particular) is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted to the hospital with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously., Level of Evidence: Level III, retrospective cohort study, treatment study., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Metabolic syndrome has been associated with increased morbidity following surgical procedures, yet its impact in acute orthopaedic trauma remains unclear. The purpose of this study was to evaluate the influence of metabolic syndrome on in-hospital (1) complications, (2) length of stay, and (3) nonroutine discharge in patients sustaining an isolated ankle fracture., Methods: Using the National Health Discharge Survey (NHDS) database for the years 2001 through 2007, an estimated 669 841 patients with isolated ankle fractures treated operatively were identified and separated into groups with and without metabolic syndrome. Multivariable binary logistic regression analysis was performed for each of the outcome variables., Results: Metabolic syndrome was an independent risk factor for increased nonroutine discharge (OR = 1.8) and the development of in-hospital complications (OR = 2.1). The presence of metabolic syndrome was not an independent risk factor for prolonged hospital stay., Conclusion: Patients with metabolic syndrome sustaining an isolated ankle fracture are at increased risk for in-hospital complications and a less rapid return of independent functional mobility, as evidenced by the higher need for posthospitalization care., Level of Evidence: Level III, epidemiologic study.

Background: Psychiatric comorbidity has been associated with increased health risks and poor long-term treatment outcomes in numerous medical disciplines, but its effect in short-term perioperative settings is incompletely understood. The purpose of this study was to evaluate the influence of a preoperative diagnosis of depressive disorder, anxiety disorder, schizophrenia, or dementia on in-hospital (1) adverse events, (2) blood transfusion, and (3) nonroutine discharge in patients undergoing shoulder arthroplasty., Methods: Using the National Hospital Discharge Survey (NHDS) database, we identified 348,824 discharges having undergone partial or total shoulder arthroplasty from 1990 to 2007. Multivariable regression analysis was performed for each of the outcome variables., Results: The prevalence of diagnosed depressive disorder was 4.4%, anxiety disorder, 1.6%; schizophrenia, 0.6%; and dementia, 1.5%. Preoperative psychiatric disorders, with the exception of schizophrenia, were associated with higher rates of adverse events. Depression and schizophrenia were associated with higher perioperative rates of blood transfusion. Any preoperative psychiatric illness was associated with higher rates of nonroutine discharge., Conclusions: Patients with preoperative psychiatric illness undergoing shoulder arthroplasty are at increased risk for perioperative morbidity and posthospitalization care. Preoperative screening of psychiatric illness might help with planning of shoulder arthroplasty., (Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Objectives: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment., Design: Web-based reliability study., Setting: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey., Participants: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns., Main Outcome Measurements: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons., Results: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA., Conclusions: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Upper extremity trauma and resulting disability is a stressful event and can affect a patient's personality. Several studies have shown that this injury type has serious psychological and/or social consequences. We systematically reviewed the evidence on the consequences of disability after a complex trauma (combination of soft tissue, osseous, vascular, and nerve involvement) of the upper extremity. We tried to find out the potential crucial factors that could determine the final hand function. In addition, we considered the challenges that need to be addressed to eliminate the adverse or negative effects that arise from upper limb trauma. In the literature, there is a growing interest to study changes in patients' quality of life and return to work. Psychological morbidity is an important part of patients' perceived general health. These issues could play an important role in the final functional outcome of the therapy. An early identification and treatment of trauma-related distress in patients may prevent progression of psychological pathology and mitigate negative effects on general health status. It may be important to evaluate the amount of psychological distress when caring for patients with hand injuries., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Patient expressions reflect disability and psychological factors. The aim of this study was to list common phrases and feelings in hand surgery practice and to prospectively study the correlation of these phrases and to correlate them with possible associated feelings and disability., Methods: Eighty-three patients completed the short version of the disabilities of arm, shoulder and hand (QuickDASH) questionnaire to measure disability, the pain self-efficacy questionnaire (PSEQ) to study coping, and a pain scale. The patients also completed the phrases and feelings questionnaire, which list verbal expressions patients often use. Pearson's correlation was used to test the correlation of continuous variables, and independent t test and one-way ANOVA were used for categorical variables. All variables with p < 0.08 were inserted in a multivariable regression., Results: There was a large correlation between the individual phrases and feelings questions with PSEQ and QuickDASH. The best model for the combined phrases questionnaire included pain, PSEQ, smoking, and other pain conditions. The best model for the combination of all the feelings questions included PSEQ, pain, and marital status. The best model for QuickDASH included phrases, PSEQ, prior treatment, and working status, with phrases being the strongest factor., Conclusions: Patients use specific phrases that indicate the magnitude of their disability and the effectiveness of their coping strategies. Providers should respond to these phrases by empathetically acknowledging these aspects of the human illness experience.

Nucleotide biosynthesis is fundamental to normal cell proliferation as well as to oncogenesis. Tumor suppressor p53, which prevents aberrant cell proliferation, is destabilized through ubiquitylation by MDM2. Ubiquitin-specific protease 7 (USP7) plays a dualistic role in p53 regulation and has been proposed to deubiquitylate either p53 or MDM2. Here, we show that guanosine 5'-monophosphate synthase (GMPS) is required for USP7-mediated stabilization of p53. Normally, most GMPS is sequestered in the cytoplasm, separated from nuclear USP7 and p53. In response to genotoxic stress or nucleotide deprivation, GMPS becomes nuclear and facilitates p53 stabilization by promoting its transfer from MDM2 to a GMPS-USP7 deubiquitylation complex. Intriguingly, cytoplasmic sequestration of GMPS requires ubiquitylation by TRIM21, a ubiquitin ligase associated with autoimmune disease. These results implicate a classic nucleotide biosynthetic enzyme and a ubiquitin ligase, better known for its role in autoimmune disease, in p53 control., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Posttraumatic deformity of a tubular bone in the hand after malunion can impact function due to alteration in mobility, strength, or associated pain. Surgical intervention is often indicated, with the surgical options based on both the type and location of the deformity, as well as any associated articular, tendon, or soft tissue constraints. This article provides a management approach based on the deformity classification, location, and any associated conditions., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Study Design: Analysis of the National Hospital Discharge Survey database from 1990 to 2007., Objective: To evaluate the influence of preoperative depression, anxiety, schizophrenia, or dementia on in-hospital (1) adverse events, (2) mortality, and (3) nonroutine discharge in patients undergoing major spine surgery., Summary of Background Data: Psychiatric comorbidity is a known risk factor for impaired health-related quality of life and poor long-term outcomes after spine surgery, yet little is known about its impact in the perioperative spine surgery setting., Methods: Using the National Hospital Discharge Survey database, all patients undergoing either spinal fusion or laminectomy between 1990 and 2007 were identified and separated into groups with and without psychiatric disorders. Multivariable regression analysis was performed for each of the outcome variables., Results: Between 1990 and 2007, a total estimated number of 5,382,343 spinal fusions and laminectomies were performed. The prevalence of diagnosed depression, anxiety, and schizophrenia among the study population increased significantly over time. Depression, anxiety, schizophrenia, and dementia were associated with higher rates of nonroutine discharge. Depression, schizophrenia, and dementia were associated with higher rates of adverse events. Dementia was the only psychiatric disorder associated with a higher risk of in-hospital mortality., Conclusion: Patients with preoperative psychiatric disorders undergoing major spine surgery are at increased risk for perioperative adverse events and posthospitalization care, but its effect in perioperative mortality is more limited. Presurgical psychological screening of candidates undergoing spine surgery might ultimately lead to the enhancement of perioperative outcomes in this growing segment of the US population., Level of Evidence: N/A.

Background: The Pain Catastrophizing Scale (PCS) and Short Health Anxiety Inventory (SHAI) can help hand surgeons identify opportunities for psychologic support, but they are time consuming. If easier-to-use tools were available and valid, they might be widely adopted., Questions/purposes: We tested the validity of shorter versions of the PCS and SHAI, the PCS-4 and the SHAI-5, by assessing: (1) the difference in mean scaled scores of the short and long questionnaires; (2) floor and ceiling effects between the short and long questionnaires; (3) correlation between the short questionnaires and the outcome measures (an indication of construct validity); and (4) variability in disability and pain, between the short and long questionnaires., Methods: One hundred sixty-four new or followup adult patients in one hand surgery clinic completed the SHAI-18, SHAI-5, PCS-13, PCS-4, Patient Health Questionnaire (PHQ)-9, PHQ-2, DASH, and QuickDASH questionnaires, and an ordinal pain scale, as part of a prospective cross-sectional study. Mean scores for the short and long questionnaires were compared with paired t-tests. Floor and ceiling effects were calculated. Pearson's correlation was used to assess the correlation between the short and long questionnaires and with outcome measures. Regression analyses were performed to find predictors of pain and disability., Results: There were small, but significant differences between the mean scores for the DASH and QuickDASH (QuickDASH higher), SHAI-18 and SHAI-5 (SHAI-18 higher), and PCS-13 and PCS-4 (PCS-4 higher), but not the PHQ-9 and PHQ-2. Floor effects ranged between 0% and 65% and ceiling effects between 0% and 3%. There were greater floor effects for the PHQ-2 than for the PHQ-9, but floor and ceiling effects were otherwise comparable for the other short and long questionnaires. All questionnaires showed convergent and divergent validity and criterion validity was shown in multivariable analyses., Conclusions: Content validity, construct convergent validity, and criterion validity were established for the short versions of the PCS and SHAI. Using shorter forms creates small differences in mean values that we believe are unlikely to affect study results and are more efficient and advantageous because of the decreased responder burden.

Background: Psychological factors are important mediators of the differences between impairment and disability. The most commonly used measures of disability and psychological factors are lengthy and are usually administered as paper questionnaires. The aim of this study was to assess the correlation between perceived disability and psychological factors with use of the user-friendly, web-based Patient Reported Outcomes Measurement Information System initiative, and to compare its correlation with a frequently used, paper-based, pain self-efficacy questionnaire., Methods: A cohort of 213 patients completed a web-based version of the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the pain self-efficacy questionnaire, the Patient Reported Outcomes Measurement Information System-based computerized adaptive testing Pain Interference questionnaire, and the Patient Reported Outcomes Measurement Information System-based computerized adaptive testing Depression questionnaire. Bivariate and multivariable analyses measured the correlation of these psychological measures with QuickDASH., Results: There was large correlation between QuickDASH and the Pain Interference computerized adaptive testing (r = 0.74; p < 0.001), between the Pain Interference computerized adaptive testing and the pain self-efficacy questionnaire (r = -0.72; p < 0.001), and between QuickDASH and the pain self-efficacy questionnaire (r = -0.76; p < 0.001). The Depression computerized adaptive testing showed a medium correlation both with QuickDASH (r = 0.37; p < 0.001) and with the Pain Interference computerized adaptive testing (r = 0.40; p < 0.001). The best multivariable model for QuickDASH included the Pain Interference computerized adaptive testing, prior treatment received, and smoking, and accounted for 57% of the variability. Fifty-one percent of the variability in the QuickDASH was explained by pain interference alone., Conclusions: Maladaptive responses to upper-extremity pain are accurately measured by the relatively user-friendly Patient Reported Outcomes Measurement Information System-based computerized adaptive testing questionnaire.

Background: A low response rate is believed to decrease the validity of survey studies. Factors associated with nonresponse to surveys are poorly characterized in orthopaedic research., Questions/purposes: This study addressed whether (1) psychologic factors; (2) demographics; (3) illness-related factors; and (4) pain are predictors of a lower likelihood of a patient returning a mailed survey., Methods: One hundred four adult, new or return patients completed questionnaires including the Pain Catastrophizing Scale, Patient Health Questionnaire-9 depression scale, Short Health Anxiety Index, demographics, and a pain scale (0-10) during a routine visit to a hand and upper extremity surgeon. Of these patients, 38% had undergone surgery and the remainder was seen for various other conditions. Six months after their visit, patients were mailed the DASH questionnaire and a scale to rate their satisfaction with the visit (0-10). Bivariate analysis and logistic regression were used to determine risk factors for being a nonresponder to the followup of this study. The cohort consisted of 57 women and 47 men with a mean age of 51 years with various diagnoses. Thirty-five patients (34%) returned the questionnaire. Responders were satisfied with their visit (mean satisfaction, 8.7) and had a DASH score of 9.6., Results: Compared with patients who returned the questionnaires, nonresponders had higher pain catastrophizing scores, were younger, more frequently male, and had more pain at enrollment. In logistic regression, male sex (odds ratio [OR], 2.6), pain (OR, 1.3), and younger age (OR, 1.03) were associated with not returning the questionnaire., Conclusions: Survey studies should be interpreted in light of the fact that patients who do not return questionnaires in a hand surgery practice differ from patients who do return them. Hand surgery studies that rely on questionnaire evaluation remote from study enrollment should include tactics to improve the response of younger, male patients with more pain., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: Psychiatric comorbidity is known to contribute to illness (the state of feeling unwell/unable to rely on one's body) and increased use of healthcare resources, but the effect on inpatient outcomes in fracture care is relatively unexplored., Questions/purposes: Our primary null hypothesis is that a concomitant diagnosis of depression, anxiety, dementia, or schizophrenia is not associated with (1) discharge to another care facility rather than home after lower extremity fractures. Secondary study questions address the associations between psychiatric comorbidity and (2) longer inpatient stay and inpatient (3) adverse events; (4) blood transfusion; and (5) mortality after lower extremity fractures., Methods: Using the National Hospital Discharge Survey database, we analyzed a total estimated number of 10,669,449 patients with lower limb fractures from 1990 to 2007. Sixty-four percent were women, and the mean±SD age was 67±22 years. The prevalence in the study population was 3.2% for depression, 1.6% for anxiety, 0.6% for schizophrenia, and 2.9% for dementia., Results: A discharge diagnosis of psychiatric comorbidity was associated with a lower rate of discharge to home after accounting for an association with greater medical comorbidity (schizophrenia: odds ratio [OR], 5.6, 95% confidence interval [CI], 5.5-5.8; dementia: OR, 1.3, 95% CI, 1.2-1.3; depression: OR, 1.2, 95% CI, 1.2-1.3; anxiety: OR, 1.04, 95% CI, 1.02-1.06). Hospital stay was longer for patients with schizophrenia and dementia but shorter in patients with depression or anxiety compared with patients without any mental disorders. Schizophrenia was associated with more in-hospital adverse events and depression and anxiety with fewer events. A diagnosis of depression was associated with blood transfusion. Psychiatric comorbidity was not associated with a higher risk of in-hospital death., Conclusions: Optimal inpatient management of patients with lower extremity fractures should account for the influence of psychiatric comorbidities, dementia and schizophrenia in particular.

Mediators in the synovial fluid are thought to play a major role in osteoarthritic cartilage turnover. The purpose of the current study was to investigate the role of oncostatin M (OSM) in osteoarthritis (OA) by evaluating the presence of the cytokine and its receptors in the OA joint and interfering with its activity in synovial fluid co-cultured with cartilage explants. OSM levels were increased in the synovial fluid of osteoarthritic patients compared to healthy donors. Immunohistochemistry confirmed the presence of both the leukaemia inhibitory factor (LIF) and OSM receptors for OSM throughout the whole depth of osteoarthritic cartilage and synovial tissue, whereas in healthy cartilage their presence seemed more restricted to the superficial zone. Blocking OSM activity, using an activity inhibiting antibody, in 25 % osteoarthritic synovial fluid added to OA cartilage explant cultures increased glycosaminoglycan (GAG) content from 18.6 mg/g to 24.3 mg/g (P < 0.03) and total production from 7.0 mg/g to 11.9 mg/g (P < 0.003). However, OSM exogenously added to cartilage explant cultures reflecting low and high concentrations in the synovial fluid (5 and 50 pg/mL) did not affect cartilage matrix turnover, suggesting that factors present in the synovial fluid act in concert with OSM to inhibit GAG production. The current study indicates the potential to enhance cartilage repair in osteoarthritis by modulating the joint environment by interfering with OSM activity.

Purpose: To assess whether there was a difference in score between paper and telephone administration of disability and psychological questionnaires relevant to patients with an upper extremity illness., Methods: The short version of the Disabilities of the Arm, Shoulder, and Hand score, the 5-question version of the Short Health Anxiety Inventory, the 4-question version of the Pain Catastrophizing Scale, the Patient Health Questionnaire-2, and an ordinal pain scale were completed by 135 patients both in the office and the next day over the phone. We compared scores with repeated measures analysis of variance and Pearson correlation. We used intraclass correlation coefficients to test the level of agreement., Results: There were small but significant differences between paper and phone administration of the short version of the Disabilities of the Arm, Shoulder, and Hand scores and pain scores, but not the Patient Health Questionnaire-2, Short Health Anxiety Inventory-5, and Pain Catastrophizing Scale-4. There was a large Pearson correlation and excellent intraclass correlation coefficient agreement, as well., Conclusions: Shorter questionnaires can be used to assess disability and psychological factors by phone. Phone administration of measures of disability and psychological factors can replace paper administration in studies that do not require in-person examination., (Copyright © 2013 American Society for Surgery of the Hand. All rights reserved.)

Background: Questionnaires are often used to quantify the subjective aspects of illness such as disability, coping strategies, or symptoms of depression. Most questionnaires were validated in a paper-based format, but direct entry into a computer is becoming commonplace. The aim of this study was to assess differences in outcome of questionnaires pertinent to hand and upper extremity illness when they were administered in a computer or paper format., Methods: Ninety-nine patients completed both paper and web versions of the short forms of the Disabilities of Arm, Shoulder, and Hand; the Pain Catastrophizing Scale; the Short Health Anxiety Index (SHAI-6); the Patient Health Questionnaire Depression Scale; and a pain scale and the Pain Self-Efficacy Questionnaire sequentially during a single visit. We alternated starting with the paper or the web version after every five patients., Results: The cohort consisted of 46 females and 53 males with a mean age of 49 years. There were significant differences in SHAI-6 and the pain scale, but not in the other measures. The intraclass correlation was high., Conclusions: The use of these questionnaires in electronic format is valid provided that the small differences we observed are not important to the primary study question. In our opinion, for most studies, the advantages of using an electronic format outweigh the small additional variation that might be introduced in the measures in an electronic format.

Purpose: It is our impression that there is substantial, unexplained variation in hand surgeon recommendations for treatment of peripheral mononeuropathy. We tested the null hypothesis that specific patient and provider factors do not influence recommendations for surgery., Methods: Using a web-based survey, hand surgeons recommended surgical or nonsurgical treatment for patients in 2 different scenarios. Six elements of the first scenario (symptoms, circumstances, mindset, diagnosis, objective testing, and expectations) had 2 possibilities that were each independently and randomly assigned to each rater. For the second scenario, 2 different scenarios were randomly assigned to each rater. Multivariable logistic regression sought factors associated with a recommendation for surgery., Results: A total of 186 surgeons of the Science of Variation Group completed a survey regarding recommendation of surgery for 2 different patients based on clinical scenarios. Recommendations for surgery did not vary significantly according to provider characteristics. For the various elements in scenario 1, recommendation for surgery was more likely for patients who were self-employed and continued to work and who had objective electrodiagnostic abnormalities. For the 2 vignettes used in scenario 2, a recommendation for surgery was associated with abnormal electrophysiology., Conclusions: The findings of this study suggest that-at least in a survey setting-surgeons prefer to offer peripheral nerve decompression to patients with abnormal electrophysiology, particularly those with effective coping strategies., Clinical Relevance: The role of objective verification of pathophysiology is debated, but it is an influential factor in recommendations for hand surgery., (Copyright © 2013 American Society for Surgery of the Hand. All rights reserved.)

Objective: In patients with trapeziometacarpal arthrosis, we tested the hypothesis that there is no difference in arm-specific disability 5-15 weeks after prescription of a pre-fabricated neoprene or a custom-made thermoplast hand-based thumb spica splint with the metacarpophalangeal joint included and the first interphalangeal joint free., Method: One hundred nineteen patients with a diagnosis of trapeziometacarpal arthrosis were prospectively randomized to wear either a neoprene or a thermoplast hand-based thumb spica splint. At enrollment, patients completed a set of validated questionnaires. An average of 9 weeks later, patients returned for a second visit. Bivariable analyses assessed factors associated with disability, pain and satisfaction. Analysis was by intention-to-treat., Results: Sixty-two patients (32 with a neoprene and 30 with a thermoplast splint) completed the study, 51 patients (43%) did not return for the second visit, and six did not complete the protocol for other reasons. Non-completers were significantly younger than completers (P < 0.00044). On average completers rated the neoprene splint as more comfortable (P = 0.048), but there were no detectable differences in Disabilities of the Arm, Shoulder and Hand (DASH), change in DASH, pain, satisfaction, pinch or grip strength between the two splint types in our sample., Conclusion: When compared to custom-made thermoplast splints, pre-fabricated neoprene hand-based thumb spica splints are, on average, more comfortable, less expensive, and as effective in treating trapeziometacarpal arthrosis. This trial was registered at Clinicaltrials.gov (NCT00438763)., (Copyright © 2013 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Missing data are unavoidable in clinical research. Older age, female gender, and fewer years of education are risk factors for missing items in a questionnaire. This study assessed the differences between patients with complete and incomplete Disabilities of the Arms, Shoulder and Hand (DASH) questionnaires in terms of demographics and psychological factors., Methods: We analyzed a convenience sample of 1,204 patients enrolled in eight prospective studies. The DASH and the Pain Catastrophizing Scale were completed by all patients. The Center for Epidemiologic Studies Depression scale, Patient Health Questionnaire, Pain Anxiety Symptoms Scale, and an ordinal pain scale were completed by 745, 493, 545, and 391 patients, respectively. Bivariate analysis and binary logistic regression were used to determine risk factors for incomplete (one or more unanswered question) or invalid (more than three unanswered questions) DASH questionnaires., Results: Thirty-one percent of patients did not complete all questions on the DASH. Patients with an incomplete DASH were older, had fewer years of education, and had higher levels of catastrophic thinking, depression, and pain anxiety. Age and catastrophic thinking were retained in the best logistic regression models of predictors of both incomplete and invalid DASH questionnaires., Conclusions: The observation that patients who complete disability questionnaires are different from patients who do not may affect the interpretation of clinical research. Computer adaptive testing may be preferable to avoid incomplete questionnaires., Level of Evidence: Prognostic Level II.

So far, predictive models with individualized estimates of prognosis for patients with peripheral nerve injuries are lacking. Our group has previously shown the prognostic value of a standardized scoring system by examining the functional outcome after acute, sharp complete laceration and repair of median and/or ulnar nerves at various levels in the forearm. In the present study, we further explore the potential mathematical model in order to devise an effective prognostic scoring system. We retrospectively collected medical record data of 73 cases with a peripheral nerve injury in the upper extremity in order to estimate which patients would return to work, and what time was necessary to return to the pre-injury work. Postoperative assessment followed the protocol described by Rosén and Lundborg. We found that return to pre-injury work can be predicted with high sensitivity (100%) and specificity (95%) using the total numerical score of the Rosén and Lundborg protocol at the third follow-up interval (TS3) as well as the difference between the TS3 and the total score at second follow-up interval (TS2). In addition, the factors age and type of injured nerve (median, ulnar, or combined) can determine the time of return to work based on a mathematical model. This prognostic protocol can be a useful tool to provide information about the functional and social prospects of the patients with these types of injuries., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: We tested the null hypothesis that there is no difference in the change in volar tilt of the articular surface of the distal radius on lateral radiographs obtained before suture removal and 3 months or more after surgical fracture fixation when 1 or 2 rows of screws are used in the distal part of a volar locked plate., Methods: We retrospectively identified 364 consecutive patients with a distal radius fracture treated by 2 surgeons with open reduction and volar locked plate fixation between 2007 and 2011 at our institution. A manually case-matched design with one-to-one matching of 2 different strategies for screws in the distal part of the plate (1 row versus 2 rows) on the basis of sex, AO type, presence of dorsal comminution, ulna fracture, mechanism of injury, and age (± 8 y) resulted in a group of 34 pairs, 68 total fractures. Radiographic alignment was measured before suture removal and 3 months or more after surgery., Results: The change in volar tilt of the articular surface was -1.2° in the 1-row group and -0.9° in the 2-row group, which was not significantly different. The secondary displacement of radial inclination and ulnar variance were likewise small and not statistically significant., Conclusions: We found no advantage of 2 rows of distal screws over a single row of screws with respect to maintenance of achieved restoration of volar angulation after volar locked plate fixation of AO type A and C fractures of the distal radius., Type of Study/level of Evidence: Therapeutic III., (Copyright © 2013 American Society for Surgery of the Hand. All rights reserved.)

Introduction: This study aimed to determine whether, as in osteoarthritis, increased levels of interleukin-6 (IL-6) are present in the synovial fluid of patients with symptomatic cartilage defects and whether this IL-6 affects cartilage regeneration as well as the cartilage in the degenerated knee., Methods: IL-6 concentrations were determined by ELISA in synovial fluid and in conditioned media of chondrocytes regenerating cartilage. Chondrocytes were obtained from donors with symptomatic cartilage defects, healthy and osteoarthritic donors. The effect of IL-6 on cartilage regeneration and on metabolism of the resident cartilage in the knee was studied by both inhibition of endogenous IL-6 and addition of IL-6, in a regeneration model and in osteoarthritic explants in the presence of synovial fluid, respectively. Readout parameters were DNA and glycosaminoglycan (GAG) content and release. Differences between controls and IL-6 blocked or supplemented samples were determined by univariate analysis of variance using a randomized block design., Results: Synovial fluid of patients with symptomatic cartilage defects contained more IL-6 than synovial fluid of healthy donors (P = 0.001) and did not differ from osteoarthritic donors. IL-6 production of osteoarthritic chondrocytes during cartilage regeneration was higher than that of healthy and defect chondrocytes (P < 0.001). Adding IL-6 increased GAG production by healthy chondrocytes and decreased GAG release by osteoarthritic chondrocytes (P < 0.05). Inhibition of IL-6 present in osteoarthritic synovial fluid showed a trend towards decreased GAG content of the explants (P = 0.06)., Conclusions: Our results support a modest anabolic role for IL-6 in cartilage matrix production. Targeting multiple cytokines, including IL-6, may be effective in improving cartilage repair in symptomatic cartilage defects and osteoarthritis.

Background: Symptoms and psychosocial factors are suggested to account for more of the variation in disability than physical impairment, but perhaps less so at the level of specific tasks. This study assessed the influence of impaired wrist motion on specific tasks on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire., Methods: Sixty-three patients with an operatively treated fracture of the distal radius completed the Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale, and Center for Epidemiologic Studies Depression Scale (CES-D) just before surgery and the DASH questionnaire 3 months after surgery. Nine questions on the DASH were selected as potentially sensitive to changes in wrist motion and evaluated in bivariate and multivariable analyses., Results: In multivariable models of factors associated with specific tasks, only "Open a tight or new jar" was affected by wrist flexion and PCS accounting for 33 % of the variation. Motion, pain, and PCS were significant predictors of the DASH score. Among the eight tasks not related to wrist motion, 33 % of the variation in disability with writing was accounted for by PCS and limb dominance; 20 % of disability preparing a meal by pain, CES-D, and PCS; 14 % of disability with making a bed by pain and CES-D; and 23 % of changing a light bulb overhead by age, pain, and fracture type., Conclusions: After volar plate fixation of a fracture of the distal radius, upper extremity disability based on select items from the DASH questionnaire correlated minimally with impairment of wrist motion, even at the level of specific tasks., Level of Evidence: Prognostic Level II.

Background: Studies of patients with back pain, cancer, and in a general medical practice note that the use of certain phrases by a patient when communicating with their health provider can indicate greater disability and distress than expected for patients with a given disorder. However, it is unclear whether such phrases apply to patients with hand and arm disorders., Questions/purposes: We assessed whether specific patient phrases are associated with symptoms, disability, and psychologic factors in patients with hand and arm disorders., Methods: We recorded and coded 61 interviews of new patients. Specific expressions of patients were listed and categorized into six phrase categories: "I can't", "Find it and fix it", "Something is wrong", "It's serious", "Deemphasis (hoping)", and "Protective mindset". Patients completed questionnaires for arm-specific disability (DASH), depression (Patient Health Questionnaire [PHQ-9]), pain catastrophizing (Pain Catastrophizing Scale [PCS]), and heightened illness concern (Whiteley Index)., Results: Patients who endorsed phrases in the category "I can't" had higher scores on the PCS, Whiteley, DASH, and pain; they also had longer visits. Patients expressing "Something is wrong" had higher scores for the PCS, pain, and duration of visit. Patients using "It's serious" had a higher score for pain. Finally, patients using "Protective mindset" had lower PHQ-9 scores and younger age., Conclusions: Patient word choice may indicate underlying distress or ineffective coping strategies that represent important opportunities for empathy and support, including evidence-based cognitive and behavioral interventions., Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Purpose: Grip strength is influenced primarily by body mass index, sex, and age. It is also partly voluntary and correlates with symptoms of depression. This study examined whether psychological factors influence grip more in the setting of injury than in healthy volunteers., Methods: Grip strength was evaluated in one hundred subjects, 50 healthy individuals and 50 patients 6 weeks after a nonsurgically treated fracture of the distal radius. Grip strength was measured as the mean of 3 attempts, and patients completed questionnaires for arm-specific disability (Disabilities of the Arm, Shoulder, and Hand), depression, pain anxiety, catastrophic thinking, and negative thoughts in response to pain., Results: The mean grip strength in the injured group was 55% of the uninjured side. Pain anxiety accounted for 9% of the variability in grip strength in injured wrists. Among healthy patients, sex was the only correlate of dominant-side grip strength, and body mass index accounted for 8% of the variation in the grip strength of the nondominant side divided by the dominant side., Conclusions: The majority of the variation in grip strength remains unaccounted for, but physical factors correlate best with grip strength and percent grip strength of the nondominant side divided by the dominant side in healthy patients, and psychological factors correlate best with absolute grip in patients recovering from distal radius fractures., Clinical Relevance: The influences on grip strength are complex, but the differences among recovering and healthy patients demonstrate a role for nonphysical factors in grip strength during recovery., (Copyright © 2012. Published by Elsevier Inc.)

Purpose: Motivation, job satisfaction, burnout, and secondary gain are factors that can influence return to work and disability after orthopedic injuries. The current study evaluated the separate effects of job satisfaction, burnout, and secondary gain on arm-specific disability after a finger injury., Methods: Ninety-three employed patients with finger injuries were enrolled in this prospective study, and 51 completed the follow-up. Burnout (measured with Shirom-Melamed's Burnout Measure), job satisfaction (measured with the Job Descriptive Index questionnaire), and demographics were assessed at the initial visit. After 6 months, arm-specific disability was measured with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and general health status was measured with the Short Form-36 (SF-36) survey, mental component summary (MCS) and physical component summary (PCS)., Results: In the 51 patients with complete follow-up, the mean DASH score was 12, the mean SF-36 PCS was 48, the mean SF-36 MCS was 49, and the mean pain rating was 2.1. In multivariable analysis, pain and worker's compensation status explained 52% of the variability in DASH scores (pain alone accounted for 49%); pain accounted for 14% of the variability in SF-36 PCS scores; and worker's compensation accounted for 11% of the variation in the SF-36 MCS scores., Conclusions: The majority of variation in the SF-36 PCS and MCS scores remained unaccounted for by the models, but pain and worker's compensation were more important than job burnout or job satisfaction. Pain and worker's compensation were also significant predictors of the DASH., Clinical Relevance: Worker's compensation and pain were more important than job satisfaction and burnout in explaining variations in arm-specific disability in patients with finger injuries., (Copyright © 2012 American Society for Surgery of the Hand. All rights reserved.)

Stretching exercises are an important part of recovery after sustaining a fracture of the distal radius. However, from the patient's perspective, painful stretching exercises can be counterintuitive after injury. Stretching exercises are straightforward and do not require a significant amount of coaching. It is ultimately the protectiveness, passivity, and sometimes a sense of futility that require coaching. The key for the provider is to empathize with the difficult and counterintuitive nature of the recovery process., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: R117H is a frequent missense mutation included in most CFTR mutation panels. However knowledge about the residual function of R117H-CFTR channels in cystic fibrosis-affected organs, e.g. airways, intestines and sweat glands is presently lacking., Methods: We evaluated clinical CF symptoms and assessed CFTR function by sweat tests, nasal potential difference and intestinal current measurements in 2 homozygous R117H individuals (7T variant)., Results: The CFTR activity in airways and intestine was within the normal range. However both individuals presented with a borderline sweat test and the male patient was infertile., Conclusions: The lack of impact of the R117H mutation on chloride secretion in intestine and nose contrasts with the ~80% loss of CFTR activity reported in patch clamp studies. Apparently CFTR activity is not rate-limiting for chloride secretion in both tissues at levels >20% of normal, or compensatory factors may operate that are absent in heterologous host cells in vitro., (Copyright © 2011 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Background & Aims: Lubiprostone alleviates constipation by stimulating intestinal fluid secretion, purportedly through activation of ClC-2-type Cl(-) channels. Intestinal obstruction is also a recurrent cause of distress in cystic fibrosis (CF) patients, caused by loss of CF transmembrane conductance regulator (CFTR) Cl(-) channel activity. Because ClC-2 recruitment might be beneficial to CF patients, we investigated lubiprostone's mode of action., Methods: Cl(-) transport was measured in an Ussing chamber, in 3 model systems: (1) T84 colonocytes, (2) intestinal epithelium of wild-type and CF mice, and (3) intestinal epithelium of CF patients and controls., Results: In T84 monolayers, lubiprostone induced a robust secretory response. Selective permeabilization of the basolateral plasma membrane revealed that lubiprostone activated an apical Cl(-) conductance. The lubiprostone response was attenuated by H89, an inhibitor of the cAMP-dependent protein kinase, and lubiprostone precluded responsiveness to the cAMP agonist forskolin. CFTR blockage by CFTRinh172, but not ClC-2 blockage by CdCl(2), inhibited the lubiprostone response. Lubiprostone induced a CdCl(2)-insensitive secretory response in mouse intestine, but failed to induce intestinal Cl(-) secretion in Cftr-null mice. Correspondingly, lubiprostone induced a secretory response in human intestinal epithelium, but not in tissue of CF patients. The EP(4)-type prostanoid receptor antagonist L-161,982 blocked the lubiprostone response in all 3 models studied. In T84 cells, lubiprostone induced a rise in cAMP levels that was sensitive to EP(4)-receptor blockage., Conclusions: Lubiprostone enhances intestinal Cl(-) and fluid secretion via prostanoid receptor signaling, triggering activation of CFTR. Therefore, it is of limited use for treatment of CF-related intestinal disease.

Cystic fibrosis, an autosomal recessive disease frequently diagnosed in the Caucasian population, is characterized by deficient Cl- transport due to mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. A second major hall-mark of the disease is Na+ hyperabsorption by the airways, mediated by the epithelial Na+ channel (ENaC). In this study, we report that in human airway epithelial CF15 cells treated with the CFTR corrector miglustat (n-butyldeoxynojyrimicin), whole-cell patch-clamp experiments showed reduced amiloride-sensitive ENaC current in parallel with a rescue of defective CFTR Cl- channel activity activated by forskolin and genistein. Similar results were obtained with cells maintained in culture at 27 degrees C for 24 h before electrophysiology experiments. With monolayers of polarized CF15 cells, short-circuit current (Isc) measurements also show normalization of Na+ and Cl- currents. In excised nasal epithelium of cftr(F508del/F508del) mice, like with CF15 cells, we found normalization of amiloride-sensitive Isc. Moreover, oral administration of miglustat (6 days) decreased the amiloride-sensitive Isc in cftr(F508del/F508del) mice but had no effect on cftr-/- mice. Our results thus show that rescuing the trafficking-deficient F508del-CFTR by miglustat down-regulates Na+ absorption. A miglustat-based treatment of CF patients may thus have a beneficial effect both on Cl- and Na+ transports.

Most cells have to perform their physiological functions under a variable osmotic stress, which, because of the relatively high permeability of the plasma membrane for water, may result in frequent alterations in cell size. Intestinal epithelial cells are especially prone to changes in cell volume because of their high capacity of salt and water transport and the high membrane expression of various nutrient transporters. Therefore, to avoid excessive shrinkage or swelling, enterocytes, like most cell types, have developed efficient mechanisms to maintain osmotic balance. This chapter reviews selected model systems that can be used to investigate cell volume regulation in intestinal epithelial cells, with emphasis on the regulatory volume decrease, and the methods available to study the compensatory redistribution of (organic) osmolytes. In addition, a brief summary is presented of the pathways involved in osmosensing and osmosignaling in the intestine.