Current concepts in the management of the rheumatoid hand

Hand surgeons are an integral part of the management team for patients with rheumatoid arthritis. There is now a greater understanding of the national use of rheumatoid hand surgery, which highlights the differences between hand surgeons and rheumatologists regarding the treatment of the rheumatoid hand. Advances in medical treatments have also decreased the prevalence of hand deformities caused by this disease. Hand surgeons today have less exposure to treating rheumatoid hand, but despite more effective medical options, surgery may still offer patients hope for improvement of hand function and appearance. This article summarizes the current state of rheumatoid hand surgery and discuss the surgical treatment strategies for optimizing outcomes for patients with rheumatoid arthritis.     

Rheumatoid hand surgery: differing perceptions amongst surgeons, rheumatologists and therapists in the UK

Rheumatoid arthritis is a systemic disease that requires coordinated management by rheumatologists, surgical specialists and therapists working in a multidisciplinary team. Differences of opinion within the team may adversely affect patient care. Our aim was to assess differences in perception about rheumatoid hand surgery between rheumatologists, hand surgeons and hand therapists in the UK. We used a postal questionnaire to assess commonly performed rheumatoid hand operations. For each procedure, respondents rated the most important indication for surgery and scored effectiveness at reducing pain, improving function and aesthetics, and preventing deformity. Statistically significant differences were found between all three groups with regards to expected outcome and main indications for surgery. We concluded that significant differences do exist in the perceptions of rheumatologists, surgeons and therapists. Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team.     

The current state of hand transplantation

Hand transplantation is the most common form of modern composite tissue allotransplantation. Successful application of this technology requires a multidisciplinary approach incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and others. Functional outcomes can be life changing for properly selected candidates. Hand transplantation is becoming more common, with more centers offering this relatively new reconstructive modality. Its success depends on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection but has minimal or acceptable morbidity.     

The creation of a geriatric trauma unit "G-60"

Many elderly trauma patients have isolated orthopedic injuries compounded by chronic medical conditions. We organized a trauma unit, led by trauma surgeons, that is designed to expedite the care of geriatric patients through a multidisciplinary approach. The development of G-60, our Geriatric Trauma Unit, began with discussion between trauma surgeons and hospital administration. Dialogue between trauma surgeons and emergency department physicians yielded triaging, disposition, and admission criteria. Orthopedic surgeons helped implement a goal of operative management in 48 hours. Internal medicine assisted in optimizing chronic disease and providing preoperative clearance with involvement of cardiology and anesthesiology. Meetings were held among surgeons, physical therapists, occupational therapists, respiratory therapists, nutritionists, pharmacists, social workers, case managers, internists, a geriatrician, and physical medicine and rehabilitation. A unit in the hospital was chosen, and a paging system was implemented. Six months lapsed from inception to fulfillment. The multidisciplinary team has achieved several improvements in this population. Through a multidisciplinary approach, a geriatric trauma unit was created that expedites triage, optimizes chronic illness to facilitate definitive management, and provides safe discharge.     

Screening for Falls and Osteoporosis: Prevention Practice for the Hand Therapist

Fractures of the upper extremity are considered a hallmark of underlying osteopenia or osteoporosis and strong predictors of subsequent fractures. Falling is the strongest single risk factor for fractures in older adults. Studies have shown that interventions to prevent falls can significantly reduce this risk factor. Hand therapists working with patients with an upper extremity injury from a fall cannot assume that screening for osteoporosis or the likelihood of falls has been addressed by other health care professionals. The purposes of this article are to 1) summarize osteoporosis and falls risk screening, 2) describe how fall prevention strategies can be integrated into hand therapy practice, and 3) present evidence for federal and professional organizational support of prevention practice.     

Management of the upper limb in cerebral palsy

The management of the upper limb in cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, occupational therapists, physiotherapists, orthotists and upper extremity surgeons. Interventions are generally aimed at improving function and cosmesis by spasticity management, preventing contractures and correcting established deformities. Treatment objectives vary according to each child and range from static correction of deformities to ease nursing care, to improvements in dynamic muscle balance to augment hand function. Botulinum toxin A therapy has been shown to relieve spasticity and improve function in the short term. Surgery is also effective but requires careful patient selection, as many children with cerebral palsy are not candidates for surgery. Occupational therapy and physiotherapy have small treatment effects alone but are essential adjuncts to medical and surgical management.     

The hand in recessive dystrophic epidermolysis bullosa

Recessive dystrophic epidermolysis bullosa is still a difficult challenge for surgeons and doctors. Hand retractions are different from burns. The medical team must have a good knowledge of the disease. Surgery must be performed with the collaboration of every member of the team, as well as the family. In young children, complete correction of the retractions is possible. On the other hand, when retractions are present for a long time in children and adolescents, surgery is purely functional. Static and dynamic splints delay recurrences, but their prolonged use presents psychological obstacles in adolescents and adults.     

Update on advances in upper extremity prosthetics

Upper extremity amputations are common. Fortunately, most of these involve loss of only a finger or portion thereof. Hand and upper limb surgeons are best suited to lead the team and help these patients following these injuries. Proximal amputations can be devastating for the patient, but recent prosthetic advances have helped many patients lead a better life and, often, return to activities they were involved in before their amputation. The purpose of this article is to review the current prostheses available for upper extremity amputees.     

Beyond the hand and upper extremity: The role of hand therapists in care of people with rheumatic diseases

Study designInvited Clinical CommentaryBackgroundArthritis is one of the most frequently reported causes of disability in the United States and the prevalence is expected to increase in the coming decades. While many rheumatic diseases involve hand impairments, most are systemic and involve more than the musculoskeletal system. Functional and work disability are high and people would benefit from the services of occupational and physical therapists.Purpose of studyThis paper reviews concepts of self-management, and symptoms that contribute to limitations and restrictions to participation in daily life in people with rheumatic diseases and suggests roles for hand therapists beyond the immediate hand impairments.MethodsThe impact of selected rheumatic diseases on functional and work disability are reviewed along with strategies for symptom management and self-management. Upper extremity impairments of selected rheumatic diseases are also discussed.ResultsThe role for hand therapists in evaluating and addressing the complex needs of persons with rheumatic diseases, including less common diseases, is discussed. Outcome measures for fatigue, muscle involvement, ergonomics and computer use, and work disability are introduced. Finally, strategies for self-management and prevention of work and functional disability, along with symptom management for fatigue and pain are presented.ConclusionHand therapists can play a vital role in chronic rheumatic disease management to improve self-management and increase participation in meaningful activities. Patients, primary care and rheumatology providers need to be educated about the scope of services occupational and physical therapists provide beyond the hand impairments.     

Virtual health care & telehealth: Current therapy practice patterns

Study designSurvey Study.PurposeTo investigate recent practice changes with respect to the provision of virtual visits by hand therapists due to the COVID-19 pandemic by asking about changes in the frequency of virtual visits, the assessments and treatments currently provided virtually, and the opinions of therapists on the future on virtual visits in hand therapy practice.MethodsThe survey was distributed to the American Society of Hand Therapists (ASHT), the Australian Hand Therapy Association (AHTA), the Canadian Society of Hand Therapists (CSHT), and the European Federation for the Societies of Hand Therapy (EFSHT).ResultsOf the 819 responses, there were 573 therapists (70%) who reported that they currently use virtual visits in their practice. Only 38 therapists (4.6%) were providing virtual visits prior to COVID-19, representing a 15-fold increase in virtual visits since the beginning of the pandemic. Only 26% (n = 213) reported that they used patient-reported outcome measures (PROM) in conjunction with their virtual visits. Approximately 78% (n = 638) said that they thought there is a sustainable future for this method of care in hand therapy practice.DiscussionThis survey has helped identify the changing landscape in the provision of rehabilitation and established some of the common assessments and interventions currently utilized by hand therapists in the virtual environment. Next, steps for research are to investigate the reliability and validity of some of the assessments and interventions used, to establish whether virtual care will provide good outcomes for patients, and ultimately understand the optimal combination of conventional therapy and virtual care.     

An overview of HIV infection and AIDS: etiology, pathogenesis, diagnosis, epidemiology, and occupational exposure

Thanks to a worldwide collaborative effort among health care providers, academia, governments, and industry, our knowledge base about infection caused by the human immunodeficiency virus (HIV) has expanded exponentially. During the past 2 decades, we have learned about its pathogenesis, virology, immunology, epidemiology and treatment. In the developed world, the approach to persons with HIV disease has evolved from palliative disease care to use of a chronic disease model, where survival is measured by decades, not months or years. More and more, clinical decision-making for HIV-infected patients is driven by comorbidities, including cardiothoracic disease. Thus, our clinically stable HIV population is increasingly accessing those health care services required by any maturing population, including the usual services of cardiothoracic surgeons. In this article, we review the basic facts of HIV disease, with an emphasis on occupational risks and infection control procedures.     

Screening and Evaluation of the Cardiovascular and Pulmonary Systems in Patients Presenting with Upper Extremity Impairments

Narrative ReviewGiven the prevalence of cardiovascular and pulmonary (CV-P) disease, it is likely that a substantial portion of patients seeking services from hand therapists have diagnosed or yet to be diagnosed disease in one or both of these systems. Pain originating from these systems is more common in the chest, shoulder, and scapular regions, but both systems can refer pain into the medial aspect of the forearm and hand. Pancoast's tumors of the lung, myocardial ischemia, and myocardial infarction are examples of specific pathologies capable of referring pain into these upper extremity regions. Another concern for the hand therapist is that upper extremity exercise is more stressful on the cardiovascular system than lower extremity exercise. Because of this, hand therapists need to be able to recognize when to discontinue or modify exercise interventions based on inappropriate cardiovascular system responses. Thus, the purpose of this review is to present 1) screening for potential pathology in the CV-P systems, 2) methods typically available to hand therapists for monitoring these systems, 3) criteria that indicate the need for therapy modification or medical referral, and 4) symptomatology of some common cardiac and pulmonary pathologic conditions the hand therapist may encounter.Level of Evidence5.     

Merkel cell carcinoma of the skin: two case reports located at the hand, with a review of litterature

The Merkel cell carcinoma of the skin are rare neuroendocrine tumours, with a dermal location. Their severity and metastatic potential are higher than cutaneous melanomas'. Two cases are reported at the hand. A review of literature displays the pejorative prognosis of these tumours. Hand surgeons must be aware of them, in order to fasten the diagnosis and include the patient among a multidisciplinary medical team.     

Treatment of complex regional pain syndrome of the lower extremity

Complex regional pain syndrome, formerly known as reflex sympathetic dystrophy or causalgia, is a difficult therapeutic problem for the orthopaedic surgeon treating an affected lower extremity. Despite many divergent and often conflicting theories, the cause of the severe pain, alterations in regional blood flow, and edema is unknown. Interventions that have proved successful for treating similar conditions in the arm and hand frequently do not relieve pain similarly in the lower extremity. Common treatment regimens target individual components of this symptom complex, namely, sympathetic or afferent nerve hyperactivity, vasomotor instability, or regional osteoporosis. Despite widespread use of some of these treatments, few controlled clinical trials quantify their effectiveness. This challenging syndrome is best managed by a multidisciplinary team, including chronic pain management specialists, physical therapists, and orthopaedic surgeons.     

Replantation of the upper extremity: Indications and outcomes

Since the introduction of microsurgical technique over 40 years ago, replantation of the upper extremity has been performed throughout the world with regularity. Instead of focusing solely on survival of the replanted parts, hand surgeons are more aware of the functional, health-related quality of life and economic issues associated with this complex procedure. Derived from several decades of experience, the indications for replantations in the upper extremity have become more defined and the functional outcomes have improved. In indicated cases, replantation procedures provide patients with reconstruction that is unmatched by any other means. This article discusses the current status of replantation and condenses the particulars of performing upper-extremity replantations. Copyright © 2002 by the American Society for Surgery of the Hand