Background: Hand injuries are a significant and rising burden on the Emergency Department (ED), often leading to protracted waiting times for patients awaiting specialist input. To combat this, a new treatment pathway for hand trauma was introduced at our institution to reduce waiting times and pressure on the ED. Methods: The treatment pathway performance using waiting times, length of stay and cost metrics was measured prior to and following the introduction of a new treatment pathway. Results: There were 15,539 patients reviewed in total. After the new pathway had been introduced, the number of assessments in ED significantly reduced (Year 1: 907 [19.9%] vs. Year 2: 422 [7.9%]; p < 0.001), and the proportion of patients who had an operation on the same day that they were assessed significantly increased (69 [1.5%] vs. 403 [7.5%] patients; p < 0.001). The median waiting time from assessment to operation and length of stay also significantly reduced following the introduction of the treatment pathway (Year 1: 53 hours and Year 2: 45 hours; p < 0.001). Conclusions: Our data over 3 years shows that these changes have been maintained and, in some cases, have continued to improve since the introduction of the new treatment pathway. We advocate the use of such an approach for all hand trauma centres worldwide to replicate these improvements in patient care. Level of Evidence: Level III.

Background: Phalangeal fractures are common in hand injuries which: comprising of 23% of all hand and forearm fractures. The current consensus is that focus of treatment should be on prompt irrigation and debridement to reduce infection risk. These infections are significant as they can lead to serious sequelae including osteomyelitis. The aim of this study was to determine the incidence of infection amongst patients with open fracture of distal phalanx who had been treated with K-wire fixation and the timing of their operative management compared to the UK national guideline. Methods: We performed a retrospective case-note analysis of the patients treated for open distal phalangeal fractures at a regional hands centre over the period of 12 months, and compared with the national guidelines. Data collected included patient demographics, mechanism of injury, length of time taken from injury to first washout, length of time K-wire remains in situ, and infection rate. Results: Half of the patients (n = 19) met the guideline and were treated with washout within the first 24 hours. Infection rates in this group was 11%. This compared with 26% in those patients that did not receive washout within 24 hours. Conclusions: This study demonstrates the difficulty in always meeting national guidelines and suggests key reasons for this. The authors propose a set of local, easily-achieved interventions to raise awareness and compliance with the national guidelines and reduce infection. Furthermore, it highlights the importance of carefully selecting cases that required percutaneous K-wire fixation.

Nerves may be inadvertently injured during trauma surgery due to distorted anatomy, traction applied to a limb, soft tissue retraction, by power tools, instrumentation and from compartment syndrome. Elective orthopaedic surgery has additional risks of joint dislocation for arthroplasty surgery, limb lengthening, thermal injury from cement and direct injury from peripheral nerve blocks.The true incidence is unknown, and many cases are diagnosed as neurapraxia with the expectation of a full and timely recovery without the need for intervention. The incorrect assignation of a neurapraxia diagnosis may delay treatment for a higher grade of injury and in addition fails to recognize that a diagnosis of neurapraxia should be made with caution and a commitment to regular clinical review. Untreated, a neurapraxia can deteriorate and result in axonopathy. The failure to promptly diagnose such a nerve injury and instigate treatment may result in further deterioration and expose the clinician to medicolegal challenge.The focus of this review is to raise awareness of iatrogenic peripheral nerve injuries in orthopaedic limb surgery, the importance of regular clinical examination, the role of investigations, timing and nature of interventions and also to provide a guide to when onward referral to a specialist peripheral nerve injury unit is recommended. Cite this article: EFORT Open Rev 2021;6:607-617. DOI: 10.1302/2058-5241.6.200123.

In this study, we characterised the effect that seeding keratinocytes on the papillary and reticular dermis had on the extracellular matrix and tissue integrity ex vivo. Human skin explants from consented patients ( n = 6) undergoing routine surgery were cultured at a liquid–air interface, dermal-side up, and autologous keratinocytes seeded on the exposed papillary or reticular layer. After 7–21 days, histological and immunohistochemical evaluation of the morphology and extracellular matrix was performed. While the dermis remained robust in all explants cultures, keratinocytes seeded on the papillary layer showed less tissue infiltration and remodelling and formed clusters across the tissue. In contrast, keratinocytes seeded on the reticular layer infiltrated the tissue homogenously with an intact single-cell-layer surface coverage and structural changes characterised by increased deposition of ground substance, glycosaminoglycans, and collagen VII in 14 days. In addition, while the papillary section showed more new laminin deposition by 14 days than the reticular section, the latter expressed more connexin 43. These differences in re-epithelialisation and extracellular matrix characteristics suggest that wound depth and graft thickness may play a key role in wound healing and indicate that ECM characteristics should be factored in when designing biomaterials for wound applications and in the selection of recipient sites when using cells for grafting.

The purpose of this study was to explore the difference in clinical outcome of 2-strand and 4-strand flexor tendon repairs in a single unit in adult population. A total of 109 complete divisions of a single flexor tendon were analyzed from 2016 to 2018 retrospectively. Thirty flexor tendons were repaired with 2-strand and 79 tendons were repaired with 4-strand technique. There was no significant difference in the complication rate including rupture, infection, and adhesions. These results support that 4-strand is not superior than 2-strand and that lower volume type of repair would be preferable.