This study describes the introduction of a virtual pathway for the management of suspected scaphoid fractures and reports patient-reported outcome measures (PROMs) and satisfaction following treatment with this service.

All adult patients that presented with a clinically suspected scaphoid fracture that was not visible on presentation radiographs over a one-year period were eligible for inclusion in the pathway. Demographics, examination findings, clinical scaphoid score (CSS) and standard four view radiographs were collected at presentation. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year post presentation and included the QuickDASH, EQ-5D-5L, the Net Promoter Score (NPS) and return to work.

There were 221 patients referred to the virtual pathway. The mean age was 41 (range 16–87; SD 18.4 years) and there were 99 men (45%). There were 189 (86%) patients discharged with advice and 19 (9%) patients were recalled for clinical review (seven undisplaced scaphoid fractures, six other acute fractures of the hand or wrist, two scapholunate ligament injuries, and four cases where no abnormality was detected). Thirteen patients (6%) initiated follow-up with the hand service; no fracture or ligament injury was identified within this group. PROMs were available for 179 (81%) patients at a mean of 19 months follow-up (range: 13 – 33 months). The median QuickDASH score was 2.3 (IQR, 0–15.9), the median EQ-5D-5L was 0.85 (IQR, 0.73–1.00), the NPS was 76, and 173 (97%) patients were satisfied with their treatment. There were no documented cases of symptomatic non-union one year following injury.

This study reports the introduction of a virtual pathway for suspected scaphoid fractures, demonstrating high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases.

Introduction

Carpal tunnel syndrome is a common neuropathy of the median nerve. Occupation has been widely examined as a risk factor for the development of carpal tunnel syndrome. The aim of this study was to examine the validity of the United Kingdom (UK) NS-SEC (National Statistics Socioeconomic Classification) in the assessment of correlation between occupation and CTS.

A rolled-up finger from a surgical glove has been described in the literature and commonly used as a tourniquet during procedures on digits. The National Patient Safety Agency (NPSA) issued a rapid response report in December 2009 that recommended the use of CE marked finger tourniquets and prohibited the use of surgical gloves for this purpose. This study aimed to measure the pressures exerted by a range of digital tourniquets.

A Tekscan FlexiForce¯ pressure sensor was used to measure the surface pressures under different types of finger tourniquet applied to a cylinder representing a finger. The tourniquets tested were the Toe-niquet^™, the T-Ring^™ and a tourniquet made using a rolled up surgical glove finger.

The pressure exerted by these tourniquets varied between types and depended on the size of model finger. The lowest mean pressures were produced by the T-Ring(tm) and glove finger tourniquet on a small finger (146 and 120 mmHg), while the highest pressures were produced by the Toe-niquet(tm), which produced 663 and 1560mmHg on the small and large finger models respectively. There was a significant overall difference between tourniquet type (p<0.001) and finger size (p<0.001).

Wide variability in surface pressures is a function of material type, product design and finger size. It is difficult to anticipate and regulate pressures generated by non-pneumatic tourniquets. Tourniquet safety must also focus on procedural issues, ensuring the removal of the tourniquet at the end of procedure, through increased use of surgical checklists.

The suture properties associated with a successful tendon repair are: high tensile strength, little tissue response, good handling characteristics and minimal plastic deformation. Plastic deformation contributes to gap formation at a tendon repair site. Gaps greater than 4mm are prone to failing. This study investigates whether the plastic deformation demonstrated by two commonly used suture materials can be reduced by manual pre-tensioning.

Twenty sutures of both Prolene 3/0 (Ethicon, UK) and Ethibond 3/0 (Excel, Johnson and Johnson, UK) were tested. Half of the sutures in each group were manually pre-tensioned prior to knot tying and half were knotted without pre-tensioning. All knots were standard surgical knots with six throws. The suture lengths were measured before and after a standardised cyclical loading regime on an Instron tensile tester. The regime was designed to represent the finger flexion forces produced in a typical rehabilitation programme. All sutures were subsequently tested to their ultimate tensile strength.

After cyclical loading the pre-tensioned sutures demonstrated a mean increase in suture length of 0.7% (range 0.1-1.9%). The sutures not pre-tensioned showed a mean increase of 5.4% (range 3.3-7%). This equates to 87% less plastic deformation (p <0.05 Students' T-test) upon pre-tensioning. There were no differences with Ethibond. Pre-tensioning had no effect on ultimate tensile strength for either group.

Manual pre-tensioning reduces plastic deformation in Prolene 3/0 sutures without affecting the ultimate tensile strength. This simple technique could theoretically diminish gap formation at the site of a tendon repair.