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Traffic enforcers are exposed to various occupational health and safety hazards, including noise pollution, which may lead to occupational hearing loss. This cross-sectional study aimed to estimate the prevalence of hearing loss and to assess the relationship between occupational noise exposure level (ONEL) and abnormalities in air conduction thresholds among Metropolitan Manila Development Authority (MMDA) employees along Epifanio delos Santos Avenue, Philippines. Eight-hour ONELs were measured among 108 participants working with greater than 5 years of service. Participants had hearing evaluations using pure tone audiometry (PTA) to calculate the prevalence of hearing loss. Generalized linear models with a Poisson distribution were fitted to estimate the association between ONEL and audiologic abnormalities, controlling for confounding factors. Approximately 16% of employees had hearing loss. The prevalence of hearing loss was higher with ONEL exposures greater than 85 A-weighted decibels (dBA), with traffic enforcers exposed to higher ONELs than office workers. ONELs greater than 85 dBA were related to audiologic abnormalities at different frequencies in PTA. The prevalence of audiologic abnormalities at 4000 Hz and 6000 Hz was 48% higher (adjusted prevalence ratio [aPR], 1.48; 95% CI, 1.12-1.96) and 25% higher (aPR, 1.25; 95% CI, 1.00-1.55), respectively, among participants with ONELs greater than 85 dBA than with ONELs less than or equal to 85 dBA. Participants exposed to ONELs greater than 85 dBA, more likely traffic enforcers, may have increased risk of audiologic abnormalities. Regular ONEL monitoring is warranted for occupational risk assessment of traffic enforcers. A hearing conservation program may need to be considered for this population. Additional studies are needed to determine trends in hearing deterioration among traffic enforcers.

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Purpose: The objective of this study was to compare the outcomes of a single nerve transfer (SNT) with double nerve transfer (DNT) in the restoration of shoulder function in patients with upper (C5-6) or extended upper-type (C567) brachial plexus injuries. Methods: A retrospective review of patients with C5-6 or C567 brachial plexus injuries operated on with nerve transfers from January 1, 2005, to December 31, 2017, was completed. The outcomes between SNT and DNT groups were evaluated with the Filipino Version of the Disabilities of the Arm, Shoulder, and Hand (FIL-DASH) scores, pain scores, muscle strength recovery, and range of motion. A subgroup analysis on surgical delay (< or ≥ 6 months), diagnosis (C5-6 or C567), and length of follow-up (< or ≥ 24 months) was also performed. All statistical significance was set at P < .05. Results: A total of 22 patients with SNT and 29 with DNT were included in this study. There was no significant difference between the SNT and DNT groups as to postoperative FIL-DASH scores, pain, recovery of ≥M4, and range of motion for shoulder abduction and external rotation, although the absolute values for shoulder function were greater in the DNT than the SNT group. There was no significant difference between the SNT and DNT groups for surgical delay, diagnosis, and length of follow-up. A stronger recovery of ≥M4 for external rotation was observed in the DNT group compared to the SNT group if nerve transfer was performed in less than 6 months (86% vs 41%). Conclusions: The outcomes for shoulder function between the 2 groups were similar, although the DNT group performed slightly better, especially with external rotation. Patients operated on less than 6 months from injury will benefit more from DNT for shoulder function, especially for external rotation. Clinical relevance: Double nerve transfer may result in improved shoulder function.

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The use of wide-awake local anesthesia, no tourniquet (WALANT) has been adapted by most hand surgeons in the Philippines. This is especially true for centers with a large volume of patients needing specialized care for the hand. The use of WALANT has enabled surgeons to do procedures on an outpatient basis, thus potentially creating cost-saving measures for patients and health care facilities. Aside from common outpatient procedures like carpal tunnel syndrome, trigger finger, and de Quervain tenosynovitis, open reduction internal fixation of hand fractures, acute tendon repairs, tendon transfers, and reconstructions have been performed under WALANT as outpatient procedures. The future of WALANT surgery in the Philippines is promising. Teaching WALANT to other areas of the country can counterbalance the large disproportion of hand surgeons to patients and the concentration of specialized care in urban areas. This will enable patients to receive surgical hand care without going to large urban centers.

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BACKGROUND: Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries. OBJECTIVE: To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries. METHODS: A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P < .05. RESULTS: Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance. CONCLUSION: Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.

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Sharps and needlestick injuries are serious work-related injuries to the hand in healthcare workers (HCWs). We present two cases of HCWs with hand injuries from opening a medicinal glass ampoule. The index finger (IF) was involved in both cases, with an associated flexor tendon injury, presenting as inability to flex the proximal and distal interphalangeal joints. Sensation was intact, and radiographs showed no foreign body.The surgical repair of the flexor tendon injury was carried out using the Wide-awake Local Anaesthesia No Tourniquet technique. The quality of the repair was tested intraoperatively. Physiotherapy involved gradual progression of finger flexion from 30% to 50% to full range of motion. At 36 and 42 months follow-up, they regained the IF range of motion and returned to work.Flexor tendon injuries from opening medicinal glass ampoules are rare but can be devastating, with a long rehabilitation process after surgical repair.

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BACKGROUND: Traumatic brachial plexus injuries are devastating injuries with lifelong disability and pain. The objective of this paper was to determine the functional disability of adult patients with traumatic brachial plexus injuries. PATIENTS AND METHODS: A cross-sectional study was done to determine the functional disability of patients using the FIL-DASH (Filipino Disability of the Arm, Shoulder and Hand) and the BPI (Brief Pain Inventory) Severity Pain Score (Tagalog version) questionnaires to determine the functional disability and quality of life of patients with traumatic brachial plexus injuries. A regression analysis was done to determine the factors associated with the FIL-DASH score with the level of significance set at p < 0.05. RESULTS: A total of 126 adult patients with traumatic brachial plexus injuries were evaluated with a mean age of 30.1(standard deviation [SD], 9.1; range, 17-69). There were 123 males and three females. The mean quality of life (FIL-DASH Score) of the 126 patients was 45.6 (95% CI: 42.5 - 48.7), (SD, 17.4), (range, 2.5 - 89.2), the mean BPI Severity Pain Score was 16.1 (95% CI: 14.6-17.8; SD, 8.9; range, 0-36) among 126 patients. On multivariate analysis using the hierarchical method of model building, higher range of elbow flexion, lower Brief Pain Inventory Severity Score, and longer months from injury were found to be associated with a better FIL-DASH score. CONCLUSION: The study showed that elbow flexion recovery, pain and duration of the injury were significantly associated with the FIL-DASH scores.

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Background: The objective of this paper was to determine the validity, reliability and internal consistency of the translated FILIPINO DASH (FIL-DASH) questionnaire in patients with traumatic brachial plexus injuries. Methods: Thirty-five adult patients with traumatic brachial plexus injury were enrolled in the validation stage. The same questionnaire was given to the patient between 7 to 14 days for the test-retest reliability. The validated Filipino version of the SF-36 was used as the gold standard to determine the construct validity of the translated DASH. We also compared the DASH score with the SF-36 total and subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Acuity Scale (VAS) for Pain. Results: The internal consistency was adequate, with Cronbach's Alpha for the 30 items of 0.93 and an average inter-item covariance of 0.399. The test-retest reliability was 0.87 (p < 0.001). There was no significant difference in establising the validity of the translated DASH against SF-36 total and Subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Analogue Scale (VAS). Conclusions: The translated DASH (FIL-DASH) questionnaire was internally consistent and showed no difference in testing for test-retest reliability and validity against functional outcome measures and pain scales validated for adult Filipinos.

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Hand infection has been associated with increased morbidity in people with diabetes mellitus. PURPOSE: This study was conducted to determine risk factors for hand wound infection in patients with diabetes mellitus. METHODS: A 1:3 matched prospective case-control study was conducted from December 2006 to December 2016. All study patients were consecutively identified through the inpatient records upon admission to the University of the Philippines Manila, Philippine General Hospital (Manila, Philippines), for a hand wound infection necessitating surgical treatment and were followed until hospital discharge, wound healing, or death. Adults (≥18 years old) with diabetes mellitus for at least 6 months and with (study group) or without (control group) a hand wound infection were eligible to participate. Persons with a history of amputation or who were in a chronic debilitated state were excluded. Infection was defined as the presence of inflammation and purulent discharge. Eligible control patients were consecutively recruited from the outpatient clinics and were matched to the study patients by age (± 5 years) and gender. Demographic (eg, age, gender, education, occupation, tobacco use) and clinical data (body mass index [BMI], duration of diabetes, HbA1c levels, wound location and duration, delay in treatment, neuropathy, surgical procedures, length of hospital stay, and presence of arteriovenous [AV] fistula) were collected from patient records and entered into Excel spreadsheets for analysis. Regression analysis was performed and reported as odds ratio (OR) with 95% confidence intervals (CI). Level of significance was set P <.05. RESULTS: Participants included 30 study and 90 control patients. No significant differences between study and control patients were noted in terms of BMI, duration of diabetes, presence of peripheral neuropathy, occupation, or education. Significantly more study patients had elevated HbA1c (86 vs. 30; P = .0001), used tobacco (17 vs. 8; P = .0001), and had an AV fistula (3 vs. 0; P = .015). After multivariate analysis, HbA1c ≥48 mmoL/moL (OR = 18.8; 95% CI: 2.3-153.8; P = .006) and tobacco use (OR = 10.7; 95% CI: 3.5-32.7; P = .0001) were identified as independent risk factors for hand/upper extremity infection. CONCLUSION: Patients with diabetes who smoked or exhibited elevated HbA1c levels were at higher risk of having a hand infection. Further research and efforts to help people with diabetes stop smoking and maintain good glycemic control may help decrease the burden of hand infection.

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Background The use of the fibula autograft has been a reliable method in the reconstruction of long bone defects after tumor resection. The objective of this study was to report the outcomes fibular grafting in terms of graft union, functional score, complications, and oncologic outcome. Methods A retrospective review of patients with fibular grafting after tumor resection was done from January 1, 1993 to December 31, 2013. The primary outcome was graft union and the revised musculoskeletal tumor society scoring system (MSTS score). The secondary outcomes were oncologic outcomes, complications, and the factors associated with graft union. Results A total of 52 patients with a mean follow-up of 42 months (SD, 33; range, 12-132 months) were included. The overall union for all fibular grafts was 37 of 52. The use of vascularized free fibula flaps had a higher union rate compared with nonvascularized fibula grafts. The use of a vascularized free fibular flap was four times likely to unite (95% CI 1.1-12.8, p = 0.039) compared with nonvascularized fibular grafts. The mean MSTS score in 36 patients was 82.5 (SD, 12.9) at 35 months from surgery (SD, 30). A total of 39 complications were present in 29 patients. On final follow-up, 45 of 52 patients were alive, six patients had died of disease and one died of other causes. Conclusion A higher union rate was achieved using vascularized free fibular flaps compared with nonvascularized fibular grafts for long bone reconstruction after tumor resection. There was no difference in terms of MSTS score between the two types of grafts.

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BACKGROUND: Restoration of elbow function in traumatic brachial plexus injury patients remains the priority in the reconstruction of the involved extremity. In cases of complete nerve root injuries and in delayed cases, the only option for elbow reconstruction is the functional free muscle transfer. The purpose of this paper was to present the clinical outcomes and complications of functioning free muscle transfers using the gracilis muscle for the restoration of elbow flexion in brachial plexus injury patients in a tertiary institution from January 1, 2005 to January 31, 2014. PATIENT AND METHODS: A retrospective review of all patients who had functioning free muscle transfers for elbow flexion was done with a minimum of 12 months follow-up. Outcome measures were elbow flexion in terms of range of motion in degrees, muscle strength of the transferred muscle, VAS (visual analogue scale) for pain, postoperative DASH scores and complications of the procedure. RESULTS: There were 39 males and three females. The average age at the time of surgery was 28.6 (SD, 8.5) years. The average delay to surgery was 16 months (range, 3-120 months). The flap success rate for viability was achieved in 38 of 42 patients. The average follow-up for the 38 patients was 30 months (range, 12-103 months, SD 19 months). Success rate of at least M3/5 muscle strength was achieved in 37 of 42 patients with an average range of elbow flexion of 107° (SD, 20.4°). The average post-operative VAS for pain was 3.6 (SD, 3.0). The average post-operative DASH score was 43.09 (SD, 14.9). There were a total of 10 minor complications and five major complications. CONCLUSION: Functioning free muscle transfer using the gracilis muscle was a reliable procedure in the restoration of elbow flexion in patients with incomplete brachial plexus injury treated beyond 6 months from the time of injury and in patients with complete injuries.

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The objective of this article was to evaluate the clinical results of nerve transfer procedures for the restoration of shoulder abduction and external rotation in patients with traumatic brachial plexus injuries. A retrospective study was done to determine the results of nerve transfers for shoulder function in patients with traumatic brachial plexus injuries. The authors evaluated shoulder abduction and external rotation in terms of type of nerve transfer performed (single vs. double) and the time delay to surgery (greater or less than 6 mo). A total of 20 patients were evaluated with 5 patients having double nerve transfers and 15 patients having single nerve transfers to restore shoulder function. All surgeries were done within 12 months of injury. The average follow-up for the 20 patients was 28.4 ± 17.5 months (minimum of 12 mo follow-up for all patients). The mean shoulder abduction and external rotation for the single nerve transfer group was 71.3 ± 48 degrees and 56 ± 44 degrees, respectively. For the double nerve transfer group, the mean shoulder abduction and external rotation was 123 ± 49 degrees and 86 ± 35 degrees, respectively. The difference was significant for the shoulder abduction (p = 0.05) but not for the external rotation (p = 0.19). In terms of time delay to surgery, there was no difference between surgery done in 6 months or less versus those done greater than 6 months but less than 12 months for shoulder abduction (88.1 ± 47.7 degrees and 77.1 ± 63.4 degrees, respectively, p = 0.67) and shoulder external rotation (63.8 ± 42.2 degrees and 62.8 ± 49.3 degrees, respectively, p = 0.96). The results of this study showed that nerve transfers can restore functional shoulder abduction and external rotation. Double nerve transfers tend to have significantly greater range of shoulder abduction compared with single nerve transfers if done within 1 year of injury.

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We report a case of a 10-month-old boy with a left extended upper type (C5-C7) obstetric brachial plexus injury that was treated with double nerve transfer (partial ulnar and partial median nerve transfer) to restore elbow flexion and spinal accessory nerve transfer to the suprascapular nerve to restore shoulder abduction. At 60 months' follow-up, shoulder abduction was 0-150° (M4) and elbow flexion was 0-140° (M5). Elbow, wrist and finger extension improved to M5. However, shoulder external rotation was only 0-30° (from full internal rotation). No weakness on finger and wrist flexion was observed. Double nerve transfers to restore elbow flexion can be safely done in obstetric brachial plexus injuries with good results. Secondary surgeries may be needed to improve external rotation.

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BACKGROUND: An experimental study was done to compare the efficacy of inside-out vein graft versus autogenous nerve graft as nerve conduit in promoting axonal regeneration in a rat model.METHODS: The study used 16 Spraque-Dawley rats randomly divided into two groups: the inside-out vein graft group and control group (autognous nerve graft). The outcomes measured were histomorphology (axon number and diameter), muscle twitch response (amplitude) and the walking track analysis at 2, 4 6 and 8 weeks.RESULTS: The inverted vein graft and control groups showed similar axon diameter (P=0.76), and axon number (P=0.85), weeks and similar muscle twitch responses (P=0.87) after eight weeks. The walking track analysis showed no significant difference between the two groups at eight weeks.CONCLUSION: The study showed that the inside-out vein graft group had similar motor recovery as compared to control group based on the muscle twitch analysis and walking track analysis in a rat model.In terms of histomorphometric analysis, the two groups were similar in terms of axon diameter and axon count.

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INTRODUCTION: Distal radius fractures are common fractures which are treated by orthopaedic surgeons. However, they are complex injuries with a variable prognosis and if they are not treated optimally, they can be associated with various complications. METHODS AND MATERIALS: We studied 80 cases of closed distal radius fractures. These patients were treated and their X-rays were evaluated to determine whether the reduction was radiologically acceptable or not. These patients were then followed up at 1.5 and 3 months to evaluate them both radiologically as well as functionally by using the Modified Mayo Scoring System and the Gartland and Werley's Functional Scoring System. RESULTS: In our study, 68 patients had an acceptable reduction and 12 patients had an unacceptable reduction. All the fractures healed by the end of the study. The radiological parameters improved from the pre-operative to the immediate post-operative X-ray and all the parameters remained the same till 3 months of follow up. The grip strength improved during the 1.5 to the 3 months follow up. We observed that the trend of the final X-ray score correlated with the pre-treatment X-ray score: however, the functional outcome did not correlate with the X-ray scores. CONCLUSION: We could not find any correlation between an acceptable reduction to a better functional outcome according to the G and W and the MM scores. We believe that a longer follow up will give us the true functional outcome of these patients and thus a true picture of the correlation between them.

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The objective of this study was to compare the clinical results of unstable distal radius fractures treated with ORIF with plate and screws compared to EF. Patients with unstable distal radius fractures treated with ORIF or EF from January 2005 to December 2010 were reviewed in terms of the Modified Mayo Wrist Score, range of motion, pain, grip strength, and radiologic parameters. Results showed that there was no difference in the Modified Mayo Wrist Score between ORIF (17 patients) and EF (11 patients) (p = 0.07). The ORIF group had better wrist flexion, wrist extension, pronation and supination compared to the EF group (p < 0.05). There were no significant differences in terms of radial and ulnar deviation, grip strength, pain and postoperative radiologic parameters (p < 0.05). Better wrist flexion, wrist extension and forearm rotation can be expected in ORIF compared to EF in the management of unstable distal radius fractures.

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INTRODUCTION: The advent of pedicle screws which provide distraction and derotation has led to higher correction of major curves. Newer methods have been devised to evaluate preoperative coronal flexibility, including lateral-bending (LB), push-prone (PP) and fulcrum-bending (FB) radiographs. Documentation of a consistent radiographic method predictive of correction rate has not been established. OBJECTIVE: To determine the most predictive radiographic method for evaluating spine flexibility and correction by comparing the correction rate (CR), flexibility rate (FR) and correction index (CI) of the Cobb's angle using the different radiographic methods. METHODS: Preoperative radiographs of 20 patients who underwent spinal fusion for adolescent scoliosis were obtained using the LB, PP, and FB method and compared with postoperative radiographs. RESULTS: Comparing the mean Cobb angles using the different methods to that of postoperative standing showed that only the FB method is not significantly different from the latter (p=0.669). There was significant difference between the Cobb's angle measured on the LB and PP and that measured on postoperative standing (p=0.043, p=0.008). Comparing the mean flexibility of the different methods with the mean CR also showed that the mean FR of LB (p=0.007) and PP (p=0.00013) were significantly different from the CR while that of FB is not significantly different from the CR (p=0.687). CONCLUSION: The FB radiograph demonstrated no statistical difference compared to postoperative radiograph, FR and CI.

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We present a case of an 8-year-old girl with a high grade osteogenic sarcoma of the proximal humerus treated with wide resection and vascularized proximal humerus treated with wide resection and vascularized proximal fibular epiphyseal transfer. At 5 years after reconstruction, the patient is tumor free and had a Musculoskeletal Tumor Score of 26/30 or 86.7%. The functional outcomes in terms of shoulder range of motion and pain were good. Complications include transient peroneal nerve palsy and mild valgus instability of the knee.

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The goal of surgery in fingertip amputation is to restore finger length, preserve function and at the same time provide cosmetic acceptability. Treatment options are varied and can range from simple suturing of the stump to microvascular replantation surgery. We report three cases of fingertip amputations in one adult and two pediatric patients treated with non-microsurgical replantation of the fingertip using the palmar "pocket" technique.

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BACKGROUND: The coverage of soft tissue defects of the distal leg, ankle or foot poses several challenges to the reconstructive surgeon. Reconstructive procedures may range from simple skin grafting to complicated free tissue transfers. The reverse sural flap has been one of the most dependable methods for soft tissue coverage of such complex wounds. The purpose of this paper was to compare the clinical results of reverse sural flaps harvested with a fascial versus a fasciocutaneous pedicle. METHODS: A retrospective cohort of twenty-six patients who underwent a reverse sural flap procedure for complex wounds of the distal lower extremity was examined from January 1, 2003 to December 31, 2009, with a minimum follow-up of one month. Fifteen patients had a fascial pedicled flap, while eleven patients had fasciocutaneous pedicled flaps with a minimum of one month follow-up. The primary outcome was flap-related complications. Fisher's exact test was used to determine the differences between the two groups and the level of significance was set at p?0.05. RESULTS: All flaps survived. Flap-related complications were more common in the fascial pedicled flap (6/15) compared with the fasciocutaneous pedicled flap (1/11). The difference was not significant (p=0.09). In terms of cosmetic acceptability, 11 patients (11/15) in the fascial pedicle group and five patients (5/11) in the fasciocutaneous pedicle group expressed that the sural flap was acceptable. CONCLUSION: Reverse sural flap was a reliable reconstructive procedure for coverage of soft tissue defects of the distal leg, ankle or foot. There was no significant difference in terms of complication rates for those with fascial compared with those with fasciocutaneous flaps. Cosmetic acceptability was higher for the fascial pedicled flap.

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