title: Obstacles to the Care of Patients With Multicomponent Volar Wrist Lacerations at a County Hospital.
abstract: BACKGROUND
  Multicomponent volar wrist lacerations of "spaghetti wrist" injuries are devastating injuries of the upper extremity. These patients require long-term commitment to rehabilitation. Patients presenting to our county hospital represent a unique and complex patient population in terms of psychosocial considerations. We aimed to identify obstacles to care and optimal recovery in this patient population.
  
  
  METHODS
  A patient database was queried for ICD-9 codes related to major upper extremity nerve injuries, which were treated by plastic surgery faculty at San Francisco General Hospital from 2008 to 2014. A retrospective chart review was performed to identify patients with spaghetti wrist injuries. Charts were reviewed for patient demographics including age, occupation, handedness, psychiatric illness, isolated versus polytrauma, and employment status. Injuries were categorized for mechanism of injury, structures involved, and timing and method of surgical treatment. Outcomes were assessed for motor recovery, sensory recovery, and tendon function.
  
  
  RESULTS
  We identified 18 patients with multicomponent volar wrist lacerations. Average patient age was 31 years. The most common mechanism of injury was accidental/work-related (n = 9, 50%), followed by self-inflicted (n = 4, 22%). Thirty-nine percent (n = 7) of patients had a psychiatric diagnosis, most commonly depression (n = 4, 22%). Eighty-nine percent (n = 16) of patients had an isolated injury to the upper extremity, and 39% (n = 7) had an injury to the dominant hand. Fifty percent (n = 9) of patients were lost to follow-up, with 28% (n = 5) having no known care plan. Motor, sensory, and tendon function outcomes for those with adequate follow-up were comparable to previously published studies.
  
  
  CONCLUSIONS
  Multicomponent volar wrist lacerations can be devastating, and although we are able to provide patients with appropriate timely surgical care, these patients require long-term care far beyond the operating room for optimal outcomes. Psychiatric illness, socioeconomic limitations, poor patient compliance, and irregular follow-up are obstacles to care. These issues highlight the need for better social support systems and mental health care to provide access to the services necessary to optimize recovery.
authors.affiliation: From the San Francisco General Hospital, University of California San Francisco, San Francisco, CA.
authors.forename: Carolyn J
authors.initials: CJ
authors.lastname: Vaughn
authors.forename: Shyam S
authors.initials: SS
authors.lastname: Raghavan
authors.forename: Scott L
authors.initials: SL
authors.lastname: Hansen
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Terry
mesh_terms: D000293:Adolescent; D000328:Adult; D000359:Aftercare / Q000379:methods / Q000523:psychology / Q000706:statistics & numerical data; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006766:Hospitals, County; D006801:Humans; D022125:Lacerations / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D008297:Male; D008605:Mental Health Services; D008875:Middle Aged; D010349:Patient Compliance / Q000523:psychology / Q000706:statistics & numerical data*; D059348:Peripheral Nerve Injuries / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D011584:Psychology; D020127:Recovery of Function; D012189:Retrospective Studies; D012495:San Francisco; D012944:Social Support; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D014954:Wrist Injuries / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D055815:Young Adult