Elbow, Wrist, and Hand Injuries

  • Danielle L. Scher
  • Emily H. Shin
  • Jennifer M. Wolf
  • Leon J. Nesti
Chapter
First Online:

Abstract

Upper extremity injuries in the military are common and include acute traumatic and chronic overuse type injuries, and are variable depending on specific occupational demands. Both bony and soft tissue injuries may require surgery and can affect return to duty and military readiness of the soldiers. Similar to the general population, carpal tunnel syndrome is common and is most often treated surgically.

Keywords

Hand Injury Military Occupation Upper extremity 
This is a preview of subscription content, log in to check access.

References

  1. 1.
    Morse TF, Dillon C, Warren N, Levenstein C, Warren A. The economic and social consequences of work-related musculoskeletal disorders: the Connecticut Upper-Extremity Surveillance Project (CUSP). Int J Occup Environ Health. 1998;4(4):209–16.CrossRefPubMedGoogle Scholar
  2. 2.
    Peake JB. Reflections on injuries in the military: the hidden epidemic. Am J Prev Med. 2000;18(Suppl 3):4–5.CrossRefPubMedGoogle Scholar
  3. 3.
    Brininger TL, Antczak A, Breland HL. Upper extremity injuries in the U.S. military during peacetime years and wartime years. J Hand Ther. 2008;21(2):115–22, (quiz 123). doi:10.1197/j.jht.2007.10.010.CrossRefPubMedGoogle Scholar
  4. 4.
    Jones BH, Canham-Chervak M, Canada S, Mitchener TA, Moore S. Medical surveillance of injuries in the U.S. Military descriptive epidemiology and recommendations for improvement. Am J Prev Med. 2010;38(1 Suppl):S42–S60. doi:10.1016/j.amepre.2009.10.014.CrossRefPubMedGoogle Scholar
  5. 5.
    Hauret KG, Taylor BJ, Clemmons NS, Block SR, Jones BH. Frequency and causes of nonbattle injuries air evacuated from operations Iraqi freedom and enduring freedom, U.S. Army, 2001–2006. Am J Prev Med. 2010;38(1 Suppl):S94–S107. doi:10.1016/j.amepre.2009.10.022.CrossRefPubMedGoogle Scholar
  6. 6.
    Blank E, Lappan C, Belmont PJJ, et al. Early analysis of the United States Army’s telemedicine orthopaedic consultation program. J Surg Orthop Adv. 2011;20(1):50–5.PubMedGoogle Scholar
  7. 7.
    Frank AJ. Orthopedic injuries before combat deployment–will the soldiers be ready for combat when their unit is called upon? Mil Med. 2011;176(9):1015–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Wilson DJ, Parada SA, Slevin JM, Arrington ED. Intrasubstance ruptures of the biceps brachii: diagnosis and management. Orthopedics. 2011;34(11):890–6. doi:10.3928/01477447-20110922-25.CrossRefPubMedGoogle Scholar
  9. 9.
    Neves EB, de Souza MN, de Almeida RMVR. Military parachuting injuries in Brazil. Injury. 2009;40(8):897–900. doi:10.1016/j.injury.2009.01.136.CrossRefPubMedGoogle Scholar
  10. 10.
    Traumatic isolated closed rupture of the short head of the biceps brachii in a military paratrooper. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1759–61. doi:10.1007/s00167-010-1108-2.Google Scholar
  11. 11.
    Heckman JD, Levine MI. Traumatic closed transection of the biceps brachii in the military parachutist. J Bone Joint Surg Am. 1978;60(3):369–72.PubMedGoogle Scholar
  12. 12.
    Bricknell MC, Craig SC. Military parachuting injuries: a literature review. Occup Med (Lond). 1999;49(1):17–26.CrossRefGoogle Scholar
  13. 13.
    Schneider A, Bennett JM, O’Connor DP, Mehlhoff T, Bennett JB. Bilateral ruptures of the distal biceps brachii tendon. J Shoulder Elbow Surg. 2009;18(5):804–7. doi:10.1016/j.jse.2009.01.029.CrossRefPubMedGoogle Scholar
  14. 14.
    Nelson JP, Pederson LL. Military tobacco use: a synthesis of the literature on prevalence, factors related to use, and cessation interventions. Nicotine Tob Res. 2008;10(5):775–90. doi:10.1080/14622200802027123.CrossRefPubMedGoogle Scholar
  15. 15.
    Forgas LB, Meyer DM, Cohen ME. Tobacco use habits of naval personnel during Desert Storm. Mil Med. 1996;161(3):165–8.PubMedGoogle Scholar
  16. 16.
    Jacobson IG, Horton JL, Smith B, et al. Bodybuilding, energy, and weight-loss supplements are associated with deployment and physical activity in U.S. military personnel. Ann Epidemiol. 2012;22(5):318–30. doi:10.1016/j.annepidem.2012.02.017.CrossRefPubMedGoogle Scholar
  17. 17.
    Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908–15. doi:10.1053/jhsu.2001.26322.CrossRefPubMedGoogle Scholar
  18. 18.
    Kuo C-L, Pan R-Y, Wu J-L, Huang W-S, Wang S-J. Stress fractures of forearm bones in military recruits of rifle drill training. J Trauma. 2009;67(4):742–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Wu J-L, Huang G-S, Wu C-C, Lee C-H, Wu S-S. Stress fracture of the ulna occurring in military recruits after rifle drill training. Mil Med. 2004;169(10):839–41.CrossRefPubMedGoogle Scholar
  20. 20.
    Matin P. Basic principles of nuclear medicine techniques for detection and evaluation of trauma and sports medicine injuries. Semin Nucl Med. 1988;18(2):90–112.CrossRefPubMedGoogle Scholar
  21. 21.
    Constantini N, Finestone AS, Hod N, et al. Equipment modification is associated with fewer stress fractures in female Israel border police recruits. Mil Med. 2010;175(10):799–804.CrossRefPubMedGoogle Scholar
  22. 22.
    Lauder TD, Williams MV, Campbell CS, Davis G, Sherman R, Pulos E. The female athlete triad: prevalence in military women. Mil Med. 1999;164(9):630–5.PubMedGoogle Scholar
  23. 23.
    Babatunde OO, Forsyth JJ. Association between depot medroxyprogesterone acetate (DMPA), physical activity and bone health. J Bone Miner Metab. 2013. doi:10.1007/s00774-013-0497-y.Google Scholar
  24. 24.
    Wasserzug O, Balicer RD, Boxman J, Klement E, Ambar R, Zimhony O. A cluster of septic olecranon bursitis in association with infantry training. Mil Med. 2011;176(1):122–4.CrossRefPubMedGoogle Scholar
  25. 25.
    Army HDOT, MC C. FM 21-10 MCRP 4-11.1D. 2000.Google Scholar
  26. 26.
    Wolf JM, Mountcastle S, Burks R, Sturdivant RX, Owens BD. Epidemiology of lateral and medial epicondylitis in a military population. Mil Med. 2010;175(5):336–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Smidt N, van der Windt DAWM, Assendelft WJJ, Deville WLJM, Korthals-de Bos IBC, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657–62. doi:10.1016/S0140-6736(02)07811-X.CrossRefPubMedGoogle Scholar
  28. 28.
    Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065–74. doi:10.1093/aje/kwj325.CrossRefPubMedGoogle Scholar
  29. 29.
    Stannard JP, Bucknell AL. Rupture of the triceps tendon associated with steroid injections. Am J Sports Med. 1993;21(3):482–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Van Tassel DC, Owens BD, Wolf JM. Incidence estimates and demographics of scaphoid fracture in the U.S. population. J Hand Surg Am. 2010;35(8):1242–5. doi:10.1016/j.jhsa.2010.05.017.CrossRefPubMedGoogle Scholar
  31. 31.
    Wolf JM, Dawson L, Mountcastle SB, Owens BD. The incidence of scaphoid fracture in a military population. Injury. 2009;40(12):1316–9. doi:10.1016/j.injury.2009.03.045.CrossRefPubMedGoogle Scholar
  32. 32.
    Burtis MT, Faillace J, Martin LF, Hermenau S. Scaphoid fracture detection in a military population: a standardized approach for medical referral. Mil Med. 2006;171(5):404–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-A(4):483–8.PubMedGoogle Scholar
  34. 34.
    Wolf JM, Sturdivant RX, Owens BD. Incidence of de Quervain’s tenosynovitis in a young, active population. J Hand Surg Am. 2009;34(1):112–5. doi:10.1016/j.jhsa.2008.08.020.CrossRefPubMedGoogle Scholar
  35. 35.
    Garland FC, Garland CF, Doyle EJJ, et al. Carpal tunnel syndrome and occupation in U.S. Navy enlisted personnel. Arch Environ Health. 1996;51(5):395–407. doi:10.1080/00039896.1996.9934428.CrossRefPubMedGoogle Scholar
  36. 36.
    Bongers FJM, Schellevis FG, van den Bosch WJHM, van der Zee J. Carpal tunnel syndrome in general practice (1987 and 2001): incidence and the role of occupational and non-occupational factors. Br J Gen Pract. 2007;57(534):36–9.PubMedCentralPubMedGoogle Scholar
  37. 37.
    de Krom MC, Knipschild PG, Kester AD, Thijs CT, Boekkooi PF, Spaans F. Carpal tunnel syndrome: prevalence in the general population. J Clin Epidemiol. 1992;45(4):373–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Mondelli M, Giannini F, Giacchi M. Carpal tunnel syndrome incidence in a general population. Neurology. 2002;58(2):289–94.CrossRefPubMedGoogle Scholar
  39. 39.
    Nordstrom DL, DeStefano F, Vierkant RA, Layde PM. Incidence of diagnosed carpal tunnel syndrome in a general population. Epidemiology. 1998;9(3):342–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Stevens JC, Sun S, Beard CM, O’Fallon WM, Kurland LT. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology. 1988;38(1):134–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Wolf JM, Mountcastle S, Owens BD. Incidence of carpal tunnel syndrome in the US military population. Hand (N Y). 2009;4(3):289–93. doi:10.1007/s11552-009-9166-y.CrossRefGoogle Scholar
  42. 42.
    Palmer BN. Carpal tunnel syndrome, active component, U.S. Armed Forces, 2000–2010. MSMR. 2011;18(7):12–5.PubMedGoogle Scholar
  43. 43.
    Lalumandier JA, McPhee SD, Riddle S, Shulman JD, Daigle WW. Carpal tunnel syndrome: effect on Army dental personnel. Mil Med. 2000;165(5):372–8.PubMedGoogle Scholar
  44. 44.
    Shaffer SW, Moore R, Foo S, Henry N, Moore JH, Greathouse DG. Clinical and electrodiagnostic abnormalities of the median nerve in US Army dental assistants at the onset of training. US Army Med Dep J. 2012:72–81.Google Scholar
  45. 45.
    Greathouse DG, Root TM, Carrillo CR, et al. Clinical and electrodiagnostic abnormalities of the median nerve in Army dental assistants before and after training as preventive dental specialists. US Army Med Dep J. 2011:70–81.Google Scholar
  46. 46.
    Penn-Barwell JG, Bennett PM, Powers D, Standley D. Isolated hand injuries on operational deployment: an examination of epidemiology and treatment strategy. Mil Med. 2011;176(12):1404–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Anakwe REB, Standley DM. Hand injuries at a British Military Hospital on operations. J Hand Surg Br. 2006;31(2):240–3. doi:10.1016/j.jhsb.2005.06.025.CrossRefPubMedGoogle Scholar
  48. 48.
    Miller MA, Hall BT, Agyapong F, Kelly KJ, McArthur T. Traumatic noncombat-related hand injuries in U.S. troops in the combat zone. Mil Med. 2011;176(6):652–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Greer MA. Incidence of metacarpal fractures in U.S. soldiers stationed in South Korea. J Hand Ther. 2008;21(2):137–41, (quiz 142). doi:10.1197/j.jht.2007.08.017.CrossRefPubMedGoogle Scholar
  50. 50.
    Anakwe RE, Aitken SA, Cowie JG, Middleton SD, Court-Brown CM. The epidemiology of fractures of the hand and the influence of social deprivation. J Hand Surg Br. 2011;36(1):62–5. doi:10.1177/1753193410381823.CrossRefGoogle Scholar
  51. 51.
    Busche MN, Knobloch K, Rosenthal H, Vogt PM. Stress fracture of the hamate body and fourth metacarpal base following military style push-ups: an unusual trauma mechanism. Knee Surg Sports Traumatol Arthrosc. 2008;16(12):1158–60. doi:10.1007/s00167-008-0634-7.CrossRefPubMedGoogle Scholar
  52. 52.
    Taylor KF, Lanzi JT, Cage JM, Drake ML. Radial collateral ligament injuries of the thumb metacarpophalangeal joint: epidemiology in a military population. J Hand Surg Am. 2013;38(3):532–6. doi:10.1016/j.jhsa.2012.12.003.CrossRefPubMedGoogle Scholar
  53. 53.
    Gondusky JS, Reiter MP. Protecting military convoys in Iraq: an examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II. Mil Med. 2005;170(6):546–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Covey DC. Combat orthopaedics: a view from the trenches. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S10–7.PubMedGoogle Scholar
  55. 55.
    Marshall TJJ. Combat casualty care: the Alpha Surgical Company experience during Operation Iraqi Freedom. Mil Med. 2005;170(6):469–72.CrossRefPubMedGoogle Scholar
  56. 56.
    Hofmeister EP, Mazurek M, Ingari J. Injuries sustained to the upper extremity due to modern warfare and the evolution of care. J Hand Surg Am. 2007;32(8):1141–7. doi:10.1016/j.jhsa.2007.07.007.CrossRefPubMedGoogle Scholar
  57. 57.
    Weil YA, Mosheiff R, Liebergall M. Blast and penetrating fragment injuries to the extremities. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S136–9.PubMedGoogle Scholar
  58. 58.
    Owens BD, Kragh JFJ, Macaitis J, Svoboda SJ, Wenke JC. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma. 2007;21(4):254–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Dougherty AL, Mohrle CR, Galarneau MR, Woodruff SI, Dye JL, Quinn KH. Battlefield extremity injuries in Operation Iraqi Freedom. Injury. 2009;40(7):772–7. doi:10.1016/j.injury.2009.02.014.CrossRefPubMedGoogle Scholar
  60. 60.
    Cancio LC, Horvath EE, Barillo DJ, et al. Burn support for Operation Iraqi Freedom and related operations, 2003 to 2004. J Burn Care Rehabil. 2005;26(2):151–61.CrossRefPubMedGoogle Scholar
  61. 61.
    Chapman TT, Richard RL, Hedman TL, Renz EM, Wolf SE, Holcomb JB. Combat casualty hand burns: evaluating impairment and disability during recovery. J Hand Ther. 2008;21(2):150–8, (quiz 159). doi:10.1197/j.jht.2007.12.003.CrossRefPubMedGoogle Scholar
  62. 62.
    Hedman TL, Renz EM, Richard RL, et al. Incidence and severity of combat hand burns after All Army Activity message. J Trauma. 2008;64(2 Suppl):S169–72–.(discussion S172–3).CrossRefPubMedGoogle Scholar
  63. 63.
    Birch R, Misra P, Stewart MPM, et al. Nerve injuries sustained during warfare: part I–Epidemiology. J Bone Joint Surg Br. 2012;94(4):523–8. doi:10.1302/0301-620X.94B4.28483.CrossRefPubMedGoogle Scholar
  64. 64.
    Bowyer G. Debridement of extremity war wounds. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S52–6.PubMedGoogle Scholar
  65. 65.
    Beitler AL, Wortmann GW, Hofmann LJ, Goff JMJ. Operation Enduring Freedom: the 48th Combat Support Hospital in Afghanistan. Mil Med. 2006;171(3):189–93.CrossRefPubMedGoogle Scholar
  66. 66.
    Eardley WGP, Stewart MPM. Early management of ballistic hand trauma. J Am Acad Orthop Surg. 2010;18(2):118–26.PubMedGoogle Scholar
  67. 67.
    Covey DC, Lurate RB, Hatton CT. Field hospital treatment of blast wounds of the musculoskeletal system during the Yugoslav civil war. J Orthop Trauma. 2000;14(4):278–86. (discussion 277).CrossRefPubMedGoogle Scholar
  68. 68.
    Covey DC. Blast and fragment injuries of the musculoskeletal system. J Bone Joint Surg Am. 2002;84-A(7):1221–34.PubMedGoogle Scholar
  69. 69.
    Lin DL, Kirk KL, Murphy KP, McHale KA, Doukas WC. Evaluation of orthopaedic injuries in Operation Enduring Freedom. J Orthop Trauma. 2004;18(8 Suppl):S48–S53.CrossRefPubMedGoogle Scholar
  70. 70.
    Braakenburg A, Obdeijn MC, Feitz R, van Rooij IALM, van Griethuysen AJ, Klinkenbijl JHG. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg. 2006;118(2):390–7. (discussion 398–400).CrossRefPubMedGoogle Scholar
  71. 71.
    Mendonca DA. Negative pressure wound therapy: an important adjunct to wound care. South Med J. 2006;99(6):562–3.CrossRefPubMedGoogle Scholar
  72. 72.
    Leininger BE, Rasmussen TE, Smith DL, Jenkins DH, Coppola C. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. J Trauma. 2006;61(5):1207–11.CrossRefPubMedGoogle Scholar
  73. 73.
    Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563–76. (discussion 577).CrossRefPubMedGoogle Scholar
  74. 74.
    Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553–62.CrossRefPubMedGoogle Scholar
  75. 75.
    Fang R, Dorlac WC, Flaherty SF, et al. Feasibility of negative pressure wound therapy during intercontinental aeromedical evacuation of combat casualties. J Trauma. 2010;69(1 Suppl):S140–5.CrossRefPubMedGoogle Scholar
  76. 76.
    Taylor CJ, Chester DL, Jeffery SL. Functional splinting of upper limb injuries with gauze-based topical negative pressure wound therapy. J Hand Surg Am. 2011;36(11):1848–51. doi:10.1016/j.jhsa.2011.08.023.CrossRefPubMedGoogle Scholar
  77. 77.
    Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–8.PubMedGoogle Scholar
  78. 78.
    Wilson KW, Dickens JF, Heckert R, et al. Heterotopic ossification resection after open periarticular combat-related elbow fractures. J Surg Orthop Adv. 2013;22(1):30–5.CrossRefPubMedGoogle Scholar
  79. 79.
    Stein DA, Patel R, Egol KA, Kaplan FT, Tejwani NC, Koval KJ. Prevention of heterotopic ossification at the elbow following trauma using radiation therapy. Bull Hosp Jt Dis. 2003;61(3–4):151–4.PubMedGoogle Scholar
  80. 80.
    Alfieri KA, Forsberg JA, Potter BK. Blast injuries and heterotopic ossification. Bone Joint Res. 2012;1(8):192–7.CrossRefPubMedGoogle Scholar
  81. 81.
    Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma. 2009;67(4):752–7. doi:10.1097/TA.0b013e3181808115.CrossRefPubMedGoogle Scholar
  82. 82.
    Fleming ME, Watson JT, Gaines RJ, O'Toole RV. Evolution of orthopaedic reconstructive care. J Am Acad Orthop Surg. 2012;20(1 Suppl):S74–9. doi:10.5435/JAAOS-20-08-S74.CrossRefPubMedGoogle Scholar
  83. 83.
    Grewal NS, Kumar AR, Onsgard CK, Taylor BJ. Simultaneous revascularization and coverage of a complex volar hand blast injury: case report using a contralateral radial forearm flow-through flap. Mil Med. 2008;173(8):801–4.CrossRefPubMedGoogle Scholar
  84. 84.
    Chattar-Cora D, Perez-Nieves R, McKinlay A, Kunasz M, Delaney R, Lyons R. Operation Iraqi freedom: a report on a series of soldiers treated with free tissue transfer by a plastic surgery service. Ann Plast Surg. 2007;58(2):200–6.CrossRefPubMedGoogle Scholar
  85. 85.
    Tintle SM, Wilson K, McKay PL, Andersen RC, Kumar AR. Simultaneous pedicled flaps for coverage of complex blast injuries to the forearm and hand (with supplemental external fixation to the iliac crest for immobilization). J Hand Surg Br. 2010;35(1):9–15. doi:10.1177/1753193409347428.CrossRefGoogle Scholar
  86. 86.
    Potter BK, Burns TC, Lacap AP, Granville RR, Gajewski D. Heterotopic ossification in the residual limbs of traumatic and combat-related amputees. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S191–7.PubMedGoogle Scholar
  87. 87.
    Alfieri KA, Forsberg JA, Potter BK. Blast injuries and heterotopic ossification. Bone Joint Res. 2012;1(8):192–7.CrossRefPubMedGoogle Scholar
  88. 88.
    Moritomo H, Tada K, Yoshida T. Early, wide excision of heterotopic ossification in the medial elbow. J Shoulder Elbow Surg. 2001;10(2):164–8. doi:10.1067/mse.2001.112055.CrossRefPubMedGoogle Scholar
  89. 89.
    Baldwin K, Hosalkar HS, Donegan DJ, Rendon N, Ramsey M, Keenan MAE. Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies. J Hand Surg Am. 2011;36(5):798–803. doi:10.1016/j.jhsa.2011.01.015.CrossRefPubMedGoogle Scholar
  90. 90.
    Department of the Army H. Army Regulation 40–501. 2011.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Danielle L. Scher
    • 1
  • Emily H. Shin
    • 2
  • Jennifer M. Wolf
    • 3
  • Leon J. Nesti
    • 2
  1. 1.Department of Orthopaedics, Brian Allgood Army Community HospitalAPOUSA
  2. 2.Walter Reed National Military Medical CenterBethesdaUSA
  3. 3.University of ConnecticutHartfordUSA

Personalised recommendations