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PubMed2005

Physician perceptions of upper extremity reconstruction for the person with tetraplegia.

PURPOSE: Upper extremity reconstruction for people with tetraplegia can improve upper-limb function substantially and enhance independence; however, these surgical procedures rarely are performed. This study attempted to identify barriers preventing appropriate candidates from receiving these procedures. METHODS: A questionnaire was mailed to a national sample of 379 hand surgeons and 384 physiatrists with an interest in spinal cord medicine. The statistical model assessed 2 main outcomes of the physician survey: (1) whether the provider had been involved in at least one of these procedures in the past year and (2) whether the provider desired to be more involved. We hypothesized that these outcomes were associated with provider attitudes and beliefs and failures of the health care system referral networks. RESULTS: Most hand surgeons and physiatrists believed that these procedures were beneficial; however, few had either performed or referred even one case over the past year. Multivariable models suggested that a predominant factor in whether these procedures were being performed was the presence of a relationship between the surgeon and physiatrist. CONCLUSIONS: A lack of coordinated cross-specialty relationships appears to present the largest barrier to the appropriate use of upper extremity reconstruction for people with tetraplegia.

Attitude of Health Personnel↗

PubMed2002

Upper-extremity torque production in men with paraplegia who use wheelchairs.

OBJECTIVES: To study maximal upper-extremity torque values and agonist/antagonist torque ratios in a sample of individuals with paraplegia and to compare these values with a sample of age-, gender-, and weight-matched able-bodied individuals. DESIGN: Cross-sectional, case-control study. SETTING: A biomechanics laboratory. PARTICIPANTS: A convenience sample of 15 men with complete (American Spinal Injury Association class A) T5-L2 paraplegia and 15 able-bodied control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Maximal isometric torques of 12 upper-extremity muscle groups (shoulder, elbow, and wrist flexion and extension; shoulder abduction and adduction; shoulder internal and external rotation; elbow pronation and supination) were measured with custom dynamometers. RESULTS: Maximal torque values and agonist/antagonist torque ratios for the shoulder, elbow, and wrist functions did not differ between the control subjects and those with complete paraplegia, with the exception of the supination/pronation torque ratio, which was significantly higher in the able-bodied control group. CONCLUSION: Wheelchair propulsion and other functional activities, such as transfers, do not significantly affect maximum torque production of the upper extremities in individuals with paraplegia. On the basis of these findings, arguments that upper-extremity muscle imbalances are important contributory factors to upper-extremity pain and dysfunction in this group may be too simplistic.

Adult↗

PubMed1990

Evaluation of quantitative measures of upper extremity speed and coordination in healthy persons and in three patient populations.

Upper extremity tracking tests have been used extensively in clinical studies in patients with neurologic disorders. We evaluated several new measures of upper extremity performance derived from step-response and phase-plane analysis techniques; both techniques are founded in automatic control theory. Using a computer-based tracking test, a visual step function stimulus was applied in 15 healthy subjects and 45 patients from multiple sclerosis, myasthenia gravis, and Parkinson disease populations. The upper extremity response of the subject was analyzed to find the reliability and discriminating power measures that quantify speed, coordination, and steadiness of the upper extremity response during the tracking task. Results show that reliability of the measures, although variable across the populations tested, is generally high (greater than 0.7). The speed and coordination measures derived from phase-plane analysis are more discriminating than the measures of step-response analysis for the populations tested. Some of the measures may be useful for monitoring patient performance, the other measures can be potentially helpful in diagnosis of the disorders.

Arm↗

PubMed1997

Neurologic injury in the upper extremity after total hip arthroplasty.

The results of 7150 consecutive primary and revision total hip arthroplasties performed between 1976 and 1990 were reviewed retrospectively. Sixteen upper extremity neurologic palsies were identified in 16 patients. The incidence of upper extremity nerve palsies after total hip arthroplasty was 0.22%. There were five men and 11 women (average age, 59.5 years; range, 27-81 years). The neurologic injuries consisted of 10 ulnar palsies, four brachial plexopathies, one axillary nerve palsy, and one median nerve palsy. Patients were evaluated with respect to age, gender, preoperative diagnosis, type of procedure (primary versus revision), and surgical approach. Preoperative diagnoses included: inflammatory arthritis (11), osteoarthritis (two), avascular necrosis (one), developmental dysplasia of the hip (one), and posttraumatic arthritis (one). Fourteen of 16 patients (88%) had complete recovery. Two patients (12%) had persistent symptoms despite operative intervention. The only significant predisposing factor to developing an upper extremity neurologic injury after total hip arthroplasty was the preoperative diagnosis of an inflammatory arthropathy. Upper extremity neurologic injuries after total hip arthroplasty are rare. Patients with the preoperative diagnosis of an inflammatory arthropathy are at greater risk for experiencing upper extremity neurologic injury. The prognosis is favorable, with 88% of patients having complete recovery. Cautious induction of anesthesia and careful attention to patient positioning in the perioperative, intraoperative, and postoperative period are essential to help minimize the incidence of neurologic injuries in the upper extremity after total hip arthroplasty.

Adult↗

PubMed2002

Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities.

BACKGROUND: The optimal strategy for diagnosis of deep venous thrombosis (DVT) is less well established for the upper extremities than for the lower extremities. Duplex color ultrasonography can be difficult to perform in the upper extremities because of their anatomy, and contrast venography is often indicated. Moreover, limited data exist on the use of duplex color ultrasonography in this setting. OBJECTIVE: To determine the accuracy of duplex ultrasonography for diagnosis of DVT of the upper extremities. DESIGN: Prospective study of duplex ultrasonography compared with venography. SETTING: A teaching hospital in Amsterdam, the Netherlands. PATIENTS: 126 consecutive inpatients and outpatients with suspected DVT of the upper extremities. MEASUREMENTS: Contrast venography was obtained after duplex ultrasonography and was judged independently. A three-step protocol, involving compression ultrasonography, color ultrasonography, and color Doppler ultrasonography, was used. Sensitivity, specificity, and likelihood ratios for ultrasonography as a whole were calculated. The independent value of each step was assessed. RESULTS: Venography and ultrasonography were not feasible in 23 of 126 patients (18%) and 1 of 126 patients (0.8%), respectively. Results of ultrasonography were inconclusive in 3 patients. Venography demonstrated thrombosis in 44 of 99 patients (44%); in 36 patients (36%), thrombosis was related to intravenous catheters or malignant disease. Sensitivity and specificity of duplex ultrasonography were 82% (95% CI, 70% to 93%) and 82% (CI, 72% to 92%), respectively. Venous incompressibility correlated well with thrombosis, whereas only 50% of isolated flow abnormalities proved to be thrombosis-related. CONCLUSIONS: Duplex ultrasonography may be the method of choice for initial diagnosis of patients with suspected thrombosis of the upper extremities. However, in patients with isolated flow abnormalities, contrast venography should be performed.

Adolescent↗

PubMed1988

Late complications of the weight-bearing upper extremity in the paraplegic patient.

Paraplegic patients rely almost exclusively on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion. Eighty-four paraplegic patients whose injury level was T2 or below and who were at least one year from spinal cord injury were screened for upper extremity complaints. Fifty-seven (67.8%) had complaints of pain in one or more areas of their upper extremities. The most common complaints were shoulder pain and/or pain relating to carpal tunnel syndrome. Twenty-five (30%) complained of shoulder pain during transfer activities. Symptoms were found to increase with time from injury. As the long-term survival of spinal cord injured patients continues to improve, an increased awareness of the complications of the weight-bearing upper extremity is necessary to keep these patients functioning in society.

Arm↗

PubMed2006

Upper-extremity mucormycosis infections in immunocompetent patients.

PURPOSE: Mucormycosis can produce an aggressive and sometimes fatal soft tissue infection seen most commonly in immunocompromised individuals. Eradication consists of surgical resection and antifungal chemotherapy. Knowledge regarding infectious mucormycosis in the upper extremity has been limited to case reports involving mainly immunocompromised individuals. The purpose of this study was to identify risk factors for the development of mucormycosis infections within the upper extremity in immunocompetent individuals and to evaluate the effectiveness of the present therapies. METHODS: A 12-year retrospective review of all fungal infections involving the upper extremity was conducted in our institution. Seven immunocompetent patients with infectious cutaneous mucormycosis of the upper extremity were identified from 223 primary upper-extremity fungal infections. RESULTS: In the 7 patients 3 infections resulted from heavy soil contamination after motor vehicle collisions and 4 resulted from conveyor belt injuries in agricultural facilities. All patients had considerable upper-extremity soft tissue loss and 6 of the 7 patients had upper-extremity fractures or dislocations. Patients had an average of 10 surgical debridements. Four infections resulted in amputations: 1 partial hand amputation, 1 below the elbow, 1 above the elbow, and 1 at the glenohumeral joint. CONCLUSIONS: Mucormycosis can produce limb-threatening infections in an immunocompetent host. Hand surgeons must have suspicion of such infections in patients with grossly contaminated open wounds.

Adult↗

PubMed2006

Kinesio taping in stroke: improving functional use of the upper extremity in hemiplegia.

The purpose of this article is to present the Kinesio taping method used to improve the upper extremity function in the adult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve a functional upper extremity. The only taping technique for various upper extremity conditions that has been described in the literature is the athletic taping technique. In this article, some interpretation is offered on proper assessment of the nonfunctional upper extremity, including the emphasis on postural alignment, trunk control, and scapula alignment. The Kinesio taping method in conjunction with other therapeutic interventions may facilitate or inhibit muscle function, support joint structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred body alignment. Restoring trunk and scapula alignment after the stroke is critical in an effective treatment program for the upper extremity in hemiplegia.

Adult↗

PubMed2003

Upper extremity interaction with a deploying side airbag: a characterization of elbow joint loading.

Computer simulations, dummy experiments with a new enhanced upper extremity and small female cadaver experiments were used to analyze the small female upper extremity response under side airbag loading. After establishing a worst case initial position, three tests were performed with the fifth percentile female hybrid III anthropometric test dummy and six experiments with small female cadaver subjects. A new fifth percentile female enhanced upper extremity was developed for the dummy experiments that included a two-axis wrist load cell in addition to the existing six-axis load cells in both the forearm and humerus. Forearm pronation was also included in the new dummy upper extremity to increase the biofidelity of the interaction with the handgrip. Instrumentation for both the cadaver and dummy tests included accelerometers and MHD angular rate sensors on the forearm, humerus, upper and lower spine. In order to quantify the applied loads to the cadaver hand and wrist from the door mounted handgrip, the handgrip was mounted to the door through a five-axis load cell and instrumented with accelerometers for inertial compensation. All six of the cadaver tests resulted in upper extremity injuries including comminuted mid-shaft humerus fractures, osteochondral fractures of the elbow joint surfaces, a transverse fracture of the distal radius and an osteochondral fracture of the lunate carpal bone. The results from the 6 cadaver tests presented in this study were combined with the results from 12 previous cadaver tests. A multivariate logistic regression analysis was performed to investigate the correlation between observed injuries and measured occupant response. Using inertially compensated force measurements from the dummy mid-shaft forearm load cell, the linear combination of elbow axial force and shear force was significantly (P=0.05) correlated to the observed elbow injuries.

Air Bags↗

PubMed2003

Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula.

BACKGROUND: In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized. METHODS AND RESULTS: In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina. CONCLUSIONS: Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.

Arteriovenous Shunt, Surgical↗

PubMed2003

Upper extremity arterial injuries in athletes.

Upper extremity arterial injury resulting in hand and digit ischemia can occur in athletes who perform repetitive, high-stress, overhead arm motions. The initial presentation of these injuries often mimics the more common musculoskeletal injuries found in these athletes, and therefore, a high index of suspicion is essential to establish the diagnosis in a timely fashion. There are several described mechanisms of injury, most of which involve extrinsic compression and injury to the axillary artery or its branches from the humeral head. The clinical diagnosis is confirmed with noninvasive vascular laboratory testing, and the anatomy is generally confirmed using contrast arteriography. Surgical repair is almost always successful in these patients, allowing full recovery with return to competition.

Arteries↗

PubMed2006

[Improved outcome of nerve injuries in the upper extremity].

Nerve injuries in the upper extremity can result in severe disability. In the past three decades, progress in microsurgical techniques and instruments have resulted in improved outcomes for nerve injuries. If the prognosis is reasonably good, nerve repair is usually preferred over tendon or flap transfer procedures. However, lesions of peripheral stem nerves such as high radial nerve palsy may still yield unsatisfactory results, despite technically well-executed nerve repair. Prognosis further depends on the age of the patient; the regenerative process is delayed in older patients. Further criteria for the indication for tendon transfers are the personal and professional profiles of individual patients. Tendon or flap transfers to restore sensation can be performed at any time post trauma when it becomes clear that long-term rehabilitation is required. These procedures abbreviate the interval during which hand function is severely impaired, so that patients have alternatives to persistent nerve palsy with the need of permanent external splints, and long and costly rehabilitation can be shortened. Sophisticated techniques allow minimal donor site morbidity and leave options open in case function of the reconstructed nerve returns. The present article gives an overview of the most common procedures to restore hand function and sensation in the most important digits and provides help for decision making.

Neurosurgical Procedures↗

PubMed2005

Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study.

PURPOSE: More than 100,000 Americans live with the disability of tetraplegia. For these people their level of independence often is related to the function of the upper extremity. Reconstructive procedures can improve the use of the upper limb and multiple case series have shown benefit from these procedures for appropriate candidates. Discussions with patients and surgeons, however, suggest that these procedures rarely are performed. This study attempted to assess whether upper extremity reconstruction for the tetraplegic population is being used properly. METHODS: Data from 2 inpatient national databases were used (the National Inpatient Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000. Patients were selected by International Classification of Diseases (ICD-9) diagnosis codes for tetraplegia and procedure codes that could represent upper extremity reconstruction. The recommended rate of these surgeries was based on the annual incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these people would benefit from upper extremity surgery. RESULTS: Our health care data analysis showed that fewer than 355 of these surgeries were performed in the United States in any year queried. The calculated recommended rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates were receiving upper extremity reconstruction. We also found changes in the expected primary payor, with Medicaid paying for far fewer procedures in 2000 compared with 1988 claims. Finally over the course of time it appears that far fewer of these procedures are being performed. CONCLUSIONS: Functional upper extremity reconstruction for the tetraplegic population is profoundly underused in the United States. Various factors could be causing this disparity of care and we recommend further research into the potential barriers to health care for this vulnerable population.

Adult↗

PubMed1994

Proximal venous outflow obstruction in patients with upper extremity arteriovenous dialysis access.

To evaluate the impact of central venous obstruction on upper extremity hemodialysis access failure, we retrospectively analyzed our recent experience in managing this problem. We reviewed 158 upper extremity hemodialysis access procedures performed in 122 patients during a 1-year period. Fourteen (11.5%) patients had central vein obstruction as the cause of severe arm swelling, graft thrombosis, or graft malfunction. All 14 patients had had bilateral temporary subclavian vein dialysis catheters and failed upper extremity arteriovenous access. Seventeen lesions were treated in 14 patients including eight subclavian vein occlusions, six subclavian vein stenoses, two internal jugular vein stenoses, and one superior vena cava stenosis. Twenty-one procedures were performed including 17 percutaneous transluminal balloon angioplasties (PTAs) with stent placement in 13, two axillary to innominate vein bypasses, and two axillary to internal jugular vein bypasses. All patients had resolution of symptoms. Thirteen (76%) PTAs were initially successful but in four (24%) cases it was impossible to recanalize the vein. Eight (47%) PTAs provided functional hemodialysis access for 2 to 9 months, two (12%) restenosed at 3 and 10 months and were successfully redilated, two occluded at 2 and 4 months and were unable to be recanalized, and one failed immediately after a successful PTA. Four PTA failures were followed by venous bypass, which remained patent and provided functional access 7 to 13 months after surgery. Of nine stenotic venous lesions six (67%) were successfully dilated without restenosis, whereas of eight occluded veins only two (25%) were successfully treated without recurrence. Temporary central hemodialysis catheters produce a significant number of symptomatic central vein obstructions in patients with upper extremity arteriovenous access.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon↗

PubMed1996

Histoplasma capsulatum necrotizing myofascitis of the upper extremity.

Necrotizing myofascial fungal infections of the upper extremity is a rare event even in immunocompromised hosts. We report the course of a renal transplant patient who developed extensive necrotizing myofascial infection of an upper extremity secondary to Histoplasma capsulatum. Initial, functional, upper limb salvage was achieved after aggressive surgical debridement and high doses of amphotericin B. The patient ultimately succumbed to systemic fungal sepsis. The etiology and treatment of these infections are discussed.

Amphotericin B↗

PubMed2000

Effect of trunk rotation and arm position on gross upper extremity adduction strength and muscular activity.

The aim of the experiment was to determine the impact of axial trunk rotation and arm position on upper extremity adduction force and muscle activity. Ten healthy male subjects performed graded maximum voluntary contractions under isometric conditions in seven upper extremity positions and three trunk postures (neutral and 90 degrees left/right rotated) in a simulated manual materials handling task. A custom built lightweight force-measuring device was held between the palmar surfaces of the hands and subjects compressed the lateral surfaces of the device. Muscle activity was recorded bilaterally over the muscle bellies of the anterior deltoid, the long head of the biceps brachii and over the flexor carpi radialis. The activity of the right pectoralis major was also recorded unilaterally. Descriptive, multivariate analysis of variance (MANOVA) and post-hoc Scheffé comparisons were performed on the mean and peak force as well as the EMG [electromyographic] data. Further analysis was performed on the force-EMG relationship at 20% intervals of maximum voluntary contraction (force). Both upper extremity adduction force and EMG were significantly affected by position (p<0.01) but not by trunk rotation. The muscle activity increased and force decreased with flexion of the upper extremity. Pearson correlation coefficients between force and EMG were low. The biceps and flexors were the most active muscles depending upon upper extremity position, and the right pectoralis major muscle activity expressed the highest correlation with force. The present findings confirm earlier hypotheses that upper extremity adduction strength is not significantly affected by trunk rotation.

Adult↗

PubMedDate not supplied

Effect of upper extremity posturing on measured resting energy expenditure of nonambulatory tube-fed adult patients with severe neurodevelopmental disabilities.

PURPOSE: To ascertain the effect of upper extremity posturing on measured resting energy expenditure (MEE) for patients with severe neurodevelopmental disabilities. METHODS: Twenty-four nonambulatory adult patients with severe neurodevelopmental disabilities referred for evaluation of enteral tube feeding and who had a steady-state MEE performed were studied. Steady-state indirect calorimetry measurements were done through a canopy system. Patients were stratified according to the topography of their neuromotor impairment and motor function as having either fixed upper extremity contractures (Fixed UE) or with preservation of limited functional and nonfunctional upper extremity movement (Preserved UE). RESULTS: Despite a similar age, weight, height, and gender distribution between groups, those patients with Fixed UE (n = 13) had a significantly lower MEE than those with Preserved UE (n = 11): 893 +/- 91 versus 1144 +/- 262 kcal/d (p < .01), respectively. The Harris-Benedict equations' predicted energy expenditures were similar to MEE for patients with Preserved UE (1212 +/- 156 versus 1144 +/- 262 kcal/d, respectively, p = N.S.). Patients with Fixed UE had a significantly lower MEE than predicted by the Harris-Benedict equations (893 +/- 91 versus 1128 +/- 123 kcal/d, respectively, p < .01) CONCLUSIONS: Patients with fixed upper extremity contractures have a significantly lower MEE than those with preserved upper extremity movement. MEE for nonambulatory tube-fed adult patients with severe neurodevelopmental disabilities and fixed upper extremity contractures is significantly lower than predicted by the Harris-Benedict equations.

Adult↗

PubMed2003

Radiographic findings of the upper extremity in collegiate rodeo athletes.

INTRODUCTION AND PURPOSE: Upper-extremity trauma has been extensively studied in traditional sports to reduce predisposition to injury. Limited attention has been directed toward nontraditional, high-collision sports such as rodeo. Therefore, the purpose of this study was to quantify radiographic changes of the upper extremity in collegiate rodeo athletes after seasonal competition. METHODS: After written informed consent, 25 male roughstock athletes (age = 21.0 +/- 1.4 yr; height = 174.5 +/- 5.7 cm; weight = 73.0 +/- 5.9 kg) competing in the College National Finals Rodeo reported for standard anteroposterior and lateral x-rays of both arms (hand/wrist, forearm, and elbow). RESULTS: Radiographs revealed 82 total abnormalities involving both left and right extremities of all athletes. Hand/wrist findings included 24 fractures (19 healed, 5 nonunion) involving scaphoid, styloid, interphalangeal, phalanx, and various metacarpals. Fourteen cases of degenerative joint disease (scaphoid/radius, scapholunate, triangulofibrocartilage, and carpometacarpal), joint calcification, dorsal instability, and scapholunate dissociation were observed. Forearm findings included ulnar cortical thickening, healed stress fractures, and plates/screws. Elbow findings revealed ulnar/humeral degeneration, calcification, posterior olecranon tip fracture, traction spurs, and joint space narrowing with loose bodies. CONCLUSION: Findings indicate a significant amount of radiographic evidence of repetitive trauma to the upper extremity in this sport. Development and mandatory use of effective external bracing beyond existing techniques at the collegiate level of competition should be encouraged.

Adult↗