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Upper-extremity deep venous thrombosis (DVT) has been understudied in the rehabilitation population. Patients undergoing rehabilitation often have many risk factors that predispose them to DVT. It is important to recognize upper-extremity DVT, because recent studies have shown it to pose a significant risk for pulmonary embolus and death. This is the first reported association of an upper-extremity DVT with paralysis.
BACKGROUND: Post-thrombotic syndrome is a chronic, potentially debilitating complication of deep vein thrombosis (DVT) of the lower extremity. Comparatively little is known about post-thrombotic syndrome after upper extremity DVT (UEDVT). OBJECTIVE: To perform a systematic review of clinical studies that have examined the incidence, clinical features, risk factors and management of post-thrombotic syndrome after UEDVT. METHODS: Using combinations of keywords venous thrombosis, postphlebitic syndrome, thrombophlebitis, arm swelling, post-thrombotic syndrome, UEDVT, Paget-Schroetter syndrome, thoracic outlet syndrome, axillary vein, subclavian vein, and central venous catheter, the MEDLINE database was searched for English language articles published between January 1967 and December 2004. Retrieval and review of articles were restricted to clinical studies in humans that described long-term outcomes after objectively confirmed UEDVT. RESULTS: Seven studies were reviewed. The frequency of PTS after UEDVT ranges from 7-46% (weighted mean 15%). Residual thrombosis and axillosubclavian vein thrombosis appear to be associated with an increased risk of PTS, whereas catheter-associated UEDVT may be associated with a decreased risk. There is currently no validated, standardized scale to assess upper extremity PTS, and little consensus regarding the optimal management of this condition. Quality of life is impaired in patients with upper extremity PTS, especially after DVT of the dominant arm. CONCLUSIONS: PTS is a frequent complication of UEDVT, yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified.
AIM: Arteriovenous fistula (AVF) is usually surgically created in a patient's upper extremity to provide adequate blood flow during haemodialysis. Blood flow distal to an AVF is altered and theoretically could change pulse oximetry (SpO2) reading, systemic blood pressure and skin temperature. The authors conducted a prospective case-control study to measure changes in these parameters in the upper extremity of patients who have had an AVF. METHODS: In patients with an upper extremity AVF, the authors conducted a prospective case-control study using the patient's own non-AVF upper extremity as the control. The authors evaluated other factors that may have influenced blood flow changes distal to an AV fistula like gender, presence of AVF aneurysm, peripheral vascular disease, diabetes mellitus and vasodilator therapy. RESULTS: Thirty patients were enrolled, skin temperature and blood pressure were significantly altered in the hand distal to the AVF, but there was no significant change in the SpO2. CONCLUSION: An upper extremity AVF alters blood pressure and temperature measurements when compared with the contralateral non-AVF side, but there is no difference in SpO2 provided an adequate signal quality is detected.
OBJECTIVE: In 1962, the procedure of arterial thrombembolectomy with the Fogarty catheter was established. Numerous studies have been published studying thrombembolectomies of the lower extremities. Limited information, however, is available following thrombembolectomy of the upper extremity after arterial occlusion. The aim of the present study, therefore, was to determine long-term results (3-5 years after thrombembolectomy) following thrombembolectomy of the upper extremity with the Fogarty catheter in a large retrospective clinical study. DESIGN: In the present study, 251 patients were encountered. Over a period of 20 years, 283 thrombembolectomies with the Fogarty catheter were performed on the upper extremity at the surgical department of the University of Munich. MAIN OUTCOME MEASUREMENTS: The appearance of local and general complications in the postoperative phase, as well as long-term results, were evaluated. RESULTS: The results indicate that general complications - i.e., cardiac insufficiency, cerebral ischemia, etc. - occurred in 18 patients (7.2%). Local complications - i.e., wound infection, persistence of ischemia, or hematoma - were evident in 51 patients (20.3%). Re-occlusion following thrombembolectomy was found in 21 patients (8.8%). The affected extremity had to be amputated in five cases (2.0%), and 14 patients (5.6%) died during the postoperative phase. As a result of multimorbidity of the patients and average age at the time of surgery (73 years), 40% of the patients had died before the date of examination. Nonetheless, 111 patients of the 117 living patients showed no complaints or minor coldness and pain following heavy exercise. CONCLUSIONS: The results of the present study indicate that, in most cases, thrombembolectomy with the Fogarty catheter represents a successful surgical method for the acute treatment of arterial occlusion of the upper extremity.
PURPOSE: To evaluate the clinical pathology and postoperative outcomes of patients with neurilemmoma in the upper extremity who underwent tumour enucleation, and the correlation factors for neurological deficits apart from enucleation of nerve fascicles. METHODS: Magnetic resonance imaging was used to evaluate the state of lesions of the patients with upper-extremity neurilemmoma who underwent tumour enucleation. To find out the correlation factors for neurological deficits, the patients were then divided into 2 groups based on their recovery period-group A (shorter than 6 months) and group B (at 6 months or longer). Duration of the illness, the affected nerve, and the size and histological type of the tumour were then compared between the 2 groups. RESULTS: Of the 20 patients who underwent tumour enucleation for neurilemmoma in the upper extremity, 19 had a single nerve affected and one had multiple lesions involving two nerves. The tumours in 6 patients were of Antoni A type histology and in the remaining 14 patients were of a mixed type. Antoni B type alone was not observed. 15 patients showed postoperative neurological deficits. No neurological deficits were observed in 5 patients. Neurological deficits were fully recovered in all patients except the one with a lesion in the digital nerve. Apart from enucleation of nerve fascicles, the period required for the recovery of neurological deficits was correlated to the duration of the illness (p=0.04) and the histological type of the tumour (p=0.03). CONCLUSION: Most of the patients with neurilemmoma (95%) had a single nerve affected. A majority of patients (70%) had the mixed type of Antoni A and Antoni B histology; Antoni B type alone was not observed. Neurological deficits were observed in 75% of patients. In patients with neurilemmoma developing in the upper extremity, the period required for recovery from postoperative neurological deficits was short when the duration of illness was short and when Antoni A type histology was present.
Upper-extremity deep venous thrombosis (UEDVT) is an increasingly important clinical problem in children. These events are classified as primary or secondary, with the latter being the most common and usually associated with the presence of a central venous line. Among primary UEDVT, the so-called Paget-Schroetter syndrome, effort-related or exercise-induced upper-extremity thrombotic event represents an extremely rare finding that has never been described in a pediatric series. The objective of the second part of this two-part article is to report the first pediatric series in a group of adolescents with this condition from a single center, describing their clinical features, management, and outcome. A retrospective chart review of 6 patients seen between December 2003 and April 2005 was conducted, with a median follow-up of 9 months (range 2-17). Four females and two males, all Caucasian, were enrolled with a median age of 16 years (range 14-17). In all cases, strenuous exercise was present in the month preceding diagnosis and mild trauma was present in only one case (weight lifting). At presentation, all patients had objective swelling of the affected limb for a median of 4 days (range 2-14), and 4 patients had UEDVT of the dominant arm. Thrombophilia investigation revealed that 50% had a combined prothrombotic state at presentation, and all patients were/are being treated with anticoagulation for 6 months (low-molecular-weight heparin followed by warfarin). Continuation of the initial symptoms was present in all cases but one at the 3-month clinic follow-up (last case has yet to reach 3 months of follow-up), and residual moderate to severe postthrombotic syndrome was present in all 3 cases followed for more than 12 months. Of those 3 patients followed for more than 1 year, 2 patients recurred despite having complete resolution of the thrombus after 6 months of anticoagulation, and the third patient underwent surgery with clinical improvement. Adolescents with UEDVT treated only with anticoagulation seem to have a poor outcome.
The accepted method of treatment for acute, contaminated, upper extremity wounds is serial débridement and delayed closure. Emergency free tissue transfer challenges these concepts by advocating radical débridement and early closure of these wounds. The use of emergency free tissue transfer in the upper extremity allows early motion and possibly lowers the rates of infection, nonunion, flap failure, and the length of hospital stay. The decision to carry out emergency free tissue transfer is made after evaluating the patient's systemic condition and the following factors: (1) extent of débridement, (2) bacterial load, (3) fracture type, (4) anatomical location of the wound, and (5) presence of exposed vital structures. When conditions are ideal, emergency free tissue transfer may be the best choice for closure of acute, contaminated, upper extremity wounds.
The labor market impact of upper extremity musculoskeletal injuries that result in permanent disability was estimated using data from the State of California. Administrative data on disability evaluations and resulting ratings was matched to data on the earnings of over 7000 injured workers. Using these data, labor market experience pre- and postinjury was tracked. Each injured worker was matched to a set of control workers who worked at the same firm, had the same tenure at the firm, and earned the same income at the time of injury. By comparing the injured and uninjured workers, lost earnings and the impact of injury on return to work was estimated. Evidence of considerable lost earnings resulting from injury was found. The results are compared to "disability ratings" that are used to set compensation under California's workers' compensation program. The disability rating was also found to predict poorly differences across upper extremity injuries in losses. In particular, those with shoulder injuries have larger losses than those with elbow or wrist injuries, despite receiving the same disability ratings.
Infusion of dilute contrast agent through an upper extremity vein results in marked opacification of the superior vena cava and the ipsilateral subclavian and brachiocephalic veins in computed tomography of the upper mediastinum. Also, the cranial arteries are well opacified. Images obtained by this method display anatomical relationships to better advantage and permit more accurate interpretation of anatomical relationships of the upper mediastinal masses. Improved anatomical details are obtained as compared to noncontrast scans or scans after bolus injection. In cases of suspected venous occlusion, functional diagnostic information is also achieved.
PURPOSE: To review the clinical features of a large series of active patients with a stress fracture in a non-weight-bearing location of the upper extremity or ribs. DESIGN: Multicenter cross-sectional study. SETTING: Multiple academic medical centers. PARTICIPANTS: 44 patients with a diagnosis of upper extremity or rib stress fracture. MAIN OUTCOME MEASURES: Clinical features according to anatomic location, primary sport, and subdivided according to the nature of the sport-specific skills involved. RESULTS: A diagnosis of stress fracture was made in 44 patients based on history and physical examination, and confirmed by radiography, scintigraphy, magnetic resonance imaging (MRI), computed tomography (CT), or a combination of imaging techniques. Patients were subjectively divided into four categories based on the predominant type of upper extremity activity required for participation in their sport: 1) weight lifter (e.g., football, weight lifting, wrestling); 2) upper extremity weight bearer (e.g., gymnastics, diving, cheerleading); 3) thrower (e.g., pitcher, soccer goalie, javelin); or 4) swinger (e.g., golf, tennis). We noted that all fractures in the weight bearers occurred distal to the elbow, whereas in the throwers most fractures affected the shoulder girdle. Lower rib stress fractures predominated in the swingers group, whereas weight lifters had fractures located throughout the upper extremity. CONCLUSION: Stress fracture should be considered in the differential diagnosis of athletes presenting with upper extremity or rib pain of bony origin that is of insidious onset. Further study of the sport-specific patterns of injury described here may improve our ability to treat and prevent these injuries.
Shoulder kinesthesia has not been extensively studied in upper extremity athletes. The purpose of this study was to determine if there were differences in threshold to detection of passive motion between dominant and nondominant shoulders of healthy overhead athletes in two positions, 0 degrees and 75 degrees of external rotation. In addition, the study attempted to determine if there was a relationship between the range of external rotation (ER) and internal rotation (IR) and the threshold to detection of passive motion values. Shoulder kinesthesia was assessed in the dominant and nondominant shoulders of 20 collegiate athletes participating in unilateral upper extremity sports. A proprioceptive testing device passively moved the shoulder into internal and external rotation. The dominant shoulder had a significantly greater difficulty detecting motion compared with the nondominant arm at both 0 degrees and 75 degrees of external rotation. Both shoulders exhibited enhanced kinesthesia (lower threshold to detection of passive motion scores) at 75 degrees of external rotation compared with 0 degrees, where the glenohumeral joint capsule is relatively taut. The results of this study suggest that healthy upper extremity athletes may have kinesthetic deficits in their throwing shoulder compared with their nondominant shoulder.
With the increasing frequency of mass disasters, identification of an isolated upper extremity and determination of the stature of the person it belonged to have created problems for investigation of the identity of some victims. Despite a need for such a study, there is a lack of systematic studies to identify fragmented and dismembered human remains. The purpose of this study was to analyze anthropometric relationships between dimensions of the upper extremity and body height. Analyses were based on a sample of middle class male (n = 202) and female (n = 108) Turks residing in Istanbul, Turkey. Five variables were entered into the analyses. For male subjects, forearm length was selected as the first factor, followed by hand length and finally upper arm length. For female subjects, upper arm length was selected first, followed by forearm length and finally hand length. There were also individually calculated formulae for some of these measurements that provided smaller R2 values. The study suggested that estimation of a living height could be made possible by using various dimensions of the upper extremity. One must consider differences between populations to apply such functions to other populations.
A rational approach to the restoration of function of the upper extremity has been outlined for the burned patient. If these guidelines are followed and the joints of the upper extremity approached individually with a goal of restoring as much range of motion as possible, great functional improvement may be anticipated. The surgical procedures must be augmented with vigorous PT and strong patient motivation. With this combination improvement of function of the upper extremity can be provided that is gratifying to both the surgeon and the patient.
Orthopaedic injuries are common among trauma patients and can result in long-term problems. Considerable data are available regarding functional outcomes following lower extremity trauma. There is, however, a paucity of data available for upper extremity trauma patients. Whilst currently available instruments appear to assess outcomes of relevance in trauma populations, the reliability, validity and responsiveness of these instruments have not been evaluated in the upper extremity trauma population. This paper reviews instruments designed for patient self-evaluation of musculoskeletal disorders of the upper extremity, and instruments used in an orthopaedic trauma population to assess functional recovery following injury. The Musculoskeletal Functional Assessment (MFA), Short Musculoskeletal Functional Assessment (SMFA), Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons Shoulder Scale (ASES-s), American Shoulder and Elbow Surgeons Elbow Scale (ASES-e), Patient Rated Elbow Evaluation (PREE), and the Patient Rated Wrist Evaluation (PRWE) were reviewed. Until research is published outlining the evaluation of assessment instruments in upper extremity orthopaedic populations, authors will need to conduct their own validation studies before investigating outcomes in specific trauma populations.
Two hundred twenty upper extremity radionuclide venograms were performed using upper extremity injection of 5 mCi of Tc-99m DTPA in each arm of patients with indwelling central lines. Evidence of obstruction was found in 123 patients, collateral flow without anatomic obstruction in six patients, and a slow-flow pattern in 12 patients. Twenty-six of these also underwent upper extremity contrast venography within 48 hours of the scan. Contrast venograms and radionuclide venograms agreed in 19 patients (16 correctly identified as obstructed, three correctly identified as unobstructed). Six patients showed the slow-flow pattern without collaterals or obstruction. Subsequently, six follow-up contrast studies showed no evidence of obstruction or collaterals. The authors conclude that obstruction with collateral flow on radionuclide venograms correctly predicts obstruction. However, the slow-flow pattern does not and should not be used as the sole criterion to diagnose partial obstruction.
BACKGROUND: Impeding the use of workers' compensation databases for surveillance of cumulative trauma disorder of the upper extremity (CTDUE) is the lack of valid and reliable extraction strategies. METHODS: Using the Z795-96 Coding of Work Injury or Disease Information standard, an algorithm was developed to classify claims as definite, possible, or non-CTDUE. Reliability was assessed with standardized claim reviews. RESULTS: Moderate to substantial agreement (Kappa = 0.48, 95% CI 0.42-0.54, n = 328; weighted Kappa = 0.75, 95% CI 0.70-0.80, n = 328) was demonstrated. The algorithm produced relatively homogeneous groups of definite and non-CTDUE claims but 29.1% of the possible CTDUE claims were categorized as definite CTDUE by claim review. Part of body agreement was almost perfect (Kappa = 0.81-1.00) when determining whether the upper extremity or specific parts of the upper extremity were involved. CONCLUSIONS: The algorithm can be used to estimate the number of CTDUE and extract homogeneous groups of definite and non-CTDUE claims. Furthermore, certain upper extremity part of body codes can be used to target anatomically defined claims.
Endoscopic techniques for surgery of the upper extremity show great promise based on recent discoveries of anatomic tissue planes. These planes can be dissected using new technology consisting of endoscopic balloons that create optical cavities that permit "incisionless" surgery. This article contains a review of the anatomic principles, new surgical technology, and development of endoscopic tools, as well as an example of endoscopic tissue expansion placement for soft-tissue augmentation in the upper extremity. Endoscopic techniques as they relate to fractures, synovectomy, and peripheral nerve decompression are discussed.
To examine the association of upper extremity bone mass with osteoarthritis (OA) of the knee, bilateral standing knee radiographs, taken between 1985 and 1991, in 430 Caucasian male and 266 Caucasian female subjects aged 40 years and above in the Baltimore Longitudinal Study of Aging, were read by one investigator for grade of OA using Kellgren-Lawrence scales. Several measures of upper extremity bone mass, size, and density, including combined cortical thickness (CCT), total width and percentage of cortical area of the second metacarpal, and bone mineral content (BMC), width, and density of the distal third of the left radius measured with single photon absorptiometry, were assessed at the same visit. In univariate analyses, men and women with definite knee OA were significantly older, men had significantly greater radial width, and women had significantly lower bone mass as measured by both CCT and BMC. After adjustment for age and body weight, however, men with knee OA had significantly higher BMC and radial width while neither of these measures of upper extremity bone mass and size was significantly associated with the presence of definite knee OA in women. Neither measure of upper extremity bone density was significantly associated with definite knee OA in either sex. These data suggest that, although men (but not women) with definite knee OA have significantly higher levels of adjusted radial bone mass and size, subjects with knee OA do not have significantly higher levels of adjusted bone mineral density at either upper extremity site.