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Under study were results of treatment of 150 patients with multiple and associated injuries of the upper extremities. Shock took place in 44% of the patients. Early fixation of the fractures of the upper extremities allowed a successful treatment of other injuries as well. The primary invalidization made up 12% mainly because of the amputation of the upper extremities.
Acute hormone responses of growth hormone (GH), total and free testosterone (TT and FT) and cortisol (C) to heavy resistance isometric exercise were examined in ten young men [YM 26.5 (SD 4.8) years] and ten old men [OM 70.0 (SD 3.7) years]. Loading conditions of the same relative intensity were created for the lower and upper extremity actions separately as well as for both of them together lower extremity exercise (LE; knee extension), upper extremity exercise (UE; bench press extension), and lower and upper extremity exercise (LUE) performed simultaneously in a seated position. Single voluntary maximal isometric actions lasting for 5 s were performed repeatedly for ten repetitions (with a recovery of 5 s) for a total of four sets. The recovery time between the sets was 1 min. Each exercise led to large acute decreases in maximal isometric force in both YM (P < 0.001) and OM (P < 0.001) ranging from 41% to 26% with no significant differences between the groups. Serum GH concentrations increased in both YM (P < 0.05-0.01) and OM (P < 0.05) but the postexercise value in YM during LE was greater (P < 0.05) than for OM. The TT increased (P < 0.01-0.001) in YM in all three exercises, while in OM the increase occurred only during LE (P < 0.01). The exercises led to increases in FT in YM (P < 0.05 for LE and LUE), while in OM the increase occurred only during LUE (P < 0.05). The pre and postexercise FT were greater in YM (P < 0.001) than in OM. No significant changes occurred in C either in YM or in OM. The blood lactate concentrations increased during the exercises in both YM (P < 0.001) and OM (P < 0.05-0.001) but the postexercise values during LE and LUE in YM were greater (P < 0.05) than in OM. The present data would indicate that the responses of GH, TT and FT to heavy resistance isometric exercise are lowered with increasing age. The reduced acute hormone response together with the lowered basal values in FT in the older men compared to the young men may indicate decreased anabolic effects on muscles and may explain in part the loss of muscle mass and strength associated with aging.
The purpose of the study was to examine the effects of a workplace physical exercise intervention on the perceived intensity of headache and the intensity of symptoms in the neck and shoulders, as well as on the extension and flexion strength of the upper extremities. The study was a cluster randomized controlled trial. The cross-over design consisted of physical exercise intervention (15 weeks) and no-intervention (15 weeks). The subjects (n=53) were office workers (mean age 46.6 (SD 8.4)) who reported headache (n=41) symptoms in the neck (n=37) or shoulders (n=41), which had restricted their daily activities during the last 12 months. Pain symptoms were measured using the Borg CR10 scale and muscular strength with a 5RM test. Statistical analyses were based on linear mixed models. Physical exercise intervention resulted in a slight, but statistically significant, decrease in the intensity of headache and neck symptoms, as well as an increase in the extension strength of the upper extremities. The mean decrease in headache during the 5-week period was 0.64 CR10 (95% CI 0.28-1.00) (P=0.001) or 49% (95% CI 22-77), and 0.42 CR10 (95% CI 0.11-0.72) (P=0.002) or 49% (95% CI 13-85) in the intensity of neck symptoms. The mean increase in the extension strength of the upper extremities was 1.3 kg (95% CI 0.5-2.1) (P=0.001) or 4% (95% CI 1-6). The intervention had no effect on the intensity of shoulder symptoms or the flexion strength of the upper extremities. Specific exercise may be clinically important to alleviate headache and neck symptoms.
Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.
PURPOSE: To design a radiation protection system for interventional procedures of the upper extremity and to evaluate the effectiveness of the system. MATERIALS AND METHODS: The radiation protection system consisted of an image intensifier (I-I) hood and x-ray tube cover. The I-I hood encircled the I-I to protect against scattered radiation from the patient's upper extremity and the table. The I-I hood consisted of four components: a device for attaching the hoods, two acrylate hoods with an 0.50-mm Pb equivalent, and a lead curtain hood with a 0.35-mm Pb equivalent. The x-ray tube cover was constructed of lead curtain to protect against backscattering radiation from the catheter table. An extremity phantom was used to measure the scattered radiation around the angiographic apparatus. The scattering dose rates were measured with an ionization dosimeter with and without a radiation protection system. The heights of the measuring points from the floor were 50 cm (operator's lower limbs), 100 cm (operator's abdomen), and 150 cm (operator's head/neck). RESULTS: The dose rates were reduced most with the combination of the I-I hood and the x-ray tube cover. The x-ray tube cover was effective in reducing scattering when it was set close to the table and the phantom. The maximum percentage decreases in dose rates by the radiation protection system were 99% at 50 cm, 73% at 100 cm, and 100% at 150 cm. Therefore, at 50 cm and 150 cm, the high-dose-rate area around the angiographic apparatus was reduced almost completely by the radiation protection system. CONCLUSION: The radiation protection system for interventional procedures of the upper extremity was effective in reducing scattered radiation around the angiographic apparatus.
Stress fractures are common injuries in the athletic population. Although much of the published literature has focused on lower extremity stress injuries, these injuries also occur in the upper extremities. Stress injuries of bone result from repetitive loads smaller than would be required to cause an acute fracture. As bone is repetitively stressed, it behaves like any solid substance. If deformity occurs within its elastic range, it returns to its original configuration. If stressed into its plastic range, permanent deformity occurs, and microfractures propagate, causing structural failure and complete fracture of the involved bone. High clinical suspicion is required for diagnosis because of historical and physical features can be vague. Plain radiographs are often inconclusive, but bone scans and MR imaging usually help elucidate the diagnosis. Most upper extremity stress injuries will heal with nonoperative management. In rare situations these injuries can progress to nonunion, which requires surgical correction.
The results of treatment of 101 combat injuries of the upper extremities are reported. There were 84 acute injuries and 17 late complications. There was a high incidence of associated fractures (35%) and nerve lesions (51%). Over half the injuries were repaired by saphenous vein graft replacement. There were seven early amputations related to a long delay before treatment, extensive tissue damage, and sepsis with delayed hemorrhage. There were no late amputations, but residual neurologic damage gave a less than perfect result in 32 extremities. Two injuries resulted in Volkmann's contracture. Fracture specific to the management of upper-extremity arterial injuries are outlined.
In summary, thermal injury is a frequent from of upper extremity trauma that often affects young working-class males. Its management must be designed with preserving life as a priority, recognizing the additional risk factor of inhalation injury as well as the traditional predictors of mortality--age and proportion of the TBSA burned. The aim of care in dorsal hand burns is to restore wound coverage and movement within 14 days of injury. Determining the depth of thermal injury to the upper extremity is notoriously difficult and requires serial assessment over time to most accurately predict the time of healing, still considered the standard measure of burn depth despite newly developing technical assessment tools. Tangential excision and split-thickness autograft coverage are predictably uniformly successful for deep dermal burns in restoring function in both the short and long term; however, burns exposing underlying tendons, bones, or joints require individualized reconstructive procedures, including local and distant flaps, free-tissue transfers, or combinations of these procedures. Early TAM is the most successful modality for recovery of function and to minimize any one of many potential complications associated most commonly with deep wounds and prolonged periods of healing.
STUDY OBJECTIVE: To determine the spectrum of disorders in children younger than 6 years with upper-extremity injury or immobility and to identify clinical findings associated with specific disorders. DESIGN: Prospective patient series. SETTING: Urban pediatric emergency department. PARTICIPANTS: Children younger than 6 years seen during a 6-month period with injury or immobility of an upper extremity. RESULTS: We identified 178 episodes of immobility or injury of an upper extremity. Radial head subluxation (RHS) was the most frequent diagnosis (63%; 99 definite and 13 probable), followed by fracture (22%) and soft-tissue injury (STI; 13%). One patient each had humeral osteomyelitis and neurologic impairment. The mean age of children with RHS was significantly less than that of children with fractures (27 +/- 12 months versus 39 +/- 19 months, P < .01); the only diagnoses in children younger than 4 months old were infection and neurologic impairment. Multivariate regression analysis showed point tenderness and swelling correlated with fractures (P < .05). Decreased arm movement, absence of swelling, and a pull as the mechanism of injury correlated with RHS (P < .05). However, arm traction occurred in only 55% of the children with RHS (95% confidence interval = .46 to .64). By 1 week after the evaluation, all children without fractures had recovered, except one each with a sprain, osteomyelitis, and neurologic impairment. CONCLUSION: Most children with arm injury or immobility have bony or soft-tissue trauma, the majority being RHS. Clinical findings varied between diagnoses and may aid the clinician in deciding whether attempted reduction of RHS is indicated or whether radiographs are warranted first. Nontrauma diagnoses are unusual but should be considered, particularly in the child younger than 6 months old. Appropriate immobilization and follow-up are important for the management of children without a clear diagnosis at the initial evaluation.
Juvenile muscular atrophy of the distal upper extremity (JMADUE) is postulated to be a type of flexion myelopathy. However, patients with typical clinical features of JMADUE but without evidence of flexion myelopathy have been reported. We recently reported a significant association of JMADUE with airway allergy. Here we report the successful treatment by plasma exchange (PE) of two patients with both airway allergy and JMADUE without evidence of flexion myelopathy. Patient 1 had a 5-year history of allergic rhinitis and high titers of mite antigen-specific IgE, and patient 2 had an 8-year history of pollinosis and high titers of cedar pollen-specific IgE. Both patients noted progressive distal muscle atrophy and weakness of the upper extremities: patient 1 for 3 months and patient 2 for 3 years. Neurologically, both showed asymmetric intrinsic hand muscle atrophy, oblique atrophy of the forearm muscles, and weakness and contraction fasciculation (minipolymyoclonus) of these muscles without any sensory impairment. Neither had any evidence of flexion myelopathy on magnetic resonance imaging (MRI) in a flexed position. Both were subjected to PE three times. Soon after the PEs, both showed improvement of distal muscle weakness of the upper extremities and marked reduction of contraction fasciculation of the forearm muscles. Patient 1 showed marked reduction in ongoing denervation potentials in the distal muscles on needle electromyography, while patient 2 showed marked improvement of F wave persistence of bilateral median and ulnar nerves. Serum total and allergen-specific IgE decreased after PEs in both patients. PE was thus considered to be effective in these two patients having JMADUE without evidence of flexion myelopathy. These observations may suggest the involvement of an immune-mediated process in the neural damage of JMADUE without evidence of flexion myelopathy, especially in patients with atopic diathesis, and may support the notion that JMADUE is etiologically heterogeneous.
Eleven patients with upper-extremity neurological abnormalities underwent open-heart surgery performed through a median sternotomy incision. Seven of the 11 patients were referred in the routine manner to evaluate and treat the neurological problem. The remaining four were part of a consecutively studied group of 11 patients examined prospectively to determine the possible presence of abnormalities. Two of these four patients were asymptomatic. All lesions could be postulated to occur within the brachial plexus, the most common area being the median cord, but lesions were also noted in the posterior and lateral cords and upper trunk. The etiology of the problem appears to be stretching injury of the brachial plexus from retraction of the sternum, which in turn causes retroclavicular displacement of the clavicle. However, it is possible that an ischemic neuropathy could result from intraarterial procedures in some of our patients. The possibility that neurologic deficit may occur in the upper extremity should be considered by physicians who may have the opportunity to evaluate patients who undergo open-heart surgery.
A new hydrofitness device has been devised for strengthening upper extremity muscles during aquatic exercise. It consists of a molded plastic fenestrated outer shell with an inner rotating disc that can be easily adjusted to alter the surface area of its frontal presentation. By changing the surface area of its frontal presentation a graded, individualized exercise program can be prescribed. A buoyant foam disc has been incorporated into the device to prevent it from sinking to the bottom of the pool. On the basis of this evaluation, performance of this device was judged to be superior to that of other devices for strengthening upper extremity muscles during aquatic exercise.
BACKGROUND: Cumulative trauma disorder of the upper extremity (CTDUE) is an umbrella term used to describe disorders resulting from repeated use of the upper extremity over time rather than a specific incident. The primary purpose of this article is to summarize the literature regarding the rate of work-related CTDUE, while drawing attention to the various factors contributing to the wide range of reported findings. METHODS: The Cumulative Index to Nursing and Allied Health and Medline databases were searched for articles focusing on etiology or rates of occurrence of work-related CTDUE and their findings were summarized. RESULTS: Potential reasons for rising rates, a gender differential, and the substantial range in rates and rate ratios are delineated and important factors to consider when interpreting rates derived from workers' compensation data are detailed. CONCLUSIONS: Future research should attempt to correctly identify more specific categories of CTDUE in well-defined and accurately-quantified "at risk" populations to provide more meaningful information regarding the epidemiology of CTDUE and the effectiveness of control activities.
We report on 2 patients with anomalous muscles of the upper extremity causing symptoms of peripheral nerve entrapment. Our first case clinically showed a lesion of the R. dorsalis manus of nervus ulnaris produced by an accessory muscle belly at the dorsum of the hand to be identified as an extensor indicis brevis muscle. The second case presented a carpal-tunnel-syndrome, tunnel into the palm. Phylogenetically and ontogenetically these muscles are classified as atavistic. We demonstrate the homologies of the upper extremity of fishes, amphibians, reptiles, lower mammals and man, which show an upward migration of the muscle masses from the hand to the forearm. By that means the upper extremity gains additionally to the power of the reptiles paw the functionality and free motility of the human hand.
UNLABELLED: Telemedicine is a valuable resource for the delivery of health care to patients in underserved areas. The purpose of this study was to assess the reliability of asynchronous teleconsultation in the diagnosis and establishment of treatment plans for patients with disorders of the upper extremity. One hundred patients with disorders of the upper extremity were prospectively evaluated. Initial patient evaluations, done by an independent evaluator, involved a medical history, physical examination, digital images of the patient, and digitized radiographic studies. This patient information was presented electronically to two hand surgeons 6 months after one surgeon independently evaluated the patients in the outpatient clinic. The physicians formulated diagnosis and treatment plans for the patients based on the blinded electronic information. These findings then were compared with the treatment plans made by the physicians at the time of the patients' visits. Telemedicine consultation resulted in excellent agreement within observers (kappa = .92) and between observers (kappa = .86). Telemedicine consultation seems to be a reliable method for diagnosis and establishment of treatment plans in the management of upper extremity disorders. LEVEL OF EVIDENCE: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients--with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.
Variations in the arterial anatomy of the upper extremities, although uncommon, occur in up to one in five patients. Most of these variants occur in either the radial or ulnar artery; brachial artery variations are less common. The case we report is a rare anomaly consisting of brachial artery agenesis or regression. The brachial artery was absent from its origin but reconstituted as a normal-appearing vessel 3 cm above the antecubital fossa. The profunda brachii artery and the superior and inferior ulnar collateral arteries were also absent in this patient. The axillary artery served as the main collateral to the forearm. This constellation of anomalies has not been previously described or explained by developmental models in humans and other primates. We speculate that failure of development or arrest of specific vascular anlage in the upper extremity occurs at particular embryological stages because of unknown factors.
The post-thrombotic syndrome (PTS) after upper extremity deep venous thrombosis (UEDVT) has not been well characterized. The objective of our study was to describe and quantify residual symptoms, functional disability and quality of life associated with PTS after UEDVT in adults. Twenty-four patients with objectively diagnosed UEDVT (bilateral in 1 patient) at least 6 months previously were recruited from two Canadian thrombosis clinics. Data were collected on demographic characteristics, DVT risk factors and affected venous segments. The Villalta PTS scale, modified for the upper extremity, was used to diagnose PTS. Patients completed questionnaires on degree of functional disability (DASH questionnaire), and generic (SF-36) and disease-specific (VEINES-QOL) quality of life. Results were compared in patients with and without PTS. Patients were assessed a median of 13 months after the diagnosis of UEDVT. Daily ipsilateral arm or hand swelling was reported by 52% of patients and daily ipsilateral arm pain by 20% of study patients, compared with 0% and 0%, respectively, in the contralateral arm. PTS was present in 11/25 (44%) limbs (11/24 patients). One patient had severe PTS. Patients with PTS, compared with those without PTS, had significantly more functional disability (mean DASH score 20.9 vs. 3.7, p=0.009) and poorer quality of life (mean VEINES-QOL score 45.6 vs. 53.6; p=0.001; mean SF-36 Physical Component Score (PCS) 40.8 vs. 50.2; p=0.12). PTS scores were higher and quality of life was poorer when PTS involved the dominant arm. In conclusion, PTS occurs frequently after UEDVT and is associated with significant functional disability and reduced quality of life. Patients with dominant arm PTS appear to fare worse than those with non-dominant arm PTS. Larger, prospective studies to identify prognostic factors that lead to PTS after UEDVT are warranted.
Color Doppler flow imaging with linear-array transducers was performed in 130 extremities in 91 patients with suspected upper-extremity deep venous thrombosis. Thrombi were detected in 39 studies (30%). Eighty-four patients had either imaging examinations (22 studies comprising venography in 20 patients, CT in one, and MR imaging in one) or clinical follow-up (99 studies) for correlation. In studies with imaging correlation, the sensitivity of the Doppler studies was 78% and the specificity was 92%. There were two false-negative examinations in which the proximal subclavian vein either could not be imaged or the anatomy was distorted. There was one false-positive color Doppler diagnosis of deep venous thrombosis in a case of partial obstruction of the subclavian vein caused by extrinsic compression. There were no known additional errors in color Doppler imaging in patients who had clinical follow-up. Four cases of isolated superior vena cava or proximal innominate vein obstruction were missed by color Doppler imaging. Color Doppler flow imaging is an accurate, noninvasive method for the evaluation of upper-extremity deep venous thrombosis. Other imaging tests may be required when the color Doppler study is negative and central venous thrombosis is suspected.