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PubMed1996

Multifocal neurilemomas in the same upper extremity. Case report.

Multifocal neurilemomas in different nerves of the same upper extremity are rare. A 36-year-old woman presented with five neurilemomas involving the main trunks of the median and radial nerve and digital nerves of her left upper extremity. These were excised and she recovered without complications. Fifteen years later she presented with several recurrences which were removed, and two years after that she required a further operation to excise tumours. At the time of writing she has at least five tumours on different nerves of her left arm but these are causing her no problems.

Adult↗

PubMed2002

Relationship between stress and pain in work-related upper extremity disorders: the hidden role of chronic multisymptom illnesses.

BACKGROUND: Pain and fatigue are commonly associated with work-related upper extremity disorders. Occasionally these symptoms persist beyond a reasonable healing period. One potential explanation for prolonged symptom expression is the concurrent development of a stress-mediated illness or CMI (Chronic Multi-Symptom Illness). In such a scenario, the chronic regional pain and other symptoms that the individual is experiencing would be attributable to the CMI rather than to tissue damage or a biomechanical dysfunction of the upper-extremity. METHODS: This article critically reviews the case definitions of the new class of CMI disorders and evaluates the existing evidence supporting centrally mediated physiological changes (e.g., sensory hypervigilance, dysautonomia) that manifest as symptoms of pain and fatigue in some individuals experiencing chronic stressors. RESULTS: While explanations for prolonged pain and fatigue have historically focused on mechanisms involving peripheral pathology or psychiatric explanations, ample evidences support the role of altered Central Nervous System function in accounting for symptom manifestation in CMI. CONCLUSIONS: A model is presented that unites seemingly disparate findings across numerous investigations and provides a framework for understanding how genetics, triggering events, stressors, and early life events can affect CNS activity. Resultant symptom expression (e.g., pain and fatigue) from central dysregulation would be expected to occur in a subset of individuals in the population, including a subset of individuals with work-related upper extremity disorders. Thus when symptoms such as pain and fatigue persist beyond a reasonable period, consideration of CMI and associated assessment and interventions focused on central mechanisms may be worthwhile.

Arm Injuries↗

PubMed2004

A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilot study of immediate and long-term outcomes.

OBJECTIVE: To evaluate the immediate and long-term effects of 2 upper-extremity rehabilitation approaches for stroke compared with standard care in participants stratified by stroke severity. DESIGN: Nonblinded, randomized controlled trial (baseline, postintervention, 9mo) design. SETTING: Inpatient rehabilitation hospital and outpatient clinic. PARTICIPANTS: Sixty-four patients with recent stroke admitted for inpatient rehabilitation were randomized within severity strata (Orpington Prognostic Scale) into 1 of 3 intervention groups. Forty-four patients completed the 9-month follow-up. INTERVENTIONS: Standard care (SC), functional task practice (FT), and strength training (ST). The FT and ST groups received 20 additional hours of upper-extremity therapy beyond standard care distributed over a 4- to 6-week period. MAIN OUTCOME MEASURES: Performance measures of impairment (Fugl-Meyer Assessment), strength (isometric torque), and function (Functional Test of the Hemiparetic Upper Extremity [FTHUE]). RESULTS: Compared with SC participants, those in the FT and ST groups had significantly greater increases in Fugl-Meyer motor scores (P=.04) and isometric torque (P=.02) posttreatment. Treatment benefit was primarily in the less severe participants, where improvement in FT and ST group Fugl-Meyer motor scores more than doubled that of the SC group. Similar results were found for the FTHEU and isometric torque. During the long term, at 9 months, the less severe FT group continued to make gains in isometric muscle torque, significantly exceeding those of the ST group (P<.05). CONCLUSIONS: Task specificity and stroke severity are important factors for rehabilitation of arm use in acute stroke. Twenty hours of upper extremity-specific therapy over 4 to 6 weeks significantly affected functional outcomes. The immediate benefits of a functional task approach were similar to those of a resistance-strength approach, however, the former was more beneficial in the long-term.

Adult↗

PubMed2003

Reliability of upper extremity tests measured by the Ergos work simulator: a pilot study.

The objective of this paper was to assess the reliability of functional capacity evaluation (FCE) tests of the upper extremity in Ergos from three perspectives: human performance (in terms of a learning effect); order of the physical intensity (force) of the subtests (intensity effect); and performance in time (time of day effect). An experimental within-subjects design was performed. Twelve healthy males/females were tested in the morning or in the afternoon. The tests focused on sensibility, coordination, and strength of the upper extremity. A counterbalanced design was used for three orders of the three types of tests increasing in intensity. Each participant was tested three times over the course of 4 weeks. A learning effect was found in sensibility and coordination subtests. No order effect was observed in terms of the intensity of the subtests. A time effect was found in coordination tasks: keyboarding performance was better in the morning, and handling better in the afternoon. It was concluded that repeated upper extremity FCE testing in the present pilot study was found to be reliable over a 4-week period in healthy subjects.

Adult↗

PubMed1999

Perceived psychological stress and upper extremity cumulative trauma disorders.

This report presents data exploring the relationship between perceived psychological stress and several variables implicated in the etiology of upper extremity cumulative trauma disorders (UECTDs). The sample was 354 workers from three different manufacturing companies. The primary job exposure for the subjects was that they were engaged in jobs that involved repetitious movements of the upper extremities, primarily of the hands and arms. Data collection included a detailed health history, a comprehensive physical examination of the upper extremities, limited electrodiagnostic testing, Cohen's Perceived Stress Scale, Karasek's Job Content Questionnaire, demographic information, and a measurement of repetition. Descriptive analyses, analysis of variance, correlational analyses, and multiple linear regression were used to examine the data. Perceived stress, as measured in this study, was only weakly associated with repetition, job dissatisfaction, and subjective complaints related to UECTDs. In addition, factors generally accepted as related to UECTDs (e.g., repetition, female gender, hormonal influences, and existing medical conditions) were not robust predictors of perceived stress. The major limitation is related to the measurement of perceived psychological stress. Like most psychosocial phenomena, perceived stress is a complex construct, one that is difficult to measure and correlate with health outcomes. Further research is necessary to examine what role, if any, perceived stress may have in the etiology of UECTDs.

Adult↗

PubMed2006

High-pressure injection injuries to the upper extremity: a review of the literature.

OBJECTIVES: The purpose of this review was to identify the relative impact of injected material, location of injury, time to debridement, injection pressure, infection, and the use of adjuvant steroid medication upon the need for amputation after high-pressure injection injuries to the upper extremity. DATA SOURCES AND STUDY SELECTION: A Medline literature search extending from 1966 to December 2003 was performed, referencing the key words "high-pressure injection injury," "grease gun injury," "paint gun injury," "pressure gun injury," and "high-pressure injection." The results were limited to the English language and to reports involving human subjects. Each abstract was reviewed to confirm that the described injury had occurred in the upper extremity and that it had truly been a high-pressure injection. The reference pages from each of the papers were reviewed to identify additional reports of high-pressure injection injury. Manuscripts describing injuries resulting from hand held syringes or other low-pressure mechanisms were excluded. DATA EXTRACTION: All of the manuscripts were analyzed to identify the clinical outcome, age, hand dominance, site of injection, substance injected, injection pressure, elapsed time to wide debridement, use of steroids, and incidence of infection. These variables were subjected to a Pearson chi test to determine their impact upon the need for amputation. RESULTS: Four hundred thirty-five cases of high-pressure injection injury to the upper extremity were identified. The amputation rate after these injuries was 30%. The location of the injury and the material injected contributed significantly to the need for amputation. For injections of paint, paint thinner, gasoline, oil, or jet fuel (organic solvents), the amputation risk was lower if wide surgical debridement occurred within 6 hours of injury. Steroids did not impact the amputation rate or incidence of infection. The presence of infection did not affect the incidence of amputation. CONCLUSIONS: The risk of amputation after high-pressure injection injury to the upper extremity is highest with organic solvent injection into the fingers. Injections into the thumb or palm result in a much lower frequency of tissue loss. Emergent surgical debridement reduces the amputation risk after injections of organic solvents. From the available data, no conclusions could be reached regarding functional outcomes, other than amputation, after high-pressure injection injury.

Forearm Injuries↗

PubMed2003

Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience.

Microvascular free-tissue transfer has been a major advance in the treatment of complex traumatic defects of the upper extremity. One hundred and fifty microvascular free-tissue transfers were performed in 133 patients with complex traumatic upper extremity defects at Bellevue Hospital Center from 1976 to 2000. The indication for microvascular free tissue transfers was exposure of vital structure (81 percent), bone defect (11 percent), and functional deficit (8 percent). The parascapular region was the most common donor site used (26 percent). Microvascular free-tissue transfer was performed either emergently at the time of injury (9.3 percent), during days 1 to 5 post injury (19.3 percent), during days 6 to 21 (19.3 percent), or after day 21 (52 percent). The overall flap failure rate was 9 percent. A decreased incidence of flap failure was observed in patients treated from 6 to 21 days post injury (3 percent p<0.05). The most common acute complication was infection at the recipient site, observed in 14 percent of patients overall. A decreased incidence of recipient-site infection was seen in patients who received free flaps at days 6 to 21 (3 percent; p<0.05). In long-term follow-up, the incidences of osteomyelitis and nonunion were lowest in patients treated from 6 to 21 days post injury (0.0 percent and 11 percent, respectively; p<0.05). During the last 10 years, the timing of reconstruction has been altered, and now preferentially microvascular free flaps are performed 6 to 21 days post injury. The treatment algorithm has been simplified and now only four different flaps are used in the majority of patients (70 percent). With this, the authors have witnessed a decrease in failure rates from 11 percent to 4 percent, a decrease in recipient-site infections from 16 percent to 10 percent and a decrease in osteomyelitis from 12 percent to 4 percent. The preferred timing for microvascular free-tissue transfers to the upper extremity is concluded to be 6 to 21 days post injury.

Adolescent↗

PubMed1994

Primary varicose veins of the upper extremity: a report of three cases.

Primary varicose veins of the upper extremity are extremely rare. We present three cases and discuss cause, diagnosis, and treatment. Three patients, a 23-year-old man, a 31-year-old woman, and a 39-year-old man, were referred with symptomatic varicose veins of the arm. None of the patients had lower extremity varicosities. Diagnosis was made by physical examination, noninvasive and invasive procedures, and excluded vascular malformations. Surgical treatment, similar to that for lower extremity varicose veins, entailed ligation and stripping of the varicose veins. Ligation and stripping were performed and successfully eliminated the varicosities with prevention of recurrence with a mean follow-up of 17 months. Although primary varicose veins of the upper extremity are extremely rare, they can be readily diagnosed and successfully treated, similar to lower extremity varicose veins. Although not proven, the cause is likely identical to lower extremity varicose veins. Excellent functional and cosmetic results can be obtained with surgical treatment.

Adult↗

PubMed1992

Occlusive arterial disease of the upper extremity.

Occlusive and aneurysmal diseases of the large vessels of the upper extremity are uncommon experiences in most practices. Yet, by utilizing basic principles learned in the lower extremity that emphasize proper historic and physical examination, and by the selective use of angiography, these problems can be delineated and effectively treated. Some of the variations in anatomic location and the natural histories of some conditions more prevalent in the upper extremity have been emphasized.

Arm↗

PubMed2004

Large and giant congenital pigmented nevi of the upper extremity: an algorithm to surgical management.

The timing and choice of treatment of congenital giant pigmented nevi continues to evolve under the influence of changing opinions regarding the risk of malignant degeneration and the impact of excision and reconstruction on the affected child. Many studies exist to support a notable enough risk of malignancy to warrant excision, yet other series and pigmented lesion clinics suggest that the risk of malignancy does not warrant the potential scarring and deformity that has followed the surgery necessary to remove these giant lesions. To satisfy both sides in this controversy, we have been challenged to modify our surgical techniques in a manner that minimizes the risk of malignant degeneration and at the same time provides optimal functional and aesthetic outcomes for these complex reconstructions. Thirty consecutive patients with large and giant nevi of the upper extremity were treated over a 23-year period (1979-2002) by the senior author. These patients represent a subset of 259 children (12%) with large or giant congenital pigmented nevi treated and followed during this period of time. In proximal upper extremity lesions, expanded transposition flaps from the upper back and shoulder have effectively eliminated contour defects or circumferential constriction in the upper arm and axilla. An expanded free transverse rectus abdominis musculocutaneous flap has offered a possible avenue for larger lesions (shoulder and upper extremity to below the elbow), and pedicle flaps from the flank (both expanded and nonexpanded) have offered ways of improving the long-term contour in the forearm. Expanded and nonexpanded full-thickness skin grafts were chosen for reconstruction of the hand and the fingers. The authors describe in detail the surgical strategies and the techniques for reconstruction of each region of the upper extremity and then bring these ideas together in an algorithm for assessment and treatment of these challenging lesions.

Algorithms↗

PubMed2000

Classification criteria and severity assessment in work-associated upper extremity disorders: methods matter.

Work-associated musculoskeletal disorders of the upper extremity are common and disabling. Research on these disorders is needed and requires valid methods of classification of the disorders for epidemiologic studies and measurement of their impact on functional status. This commentary discusses the methodologic aspects of classification and functional status assessment in upper extremity musculoskeletal disorders.

Classification↗

PubMed1999

Age-related changes in upper extremity performance of elderly people: a longitudinal study.

The objective of this research was to study age-related changes in the upper extremity performance of healthy community-dwelling elderly people, by using a longitudinal design. In 1995-1996. gross and fine manual dexterity, global performance, motor coordination, grip strength, tactile recognition, two-point discrimination, touch/pressure threshold, and tactile localization of 264 of the 360 subjects initially evaluated in 1992-1993 were reevaluated by using the same upper extremity measuring instruments. Those who did not participate (n = 96) were found to be significantly different from those who participated in the longitudinal study. Although the survivors were younger, more active, and perceived themselves in better health than the nonparticipants, their upper extremity performance significantly decreased in the 3-year period, with a few exceptions. In general, the decline was related to the initial score but not to age.

Aged↗

PubMed1992

[Correlation between clinical features and neuroradiological findings in juvenile muscular atrophy of unilateral upper extremity (Hirayama disease)--with and without "tight dural canal in flexion"].

Myelography was performed in 12 patients with juvenile muscular atrophy of unilateral upper extremity. Seven patients showed anterior shift of lower cervical dural canal in flexion (tight dural canal in flexion) (T group), however the other 5 patients did not show "tight dural canal in flexion" (NT group). Onset of illness and sex were not different between 2 groups. However, there was a tendency that the neurological signs and symptoms were more severe in the patients of T group than those of NT group. These results suggest that "right dural canal in flexion" can be one of mechanisms which exhibit the clinical symptoms of the juvenile muscular atrophy of unilateral upper extremity. However, there may be other etiological factors in the juvenile muscular atrophy of unilateral upper extremity.

Adolescent↗

PubMed1989

Effects of unilateral brain damage on contralateral and ipsilateral upper extremity function in hemiplegia.

This article describes the long-term effects of unilateral penetrating hemispheric lesions on contralateral and ipsilateral upper extremity motor performance and functional outcome. Activities-of-daily-living skill and gross motor performance contralateral to the lesions were compared among 32 left-sided and 19 right-sided hemiplegic subjects using analysis of variance and chi-square techniques. Ipsilateral to the damaged hemisphere, fine motor tasks of simple visual motor reaction time, grip and pinch strength, finger tapping, and Purdue Pegboard performance were tested. Analysis of covariance compared each ipsilateral task to performance in the corresponding hand of 70 matched controls. Results indicate similar long-term functional ADL outcome in right and left hemisphere-damaged subjects, despite more severe contralateral functional motor deficits following lesions of the left hemisphere. Right hemisphere lesions led to ipsilateral decrements in reaction time, and lesions of either hemisphere diminished grip or pinch strength, finger tapping, and pegboard performance ipsilaterally. These results demonstrate that unilateral brain damage involving the motor areas of either hemisphere has detrimental effects on ipsilateral upper extremity motor function. Findings are discussed and related to the concept that the left hemisphere is specialized or has greater neuronal representation for bilateral motor processes. Physical therapists involved in the treatment of patients with hemiplegia should be aware that motor functions of the ipsilateral, nonparetic upper extremity may also be affected adversely by unilateral brain lesions.

Activities of Daily Living↗

PubMed1993

A checklist for evaluating ergonomic risk factors associated with upper extremity cumulative trauma disorders.

A two-page checklist for determining the presence of ergonomic risk factors associated with the development of upper extremity cumulative trauma disorders (e.g., repetitiveness, local mechanical contact stresses, forceful manual exertions, awkward postures, and hand tool usage) was developed and evaluated as part of a joint labour-management ergonomics intervention programme. This checklist was used by plant personnel at four work sites to assess the presence of upper extremity risk factors in 335 manufacturing and warehouse jobs. In addition, results generated by the checklist were compared to the results of ergonomic analyses performed by persons with advanced training (Masters degree) in occupational ergonomics for a subset of 51 jobs. Most of the jobs included in the survey were found to have significant exposures to upper extremity risk factors. Awkward work postures were common, with 90% of the jobs requiring wrist deviations outside the neutral range-of-motion. The jobs were also highly repetitive and frequently required workers to exert high hand forces. Results generated by the checklist were generally in agreement with results generated by the ergonomic analysts; however, the checklist was found to be more sensitive in identifying the presence of risk factors. The checklist was found to be an effective rapid-screening instrument for identifying jobs that expose workers to potentially harmful ergonomic stresses. However, the checklist methodology did not include sufficient documentation of work methods to identify specific job attributes associated with these exposures.

Arm Injuries↗

PubMed2000

Brachial plexus catheter reservoir for the treatment of upper-extremity cancer pain: technical case report.

OBJECTIVE AND IMPORTANCE: Infiltration of the brachial plexus with anesthetics can provide relief of upper-extremity pain from invasive cancer. Because the analgesia is short-lived, however, repeated invasive treatments are necessary. We describe the implantation of a catheter reservoir system, in which anesthetic injections through a subcutaneous port resulted in anesthetic infiltration of the brachial plexus. CLINICAL PRESENTATION: A 47-year-old Hispanic man with squamous cell carcinoma of the larynx had undergone surgical resection, radiation treatment, and chemotherapy. Two years later, he had locally recurrent disease involving the brachial plexus, neck, and chest wall. The patient's pain was minimally responsive to narcotics, which also caused severe nausea and anorexia. TECHNIQUE: The brachial plexus was localized percutaneously with a needle electrode stimulator. Contrast injection under fluoroscopy confirmed entry into the plexus sheath. With use of the Seldinger technique, two Silastic catheters were placed within the brachial plexus and attached with a "Y" connector to a reservoir. The patient experienced complete relief of upper-extremity pain after a test injection with xylocaine. Thereafter, serial injections of bupivacaine with triamcinolone at 1-week intervals provided complete pain relief. After the treatments were initiated, the patient reported improved sleep and an improvement in his quality of life. CONCLUSION: A catheter reservoir system for brachial plexus analgesia can provide safe and effective analgesia for upper-extremity pain. This technique negates the need for repeated invasive procedures and avoids the complications of neurolysis.

Anesthetics, Local↗

PubMed1995

Upper-extremity Musculoskeletal Disorders in Keyboard Operators in Brazil: A Cross-sectional Study.

This study sought to determine the prevalence of upper-extremity musculoskeletal disorders (UEMSDs) among keyboard operators in Sao Paulo, Brazil, and to compare this prevalence with that among other office workers. One hundred and thirty keyboard operators (mean age 33 years, 60 male/70 female) and 138 office workers (mean age 35 years, 82 male/56 female) from two computing centers were interviewed by a research assistant using a standardized questionnaire. Symptomatic subjects, defined as those who reported upper extremity pain or lost work time due to pain in the preceding 12 months, were examined by a rheumatologist. Mean (SD) lengths of employment were 9 (6) years for keyboard operators and 8 (6) years for office workers. Upper-extremity pain during the preceding seven days was reported by 66 keyboard operators (51%) and by 18 office workers (13%) (p < 0.0001); during the preceding 12 months, by 90 keyboard operators (69%) and by 26 office workers (19%) (p < 0.0001). UEMSDs were diagnosed following physical examination in 50 keyboard operators and in 12 office workers (9%) (p < 0.0001). Tenosynovitis was the most common disorder diagnosed among the keyboard operators (n = 23). Among the keyboard operators the prevalence of UEMSDs was significantly lower for males (p = 0.017, OR = 0.38, 95%CI = 0.17-0.86). The presence of a diagnosed UEMSD was significantly associated with duration of employment (p = 0.005) and lack of or insufficient rest breaks (p = 0.012). Keyboard operators had significantly more UEMSDs than did office workers. Strategies aimed at the reduction of repetitive strain injuries among keyboard operators, such as the provision of adequate work breaks, should be evaluated.

Journal Article↗

PubMed1990

[A case of flexion myelopathy presenting juvenile segmental muscular atrophy of upper extremities--a successful treatment by cervical spine immobilization].

A 24-year-old man was well until 1982, when he noticed weakness and atrophy of right arm especially those of biceps muscles. These symptoms did not progress until 1988. In 1988 weakness of left elbow flexion appeared and he was admitted to our hospital. On examination, he had weakness and atrophy of both upper extremities. Fasciculation was noticed in the proximal part of right arm. When his head was bent forward, dysesthesia appeared around radial side of his arm. There were no long tract sign or objective sensory loss. EMG showed neurogenic change over both his upper extremities. In plain cervical roentgenogram there existed abnormal kyphosis of cervical vertebrae. In MRI imaged with his neck flexed, cervical cord was compressed by the posterior surface of 4th cervical vertebral body, which corresponded to the top of cervical kyphosis. Based on these signs and examinations, a diagnosis of flexion myelopathy was made. Spinal immobilization by wiring and bone graft implantation ranging from C2 to C6 was performed to limit the range of anterior nuchal flexion. After this operation, improvement of muscle strength along with the disappearance of dysesthesia on neck flexion was observed. Clinically, this case closely resembles to juvenile type of distal and segmental muscular atrophy of upper extremities (Hirayama type). From our study, pathomechanism of this case seems to be a flexion myelopathy at C4 level. This view is supported also by the good recovery after the operation. This case suggests that nonprogressive atrophy of upper extremities due to flexion myelopathy can be successfully treated by cervical spine immobilization.

Adult↗