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PubMedDate not supplied

Upper extremity surgery in stroke patients.

Surgical procedures are performed on the nonfunctional upper extremity following stroke to correct spastic flexion contractures that cause pain or prevent adequate hygiene. In the upper extremity surgical procedures are most commonly performed to improve extension at the wrist, fingers or thumb. If the deformity is primarily due to spasticity rather than fixed myostatic contracture, anesthetic block of the median and/or ulnar nerve preoperatively enables the surgeon to determine that extension will be improved after the appropriate flexor tendons are lengthened. Careful presurgical evaluation of motor sensory function enables the surgeon to predictably select those patients who will benefit from surgery.

Arm↗

PubMed1994

Vascularized fibular graft for management of severe osteomyelitis of the upper extremity.

The authors analyzed 14 patients with severe osteomyelitis of the upper extremity between 1985 and 1992, managed with the vascularized fibular graft. Eleven radii, two humeri and one ulna were reconstructed. Bone loss after resection ranged from 6 to 12 cm (mean 8.14 cm). Follow-up ranged from 8 months to 7 years and 10 months (mean 3 years and 3 months). The therapeutic applications of the vascularized fibular graft in severe bone infections of the upper extremity were discussed and the good results of this surgical procedure established it as a good option for treatment. Morbidity at the donor site was minimal.

Adolescent↗

PubMed1981

Upper-extremity emboli secondary to axillofemoral graft thrombosis.

Four episodes of upper-extremity arterial emboli following axillofemoral bypass graft thrombosis are described. The source of the embolus was the blind stump of the proximal portion of the graft limb that remained patent after graft occlusion. With axillofemoral graft thrombosis, management requires treatment of the lower-limb ischemia and an awareness of the embolic potential of the acutely thrombotic graft limb. Patient evaluation and the surgical management of axillofemoral graft thrombosis with and without the complication of upper-extremity ischemia are discussed, as well as the etiology and prevention of this complication.

Arm↗

PubMed1997

Upper extremity ischemia from subclavian artery aneurysm caused by bony abnormalities of the thoracic outlet.

OBJECTIVE: To describe our experience with surgical therapy for upper extremity ischemia incident to emboli from aneurysms of the subclavian artery. DESIGN: Retrospective review case series. SETTING: Vascular surgery practice at a university hospital-based tertiary referral center. PATIENTS: All patients treated for upper extremity ischemia caused by embolism from a subclavian artery aneurysm from January 1, 1990, to July 31, 1996. INTERVENTION: All patients underwent detailed history and physical examination, screening for immunologic and hypercoaguable disorders, noninvasive vascular laboratory evaluation, and arteriography of the aortic arch in both arms and hands. Surgical treatment consisted of rib excision or fracture plating, aneurysm excision, and interposition vein grafting, with additional saphenous vein bypasses to brachial or forearm arteries as needed to provide uninterrupted circulation to the wrist. RESULTS: Twelve patients (6 males; mean age, 37 years) were treated. All had episodic upper extremity ischemia with an initial misdiagnosis of primary vasospastic disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of symptoms before correct diagnosis averaged 7 months (range, 1-36 months). All patients had bony abnormalities of the thoracic outlet (8 cervical ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All aneurysms contained intraluminal thrombus, and all patients had multiple ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating chronic and repeated embolization. All patients underwent aneurysm excision and interposition vein grafting, with additional vein bypass to the brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up was 18 months (range, 2 weeks to 63 months). Eleven patients had complete symptomatic relief, and 1 patient improved. All subclavian interposition grafts remained patient. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patient forearm arteries. There has been no limb loss. CONCLUSIONS: Hand ischemia caused by embolization from a subclavian artery aneurysm occurs in young patients without atherosclerosis and is frequently misdiagnosed as vasospasm. Despite advanced disease and multiple chronic distal arterial occlusions, surgical treatment by resection of bony abnormalities, aneurysm excision and grafting, and distal bypass grafting produces excellent results.

Adolescent↗

PubMed2001

Upper extremity deep venous thrombosis leading to pulmonary embolism after total hip arthroplasty.

Upper extremity deep venous thrombosis most commonly occurs secondary to the presence of subclavian central venous catheters. Of all upper extremity deep venous thromboses, 12% may cause pulmonary embolism; however, pulmonary embolism from a so-called primary thrombosis is uncommon. We report an unusual case of pulmonary embolism after primary deep venous thrombosis in the down arm after total hip arthroplasty.

Adult↗

PubMed2004

Disarticulation of the left upper extremity for treatment of giant primary lymphedema--case report.

This unusually rare case of giant primary lymphedema of the left upper extremity in a 21-year old woman, who had undergone five surgical procedures (two Charles' procedures and three partial resections) without lasting clinical improvement, demonstrates the difficulty in achieving satisfactory long-term results in patients with grotesquely huge extremities secondary to primary lymphedema. Disarticulation of the left upper extremity was felt to be the most appropriate surgical option in this severe congenital lymphedema patient.

Adult↗

PubMed1996

[Clinical experience in interscalene brachial plexus block combined with Ho's method of C3-4 block for shoulder and proximal upper extremity surgeries].

BACKGROUND: Brachial plexus block, first performed in 1889 by Halsted, has been widely used for surgery of shoulder and upper third of upper extremity. But the level of block is inadequate for surgery of the deeper tissue. If high volume of local anesthetic (40 ml) is used to block C3-4, complications like Horner's syndrome and phenic nerve palsy would be frequent. The landmark of C-3 and C-4 nerve root is difficult to identify. The purpose of this study was to design a new method to block easily the C-3 and C-4 nerve roots for surgery of shoulder deep tissue. METHODS: Sixty-five patients with ASA physical status I-III and age from 15 to 65 yr were studied. They included 42 male and 23 female patients who received interscalene brachial plexus block together with Ho's method of C-3, C-4 block in the space of 10 mon since 1985. The Ho's point which circumscribes the landmark for C3-4 block is a point at which the outer margin of the external jugular vein intersects the sternocleidomastoid muscle. In this technique we punctured the skin with a needle vertically at the chosen point until it touched the anterolateral side of the C-4 transverse process, normally, not deeper than 1.25 cm. This block was usually done for surgery of the shoulder and upper third of upper extremity. We used 0.5% bupivacaine 10 ml combined with 2% lidocaine 10 ml for interscalene brachial plexus block and 2% lidocaine 10 ml only for C3-4 block. RESULTS: Only 3 out of total 65 blocks failed. For these 3 cases we shifted the regimen from nerve block to general anesthesia. The successful rate was 95.4%. One case was initially planned for general anesthesia. However, difficult intubation was encountered due to masseter muscle spasm/rigidity during anesthetic induction. Three days later, this case was successfully anesthetized with this block. BP, EKG, and SaO2 did not differ preoperatively and intraoperatively. If the operation time is limited to 3 h, the result has always been satisfactory. CONCLUSIONS: Interscalene brachial plexus block combined with Ho's method of C3-4 block is technically safe and economical for patients receiving shoulder and proximal third of upper extremity surgery. We must make selection of patients carefully and exclude those whose anatomical landmarks are difficulty identified. As such, good result is expected.

Adolescent↗

PubMed1992

Biomechanical factors affecting upper extremity cumulative trauma disorders in sign language interpreters.

Symptoms associated with upper extremity cumulative trauma disorders (UECTDs) recently have been reported in professional sign language interpreters. The present investigation is a case control study of potential biomechanical factors that may exacerbate or maintain UECTD-related symptoms in this occupational group. Based on the results of a medical screening, interpreters were classified into two groups: working with pain (n = 16) and working without pain (n = 13). There were no significant differences between the groups on age, gender, years signing, years interpreting, and wrist and forearm endurance and flexibility as measured during an isokinetic strength test of the upper extremities. Subjects were exposed to a standard interpreting task. Groups were compared on measures of repetitiveness of hand/wrist motion, work/rest cycle, postural stress, and smoothness of movement. Heart rate, pain, fatigue, and perceived reduction in extremity flexibility also were measured. The group working with pain demonstrated a distinct pattern of potential biomechanical risk factors previously associated with UECTDs in other occupations. By comparison with the control group, those working with pain exhibited fewer rest breaks, more frequent hand/wrist deviations from neutral, more frequent lateral excursions from an optimal work envelope, and more rapid finger/hand movements while interpreting. Significant group differences on self-report measures of pain, fatigue, and perceived limitation in range of motion also were observed. An analysis of heart-rate response to the interpreting task revealed that both groups demonstrated a modest increase in heart rate to the interpreting task, although interpreters working with pain displayed lower heart rates across all phases of the experimental task.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2004

A new method to quantify demand on the upper extremity during manual wheelchair propulsion.

OBJECTIVE: To use an ergonomics-based rating that characterizes both demand on, and capacity of, upper-extremity muscle groups during wheelchair propulsion to help identify the muscle groups most at risk for pain or overuse injury in a relatively demanding wheelchair propulsion task. DESIGN: Case series. SETTING: Biomechanics research laboratory. PARTICIPANTS: Sixteen manual wheelchair users with complete (American Spinal Injury Association grade A) T6-L2 paraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Internal peak joint moments required by each of the major upper-extremity muscle groups for propelling a wheelchair up a ramp; isometric strength of each of the muscle groups in positions simulating wheelchair propulsion; and wheelchair propulsion strength rating (WPSR) for each muscle group, calculated by normalizing the joint demands to their capacity. RESULTS: The largest joint moment was for shoulder flexion, at 39.7+/-13.9Nm. Shoulder flexion also accounted for the peak WPSR value of 66.5%+/-20.3%. Supination and pronation movements had low peak moment requirements (3.4Nm, 5.0Nm, respectively) but high WPSR values (41%, 53%, respectively). CONCLUSIONS: Even a relatively benign ramp (2.9 degrees ) places a large demand on the musculature of the upper extremity, as assessed by using the WPSR to indicate muscular demand.

Adult↗

PubMed2006

Reconstruction of the hand and upper extremity after tumor resection.

This article reviews the surgical options available for reconstruction of the upper extremity following tumor resection. In order to achieve maximum function and limb salvage a multidisciplinary approach to patient care is emphasized. With proper preoperative planning, salvage of limb form and function can be accomplished in over 95% of cases. Successful reconstruction is measured by preservation of patient health, limb function, limb sensation and cosmesis and stable wound coverage. Important adjuncts to reconstruction include adequate postoperative splinting and aggressive rehabilitation to maximize long-term upper extremity function.

Arm↗

PubMed1999

Endoprosthetic reconstruction for malignant upper extremity tumors.

Between December 1980 and December 1992, 59 patients underwent 60 reconstructions with endoprostheses after resection of malignant tumors in the upper extremity. There were 32 male patients and 27 female patients, with a mean age of 33 years (range, 3-83 years). The type of reconstruction was based on the location of the primary tumor site. The histologic diagnoses included osteosarcoma, chondrosarcoma, Ewing's sarcoma, malignant fibrous histiocytoma, soft tissue sarcoma, and fibrosarcoma of bone. Most of the patients had Stage IIB disease (N = 38), as established by the Musculoskeletal Tumor Society classification. An additional six patients had metastatic tumors to the upper extremity. Twenty-seven of 59 patients died of disease progression. Two patients died of other causes (chronic leukemia, human immunodeficiency virus infection). The 30 survivors had a mean followup of 90 months (range, 60-170 months). The Musculoskeletal Tumor Society functional analysis for the patients with a minimum 2-year followup (N = 41) averaged 74%. Sixteen of the 59 (27%) patients had local complications. Problems related to mechanical failure and infection were managed successfully with second operation. Amputation was rare, occurring in three of 60 (5%) patients and was related only to local recurrence. Endoprosthetic reconstructions of the upper extremity after tumor resections have proven to be successful.

Adolescent↗

PubMed2007

Endoscopically assisted sural nerve harvest for upper extremity posttraumatic nerve defects: an evaluation of functional outcomes.

BACKGROUND: Peripheral nerve injuries in the upper extremity often require interposition of sural nerve grafts for reconstruction. Due to the poor donor-site appearance with standard techniques, and the potential for trauma to the nerve because of poor visualization during the harvest when the stepladder technique is used, the endoscope has been employed for nerve harvest. METHODS: From January of 1997 until December of 2003, 15 patients with an average age of 27.5 years with posttraumatic upper limb nerve defects of the ulnar, median, or posterior interosseous nerves (crush, cutting, or avulsion injuries) underwent reconstruction with endoscopically harvested sural nerve. The nerves were harvested using atraumatic techniques under video monitor visualization. The functional results of sensation and motor function were assessed using British Medical Research Council scales. RESULTS: All patients regained at least cutaneous pain and tactile sensibility, with most regaining two-point discrimination (nine patients achieved S3+). Two patients achieved complete recovery (S4). The 11 patients with motor nerve involvement achieved between M1+ and M5 after the initial reconstruction. Eight patients required a total of one immediate and nine secondary procedures to achieve the final outcome. The procedures included tenolysis (three patients), intrinsic tendon transfers (four patients), and opponensplasty (three patients). At the 4-year mean follow-up, grip power was M5 in 13 patients (86.7 percent) and M4 in two patients (13.3 percent). CONCLUSIONS: Upper extremity sensory and motor nerve defects can be reconstructed with interposition of endoscopically harvested sural nerve grafts. The procedure is reliable, quick, and atraumatic, and results in reasonable motor and sensory recovery.

Adolescent↗

PubMed2007

Inflammatory biomarkers increase with severity of upper-extremity overuse disorders.

MSDs (musculoskeletal disorders) from overuse are common occupational health problems that cause pain, functional loss and loss of work time. The aim of the present study was to determine whether a relationship exists between the severity of early-onset overuse-related MSDs of the upper extremity and serum levels of IL-1beta (interleukin-1beta), TNF-alpha (tumour necrosis factor-alpha), IL-6 (interleukin-6) and CRP (C-reactive protein). Twenty-two subjects with upper-extremity MSDs due to overuse for no longer that 12 weeks were stratified according to the severity of upper-extremity signs and symptoms as determined by a UBMA (upper-body musculoskeletal assessment). Nine asymptomatic subjects also participated. Serum cytokines were analysed using ELISA, and CRP was analysed using a laser nephelometry technique. CRP was strongly correlated, and TNF-alpha, IL-1beta and IL-6 were moderately correlated, with UBMA scores. Only CRP and TNFalpha were significantly associated with UBMA scores in an ordinal logistic regression analysis in which age and BMI (body mass index) were covariates. These results are of clinical importance as they suggest that early-onset overuse-related MSDs may have an inflammatory component. The possibility of using a combination of serum biomarkers to follow the progression of overuse-related MSDs or their response to therapeutic intervention may be of interest to clinical practitioners and should be the focus of future research.

Adult↗

PubMed2005

An EMG-driven model of the upper extremity and estimation of long head biceps force.

An electromyography (EMG) driven model of the upper extremity has been developed that incorporates musculoskeletal geometry of the glenohumeral and elbow joints, estimated relevant physiologic muscle parameters including optimal muscle lengths, and EMG activity. The model is designed to predict forces in muscles spanning the glenohumeral joint resulting from functionally relevant tasks. The model is composed of four sub-models that comprise a mathematical as well as graphical three-dimensional representation of the upper extremity: a musculoskeletal model for estimation of muscle-tendon lengths and moment arms, a Hill-based muscle force model, a model for estimating optimal muscle lengths, and a model for estimation of muscle activation from EMG signal of the biceps. The purpose of this paper is to describe the components of the model, as well as the data required to drive the model. Collection of data is described in the context of applying the model to determine biceps muscle forces for testing of functional tasks. Results obtained from applying the model to analyze the functional tasks are summarized, and model strengths and limitations are discussed.

Computer Simulation↗

PubMed2006

Loading modalities and bone structures at nonweight-bearing upper extremity and weight-bearing lower extremity: a pQCT study of adult female athletes.

This cross-sectional study of adult female athletes assessed whether the apparent loading-related differences in bone structure are primarily associated with the loading type or the muscle performance-related joint moments. Several structural variables at shaft sites of the tibia, radius and humerus, and distal sites of the tibia and radius were measured with peripheral quantitative computed tomography (pQCT) among 113 female national level athletes (representing hurdling, volleyball, soccer, racket-sports and swimming) and their 30 nonathletic referents. For the weight-bearing lower extremities, the loading modalities of the above sports were classified into high-impact (hurdling, volleyball), odd-impact (soccer, racket-sports) and repetitive, nonimpact (swimming) loadings; and for the nonweight-bearing upper extremities into high magnitude (functional weightlifting in hurdling and soccer), impact (volleyball, racket-sports) and repetitive, nonimpact (swimming) loadings. As expected, athletes' bone mass was substantially higher at loaded bone sites compared with the nonathletic referents, but more pertinently to the locomotive perspective, the loading-induced additional bone mass seemed to be used to build mechanically strong and appropriate bone structures. Compared with controls, the weight-bearing bone structures of female athletes (swimmers excluded) were characterized by larger diaphysis, thicker cortices and somewhat denser trabecular bone. The athletes' bones at the nonweight-bearing upper extremity were generally larger in cross-sectional area. The estimated indices of joint moment (muscle force x estimated lever arm) were explained from 29% to 50%, and the loading modalities from 8% to 25%, of the variance in most bone variables (P < 0.05) of the tibia (shaft and distal site). In contrast to the weight-bearing tibia, only the estimated joint moment was positively associated (P < 0.05) with the structural characteristics of the radius and humerus, accounting for 6% to 26% of the variance in bone variables of the shafts of these bones. Such association was not observed at the distal radius. In conclusion, at the weight-bearing lower extremity, the strong bone structure of the female athletes was attributable to muscle performance-related estimated joint moments and impact loading modality. At the shaft sites of the nonweight-bearing upper extremity, the strong bone structure was mainly attributable to the estimated joint moments. Thus, different loading history and other features of loading seemed to govern the skeletal adaptation at the upper and lower extremity.

Absorptiometry, Photon↗

PubMed2001

Intrathecal baclofen in tetraplegia of spinal origin: efficacy for upper extremity hypertonia.

STUDY DESIGN: Retrospective analysis. OBJECTIVES: To evaluate the efficacy of intrathecal baclofen (ITB) for upper extremity spastic hypertonia in tetraplegia of spinal origin. SETTING: University of Alabama at Birmingham hospital. METHODS: The medical records of 14 individuals with tetraplegia of spinal origin who underwent intrathecal baclofen pump placement were reviewed. The effects of intrathecal baclofen on spasm frequency, deep tendon reflexes, and tone (Ashworth scale) were assessed for the upper and lower extremities for a 1-year follow-up period. RESULTS: There were statistically significant declines in upper extremity spasm scores (1.8 points, P=0.012), reflex scores (1.4 points, P<0.0001) and Ashworth scores (0.6 points, P<0.0001) for the 1-year follow-up period. For the lower extremities, all decreases were significant (P<0.0001). There was also a statistically significant (P<0.0001) increase in intrathecal baclofen dosage requirements during the 1-year follow-up period to maintain the reductions in spasm frequency, reflexes and tone. CONCLUSIONS: Intrathecal baclofen is a safe and effective intervention for treating upper extremity hypertonia of spinal origin. In addition, the level of intrathecal catheter placement is felt to be of importance.

Adult↗

PubMedDate not supplied

Determinants of use of outpatient rehabilitation services following upper extremity injury.

This study documents the utilization of outpatient therapy services following upper extremity injury and identifies factors that influence the use of services. One hundred twelve patients admitted to a hand center for treatment of upper extremity injury were followed prospectively for 7 months to determine their utilization of therapy services and their perceptions of unmet need. Eighty percent of the patients used therapy services following their injury Those who were more severely injured, were female, had health insurance, or obtained disability compensation made more visits than other subjects. One third of the patients reported that they did not have an adequate number of therapy visits. Subjects cited various reasons (e.g., lack of insurance, transportation difficulties) for unmet need. These findings suggest that the variation in utilization of rehabilitation services depends on not only the severity of the injury but other patient characteristics and resources as well.

Adolescent↗

PubMed1997

Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population.

PURPOSE: Although much attention has been focused on lower extremity deep venous thrombosis (LEDVT), there is a relative paucity of data regarding the impact of upper extremity deep venous thrombosis (UEDVT) on morbidity and mortality rates. To increase our knowledge with the latter disease, we have reviewed our experience at our institution with 170 patients who had brachial, axillary, and subclavian vein thromboses. METHODS: Over the past 5 years, UEDVT was diagnosed in 170 patients by duplex scanning. The indications for duplex examination were either upper extremity swelling (95%) or as part of the workup for pulmonary embolism (5%). There were 103 women (61%) and 67 men (39%), with ages ranging from 9 to 101 years (mean, 68 +/- 17 years). The diagnosis was made in 152 patients (89%) while they were admitted to the hospital and in 18 patients (11%) in the outpatient clinic. Risk factors included presence of a central venous catheter or pacemaker in 110 patients (65%), malignancy in 63 patients (37%), concomitant LEDVT in 19 patients (11%), and history of LEDVT in 18 patients (11%). Fifty-six patients (33%) had multiple risk factors, whereas 36 patients (21%) had no obvious risk factor. RESULTS: The 1-month and 3-month mortality rates for the entire study group were 16% and 34%, respectively. Patients who had concomitant LEDVT, were 75 years of age or older, and were not treated with anticoagulation medication had a significantly higher 1-month mortality rate. Patients whose diagnoses were made in the outpatient setting were statistically younger and had a lower 3-month mortality rate when compared with the patients whose diagnoses were made as inpatients. Pulmonary embolism was documented by ventilation/perfusion scan in 12 patients (7%). Although no patient in the group in which UEDVT was diagnosed on an outpatient basis was documented to have a pulmonary embolism and 12 patients (8%) in the inpatient group had pulmonary emboli, this difference was not statistically significant. Anticoagulation medication did not totally prevent pulmonary embolism in this review. All patients were followed-up for between 0 to 49 months (mean, 13 +/- 1 months). No swelling of the affected arm was observed in 145 patients (94%); four patients complained of mild intermittent swelling (2%), and seven patients reported significant swelling (4%). CONCLUSIONS: Contrary to previous reports, these data suggest that UEDVT is associated with a low incidence of postthrombotic upper extremity swelling, but a significant incidence of pulmonary embolism and rate of mortality. This review suggests that UEDVT is at least as serious a disease entity as LEDVT and should be managed as aggressively as LEDVT.

APACHE↗