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PubMed2002

Surgical treatment of peripheral nerve injuries in upper extremities.

OUTLINE: This study presents the results of surgical treatment of nerves in upper extremities performed in our clinic over 15 years, from 1985 to 1999. Basic lines of surgical treatment of various injuries of nerves in upper extremities are presented and evaluated in the study. SYNOPSIS AND METHODS: 140 nerves in 123 patients were treated within this period. 95 reconstruction operations were performed by microsurgical technique in 95 patients. All reconstruction surgery was performed in cases characterized by complete and persisting neurological deficit and by the absence of action potentials in relevant nerves. In 42 patients, 45 nerves were reconstructed by an autologous nerve graft. In 53 patients, reconstruction surgery was performed by suture of peripheral nerve that included treatment of 65 nerves. In this group, 10 patients were treated by suturation of 2 nerves and 3 nerves were suturated in one patient. In 28 patients, external neurolysis was the final surgical therapeutic treatment. In this group, neurolysis of 2 nerves was performed in 2 patients. The presence of action potential was always an important criterion in the determination of the type of surgical intervention. The analysis of the effectiveness of surgical intervention was performed with respect to: the period elapsed between injury and operation age of the patient character of injury location of injury category of injured nerve type of surgical intervention RESULTS: The best results were observed for external neurolysis and for n. medianus. Evaluation of the effectiveness of neural suture did not reveal any significant differences between neural grafts and classical suture. Similar results were obtained for surgical treatment of isolated nerve injuries and for cases involving the reconstruction of more than one nerve. Good or excellent results were typical for early treatment, for distal injuries and for clean incised wounds, especially in young patients. CONCLUSION: Early surgical revision combined with neurolysis and reconstruction surgery (if necessary) are crucial factors determining the outcome of operation in indicated cases. With respect to reconstruction operations we did not observe any significant difference between classical suture and suture using nerve graft.

Adult↗

PubMed2001

Responses of the densely hemiplegic upper extremity to bilateral training.

OBJECTIVE: Recovery of movement in the densely hemiplegic upper extremity remains a problem after stroke. This study aimed to determine whether movement recovery could be improved in the hemiplegic arm with bilateral isokinematic training. METHODS: Within and between groups, planned comparisons investigated the effects of bilateral training on attempts at two movements by subjects with acute and chronic problems with one and two bilateral practice phases. Electromyographic (EMG) activity of middle deltoid and extensor carpi radialis longus in the hemiplegic arm was recorded during unilateral and bilateral isometric shoulder abduction and wrist extension. RESULTS: Small increases in muscle activity were demonstrated by both experimental and control subjects during most bilateral practices in both actions. However, these increases were not significantly different from the previous unilateral trial, and the bilateral effect failed to generalize to subsequent trials. Previous studies with less densely hemiplegic subjects had demonstrated generalization of improvements in movement patterns with bilateral training to unimanual actions of the densely hemiplegic arm. CONCLUSIONS: Extensive lesions may limit brain reorganization and recover of dense hemiplegia after stroke. Nonetheless, on the basis of findings from other studies in which functional improvements occurred in both acute and chronic severely stroke-affected subjects, outcome forecasting for the hemiplegic upper extremity should only eventuate after provision of practice under optimal learning conditions.

Acute Disease↗

PubMed2006

Upper extremity muscle activation during recovery of reaching in subjects with post-stroke hemiparesis.

OBJECTIVE: To investigate upper extremity muscle activation and recovery during the first few months after stroke. METHODS: Subjects with hemiparesis following stroke were studied performing a reaching task at an acute time point (mean=9 days post-stroke) and then again at a subacute time point (mean=109 days post-stroke). We recorded kinematics and electromyographic activity of six upper extremity muscles. RESULTS: At the acute time point, the hemiparetic group had delayed muscle onsets, lower modulation ratios, and higher relative levels of muscle activation (%MVIC) during reaching than controls. From the acute to the subacute time points, improvements were noted in all three variables. By the subacute phase, muscle onsets were similar to controls, while modulation ratios remained lower than controls and %MVIC showed a trend toward being greater in the hemiparetic group. Changes in muscle activation were differentially related to changes in reaching performance. CONCLUSIONS: Our data show that improvements in muscle timing and decreases in the relative level of volitional activation may underlie improved reaching performance in the early months after stroke. SIGNIFICANCE: Given that stroke is one of the leading causes of persistent physical disability, it is important to understand how the ability to activate muscles changes during the early phases of recovery after injury.

Adult↗

PubMed2003

Motor evoked potentials in predicting recovery from upper extremity paralysis after acute stroke.

OBJECTIVE: The use of motor evoked potentials (MEPs) in predicting recovery after stroke still appears to be somehow equivocal. We assessed the prognostic value of MEPs with respect to arm and hand motor recovery in acute stroke patients. METHODS: This cohort study included 43 consecutive acute stroke patients with complete paralysis of the upper extremity. MEPs of the abductor digiti minimi muscle (ADM) and the biceps brachii muscle (BB) were obtained within 10 days after stroke onset. The upper limb subset of the Fugl-Meyer Motor Assessment was used to evaluate the motor performance at regular intervals until 6 months after stroke. RESULTS: The follow-up was complete in 40 patients (2 patients died and 1 patient had a recurrent stroke); 14 patients showed motor recovery of the arm and their mean 26-week arm motor score was 17.93 (range 3-30, SD 11.68); hand motor recovery occurred in 11 patients and their mean 26-week hand motor score was 11.09 (range 4-14, SD 4.10). Stepwise logistic regression revealed prognostic models for both arm and hand motor recovery based on BB MEPs (odds ratio 7.69, confidence interval, CI, 1.16-50.95) and ADM MEPs (odds ratio 16.20, CI 2.51-104.40), respectively. CONCLUSIONS: The predictive significance of MEPs with respect to motor recovery of the upper extremity was obvious in our homogeneous sample of patients. This agrees with the paradigm that motor recovery after infarction is strongly dependent on a critical residual sparing of the corticospinal function. In this context, the test properties of MEPs in predicting motor recovery are discussed. The added value of MEPs with respect to motor recovery of the upper extremity should be regarded as established for patients with initial paralysis, especially since clinical examination alone lacks the possibility to detect the potential for motor recovery in these cases.

Adolescent↗

PubMed2001

Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery.

BACKGROUND: Intraoperative fluoroscopy is commonly used in surgical procedures on upper extremities. We compared radiation exposure from two possible positions of the mobile digital fluoroscopy unit (c-arm): (1) the standard technique, with the x-ray tube down (near the floor) and the image intensifier at the top of the c-arm, and (2) the inverted position, in which the image intensifier is used as a table and the x-ray tube is up. METHODS: A commercially available c-arm was used to irradiate a phantom hand in one of three configurations. In the first, the phantom hand was placed on an armboard equidistant from the x-ray tube and the image intensifier with the beam directed upward. In the second, the c-arm was inverted with the beam directed downward and the image intensifier used as a table. The third configuration was identical to the second except that a magnified image was used. Radiation exposure was measured at four locations corresponding to the approximate position of the surgeon's head, chest, and groin and the patient's hand. RESULTS: The amount of radiation exposure to both the surgeon and the patient was significantly less when the c-arm was used in the inverted position (p < 0.0001). The dose rate to the patient's hand was reduced by 59%. The radiation exposure to the surgeon's head, body, and groin with the inverted-c-arm technique was 67%, 45%, and 15% of the measured doses with the x-ray-tube-down configuration. When we used the magnification mode of the image intensifier, with its correspondingly smaller field size, the doses were further reduced to 46%, 32%, and 11% of the standard-configuration values. CONCLUSIONS: Use of the inverted-c-arm technique with the image intensifier as an operating table can significantly reduce radiation exposure to the surgeon and the patient during surgical procedures on upper extremities.

Arm↗

PubMed1999

A narrative review on classification of pain conditions of the upper extremities.

Local and regional musculoskeletal discomfort and pain in the shoulder girdle or upper extremities are often reported, especially in the working population. In this review we describe the most important problems and factors when classifying musculotendinous pain in the upper extremities and shoulders. This includes an analysis of how four common diagnoses (wrist tenosynovitis, lateral epicondylitis, rotator-cuff tendinitis, myofascial pain syndrome) fulfil basic criteria of validity. It is evident that there are some serious problems regarding the validity of the current classification of the conditions. Clinical criteria are often poorly defined and the reliability insufficiently tested. The relationship to objective pathoanatomic or physiological findings seems inconsistent. Although magnetic resonance and ultrasonographic imaging are promising, they are still only preliminary methods for evaluation of tendon and connective tissue structures. The prognosis with and without treatment also seems heterogeneous and can vary between studies. A generally accepted terminology is lacking in the pathogenetically complex regional muscle pain conditions.

Acute Disease↗

PubMed1998

Neuromuscular stimulation for upper extremity motor and functional recovery in acute hemiplegia.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the efficacy of neuromuscular stimulation in enhancing the upper extremity motor and functional recovery of acute stroke survivors. METHODS: Forty-six stroke survivors admitted to an inpatient rehabilitation unit were randomly assigned to receive either neuromuscular stimulation or placebo. Twenty-eight subjects completed the study. The treatment group received surface neuromuscular stimulation to produce wrist and finger extension exercises. The control group received placebo stimulation over the paretic forearm. All subjects were treated 1 hour per day, for a total of 15 sessions. Outcomes were assessed in a blinded manner with the upper extremity component of the Fugl-Meyer Motor Assessment and the self-care component of the Functional Independence Measure at pretreatment, after treatment, and at 4 and 12 weeks after treatment. RESULTS: The treatment subjects and control subjects had comparable baseline characteristics. Parametric analyses revealed significantly greater gains in Fugl-Meyer scores for the treatment group after treatment (13.1 versus 6.5; P=0.05), at 4 weeks after treatment (17.9 versus 9.7; P=0.05), and at 12 weeks after treatment (20.6 versus 11.2; P=0.06). Functional Independence Measure scores were not different between groups at any of the time periods (P>0.10). CONCLUSIONS: Data suggest that neuromuscular stimulation enhances the upper extremity motor recovery of acute stroke survivors. However, the sample size in this study was too small to detect any significant effect of neuromuscular stimulation on self-care function.

Acute Disease↗

PubMed1991

Neurofibrosarcomas of the upper extremity.

A retrospective review of all malignant hand tumors seen at the University of Michigan from 1950 to 1987 demonstrated six biopsy-proven cases of neurofibrosarcoma involving the upper extremity. There were four male and two female patients; average age at presentation was 37 years and ages ranged from 15 to 63 years. All patients had a history of von Recklinghausen's disease. Three patients were seen initially with painful enlarging masses, one with a painful mass with a neurological deficit, and two with painless enlarging masses. Three patients had radical excisions requiring upper extremity or forequarter amputation, and three patients received limited or no surgical treatment. Five patients died of metastases an average of 3 years after diagnosis. One patient remains alive 18 years after upper extremity amputation despite an early local recurrence. Early diagnosis and radical surgical excision offer the best chance of long-term survival from this highly lethal cancer.

Adult↗

PubMed1997

Tissue expansion in the upper extremities.

In this article, the authors demonstrate current concepts of soft-tissue reconstruction using tissue expansion principles. History, pathophysiology, and biomechanics of tissue expansion are reviewed. Anatomic areas of expander use in the upper extremity have been delineated, as well as new concepts of nerve and arterial elongation using intraoperative expansion techniques. The authors outline their current technique of upper extremity tissue expansion in the preoperative, intraoperative, and postoperative settings, allowing the reader to appreciate the technique of tissue expansion and its role in soft-tissue reconstruction of the upper extremity.

Adult↗

PubMed2004

From confounders to suspected risk factors: psychosocial factors and work-related upper extremity disorders.

Psychosocial variables have recently been more prominent among epidemiologic risk factors for work-related upper extremity disorders (WRUEDs), but bio-behavioral mechanisms underlying these associations have been elusive. One reason is that the psychosocial domain has included many broad and disparate variables (e.g. mood, coping skills, job control, job satisfaction, job stress, social support), and this lack of specificity in the conceptualization of psychosocial factors has produced limited hypothesis testing opportunities. Therefore, recent research efforts have focused on identifying and conceptualizing specific psychosocial factors that might more clearly delineate plausible bio-behavioral mechanisms linking psychosocial factors to WRUEDs. One such factor is workstyle, a strategy that workers may employ for completing, responding to, or coping with job demands that might affect musculoskeletal health. Preliminary studies have provided support for measurable differences in workstyle among individual workers and an association with upper extremity pain and discomfort. An initial self-report measure of workstyle has been pilot tested among office workers and shown acceptable reliability and validity. Future studies are needed to study this construct among other working populations and to determine its relationship with other clinical endpoints. Nevertheless, early findings suggest workstyle may be a potential focus of WRUED prevention efforts.

Humans↗

PubMed1985

Traumatic arterial injuries of the upper extremity: determinants of disability.

Of 233 patients who sustained vascular injuries during a 13 year period, 99 had involvement of the upper extremity. The primary site of upper extremity injuries was the brachial artery (43 patients), and the primary cause of injury was gunshot wounds. The majority of the vascular injuries were repaired primarily. Nerve injuries occurred in 56 of the patients, and they were the primary cause of disability. Edema and infection were not significant determinants of limitations in function. Gunshot wounds to the brachial artery resulted in the highest incidence of disability and limb loss.

Adolescent↗

PubMed2000

Recurrent Merkel cell carcinoma of the upper extremity.

We report a case of recurrent Merkel cell carcinoma (MCC) of the upper extremity, treated aggressively with wide local excision, regional lymphadenectomy, and immediate reconstruction. Five years after surgery, there is no clinical or diagnostic evidence of locoregional recurrence or distant disease. The patient's upper extremity and hand remain fully functional, without evidence of median or ulnar nerve dysfunction. No donor site morbidity has been noted.

Aged↗

PubMed1985

Entrapment neuropathies of the upper extremity.

Entrapment neuropathies occur in a number of different but predictable locations in the upper extremity. These neuropathies can produce a spectrum of sensory and motor deficits in the hand and upper extremity. A careful clinical examination in conjunction with electromyography and nerve conduction velocity studies can usually delineate peripheral nerve dysfunction. Prognosis depends on the degree of nerve injury, which is related to both the cause and the duration of the entrapment.

Carpal Tunnel Syndrome↗

PubMed2006

[Pediatric disability of the upper extremity and quality of life questionnaire: reliability, validity, and sensitivity to change].

OBJECTIVE: The aim of this study was to develop a specific questionnaire, designed to evaluate health-related quality of life of children and adolescents with congenital or acquired anomalies of the upper extremity. MATERIAL AND METHODS: Children who underwent operative or conservative treatment of the upper extremity at Kaunas University of Medicine Hospital and Kaunas Red Cross Hospital or conservative treatment at Kaunas Sanatorium "Zibute" and Druskininkai Sanatorium "Saulute" participated in the study. A total of 99 parents and 56 adolescents with congenital or acquired anomalies of the upper extremity filled out the questionnaires. The data were analyzed by the program SPSS 12.0.1 for Windows. RESULTS: Two versions of questionnaire were developed: one for parents of children and adolescents aged 5-18 years and another - for adolescents aged 11-18 years. Both versions consist of seven scales: self-care, daily activities, sports activities and hobby, self-image, emotional, social health, and patient's satisfaction with treatment. The testing of questionnaire reliability was performed by estimating a Cronbach alfa coefficient which varied from 0.80 to 0.97 for different scales of questionnaire designed for parents. The item-scale correlation was from 0.44 to 0.89. There was a statistically significant difference among separate items for all scales (p<0.001). The intraclass correlation coefficient ranged from 0.84 to 0.89 for all scales. Cronbach alfa coefficients of scales of questionnaire designed for children varied from 0.83 to 0.95, and item-scale correlation was moderate to strong. A statistically significant difference among separate items for all scales was obtained (p<0.001). The intraclass correlation coefficient varied from 0.79 to 0.86. The Pearson's correlation coefficient between questionnaires developed for parents and children was calculated, and strong correlation between corresponding scales was found. Sensitivity to changes was tested, and t-test was performed. A statistically significant difference in all scales was found (p<0.001).

Adolescent↗

PubMed1990

Upper extremity casting: adjunct treatment for a child with cerebral palsy hemiplegia.

A common upper extremity deformity with hemiplegia is pronation contracture of the forearm in association with flexion contracture of the elbow. Early management of the child with hemiplegic cerebral palsy is critical in optimizing overall function. The use of inhibitory upper extremity casting can enhance function and improve arm-hand position. The present paper describes the evaluation process before casting, the goals of each phase of the casting program, and the follow-up.

Arm↗

PubMed1991

Late upper extremity embolic complications of occluded axillofemoral grafts.

The use of axillary femoral grafting in the treatment of patients at high risk for aortoiliac reconstruction has become a widely accepted treatment modality. Ischemia and even loss of the donor upper extremity have been reported to occur early after graft occlusion. This report describes three patients who developed emboli to the upper extremity at nine, 15, and 34 months following occlusion of their axillary femoral graft. Based on our experience, we consider an occluded axillofemoral graft a permanent threat to the viability of the donor upper extremity. Anatomic changes suggestive of potential ischemia include: presence of a blind pouch in the graft stump, or "Y" elongation of the artery with proliferative changes in the intima.

Aged↗

PubMed1986

Upper extremity sensory feedback therapy in chronic cerebrovascular accident patients with impaired expressive aphasia and auditory comprehension.

Electromyographic (EMG) sensory feedback therapy (SFT) was used in the neuromuscular retraining of the nonfunctional upper extremity in five chronic left cerebrovascular accident (CVA) patients with impaired expressive and auditory comprehension. Speech diagnoses included global, moderate-to-severe Broca, and Wernicke aphasias. These patients had experienced increased despondency associated with previous therapy failures and often had indicated that they wished to have their involved extremity amputated, so that it would no longer be in the way. In this study, specific behavioral training strategies to increase patient involvement were used, including: general relaxation, modified SFT instruction, and home exercises, which were supported by family and/or friends. After an average of 50 therapy sessions, all patients were successfully retrained to use their right upper extremity at the gross-assist level. This resulted in feelings of increased self-esteem to the extent that amputation was no longer requested. It is concluded that EMG SFT can be beneficial in the neuromuscular reeducation of paretic upper extremity muscles of CVA patients with expressive aphasia and (impaired) auditory comprehension.

Aphasia, Broca↗

PubMed1975

Cast brace for the upper extremity.

Management of a traumatized elbow or intra-articular fracture with concomitant upper extremity long bone fracture is tedious, especially when early elbow motion is desirable. An adaptation of the lower extremity hinged cast brace to the elbow provides controlled flexion while protecting against varus/valgus stress and translation forces. A cast brace is constructed from readily-available materials, and can be applied in an out-patiet clinic. The functional results obtainable in a variety of upper extremity injuries are excellent, and the patients generally accept the elbow cast brace very well.

Adult↗