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The arteries to the upper extremities can be involved at multiple levels by a variety of diseases. Because of the critical sensitivity of motor function and sensation in the arms and hands, minor degrees of ischemia can have major clinical significance. It is essential to understand the exact pathologic process and the sites of involvement to provide proper therapy.
Upper extremity deformity after brain injury is frequently complex and dominated by spasticity or contracture. Clinical examination of the limb is often difficult and inaccurate. Dynamic electromyography provides valuable information previously unobtainable. Analysis of this data can facilitate appropriate reconstruction of the deformed limb.
OBJECTIVES: Workstyle has been proposed to help explain the link between ergonomic and psychosocial factors in work-related upper-extremity symptoms/disorders. This study investigated ergonomic factors, work demands, job stress, and workstyle on pain and functional limitations in computer users. METHODS: One hundred sixty-nine participants completed self-report ratings of job stress, ergonomic exposures, and workstyle at baseline. Three months, later ratings of pain and functional limitations were obtained. RESULTS: Multivariable logistic regression indicated that ergonomic exposure (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.3-5.5), time spent at a computer (OR = 1.9, 95% CI = 0.95-3.6), and higher scores on a workstyle measure (2.4, 95% CI = 1.1-5.3) were independently associated with case status. Path analyses revealed that a model that included ergonomic exposure, work demands, and workstyle predicted pain and functional limitations at 3 months. CONCLUSIONS: Workstyle contributes to case definition and is predictive of future pain and functional limitations in office workers with upper extremity symptoms.
An integrated case management (ICM) approach (ergonomic and problem-solving intervention) to work-related upper-extremity disorders was examined in relation to patient satisfaction, future symptom severity, function, and return to work (RTW). Federal workers with work-related upper-extremity disorder workers' compensation claims (n = 205) were randomly assigned to usual care or ICM intervention. Patient satisfaction was assessed after the 4-month intervention period. Questionnaires on clinical outcomes and ergonomic exposure were administered at baseline and at 6- and 12-months postintervention. Time from intervention to RTW was obtained from an administrative database. ICM group assignment was significantly associated with greater patient satisfaction. Regression analyses found higher patient satisfaction levels predicted decreased symptom severity and functional limitations at 6 months and a shorter RTW. At 12 months, predictors of positive outcomes included male gender, lower distress, lower levels of reported ergonomic exposure, and receipt of ICM. Findings highlight the utility of targeting workplace ergonomic and problem solving skills.
Based on existing knowledge and theory of the physiology, biomechanics, and epidemiology of distal upper extremity disorders, a semiquantitative job analysis methodology was developed. The methodology involves the measurement or estimation of six task variables (intensity of exertion, duration of exertion per cycle, efforts per minute, wrist posture, speed of exertion, and duration of task per day); assignment of an ordinal rating for each variable according to exposure data; then assignment of a multiplier value for each variable. The Strain Index is the product of these six multipliers. Preliminary testing suggests that the methodology accurately identifies jobs associated with distal upper extremity disorders versus jobs that are not; however, large-scale studies are needed to validate and update the proposed methodology.
BACKGROUND: Patients who deliberately amputate 1 or more of their own extremities present a unique set of challenges for the entire treatment team. Decisions regarding replantation of the amputated extremity must be made quickly, and the psychiatrist is involved early in the care of these difficult patients. Surgical staff may feel that replantation surgery is inappropriate for such patients, although there is limited literature addressing this issue. Therefore, the psychiatrist must also address the strong feelings that such patients generate in nonpsychiatric caregivers. METHOD: Two cases of deliberate upper-extremity self-amputation are discussed, and the world literature on self-amputation and replantation from 1966 to the present, identified via a MEDLINE search, using the key words self-amputation, self-inflicted, upper extremity, and amputation, is reviewed. RESULTS: There have been 11 reported cases (plus 2 in the current report) of deliberate upper-extremity amputation in the last 30 years. All patients have been psychotic, and many of the case reports note that patients with this presentation are rarely suicidal. Instead, the amputation usually stems from psychotically driven feelings of guilt and concrete religious preoccupations. Patients who undergo replantation often are pleased with the reattachment, and both psychiatric and surgical outcomes appear to benefit from prompt and aggressive psychiatric treatment. CONCLUSION: Patients who deliberately amputate one or more of their extremities can be unsettling as well as challenging. The psychiatrist must coordinate diagnosis and treatment among multiple services to ensure the best possible outcome. As replantation surgery becomes more common, the psychiatric implications of surgical reattachment are of increasing importance. More cases need to be described to better understand the best treatment options for this particular patient population.
Two hundred ninety-eight arterial injuries in 269 upper extremities were reviewed. Penetrating agents accounted for 250 injuries (93 percent) and blunt trauma for 19 (7 percent). Fifty-nine axillary, 126 brachial, 65 radial, and 48 ulnar arteries were damaged. Twenty-six extremities had more than one artery injured. The initial vascular examination revealed no abnormalities or was equivocal in 16 percent of all patients and in 32 percent of those with axillary artery injuries. Adjacent upper extremity structures were injured in 195 limbs (73 percent). Resection and primary anastomosis (54 percent) or vein interposition grafting (26 percent) were the most frequent methods of repair. Two deaths (0.7 percent) occurred and four amputations (1.5 percent) were required. Distal pulses were present at discharge in 93 percent of the evaluable extremities. Despite excellent success with arterial reconstruction, functional results were limited by associated nerve injuries. One hundred fifty patients (49 percent) had nerve deficits at discharge, and 71 (27 percent) had serious functional limitations.
A literature review was conducted on the current literature base to determine the strength of support for the hypothesis that women experience higher prevalences of upper extremity musculoskeletal disorders (UEMSDs) than men. Fifty-six articles were reviewed for data on gender differences in frequency, incidence or prevalence rates for musculoskeletal disorders specific to the upper extremities. These articles included both general and working populations. The majority of the studies showed that women had significantly higher incidences of various types of UEMSDs than men. This trend was consistently observed in studies based on self-report or plant/workers compensation records, with and without physical examination, and after adjusting for potential confounders such as age and physical work factors. With men as the referent, the odds ratio (OR) or prevalence ratio (PR) for UEMSDs ranged from 0.85 to 10.05 for self report. For self report combined with physical examination, the OR/PR ranged from 0.66 to 11.4. The OR/PR for carpal tunnel syndrome (CTS) ranged from 0.6 to 2.87 with confounder adjustment. These findings suggest that women do have significantly higher prevalences than men for many types of UEMSDs, even after controlling for the type of data source and confounders such as age or work factors.
In this 6-year study of 101 limbs requiring surgical intervention for upper-extremity vascular trauma, most patients were male, young, and injured by penetrating objects. Injured vessels included 13 axillary/subclavian, 23 brachial, 40 radial, and 25 ulnar arteries. Concomitant injuries included nerve injury in 50 cases, tendon laceration in 29, and bony fracture in 11. Arterial repair was accomplished by primary repair in 54 limbs, vein graft in 26 limbs, and vein patch in 3 limbs. Seventeen arterial injuries were ligated. Ancillary procedures included 30 nerve or 27 tendon repairs. The limb salvage rate was 99%. No functional deficits were noted in those cases with only a vascular injury. In 64% and 25% of patients with nerve or musculoskeletal injury, respectively, the arm was functionally impaired. Prompt diagnosis and surgical intervention eliminate vascular injury as a factor in upper-extremity limb loss or disability. Functional deficits are the result of nerve or orthopedic injuries.
Deep venous thrombosis (DVT) of the upper extremity has recently been recognized as being more common than previously reported (probably because of the increasingly frequent use of subclavian venous access). A retrospective review of patients in whom subclavian or axillary DVT had developed in the past 6 years (1980 to 1986) was conducted at the Akron General Medical Center. The major cause identified was related to subclavian venous catheterization, which accounted for 39% of all instances of subclavian and axillary DVT. Our results are correlated with a review of the literature. In our review of studies in which subclavian venous catheterizations were prospectively examined with use of objective means of diagnosis, we found that 28% of all subclavian catheterizations had venous thrombosis develop, often subclinically. This is not an innocuous disease, as suggested in the past; in our series 12% of upper-extremity DVT had pulmonary embolization (PE). In reviewing the recent literature, we found an average 12.4% incidence of PE, which often occurs during anticoagulation treatment. Diagnostic modalities are discussed and treatment regimens are reviewed along with an extensive literature review.
Deep venous thrombosis is 50 times less frequent in upper than in lower limbs. Data remain poor in the literature. Forty consecutive patients (24 males, 16 females, mean age: 54.5 years) were retrospectively analysed from 161 subjects who underwent venous explorations of the upper extremity for a 3.5 year period in the same center. Diagnosis of thrombosis was made by duplex ultrasonography (n =37) or phlebography (n =3). Main clinical manifestations were edema (n =36) and pain (n =29). Location of thrombosis was humeral (n =1), axillary (n =2), or sub-clavian (n =37, 2 bilateral). The majority of thrombosis (n =29) were secondary to cancer and venous catheter (n =19, 15 implanted ports), to central catheter alone (n =3) or cancer alone (n =7). The 11 others were associated with thoracic outlet syndrome (n =6) or apparent primary thrombosis (n =5). Thrombophilia was identified in 6 out of these 11. During follow up [mean of 9 months (0,5-36)], two patients developed pulmonary embolism, 14 a post-thrombotic syndrome and 16 patients died. Initial therapy included heparin (n =36) or fibrinolysis (n =4). Upper extremity deep venous thrombosis are mostly associated with cancers and venous catheters. Thrombophilia is frequent in the other cases. Heparin followed by oral anticoagulation is the optimal therapy whose duration depends upon underlying condition. Fibrinolysis has not been useful for preventing post-thrombotic syndrome in our study.
Twenty-eight vascular and perivascular lesions of the upper extremity in 21 patients were studied from August 1982 to December 1982 by means of a 10 MHz real-time B-mode ultrasound unit. They included eight perivascular masses, 16 arterial repairs, and five thrombosed or occluded arteries. Imaging of arteries that ranged in size from a brachial to a digital artery was reliable. Vessels were tracked proximally and distally while changes in wall compliance, luminal diameter, wall diameter, intimal integrity, and luminal compression were observed dynamically. Size, location, acoustic characteristics, and extent of vascular involvement could be determined in cases of perivascular masses. Sonographic findings were confirmed by arteriography, dynamic radionuclide imaging, computerized tomography, or surgical exploration. Ultrasonography eliminated the need for preoperative arteriography in some cases. In no instances were our ultrasonographic impressions in error when correlated with results of more invasive techniques. No adverse effects were encountered. We concluded that real-time 10 MHz ultrasonography is a safe, noninvasive, reproducible, and accurate technique that can be used quantitatively and qualitatively on the upper extremity after surgery to assess patency, pulse dynamics, and anastomotic characteristics of arterial repairs and before surgery to evaluate perivascular masses for acoustic characteristics, location, and influence on adjacent vascular structures.
OBJECTIVES: To determine whether simulation of significant impairment of the hand will have a predictable impact on degree of functional loss at the wrist and hand. DESIGN: Single subject repeat measures using before-after trial comparisons and healthy volunteer subjects. SETTING: Occupational therapy section of a large academic medical center. OTHER PARTICIPANTS: Twenty adult volunteer student subjects from an occupational therapy education (OTE) department were included. All were between ages 18 and 43 years, right hand dominant, and in excellent general health. There were 19 women and 1 man, reflecting gender distribution of the OTE student body. INTERVENTION: A simulated fusion of the carpometacarpal (CMC) joint of the thumb was achieved by immobilization in an individually fabricated splint designed to maximally restrict motion at the first CMC joint. Impairment ratings (baseline vs splinted) according to the AMA Guides were obtained by Greenleaf testing, and upper extremity function was quantitatively assessed before and after splinting. MAIN OUTCOME MEASURES: Measures of upper extremity function included grip and pinch strength, wrist torque, and speed of performance on the Valpar Small Tools test, Jebsen Hand Function test, and an exploratory measure, the Functional Life Activity Test (FLAT). RESULTS: Significant impairments were achieved for all subjects after splinting and according to Greenleaf testing. Splinting resulted in significant reductions in grip and pinch strength, wrist torque, and significant slowing of performance on the Valpar, Jebsen, and FLAT tests. Regressions of degree of impairment on degree of functional loss after splinting, and according to each of the above measures, were not significant. CONCLUSIONS: Impairment of the hand was simulated to a mild-to-moderate degree as measured according to the AMA Guides. This imposed significant reductions in motion at key joints of the wrist and hand as well as significant reductions in grip and pinch strength and wrist torque. A corresponding and significant slowing of performance on a variety of measures of upper extremity function of an industrial and nonindustrial nature was also seen. However, and for the first time, correlation and regression reveals that it is not possible to predict degree of functional loss attributable to degree of impairment for the hand. It thus appears that, for mild-to-moderate clinical impairments, the associated impairment rating is a poor estimator of functional loss at the hand and should be used cautiously, if at all, as a criterion for disability determination.
This review can only introduce the subject of tumors found involving the skin of the upper extremity. Many benign masses as well as some malignant tumors have to be considered when a patient calls to the physician's attention a lump, firm area, color change, ulcer, or other alteration in the skin. In response, the physician must have a high index of suspicion, take a careful history, and carry out a thorough examination in order to develop a safe approach. Thought has to be given to the complex anatomy of this area. Understanding of the pathophysiology of tumors and of possible later additional therapy is needed to plan an appropriate biopsy. In the brief discussions of treatment, the difficulty in choosing margins of resection and assessing the efficacy of lymph node dissection is mentioned. An open mind and assessment of future reports of studies in progress may be helpful. Whatever treatment is applied to the malignant tumors under consideration, it is my opinion that one must persist in this until one obtains tumor-free margins. The surgeon undertaking this responsibility must apply the same tumor techniques including operating room discipline that would be applied to any serious malignancy. Consultation and careful work with colleagues that are able to assess the potential for response to chemotherapy, immunotherapy, and/or radiotherapy, should be sought. Subtle hazards in our environment, such as changing risk of sun exposure, industrial chemicals, and irradiation should be pointed out to our patients. These are a challenge to the student of this subject, just as tobacco products are to those involved with malignancies of the head and neck, respiratory, and other systems. All of the previously mentioned methods must be used in the anatomically complex upper extremity to preserve function while ridding the patient of the burden of a disfiguring or painful benign process, or even a life-threatening malignancy.
Bilateral upper limb pain, isokinetic strength, grip strength, range of motion, and activities of daily living (ADL) performance were compared in 11 women with long term paraplegia and 11 activity-level matched able-bodied women of similar age, to determine whether long term wheelchair use is associated with pain and altered function in the upper extremities. The results suggest that the development of pain in the upper limbs is clearly associated with paraplegia in women (p less than 0.01). Pain was reported most frequently by the paraplegics in the shoulders and secondly in the wrists and hands. ADL where the paraplegics experienced pain most often were work/school, outdoor wheeling, household work/childcare, and loading the wheelchair to and from the car. Whilst paraplegics reported intermittent rather than constant pain, the groups' relatively young age (mean = 43 years) and average duration of injury of only 15 years suggests that preventative and management steps are required to ensure continued independence and quality of life of this group as they age.
OBJECTIVE: To investigate interlimb coupling in an adult population with left hemiplegia and an age-matched control group to better understand the unique motor control issues in stroke rehabilitation. DESIGN: A chi-square analysis was performed to compare the distribution of participants adopting a given movement pattern ratio during 2 different bimanual movement tasks for both groups. The task involved oscillating the upper limbs at the elbow in asymmetric patterns, with 1 limb oscillating at twice the frequency of the other. SETTING: Testing was done in the subjects' residences or in an outpatient clinic. PARTICIPANTS: Participants were between the ages of 45 and 75 years (mean +/- standard deviation, 63+/-9.4y), right handed, and included 18 left hemiparetic and 18 control subjects. Selection criteria for the hemiparetic group included status after nonhemorrhagic stroke within the distribution area of the right middle cerebral artery (RMCA). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Relative phase of the upper extremities. RESULTS: The hemiplegic group produced predominantly an in-phase 1-to-1 movement pattern, whereas the control group exhibited antiphase, 2-to-1 movement harmonics and, to a lesser extent, in-phase movement patterns. CONCLUSIONS: This study suggests that brain damage caused by stroke in the RMCA distribution area results in the reduction of selectable interlimb movement patterns. Specifically, bimanual upper extremity movement tended to be highly coupled in an in-phase movement pattern. Research is needed to examine the ability of stroke survivors to learn bilateral upper-extremity tasks at less stable levels of interlimb coupling.
There was the technique elaborated for the revascularized transplantation of the omentum majus flap on myocardium, upper extremity and brain. There were performed 26 operations of nondirect revascularization of myocardium, 3--of microsurgical transplantation on upper extremity and 3--on the brain.
BACKGROUND AND PURPOSE: The purpose of this study was to investigate the relationship between clinically accessible functional balance tools and sophisticated force platform measures in a standing position. SUBJECTS: Twenty persons who had hemiparesis secondary to a stroke and were ambulatory (mean age = 57.9 years, SD = 13.6, range = 35-79) were evaluated during a single testing session. METHODS: Performances on self-generated upper-extremity balance tasks using the nonparetic side (Functional Reach Test [FRT], arm raise and arm reach tasks) were compared with responses to external perturbations on the Balance System (postural sway, symmetry of weight distribution). RESULTS: No relationship was found between the upper-extremity balance tests and the force platform measures of postural sway. After suppressing the effect of age by means of partial correlation coefficients, the FRT was correlated with measures of postural symmetry in parallel stance on the Balance System (r = .66-.78). The FRT was only moderately correlated with the arm raise and arm reach tasks (r = .43 and .44). CONCLUSION AND DISCUSSION: Postural sway in response to force platform perturbations may have little relation to the postural control necessary for self-generated upper-extremity balance tasks. In contrast, the FRT and the force platform measures of postural symmetry appear to be evaluating comparable standing-balance abilities in persons with hemiparesis. The modest relationship between the FRT and the arm raise and arm reach tasks limits the finding's clinical relevance.