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PubMed1988

Upper-extremity vascular injuries.

Although upper-extremity injuries alone are usually not life-threatening, they can produce significant immediate or long-term morbidity, especially if there is an associated nerve injury. The diagnosis of an arterial injury may be readily apparent, but the excellent upper-extremity collateral circulation may create palpable distal pulses despite a significant proximal arterial injury. Therefore, a high index of suspicion and the liberal use of arteriography are necessary to avoid missing these injuries. Compression of the brachial plexus by a hematoma can produce a serious neurologic deficit. Prompt evacuation of the hematoma may significantly reduce the deficit, another fact that supports an aggressive surgical approach in these patients. The long-term results of upper-extremity vascular injuries are usually determined by the extent of any associated nerve injuries.

Arm↗

PubMed1982

Upper extremity thrombosis: etiology and prognosis.

Upper extremity thrombosis is responsible for 1-2% of all cases of deep venous thrombophlebitis (DVT). Little has changed concerning the clinical presentation, diagnostic investigation, or treatment of the disorder over the last forty years. However, a changing pattern in the natural history of the disease seems to be emerging with the advent of more invasive procedures and prolonged medical care of critically-ill individuals. Case histories of sixteen (16) patients with seventeen (17) episodes of upper extremity thrombosis are reviewed. Fewer cases of "primary" thrombosis, and fewer acute or chronic sequelae were noted in the present study than would be implied in previous reviews of the subject. It is our opinion that DVT of the upper extremity, especially when due to "secondary" thrombosis, is a more benign and self-limiting disease than has been traditionally reported.

Adult↗

PubMed1990

Fibrinolytic therapy for upper-extremity arterial occlusions.

Acute upper-extremity arterial occlusion may be due to embolic phenomena or de novo thrombosis. If the occlusion is left untreated, claudication or ischemia necessitating amputation can occur. Operative Fogarty-balloon embolectomy has been the treatment of choice for this entity. In a 6-year period the authors used fibrinolysis on nine occasions in eight patients to treat acute upper-extremity arterial occlusions. Concomitant balloon angioplasty was helpful in four cases. Success, defined as a normal hand with at least one artery that was continuously patent to the wrist, was achieved in all patients. A single significant groin hematoma was seen. Neither stroke nor death occurred in any case, and no amputations were necessary. Local transcatheter intraarterial administration of urokinase can be considered a first-line treatment for brachial artery embolus and other causes of acute upper-extremity arterial occlusion.

Adult↗

PubMed1993

Occlusive vascular disorders of the upper extremity.

Arterial occlusive disease of the upper extremity is most often due to posttraumatic occlusion of the ulnar artery. An embolic source of the ischemia should be considered most strongly when sudden ischemia or vasospasm is associated with atrial fibrillation or follows a myocardial infarction. Connective tissue disorders and several arteridities are infrequent causes of upper-extremity occlusive disease and can usually be detected by a thorough peripheral vascular examination and blood studies. Atherosclerosis of the upper extremity is usually localized to the region of the subclavian artery and can present as a subclavian steal syndrome or arm ischemia. Finally, upper-extremity venous occlusive disease occurs in association with the hypercoagulable state, venous endothelial injury, or arises in otherwise healthy patients because of venous impingement in the thoracic outlet.

Adult↗

PubMed1994

[Clinical aspects and diagnosis of arterial embolism of the upper extremity].

The upper limb embolus is rarely encountered (upper limb:lower limb emboli 1:4-5). Our problem was to determine in which way the paraclinical investigations influence the operation indication. In 1992, we have seen 10 consecutive patients with an upper limb embolus. The characteristics of our patient group are the advanced age and the cardiovascular morbidity. It was always possible to diagnose the emboli clinically. 7 duplex, 6 Dopplers and 2 angiographies were performed and have confirmed the clinical diagnosis and the clinically suspected localisation of the emboli. All the patients were operated in local anesthesy. An embolectomy with Fogarty catheter was done. After the operation, all our patients were asymptomatic. No amputation was done. We do think that when the clinic is clear enough to diagnose an embolus, no other investigations are necessary to the operation indication.

Aged↗

PubMed1998

Venous gangrene of the upper extremity.

Venous gangrene of the upper extremity is a rare entity and is the result of massive occlusion of all venous outflow of the extremity. The syndrome is strongly associated with hypercoagulable states including malignancy, low cardiac output states, and hereditary or acquired hematological abnormalities. Diagnosis can be straightforward but must be made early in the course of the process for treatment to be effective. Treatment has historically produced only modest results, and patients continue to suffer a high morbidity and mortality. We present a series of 6 patients with venous gangrene or impending venous gangrene of the upper extremities--a relatively large series. Two patients suffered from malignancy, 3 patients suffered from low-flow cardiac states, and 1 patient suffered from an overdose of calcium channel blockers. Hematological abnormalities included heparin-induced thrombocytopenia and thrombosis in 3 patients, activated protein C resistance in 1 patient, and lupus anticoagulant in 1 patient. Three patients experienced other major venous thrombotic complications, two of whom died (renal and cerebral venous infarction). Venous gangrene of the upper extremity remains a rare occurrence but one in which early identification and intervention may lead to improved outcomes.

Aged↗

PubMed2006

[Vacuum assisted closure (V.A.C.) therapy is an essential tool for treatment of complex defect injuries of the upper extremity].

INTRODUCTION: Complex injuries of the upper extremity remain a therapeutic challenge. The prognosis of the damaged extremity is often limited by soft tissue defects. Vacuum Assisted Closure (V.A.C.) therapy facilitates temporary coverage of soft tissue defects prior to surgical reconstruction. METHODS: In a retrospective study all patients with complex defect injuries of the upper extremity that were treated by V.A.C. prior to reconstruction between August 2003 and September 2005 were analyzed. RESULTS: 7 patients (6 male, 1 female, 14-70 years) were included in the study. The patients suffered from subtotal upper arm (n = 1) and forearm (n = 1) amputation, complex multilevel amputation injury of the forearm (n = 1), slash wound of the forearm with skin defect and discontinuity of all volar structures (n = 1), complex open forearm fractures with skin and soft tissue defects (n = 2), and almost complete necrosis of the flexor compartment following distal radius and proximal ulnar fracture and compartment syndrome (n = 1). Stabile defect coverage was achieved in all patients following V.A.C. therapy by myocutaneous free flaps (n = 2), split thickness skin grafts (STSG) (n = 2), sequential secondary suture (n = 1), and STSG + secondary suture (n = 2). Wound conditions improved significantly under V.A.C. therapy. 5 patients reported pain relief following induction of V.A.C. therapy. Due to reduction of tissue oedema secondary suture was facilitated in 3 patients. DISCUSSION: V.A.C. therapy represents an essential tool for treatment of complex injuries of the upper extremity with extended soft tissue defects. Decreased frequency of dressing changes as well as reduced tissue oedema considerably improved patient's comfort. Posttraumatic compartment syndrome or skin necrosis, which are often associated with macro amputations of the upper extremity, are efficiently treated with V.A.C., and secondary sutures may be performed despite initial skin defects.

Adolescent↗

PubMed1988

Upper extremity dysfunction in children with myelomeningocele.

A retrospective chart review of 138 subjects with myelomeningocele was performed to determine factors affecting upper extremity function in this population. Upper extremity dysfunction was found in 62 subjects (46.6%). A relationship was found between upper extremity dysfunction and hydrocephalus. Subjects with hydrocephalus had a significantly greater incidence of upper extremity dysfunction than subjects without hydrocephalus. No significant relationship was found between surgically treated versus spontaneously arrested hydrocephalus or number of shunt revisions and upper extremity dysfunction. A relationship was found between level of lesion of the spinal cord and upper extremity dysfunction. High level lesions had a significantly higher incidence of upper extremity dysfunction. Of 62 patients with upper extremity dysfunction only 3 (3.2%) had normal development. This was statistically significant. Little attention has been given to general developmental status in myelomeningocele children with upper extremity dysfunction. This study suggests a strong correlation between these two variables. In conclusion, hydrocephalus, level of spinal cord lesion, and developmental status, appear to be significant factors affecting upper extremity dysfunction in children with myelomeningocele.

Adolescent↗

PubMed2006

The use of somatosensory evoked potentials to determine the relationship between patient positioning and impending upper extremity nerve injury during spine surgery: a retrospective analysis.

Somatosensory evoked potential (SSEP) monitoring is used to prevent nerve damage in spine surgery and to detect changes in upper extremity nerve function. Upper extremity SSEP conduction changes may indicate impending nerve injury. We investigated the effect of operative positioning on upper extremity nerve function retrospectively in 1000 consecutive spine surgeries that used SSEP monitoring. The vast majority (92%) of upper extremity SSEP changes were reversed by modifying the arm position and were therefore classified as position-related. The incidence of position-related upper extremity SSEP changes was calculated and compared for five different surgical positions: supine arms out, supine arms tucked, lateral decubitus position, prone arms tucked, and the prone "superman" position. The overall incidence of position-related upper extremity SSEP changes was 6.1%. The lateral decubitus position (7.5%) and prone superman position (7.0%) had a significantly more frequent incidence of position-related upper extremity SSEP changes (P < 0.0001, Z-test for Poisson counts) compared with other positions (1.8%-3.2%). No patient with a reversible SSEP change developed a new postoperative deficit in the affected extremity. SSEP monitoring is of value in identifying and reversing impending upper extremity peripheral nerve injury.

Adolescent↗

PubMedDate not supplied

Use of intermittent pneumatic compression for treatment of upper extremity vascular ulcers.

Ischemic vascular ulcerations of the upper extremities are an uncommon and frequently painful condition most often associated with scleroderma and small vessel inflammatory diseases. Digital amputation has been advocated as primary therapy because of the poor outcome with medical care. Intermittent pneumatic compression (IPC) pump therapy can improve ulcer healing in lower extremity ischemic ulcerations; however, the value of this treatment in upper extremity ischemic ulcerations is not known. This observational pilot study consisted of a consecutive series of 26 patients with 27 upper extremity ischemic vascular ulcers seen at the Mayo Gonda Vascular Center from 1996 to 2003. Inclusion criteria were documented index of ulcer size and follow-up ulcer size and use of the IPC pump as adjunctive wound treatment. Twenty-six of 27 ulcers (96%) healed with the use of the IPC pump. Mean baseline ulcer size was 1.0 cm2 (SD=0.3 cm2) and scleroderma was the underlying disease in 65% (17/26) of cases. Laser Doppler blood flow in the affected digit was 7 flux units (normal greater than 100). The mean ulcer duration before IPC treatment was 31 weeks. The average pump use was 5 hours per day. The mean time to wound healing was 25 weeks. Twenty-five of 26 patients reported an improvement in wound pain with pump use. Intensive IPC pump use is feasible and associated with a high rate of healing in upper extremity ischemic ulcers. A prospective, randomized, sham-controlled study of IPC is needed to determine whether IPC treatment improves wound healing compared to standard medical care.

Adult↗

PubMedDate not supplied

Lower-extremity deep venous thrombosis after upper-extremity port catheter placement: an unusual complication.

We describe the case of a woman with breast carcinoma who experienced deep venous thrombosis of the right lower extremity after placement of a double-lumen central venous chemotherapy port catheter in the left upper extremity. Color Doppler sonography revealed a linear tubular structure within the right common femoral vein and sonographic features of thrombosis, suggesting deep venous thrombosis secondary to displacement of the port catheter.

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PubMed2002

An invisible disability: Qualitative research on upper extremity disorders in a university community.

OBJECTIVES: To understand how upper extremity disorders related to computer use affect graduate and undergraduate university students; and, to develop hypotheses for prevention and management of these disorders. METHODS: Focus group discussions concerning upper extremity disorders were conducted among sixteen symptomatic undergraduate and graduate students at a private university in the US. Discussions were tape recorded, transcribed, coded for themes, and analyzed qualitatively. RESULTS: The findings point to four main themes: 1). the essential role of computers in academic, social, and personal activities; 2). the negative impact of upper extremity disorders on students' physical and emotional well-being, including their career aspirations; 3). students' expectations and perceptions of medical care providers; and 4). recommendations for interventions. CONCLUSION: Students with upper extremity disorders experience numerous adverse consequences on a college campus. Effective strategies for prevention, and treatment of upper extremity disorders in young adults in universities are needed. Based on this research, an educational and skills development intervention would appear to be appropriate for preventing disability due to upper extremity disorders.

Adult↗

PubMed2006

Validation of the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) for children with hemiplegic cerebral palsy.

BACKGROUND: The Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) is a video-based tool for the assessment of upper extremity function in children with hemiplegic cerebral palsy. This tool includes spontaneous functional analysis and dynamic positional analysis and assesses the ability to perform grasp and release. The purpose of the present study was to assess the reliability, concurrent validity, and construct validity of this instrument. METHODS: The Shriners Hospital for Children Upper Extremity Evaluation studies for eleven subjects with hemiplegic cerebral palsy were selected for the evaluation of intraobserver and interobserver reliability. Concurrent validity was determined through analysis of the Shriners Hospital for Children Upper Extremity Evaluation, Pediatric Evaluation of Disability Inventory, and Jebson-Taylor Test of Hand Function scores for twenty children. Construct validity was determined through analysis of Shriners Hospital for Children Upper Extremity Evaluation scores for eighteen children before and after flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer. RESULTS: The absolute mean differences between the two scoring sessions for three raters were 1.2 and 1.0 for the spontaneous functional analysis and the dynamic positional analysis, respectively. Although the mean differences were significantly different from 0 (p < 0.001 and p = 0.003), the differences were small and not clinically important with regard to the total possible score. There was excellent intraobserver reliability between the two sessions with regard to both spontaneous functional analysis (r = 0.99) and dynamic positional analysis (r = 0.98). Assessment of interobserver reliability revealed absolute mean differences between four raters of 3.8 and 3.7 for the spontaneous functional analysis and the dynamic positional analysis, respectively. These differences were significantly different from 0 (p < 0.001); however, the magnitudes of these differences were not important with regard to total score or clinical interpretation. There was excellent interobserver reliability for both the spontaneous functional analysis (r = 0.90) and the dynamic positional analysis (r = 0.89). There was 100% agreement within and between examiners for the grasp-and-release section. The Shriners Hospital for Children Upper Extremity Evaluation showed fair correlation with the self-care scaled score from the Pediatric Evaluation of Disability Inventory (r = 0.47) and good inverse correlation with the non-dominant total time section of the Jebson-Taylor test (r = -0.76). The Shriners Hospital for Children Upper Extremity Evaluation wrist score improved for all eighteen subjects after the flexor tendon transfer, and the mean improvement was significant (p < 0.001). CONCLUSIONS: The present study establishes the clinical reliability, concurrent validity, and construct validity of the Shriners Hospital for Children Upper Extremity Evaluation for the assessment of upper extremity function in children with hemiplegic cerebral palsy.

Adolescent↗

PubMed1999

Psychometric assessment of patients with chronic upper extremity pain attributed to workplace exposure.

Upper extremity pain attributed to workplace exposure is a growing concern in medicine today. This study was undertaken to investigate the psychological findings in patients with chronic upper extremity pain attributed to workplace exposure. Sixty-three consecutive patients were evaluated. All patients underwent a history and physical examination by a hand surgeon and a psychological evaluation by a licensed psychologist, including a Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Physical and psychological findings were then compared. Forty-one patients (65%) showed abnormalities on MMPI-2 examination (t score > 70 = 97% confidence). This result is far above what generally would be expected in medical patients. When physical findings were grouped with psychological findings, 5 distinct groups were identified: 1 patient had normal physical and psychological results, 6 patients had normal physical findings but abnormal psychological assessments, 21 patients had abnormal physical findings but normal psychological assessments, 28 patients had both abnormal physical and psychological findings, and 7 patients had abnormal physical results but invalid MMPI-2 evaluations due to purposeful attempts to deny psychological symptoms. Identification of these groups may have diagnostic, prognostic, and treatment value. In addition, identification of these groups may help clarify several aspects of the debate over the role of psychosocial factors in the development and maintenance of chronic upper extremity pain that patients attribute to workplace exposure.

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PubMed2004

Soft tissue sarcoma of the upper extremity.

Soft tissue sarcomas of the upper extremities are rare and hand surgeons typically encounter only one or two undiagnosed soft tissue sarcomas during their careers. It is incumbent on the physician to review repeatedly the characteristics of these tumors and remain suspicious, because these lesions typically are misdiagnosed and treatment is delayed. The most common soft tissue sarcomas of the upper extremity are the epithelioid sarcoma, synovial cell sarcoma, and malignant fibrous histiocytoma. Limb salvage surgery is the treatment of choice for soft tissue sarcomas to preserve upper extremity function. Following wide tumor resection, adjuvant therapies such as chemotherapy, external beam radiation therapy, and brachytherapy may lessen local recurrence rates, but their effect on overall survival remains unclear.

Arm↗

PubMed1985

Problems of the upper extremity in gymnastics.

The majority of upper extremity problems experienced by gymnasts are not considered injuries but are regarded as consequences of the sport. Treatment of these problems should include treatment of not only the injury but also the cause. This requires the cooperation of the gymnast, his or her coach, and a physician familiar with the demands placed upon the upper extremity in gymnastics. The level of a gymnast's capabilities must be recognized. Improper techniques must be corrected. Emphasis must be placed on rehabilitation for shoulder problems and strengthening exercises for the elbow and wrist in attempt to decrease the symptoms from repeated forced extension. In the words of Peter Kormann, an Olympic medalist in gymnastics, "All gymnasts work out and compete with ongoing problems in their upper extremities. These problems are only considered serious injuries when the gymnast can no longer compete."

Arm Injuries↗

PubMed2005

Functional evaluation in children with congenital upper extremity malformations.

Achieving optimal upper limb function is a priority in the management of children with congenital hand malformations. Professionals need to be well equipped to help families understand the best surgical and rehabilitative options available for their child. Our ability as professionals clearly to define and evaluate the child's optimal function will assist in achieving this balance. This article examines the existing literature to evaluate critically functional outcome studies of children with congenital upper extremity malformations and to address the challenges of defining and measuring functional outcome in this patient population.

Child↗

PubMed1993

Upper extremity deep venous thrombosis. Underdiagnosed and potentially lethal.

The significance of upper extremity deep venous thrombosis (DVT) has been minimized in comparison to iliofemoral thrombosis, likely due to the erroneous belief that subsequent pulmonary thromboembolism is rare. The possibility of pulmonary thromboembolism originating in the upper extremity veins must now be seriously considered with catheters and medical instrumentation being performed more commonly in accessing the central venous system. It has been incorrectly assumed that the risk of pulmonary embolism was low due to the abundant collateral flow, and thus lack of stasis around an upper extremity even with venous occlusion. However, several studies, including a recent prospective trial, concluded that pulmonary embolism is not a rare complication in upper extremity DVT. Significantly, when comparing all sources of secondary upper extremity DVT, catheter-related upper extremity DVT is at greatest risk of subsequent pulmonary thromboembolism. We present an illustrative case documenting extensive pulmonary embolization that occurred following insertion of a central venous catheter and subsequent thrombosis of the right subclavian and innominate veins. With absolute contraindications to thrombolytic and anticoagulation therapy, prevention of further embolization was achieved by percutaneous insertion of a superior vena cava filter.

Aged↗