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PubMed1993

Can air plethysmography accurately identify upper extremity deep venous thrombosis?

PURPOSE: Air plethysmography (APG) is an established, noninvasive means of evaluating lower extremity venous outflow. METHODS: To determine whether APG could identify deep venous thrombosis (DVT) of the upper extremity, we measured the percentage of venous outflow in the first second (maximum venous outflow [MVO]) of four groups of arms: (1) normal volunteers (no previous central vein catheters), (2) the affected, (3) the unaffected arms of the patients with DVT (proven by venography or duplex scanning), and (4) hospital patients (no previous central vein catheters). RESULTS: The results of an analysis of variance were as follows: the mean MVO (%) of the affected arms of patients with DVT, 29.4 +/- 2.6, was significantly less than their unaffected arms, 55.3 +/- 3.9, hospital controls, 64.3 +/- 2.2, and normal volunteers, 64.2 +/- 0.9 (p < 0.05). In addition, the unaffected arms differed significantly from all groups (p < 0.05). An MVO of 45% was 2 SD below the mean MVO of the normal volunteer group. Two unaffected arms of the patients with DVT were below 45%, whereas only one affected arm of the patients with DVT was above 45% (45.6%). Therefore a comparison of the distribution of the MVO values revealed virtually no overlap of the affected arms of the patients with DVT with the other three groups. CONCLUSIONS: We conclude that APG clearly discriminated arms with documented DVT from controls and is a highly accurate means of identifying upper extremity DVT.

Adult↗

PubMed2001

Impact of a joint labor-management ergonomics program on upper extremity musculoskeletal symptoms among garment workers.

This study evaluated the effect of an ergonomics intervention program on the prevalence and intensity of symptoms of upper extremity work-related musculoskeletal disorders among 36 garment workers performing an operation called spooling. Adjustable chairs were introduced and workers were trained in their use. Symptom surveys were administered prior to and 6 months after introduction of adjustable chairs. Quantitative pre- and post-intervention measurement of joint position was performed utilizing videotapes among a subgroup of nineteen. Eighty nine percent of the cohort reported pain in either the neck or at least one upper extremity anatomic site prior to the adjustable chair intervention. Among subjects reporting pain at baseline, there were significantly decreased pain levels in 10 of 11 anatomic sites after the intervention. Among all subjects, the proportion reporting pain decreased for each anatomic site following the intervention, with statistically significant decreases in 3 sites. However, there were only modest declines in awkward posture among the videotaped subgroup. This study suggests that introduction of an ergonomics program focused on education and introduction of an adjustable chair may diminish musculoskeletal symptomatology in apparel manufacturing workers.

Adult↗

PubMed1998

Endovascular therapy for upper extremity injury.

Various endovascular techniques, including the placement of embolization coils, intravascular stents, and the use of stented grafts, have been used in the setting of traumatic upper extremity injuries. Coil embolization and stent placement are effective in a limited number of cases. Endovascular grafts have greatly extended the potential of endovascular therapy for upper extremity vascular trauma. The ideal graft material, stent, and the best mechanism for stent deployment have not been determined. In addition, long-term effectiveness of such therapy is yet to be shown. Nevertheless, endovascular grafts offer distinctive advantages in some cases and are important tools for the treatment of vascular trauma and should be included in the armamentarium of all vascular surgeons.

Angioplasty, Balloon↗

PubMed2004

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity.

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.

Adolescent↗

PubMed2006

Clinical effect of radiation synovectomy of the upper extremity joints: a randomised, double-blind, placebo-controlled study.

PURPOSE: To compare the clinical efficacy of radiosynoviorthesis (RSO) with intra-articular radionuclide plus glucocorticoid (GC) injection (group A) with that of placebo plus GC injection (group B) for the treatment of persistent synovitis in joints of the upper extremity. METHODS: At baseline and at 6 and 12 months after intra-articular injection, six clinical parameters were scored. Changes in clinical values over time were summed to provide a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). A CCI > or =6 was considered to indicate successful treatment. Differences in response rate and CCI between groups A and B were examined. Regression analyses were performed to explore whether baseline variables could predict therapeutic effect. RESULTS: Sixty-eight joints in 44 patients were treated. Six months after intra-articular injection, response rates (CCI > or =6) were 69% (25/36) in group A and 29% (9/31) in group B (p=0.001). The mean CCIs +/- standard deviation at 6 months were 6.7+/-3.2 for group A and 3.3+/-3.8 for group B (p=0.001). At 12 months the response rates were 69% (25/36) in group A and 32% (8/25) in group B (p=0.004). The mean CCIs at 12 months were 6.8+/-3.3 for group A and 4.2+/-4.7 for group B (p= 0.046). None of the baseline variables predicted the therapeutic effect. CONCLUSION: RSO (radionuclide plus GC) of upper extremity joints with immobilisation for 72 h shows a significantly better response rate than placebo plus GC in patients with persistent synovitis after at least one failed outpatient intra-articular GC injection.

Anti-Inflammatory Agents↗

PubMed1989

Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients.

To test the clinical counterpart of the learned nonuse theory, 25 chronic hemiplegic stroke and head-injured patients with minimal to moderate upper extremity extensor muscle function were required to keep their uninvolved upper extremities within a hand-enclosed sling during waking hours over a 2-week interval. During this forced use period and for 1 year thereafter, changes in force or time-based measures among 21 functional tasks were compared to values at the sixth baseline session, a preintervention time when relearning had plateaued. Significant (P less than 0.05, Friedman's repeated measures followed by Tukey multiple comparison tests) changes were seen in 19 of the 21 tasks with most persisting at the 1-year follow-up. There were no apparent differences between right- and left-sided involvement or between stroke versus head injury clients (Mann-Whitney procedure). Ratings for quality of movement scored from videotapes presented in random order showed no change over time. These data suggest that learned nonuse does occur in select neurological patients and that this behavior can be reversed through application of a forced use paradigm.

Adult↗

PubMed1985

[Basic and clinical study on functional electrical stimulation (FES) for the paralyzed upper extremity].

Functional electrical stimulation (FES) will become one of the useful reconstructive methods for the paralyzed upper extremity due to upper motor neuron lesion. As a basic study, the author analyzed the electromyogram of the grasp and the lateral pinch movements in three normal hands. On the basis of this electromyographic analysis, FES was applied for the hands of two tetraplegics and three hemiplegics using percutaneous wire electrodes. As a result, three types of holding patterns were obtained in the paralyzed hands by FES, namely, parallel extension grip, grasp and lateral pinch. Clinically, the author made a FES system for the tetraplegic patient, and utilized it for the activities of daily living. The patient could get hand opening, parallel extension grip, grasp and lateral pinch in his paralyzed hand by using this FES system, and he obtained a certain measure of independence of the activities of daily living such as eating, writing and so on.

Adult↗

PubMed2000

Distal arterial flow in patients undergoing upper extremity dialysis shunting: a prospective study using doppler sonography.

OBJECTIVE: The objective of this study was to document changes in the distal circulation after creation of a proximal upper extremity dialysis shunt and to correlate these findings with the patient's clinical condition. SUBJECTS AND METHODS: We prospectively examined 18 patients scheduled for upper extremity shunt creation. We used color and spectral Doppler sonography to examine flow in the radial and ulnar arteries, noting flow direction and peak systolic velocity. After the shunt procedure, we repeated the measurements and correlated them statistically with hand symptomatology. RESULTS: Six (33%) of 18 patients were symptomatic. The mean peak systolic velocities in the radial and ulnar arteries were 52 and 61 cm/sec, respectively, before surgery, and decreased to 12 cm/sec after surgery in the radial artery and 44 cm/sec in the ulnar artery. The mean percentage of decrease in peak systolic velocity was 77% in the radial artery and 28% in the ulnar artery. Eight patients showed reversed flow. No statistical correlation was found between change in peak systolic velocity values before and after surgery and the presence of hand symptoms. Similarly, no correlation was found between flow reversal and symptoms. The most consistent factor associated with symptoms was diabetes; all symptomatic patients were diabetic, but only 54% of the diabetic patients were symptomatic. CONCLUSION: The difference in the peak systolic velocities in the radial and ulnar arteries after shunt construction does not correlate with symptoms. The hand can tolerate a significant decrease in the peak systolic velocity and even flow reversal without symptomatology.

Adult↗

PubMed1995

Neurologic and ischemic complications of upper extremity vascular access for dialysis.

This study reviews the clinical course of 22 patients with chronic renal failure on hemodialysis with ischemic or neurologic problems in the upper extremity distal to an arteriovenous fistula. Two distinct presentations were observed. Twelve patients developed significant motor and/or sensory impairment immediately following surgical construction of the fistula. Ten patients presented with upper extremity ischemia, established or impending tissue loss, or nonhealing wounds distal to a dialysis fistula. Seventeen of the 22 patients were diabetic. Nerve conduction studies, noninvasive vascular studies, and arteriography were used to confirm the diagnosis. Sixteen of the 22 patients had ligation or revision of the fistula. Five patients underwent amputations at the metacarpal or phalangeal level, and one patient underwent below-elbow amputation.

Adult↗

PubMed2005

Constraint-induced therapy for moderate chronic upper extremity impairment after stroke.

PRIMARY OBJECTIVE: To explore the effectiveness of constraint-induced therapy (CIT) in the treatment of individuals with moderate chronic upper extremity paresis. RESEARCH DESIGN: Multiple case reports, pre-post-treatment comparisons as well as long-term follow-ups at 1 and 6 months after intervention. METHODS AND PROCEDURES: Seven subjects, each greater than 12 months post-stroke, participated in an intensive 3 weeks CIT programme. The Wolf Motor Function Test (WMFT), Motor Activity Log (MAL) and Fugl-Meyer Evaluation (FM) were used to measure outcomes. MAIN OUTCOMES AND RESULTS: Subjects exhibited notable improvements in mean WMFT scores (0.25 point increase post-treatment, 0.38 point increase at 1-month follow-up, 0.44 point increase at 6-month follow-up). Similarly, improvements were seen for mean MAL (1.71 points for AS, 1.77 points for HW) and FM scores (6 points FM-UE, 6 points FM-TOT) post-treatment. Additional improvements were seen at some follow-up assessments. CONCLUSIONS: Subjects demonstrated gains in objective measures, however, did not regain normal functional ability of their paretic upper extremities. Further investigation of the effects of CIT in this population, as well the functional significance of the objective measures used is warranted.

Adult↗

PubMed2001

Test-retest reliability of the Upper Extremity Questionnaire among keyboard operators.

BACKGROUND: Questionnaires are often used in research among workers although few have been tested in the working population. The Upper Extremity Questionnaire is a self-administered questionnaire designed for epidemiological studies and tested among workers. This study assessed reliability of the instrument. METHODS: A two-part assessment was conducted among 138 keyboard operators as part of a large medical survey. Test-retest reliability was analyzed using the kappa statistic, paired t-test, and intraclass correlation coefficient (ICC). Logistic regression models were used to test the effect of demographic and work-related factors on reliability. RESULTS: The average respondent was a white woman, age 35 years, with some college education, in permanent employment with tenure of 1.4 years. Overall, reports of symptoms were stable from Round 1 to 2. Most kappa values for symptom reports were between 0.60 and 0.89. Kappa values for right and left hand diagrams were 0.57 and 0.28, respectively. Among psychosocial items, Perceived Stress and Job Dissatisfaction Scales were most reliable (ICC = 0.88); co-worker support was least reliable (ICC = 0.44). CONCLUSION: Reliability of items on the Upper Extremity Questionnaire were generally good to excellent. Reports of symptom severity and interference with work were less stable. Demographic and work-related factors were not statistically significant in modeling the variation in reliability. Repeated use of the questionnaire with similar results suggests findings are applicable to a larger working population.

Adult↗

PubMedDate not supplied

Upper extremity blood flow in collegiate and high school baseball pitchers A preliminary report.

The arterial and venous volume blood flow in the dominant and nondominant upper extremities of five male pitchers, ages 16 to 21, was measured using color flow duplex ultrasound. Blood-flow measurements were obtained at baseline, after warm-up, and after each sequence of 20 pitches until 100 pitches were thrown. Blood flow was additionally determined 1 hour after the last pitch. The velocity of each pitch was recorded with a speed gun. Anthropomorphic measurements of the upper extremity were obtained at baseline and immediately after Pitch 100 using a standard measuring tape. The highest average arterial volume flow in the pitching arm occurred after 40 pitches, reaching a peak of 549 ml/min (56% increase from baseline). Thereafter, the average arterial blood flow steadily declined, reaching an average of 402 ml/min after the 100th pitch (14% increase from baseline). In contrast, the arterial blood flow in the nonpitching arm increased only slightly from baseline, reaching a maximal volume flow of 448 ml/min immediately after the warm-up period (10% increase from baseline). The volume flow then persistently fell to a level 30% below baseline after the 100th pitch. Although this small pilot study does not demonstrate causation between a decline in pitching performance and arterial blood flow, it suggests arterial flow in the dominant extremity falls as the pitch count increases.

Adolescent↗

PubMed2006

Role of magnetic resonance imaging in entrapment and compressive neuropathy--what, where, and how to see the peripheral nerves on the musculoskeletal magnetic resonance image: part 2. Upper extremity.

The diagnosis of nerve entrapment and compressive neuropathy has been traditionally based on the clinical and electrodiagnostic examinations. As a result of improvements in the magnetic resonance (MR) imaging modality, it plays not only a fundamental role in the detection of space-occupying lesions, but also a compensatory role in clinically and electrodiagnostically inconclusive cases. Although ultrasound has undergone further development in the past decades and shows high resolution capabilities, it has inherent limitations due to its operator dependency. We review the course of normal peripheral nerves, as well as various clinical demonstrations and pathological features of compressed and entrapped nerves in the upper extremities on MR imaging, according to the nerves involved. The common sites of nerve entrapment of the upper extremity are as follows: the brachial plexus of the thoracic outlet; axillary nerve of the quadrilateral space; radial nerve of the radial tunnel; ulnar nerve of the cubital tunnel and Guyon's canal; median nerve of the pronator syndrome, anterior interosseous nerve syndrome, and carpal tunnel syndrome. Although MR imaging can depict the peripheral nerves in the extremities effectively, radiologists should be familiar with nerve pathways, common sites of nerve compression, and common space-occupying lesions resulting in nerve compression in MR imaging.

Brachial Plexus Neuropathies↗

PubMed2005

Development and validation of a performance-based measure of upper extremity functional limitation.

BACKGROUND AND AIMS: While the standardized lower extremity physical performance battery (LEPPB) is widely used to measure lower body functional limitation, no corresponding measure has been developed for upper body functional limitation. We combined three standard measures (William's Hand Test, Hand Signature, Functional Reach) to develop an upper extremity physical performance battery (UEPPB) analogous to the LEPPB, and examined its validity. METHODS: We used baseline data from a community-dwelling cohort of 749 Mexican American and European American elders and combined times to complete the William's Hand Board, Hand Signature, and distance on Functional Reach into a single composite measure, using scoring methods analogous to those for the LEPPB. We summarize concurrent, discriminant, and construct validity evidence for the UEPPB, based on observed associations with established measures of physical functional limitation, disability, and dependence. RESULTS: All correlations were in the expected direction. Shared variance with self-reported upper and lower extremity functional limitation was 10 and 5%, respectively, and with self-reported ADL disability, ADL dependency, and IADL dependency it was 32, 26, and 31%, respectively. In multivariate models of self-reported and performance-based disability and dependency, the UEPPB and LEPPB made significant, independent contributions and, net of contextual variables (age, sex, ethnic group, education, income) explained 4 to 10% of the variance in disability and dependency. CONCLUSIONS: The UEPPB is a valid performance-based measure of upper extremity functional limitation and makes an independent contribution beyond LEPPB in explaining disability and dependence.

Activities of Daily Living↗

PubMed1999

Upper extremity salvage using the tensor fascia lata flap: report of two cases.

The tensor fascia lata pedicled flap was successfully used to salvage 3 severely injured upper extremities in 2 patients. Both patients had undergone 3 prior free tissue transfers without complete closure of their wounds. All 3 tensor fascia lata flaps (2 myocutaneous, 1 myofascial) survived entirely. We believe this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required.

Adult↗

PubMed1986

Bilateral upper extremity paralysis (Bell's cruciate paralysis) from a gunshot wound to the cervicomedullary junction.

Cruciate paralysis is characterized by midline involvement of the rostral portion of the pyramidal decussation, resulting in paralysis of the upper extremity without lower extremity involvement. The neuroanatomical basis is the more rostral and medial decussation of the upper extremity motor fibers in the medulla compared with the more caudal and lateral decussating fibers of the lower extremity at the lower boundary of the cervicomedullary junction. We believe this to be the first reported case of Bell's cruciate paralysis caused by a gunshot wound to this region. The neuroanatomical basis and the mechanisms that produce this unique clinical entity are discussed.

Arm↗

PubMed2005

A model of the upper extremity for simulating musculoskeletal surgery and analyzing neuromuscular control.

Biomechanical models of the musculoskeletal system are frequently used to study neuromuscular control and simulate surgical procedures. To be broadly applicable, a model must be accessible to users, provide accurate representations of muscles and joints, and capture important interactions between joints. We have developed a model of the upper extremity that includes 15 degrees of freedom representing the shoulder, elbow, forearm, wrist, thumb, and index finger, and 50 muscle compartments crossing these joints. The kinematics of each joint and the force-generating parameters for each muscle were derived from experimental data. The model estimates the muscle-tendon lengths and moment arms for each of the muscles over a wide range of postures. Given a pattern of muscle activations, the model also estimates muscle forces and joint moments. The moment arms and maximum moment-generating capacity of each muscle group (e.g., elbow flexors) were compared to experimental data to assess the accuracy of the model. These comparisons showed that moment arms and joint moments estimated using the model captured important features of upper extremity geometry and mechanics. The model also revealed coupling between joints, such as increased passive finger flexion moment with wrist extension. The computer model is available to researchers at http://nmbl.stanford.edu.

Biomechanical Phenomena↗

PubMed2004

The quality of reporting and outcome measures in randomized clinical trials related to upper-extremity disorders.

PURPOSE: Randomized clinical trials can provide strong evidence regarding effective treatment options. The quality of reporting and the type of outcome measures used are important when judging whether results justify change in clinical practice. The aim of this study was to assess the quality of reporting of randomized clinical trials related to treatment of upper-extremity disorders, published in 4 hand surgical and orthopedic journals during an 11-year period, and assess the type of outcome measures used in the trials. METHODS: Eligible articles were identified by reviewing all abstracts published in the 4 journals from 1992 through 2002. The quality of reporting was assessed by a modified Jadad scale that consisted of 3 items (randomization, blinding, and withdrawals/dropouts). A higher score (0-5) indicated higher quality. The outcome measures were classified according to the International Classification of Functioning, Disability and Health into the levels of body function and structure, activity, and participation. RESULTS: Of 92 articles reporting randomized clinical trials, 40 articles described appropriate randomization method that implied they were truly randomized studies, 31 articles did not describe the randomization method, and 21 articles (23%) described inappropriate randomization methods. Double or single blinding was reported in 33 articles. Absence or description of withdrawals/dropouts was shown in 77 articles. The median quality score calculated for all 92 articles was 2 (range, 0-5) points. The median score for the 28 articles published 1992 through 1996 was 1 (range, 0-5) points and for the 64 articles published from 1997 through 2002 was 3 (range, 0-5) points. All trials used outcome measures on body function and structure level; 41% used measures of activity and/or participation. CONCLUSIONS: There is a need to improve the quality of reporting of upper-extremity randomized clinical trials and to increase the use of outcome measures covering different aspects of disability.

Double-Blind Method↗