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This article describes the vascular anatomy of several nerves of the upper extremity with a view of their potential use as pedicled, vascularized nerve grafts.
From 1969 to 1980, 154 emboli of the upper extremities (UEE) were managed in our institution. They occurred in 151 patients, 66 males (44%) and 85 females (56%) aged ranged from 23 to 87 years (mean 68.9). Obstruction level was in the subclavian artery (12 cases), the axillary artery (46), the brachial artery (74 cases), the radial or ulnar artery (22 cases). Cardiac disease was present in 119 cases. Ischemia was severe in 47 cases (30%), and partial in 104 (67%). Peripheral gangrene was already present in 2 cases. 106 patients were operated on within 10 hours after the occurrence of UEE (69%). Associated systemic emboli was noted in 10 cases. The treatment consisted in 140 primary embolectomies and in 11 cases of conservative therapy (heparin 10, thrombolysis 1). Reoperation was done in 11 patients (7%) because of recurrence of UEE and in 4 cases (2%) for post-operative thrombosis. Results were good in 128 patients with clinical improvement and arterial patency.
Acute arterial thromboembolism of the upper extremity associated with the thoracic outlet syndrome is much less frequent than the neurologic manifestations, but is a potential threat to the viability of the limb if not recognized in time. The thromboembolic process originates in a damaged subclavian artery as a result of its prolonged compression, usually by congenital, much more rarely, by acquired anomalies of anatomical structures at the thoracic outlet. Major embolic complications usually occur after months or years of episodal and repetitive microemboli. A comprehensive arteriographic evaluation of the entire arterial tree in addition to other tests is essential for diagnosis. Four patterns of arterial findings are described. The scope of the surgical treatment of these manifestations it twofold: (1) decompression of the subclavian artery and (2) repair of the arterial lesions, often with additional thoracic sympathectomy. Results of management of the arterial lesions are described in three groups, based mostly on a review of data from the literature. In recent years a more aggressive approach to these lesions appears to have resulted in better management of this complex entity. A case report will illustrate some the clinical and pathological aspects of this problem. Early recognition of this unusual thromboembolic process is necessary for achieving a more complete limb salvage.
The use of small dose intravenous lidocaine without exsanguination for upper extremity fractures in children and adults is described. A twenty-plus year experience with this technique in the outpatient setting has shown it to be effective and safe. Attention to detail is essential and inadvertent tourniquet release must be avoided.
Multiple and anatomically distinct compartments are present in the upper extremity. A compartment is defined as an enclosed space formed by fascia or by a combination of fascia and bone that contains one or more muscles. Knowledge of these anatomic compartments and their contents will facilitate early diagnosis and treatment.
Previous studies have demonstrated abnormal joint torque coupling and associated muscle coactivations of the upper extremity in individuals with unilateral stroke. We investigated the effect of upper limb configuration on the expression of the well-documented patterns of shoulder abduction/elbow flexion and shoulder adduction/elbow extension. Maximal isometric shoulder and elbow torques were measured in stroke subjects in four different arm configurations. Additionally, an isometric combined torque task was completed where subjects were required to maintain various levels of shoulder abduction/adduction torque while attempting to maximize elbow flexion or extension torque. The dominant abduction/elbow flexion pattern was insensitive to changes in limb configuration while the elbow extension component of the adduction/extension pattern changed to elbow flexion at smaller shoulder abduction angles. This effect was not present in control subjects without stroke. The reversal of the torque-coupling pattern could not be explained by mechanical factors such as muscle length changes or muscle strength imbalances across the elbow joint. Potential neural mechanisms underlying the sensitivity of the adduction/elbow extension pattern to different somatosensory input resultant from changes in limb configuration are discussed along with the implications for future research.
We report 3 cases of successful vascularized ulnar nerve graft for reconstructing a large median or radial nerve defect after severe trauma of the upper extremity.
When the C-arm is used as a table in upper extremity surgery, postoperative plain radiographs can be obtained by placing the x-ray cassette directly on the image intensifier. This has many advantages, including more rapid performance than conventional techniques, a high-quality image, and no need for a recovery room radiograph. Additionally, there is no overlying splint material to obscure image detail, and the extremity can be positioned as desired by the operating surgeon.
Cancellous bone grafts can be harvested from Gerdy's tubercle on the proximal metaphysis of the tibia for surgical procedures on the upper extremity. This donor site, however, is used rarely by hand surgeons, possibly because of a lack of awareness.
In September 2005 a small working conference was held to generate potential next steps in the generation of innovative approaches to work related upper extremity symptoms and disorders among those working in office environments. This special section of the Journal includes papers written by the presenters and their collaborators. These papers provide "state of the art" summaries of research in the areas of ergonomics, biobehavioral factors and interventions, economics and integrative interventions at the workplace. Invited speakers and participants from various stakeholder groups spent a second day discussing the implications of the research presented on day one for improving the understanding and management of these disorders. Practical considerations for generating new approaches and their implementation were also discussed.
OBJECTIVES: To examine the reliability of manual tracking performance and its association with impairment and disability in individuals symptomatic of an upper extremity cumulative trauma disorder (CTD). METHODS: Volunteer and physician referred subjects (100 control, 140 CTD) tracked a target cursor moving quasi-randomly using a hand-held stylus interfaced with a digitizing tablet. Impairment was physician-rated and the Disability of the Arm, Shoulder and Hand questionnaire measured disability. Subsamples of 25 subjects per group were tested on three occasions. RESULTS: Reliability of tracking performance was excellent (ICC > or = 0.88) and sensitivity was 81%. Performance was superior in controls (p < 0.001) and deteriorated as a function of impairment level (p < 0.001). Tracking and impairment rating explained 65% of the disability score. CONCLUSIONS: Tracking performance may be an important outcome for monitoring change over time and the impact of a CTD on function in everyday activities.
The purpose of this systematic review was to evaluate the available evidence on workplace rehabilitation interventions for work-related upper extremity disorders (WRUEDs). The literature search identified a total of 811 abstracts from Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EMBASE databases. The abstracts were independently assessed by four reviewers and 53 full-text articles were identified. Twenty-one studies were then randomly allocated to two pairs of reviewers. Using a 24-item critical appraisal form, the reviewers evaluated the articles for quality and level of evidence. During this process, an additional 13 articles were discarded, resulting in eight studies. The effectiveness of these studies was limited by small sample sizes, lack of standardized outcome measures, and inadequate reporting of interventions and results. The findings of this review indicate that the evidence for workplace interventions for WRUEDs has not been established. This systematic review provides a rigorous analysis of workplace interventions for WRUEDs and emphasizes the need for further research in this area.
UNLABELLED: There is evidence that performing job tasks involving repetition, vibration, sustained posture or forceful movement may contribute to symptoms of work related upper extremity disorders. Typing is one such activity; symptoms that develop as a result of this activity can affect performance of work, self-care and leisure occupations. Studies investigating the impact of ergonomic keyboards on symptom reduction are limited, and little research exists regarding the reduction of key activation force as an intervention. METHODS: This randomized, prospective study used a sample of 68 symptomatic workers employed by a single company. One group received a commercially available ergonomic keyboard, a second group used a modified version of the same keyboard designed to reduce activation force, vibration and key travel. We measured symptoms and clinical signs, functional status, and device satisfaction in both groups over a six-month study period. CONCLUSIONS: Between-groups analyses indicated that the groups performed similarly on the outcomes of interest. Repeated-measure analysis identified a reduction of symptoms, an improvement in functional status, preference for and increased satisfaction with the intervention keyboards, and maintenance of typing speed and accuracy for both groups.
OBJECTIVE: To compare the effects of traditional Chinese acupuncture with sham acupuncture on upper-extremity (UE) function and quality of life (QOL) in patients with chronic hemiparesis from stroke. DESIGN: A prospective, sham-controlled, randomized controlled trial (RCT). SETTING: Patients recruited through a hospital stroke rehabilitation program. PARTICIPANTS: Thirty-three subjects who incurred a stroke 0.8 to 24 years previously and had moderate to severe UE functional impairment. INTERVENTIONS: Active acupuncture tailored to traditional Chinese medicine diagnoses, including electroacupuncture, or sham acupuncture. Up to 20 treatment sessions (mean, 16.9) over a mean of 10.5 weeks. MAIN OUTCOME MEASURES: UE motor function, spasticity, grip strength, range of motion (ROM), activities of daily living, QOL, and mood. All outcomes were measured at baseline and after treatment. RESULTS: Intention-to-treat (ITT) analyses found no statistically significant differences in outcomes between active and sham acupuncture groups. Analyses of protocol-compliant subjects revealed significant improvement in wrist spasticity (P<.01) and both wrist (P<.01) and shoulder (P<.01) ROM in the active acupuncture group, and improvement trends in UE motor function (P=.09) and digit ROM (P=.06). CONCLUSIONS: Based on ITT analyses, we conclude that acupuncture does not improve UE function or QOL in patients with chronic stroke symptoms. However, gains in UE function observed in protocol-compliant subjects suggest traditional Chinese acupuncture may help patients with chronic stroke symptoms. These results must be interpreted cautiously because of small sample sizes and multiple, unadjusted, post hoc comparisons. A larger, more definitive RCT using a similar design is feasible and warranted.
A multichannel functional electrical stimulation (FES) system for the restoration of quadriplegic upper extremity function is described. The system is composed of a personal computer NEC PC-8801mkII, peripheral electronic circuits, CRT display and respiratory sensors for volitional control by the patient, and percutaneous electrodes. A C4 quadriplegic patient could drink canned tea by herself by using this FES system. Distinct features of the system are as follows: 1) Versatile volitional control was realized by controlling the memory allocation of the stored stimulation data by voluntary respiratory signals. 2) Sophisticated fine control of the fingers, wrists, and elbow was realized by creating the multichannel stimulation data from recorded myoelectric activities of normal subjects during movements of the upper limb.
OBJECTIVE: The purpose of this study was to review the literature concerning upper extremity deep venous thrombosis (UEDVT) diagnosed by color Doppler duplex sonography (CDDS) in cancer patients with indwelling central venous catheters (CVCs). METHODS: From computerized databases (MEDLINE and Ovid), relevant publications regarding CDDS of the upper limb veins in cancer patients with CVCs were reviewed. RESULTS: Patients with malignancy have a higher rate of thrombosis, which is increased by the presence of CVCs. Screening CDDS in asymptomatic patients showed CVC-related UEDVT in 11.7% to 44% of patients. In symptomatic cancer patients, the range was similar to the asymptomatic ones, 6.7% to 48%. The presence of a CVC almost doubled the incidence of UEDVT in symptomatic patients. Color Doppler duplex sonography is an accurate examination for the diagnosis of UEDVT, with sensitivity ranging from 78% to 100% and specificity ranging from 82% to 100%. The main obstacle for the diagnosis of UEDVT is the presence of overlying bones, making it difficult to visualize and impossible to directly assess by compression techniques. Color and spectral Doppler sonography and the use of small transducers aid in the diagnosis. When several parameters are evaluated in combination, CDDS is a reliable method for diagnosing CVC-related thrombosis. CONCLUSIONS: Great variability in the prevalence of catheter-related thrombosis in cancer patients has been reported, although it is uniformly higher compared with patients without cancer. Color Doppler duplex sonography is the modality of choice for the diagnosis of CVC-related UEDVT in symptomatic cancer patients and for screening for asymptomatic thrombosis in this specific population.
There were analyzed the causes and factors, influencing the thromboembolic complications frequency, in performance of the upper extremity segment replantation in 220 injured persons and of microsurgical the tissues defect plasty using combined complex of tissues (CCT)--in 154 patients. The role of anticoagulational therapy in complex of remedial measures, directed on the occurrence prophylaxis and medicinal correction of hemodynamic disorders in microvascular anastomoses after the operation, was determined. The advantages of low-molecular weight heparin (Fraxiparine) administration in comparison with the standard heparinotherapy were showed: lowering of thromboembolic and hemorrhagic complications occurrence frequency, the unique method of Fraxiparine subcutaneous injection into the replanted segment and CCT was presented.
Reviews of work-related musculoskeletal disorders (WMD) of the neck and upper extremity have typically supplied little information on prognosis. This paper reports on the methods and results of a systematic search for evidence on clinical course and prognosis of nonspecific WMD i.e., those without specific clinical diagnoses. Articles were deemed relevant if they provided primary data on current or former worker cases of WMD followed over time. WMD status had to be based on clinical evaluations. The 13 studies which met these criteria were evaluated using clinical epidemiological criteria for validity of prognostic studies. None of the studies was sufficiently strong across the criteria to provide more than weaker evidence on prognosis. Prognostic factors with promise include duration of symptoms and workplace demands. In order to improve the evidence on prognosis of WMD, we recommend closer attention to the following: clear operational definition of cases; documentation of prognostic factors including duration of symptoms and severity at baseline; incorporation of multiple follow-up assessments; inclusion of a range of outcomes; and analysis using stratified or multivariate methods.