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PubMedDate not supplied

Intravenous regional anesthesia for closed treatment of fractures and dislocations of the upper extremities.

Intravenous regional anesthesia for the treatment of fractures and dislocations of the upper extremity is a very effective, consistent and safe form of analgesia which requires low doses of lidocaine and can be performed in an emergency room using a regular blood pressure cuff. Dosage should be related to body weight and the blood pressure cuff should be maintained at higher than systolic pressure for a minimum of 15 minutes after the lidocaine is injected. Release of the tourniquet should be staged as described. Ninety-one per cent of 77 patients had excellent analgesia following the IVRA. Eight per cent had fair results, but this was still adequate to perform the reduction with only minimal but definite discomfort to the patient. Only one patient failed to respond to the IVRA technique. Other advantages such as muscle relaxation during the anesthetic and rapid full return of sensation after cuff release, permit ease of reducion and early anticipation of cast discomfort or pressure pain from sharp edges of plaster. Unpleasant long term side effects of axillary block anesthesia, such as persistent paresthesia have not been seen.

Adolescent↗
PubMed2006

Upper extremity kinematics during functional activities: three-dimensional studies in a normal pediatric population.

Children with brachial plexus birth palsy, burns, cerebral palsy, spinal cord injury and upper limb malformations may have diminished ability to perform activities of daily living (ADLs) due to limited upper extremity (UE) motion. Three-dimensional (3D) imaging techniques provide a way to document multi-planar functional limitations in the UE. These techniques have not been routinely used for this purpose primarily due to a lack of standardized protocols stemming from the complex nature of UE motion. Before 3D techniques can be routinely used for quantitative analysis and determination of functional limitations, standard activities and nomenclature for UE motion must be determined, and normal arm motion defined. This study establishes a normative pediatric database of 3D kinematic values during selected ADLs, enabling future comparisons with pathologic movements. Regardless of their underlying condition, children with limited UE function and ADL performance can be studied using this protocol and compared with this age-matched normal population.

Activities of Daily Living↗
PubMed2002

Predictors of neurologic recovery in acute central cervical cord injury with only upper extremity impairment.

STUDY DESIGN: A prospective study of 22 patients with the syndrome of acute central cervical spinal cord injury with motor and sensory impairment involving only upper extremities (ACCSCI-U) was done from admission to the 2-year follow-up. OBJECTIVES: To evaluate the course of neurologic function and to identify predictors of a good neurologic recovery in patients with ACCSCI-U. SUMMARY OF BACKGROUND DATA: Little is known regarding the time-course profile of neurologic and functional recovery and the prognostic factors for neurologic recovery in patients with ACCSCI-U. METHODS: Between 1997 and 1998, 22 new cases of ACCSCI-U were identified (15 men and 7 women) with a mean age of 45.9 years (range, 13-75 years). They were all treated nonsurgically. Neurologic impairment, as evaluated by the American Spinal Injury Association (ASIA) motor and sensory scores, was assessed on patient arrival at the emergency department and followed prospectively at intervals from admission to the 2-year follow-up. The magnetic resonance imaging (MRI) studies were performed acutely (1 hours to 2 days after injury), subacutely (3-21 days after injury), and chronically (3-9 months after injury). Logistic regression analysis was used to identify the variables that were associated with neurologic improvement. RESULTS: No patient sustained cervical fractures. The mean sagittal diameter of the cervical spinal canals (14.8 mm) was smaller than that of normal subjects in Japan. Of these 22 patients, seven (32%) had radiologic evidence of developmental cervical canal stenosis and two (9%) had evidence of ossification of posterior longitudinal ligament. Thirteen (59%) had cervical spondylosis: of these, four (31%) had cervical stenosis. Nonsurgical treatment resulted in nearly full neurologic recovery within approximately 6 weeks after the injury. None of the patients went on to need surgery. Their average ASIA score of motor, light touch sensation, and pin sensation was increased from 82.2, 104.5, and 104.3 at admission to 99.3, 111.2, and 111.0, respectively, at 2 years after injury. Logistic regression analysis revealed that the best predictor associated with a better neurologic recovery of motor, light touch sensation, and pin sensation was the absence of MRI findings of abnormal signal intensity in the spinal cord, with an odds ratio of 64 (P < 0.006), 13 (P < 0.04),and 15 (P < 0.03), respectively. The results also revealed that percent deficit improvement became significant at 1 week after injury to predict neurologic recovery at 2-year follow-up points. CONCLUSIONS: In patients with ACCSCI-U, a favorable neurologic prognosis can be predicted following nonsurgical treatment. Most recovery occurred by 6 weeks, and patients with severe initial neurologic damage and old age had poorer recovery. Touch and pin sensation recovered at the same rate, whereas motor recovered more quickly. The absence of abnormal MRI signal intensity in the spinal cord and a good early neurologic improvement were the significant predictors of long-term improvement in neurologic function.

Acute Disease↗
PubMed2007

Use of Integra in a paediatric upper extremity degloving injury.

Dermal substitutes such as Integra have been used in surgery since 1981. This product was developed to cover large skin burns but it may have a role in reconstructive upper limb surgery. In upper extremity avulsion, the choice of skin cover depends on many variables. Dermal substitute is an alternative when split-thickness skin grafting is appropriate. We present a case of severe upper limb avulsion, or 'degloving', in a child of 9 years old which was treated successfully with Integra. Integra is particulary useful in growing children to cover large skin losses.

Accidents, Traffic↗
PubMed1999

The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects.

Stable wound coverage after extensive soft-tissue loss of the upper extremity remains a difficult problem in the management of large defects of the upper limb. To prevent further tissue loss owing to infection or inadequate cover when important structures such as vessels, tendons, nerves, joints, and bones are exposed, various free flaps have been introduced into the therapeutic armamentarium of acute plastic surgical management options. Emergency or delayed early reconstruction has been proposed to prevent chronic infection and further tissue loss. We report a series of 12 emergency and delayed early reconstructions of the forearm, wrist, carpus, metacarpus, and hand using the free rectus abdominis muscle flap with split-skin coverage, demonstrating the versatility of this flap within this special context. Emergency free rectus muscle flap transfer is safe, technically easy, and expandable.

Abdomen↗
PubMed2004

Use-dependent cortical plasticity in thalidomide-induced upper extremity dysplasia: evidence from somaesthesia and neuroimaging.

In this study cerebral reorganization was investigated in thalidomide-damaged subjects who use their feet to compensate for their malformed upper extremities. Tactile localization across toes was combined with fMRI to study use-dependent plasticity of the human somatosensory cortex. The manner of compensatory foot use was assessed by a questionnaire. In the behavioural experiment toes were stimulated with above threshold monofilaments and subjects had to report which toe was stimulated. When feet were employed for all everyday actions subjects made significantly fewer errors in the localization task. In subjects who use their feet only for specific actions such as grasping objects there were as many localization errors as in the control group of thalidomide-affected subjects with normal extremities. However, the patterns of mislocalizations were different with less errors occurring for the toe of the dominant foot involved in these actions. Functional MRI showed stronger haemodynamic responses to electrical stimulation of the toes in subjects using their feet for everyday actions as compared to controls. Our data show that long-term use of the feet for fine sensorimotor skills leads to better performance in tactile localization and changes in cerebral SI representation supporting the notion of use-dependent plasticity in the somatosensory cortex.

Activities of Daily Living↗
PubMed2005

Measuring levels of upper-extremity disability in employed adults using the DASH Questionnaire.

PURPOSE: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a standardized outcome measure that captures upper-extremity disability from the perspective of the patient and is used to study clinical outcomes in musculoskeletal disorders. To constitute a frame of reference for clinical values it is important for clinicians to be able to compare clinical DASH scores with those of nonclinical populations. We collected DASH data from a working population in Germany that was outside clinical considerations and used the data to identify disability levels among identified subgroups as a basis for future clinical comparisons. METHODS: We evaluated the DASH data using a convenience sample of 716 employed adults. Separate analyses were performed for each of the DASH scores, which were grouped according to age, gender, and type of vocational activity. RESULTS: The rank analysis of variance showed that statistically significant differences were found in Germany, differentiating between gender, age, and self-estimated vocational groups. Tests for interaction analyses of variance showed that increased disability was expressed as significantly higher mean DASH scores among older workers, female workers, and manual workers. CONCLUSIONS: This study provides comparative data for our clinical population and allows insight into current disability levels in a nonclinical population.

Adolescent↗
PubMed1979

[Disorders of the arterial blood supply in the upper extremities].

Arteriopathies of the upper half of the body may lead to considerable functional disturbances of the arm and severe deficits on the part of the central nervous system. Due to good comparison they scarcely cause or do not cause any complaints in a no unconsiderable part. The clinical material consisting of 4,162 patients from five annual courses had in 9.2% occlusion and stenoses localized in the supraaortic and brachial region. The in most cases systemic angiopathy here explains the frequently combined appearance with arterial processes in the pelvic and the leg region. According to the height of the occlusion we clinically differ types of carotis, shoulder girdle, upper arm and peripheral-acral obliteration, which in each case show differences concerning frequency, age of manifestation, etiology, distribution of sex and clinical degree of severity. The angiological basic diagnostics is based on the inspection, palpation of the arteries, auscultation of the vessels, bilateral measuring of the blood pressure after Riva-Rocci and functional examinations, such as fist closure test and Allen test, as well as clinical proofs or exclusions of neurovascular syndromes of the shoulder girdle. The special apparative angiological methods comprise the oscillo-, rheo- and vein occlusion plethysmography, the Doppler ultrasound technique, estimations of the ophthalmic pressure, isotopic methods and angiographic exploration. --The individual angiological examination methods are of different importance according to the height localisation of the angioorganopathy. --The incomplete syndrome of the aortic arch is taken into consideration. In short the author adopts a definite attitude to the demands of therapy.

Adult↗
PubMed2004

Cervical epidural anesthesia for combined neck and upper extremity procedure: a pilot study.

In a prospective pilot study, we evaluated the possibility of performing a total parathyroidectomy with parathyroid gland implantation into the forearm (a combined neck and upper extremity procedure) under cervical epidural anesthesia (CEA) at C6-7 level using ropivacaine. The indication for CEA was the patient's choice or a previous procedure on the neck with unilateral vocal cord paralysis. Anesthesia was induced by 10 mL of 0.75% ropivacaine plus 10 mug of sufentanil in 2 mL. Block onset time, success rate, analgesia, sensory block extent, changes in respiratory and hemodynamic variables, complications, and length of hospital stay were assessed. All 15 procedures were successfully performed under CEA. Sensory block was registered in the range C2-T10, with a lower median of T3. The upper margin of sensory block was C2 in all patients. Of the respiratory variables, the only significant decrease was observed in forced vital capacity; none of the patients developed clinically significant respiratory insufficiency. We conclude that combined procedures involving the neck and upper limbs can be performed using CEA with ropivacaine. CEA allows verbal communication with patients and early detection of vocal cord paralysis.

Aged↗
PubMed1998

Vascularized bone grafts to the upper extremities.

From 1979 to 1995 in our clinic, vascularized bone grafting was performed in 29 patients with large bone defects, established nonunion, congenital pseudoarthrosis, or avascular necrosis in the upper extremity. Four patients had traumatic bone defects, six had posttraumatic nonunions, two had congenital pseudoarthroses, five had amputations, nine had defects following tumor resection, and three had other lesions. Reconstructed sites were the humerus in 7 patients, the radius in 12, the ulna in 2, both radius and ulna in 1, and the metacarpal and phalangeal bones in 7. Donor bones were fibula in 19 cases, radius in 6, scapula in 2, and medial condyle of the femur in 2. Postoperative circulatory disturbances and venous thrombosis resulted in revision surgery in two patients. Thrombectomy and reanastomosis to other veins were performed, and these flaps took successfully. No patients required additional bone grafts. The mean period required to obtain radiographic bone union was 4 months (fibula, 4.5 months; scapula, 3.5 months; radius, 2.6 months; medial condyle of the femur, 4 months). Vascularized fibula graft is indicated in patients with large bone defects in the humerus, radius, and/or ulna. The scapula is easy to transfer to the proximal humerus on its pedicle. This donor is indicated in young women because operative scars can be hidden. The radius is usually harvested with skin, and its use is indicated in patients with bone loss in the hand including thumb amputations. Thin corticoperiosteal graft from the femur is indicated in patients with established nonunion of the humerus and radius without significant bony defects.

Adolescent↗
PubMed2006

Can quality of movement be measured? Rasch analysis and inter-rater reliability of the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES).

OBJECTIVE: Clinical scales evaluating arm function after stroke are weak at detecting quality of movement. Therefore a new scale, the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES), was developed, comprising 22 items pertaining to arm and hand performance. The scale was investigated for validity and unidimensionality using the Rasch measurement model, and for inter-rater reliability. SETTING: Twelve hospitals and rehabilitation centres in Belgium, Germany and Switzerland. PATIENTS: There were 396 patients (average age 63.38+/-12.89 years) in the Rasch study and 56 patients (average age 65.68+/-12.75 years) in the reliability study. MAIN MEASURES: The scale was examined on its fit to the Rasch model, thereby evaluating the scale's unidimensionality and validity. Differential item functioning was performed to test the stability of item hierarchy on several variables. Inter-rater reliability was examined with kappa values, weighted percentage agreement and intraclass correlation coefficients (ICC). RESULTS: Based on Rasch analysis, five items were removed. The MESUPES was divided in two tests: the MESUPES-arm test (8 items) and MESUPES-hand test (9 items). Both scales fitted the Rasch model. All items were stable among the subgroups of the sample. ICCs were 0.95 (95% confidence interval (CI) 0.91 -0.97) and 0.97 (95% CI 0.95-0.98) for the total score on arm and hand test respectively. The scale was also reliable at item level (weighted kappa 0.62 -0.79, weighted percentage agreement 85.71 -98.21). CONCLUSION: The MESUPES-arm and MESUPES-hand meet the statistical properties of reliability, validity and unidimensionality. Both tests provide a useful clinical and research tool to qualitatively evaluate arm and hand function during recovery after stroke.

Aged↗
PubMed1987

[Unexplained pain conditions of the upper extremity].

Diagnosis can be very difficult in the case of painful conditions of the upper extremity, since this is a region where the site of the changes and pathologic conditions precipitating or causing the pain is not always identical with the area where the pain is felt. This is particularly so in the case of pain resulting from vascular disease and irritation of peripheral nerves and in the thoracic outlet and inlet syndrome. Recent observations and studies suggest that this is extremely important for the etiology and pathogenesis of epicondylar periostitis and tendovaginitis, carpal tunnel syndrome, and some trophic conditions affecting the hand. Stenosis of the subclavian vein can be responsible for post-traumatic and postoperative edema of the hand and for similar changes whose "cause is unclear", and also for certain difficulties with wound healing. Preliminary experience suggests that Sudeck's dystrophy may be the most severe form of the thoracic outlet and inlet syndrome. Accordingly, transaxillary decompression of the neurovascular cord with upper thoracic sympathectomy can be recommended as a last resort for refractory Sudeck's dystrophy. The problem of epicondylitis of the lateral humerus is discussed in some detail, as is the pathogenesis of pain resulting from neuroma.

Arm↗
PubMed2006

Direct contrast-enhanced 3D MR venography evaluation of upper extremity deep venous system.

PURPOSE: To investigate the diagnostic value of direct contrast-enhanced three dimensional magnetic resonance (3D MR) venography in mapping the deep venous system of the upper extremities and to plan potential interventional procedures. MATERIALS AND METHODS: Nineteen cases with the diagnoses of end-stage renal disease with multiple hemodialysis catheter access were examined. Direct contrast-enhanced 3D MR venograms were obtained with 1.5 Tesla device with 3D-FSPGR pulse sequence and using body coil following the manual injection of gadolinium solution prepared by diluting 20 ml of contrast substance in 200 ml saline with a proportion of 1:10 through intravenous access opened symmetrically in antecubital fossa. In the workstation, evaluation was performed on three-dimensional images, two-dimensional multiplanar reformats and maximum-intensity projection method obtained from the source images. Intravenous DSA was performed on all the patients, and two radiologists evaluated MR venograms and conventional angiograms independently from each other. Results of MR venography and conventional angiography were then compared. RESULTS: In all cases, the MR venograms obtained were capable of supporting the diagnoses. Venous pathologies were found in 16 cases. In three cases central veins were evaluated to be patent. Results of MR venography and conventional angiography were consistent with each other (100% sensitivity and 100% specificity). CONCLUSION: Direct contrast-enhanced 3D MR venography is a well-tolerated sensitive technique in explaining the cause of the malfunctioning arterio-venous fistulas and in pre-surgical planning before placing new catheters or creating fistulas. It is possible to obtain high-quality images with this technique as an alternative to invasive angiography.

Adult↗
PubMedDate not supplied

Vascular problems of the upper extremity: a primer for the orthopaedic surgeon.

A focused history and thorough physical examination, combined with a working knowledge of the normal vascular anatomy, can help identify most vascular abnormalities of the upper extremity. Technologic improvements now allow accurate diagnosis by noninvasive methods. Most abnormalities can be categorized into one of five major diagnostic groups: traumatic, compressive, occlusive, tumoral (malformation), and vasospastic. Behavioral modifications and pharmacologic agents may improve symptoms. Appropriately selected surgical candidates often experience pain relief and functional improvement.

Arm↗
PubMedDate not supplied

How salient is the silent period? The role of the silent period in the prognosis of upper extremity motor recovery after severe stroke.

Transcranial magnetic stimulation (TMS) has been successful in the prediction of motor recovery in acute stroke patients with initially severe paresis or paralysis of the upper extremity. Motor evoked potentials (MEP) appear to have a high specificity but a rather low sensitivity with regard to motor recovery. The silent period (SP) has been proposed as an additional factor to the MEP for predicting motor recovery that might optimize the sensitivity of TMS. The authors reviewed the literature and case series focusing on the additional value of the SP to the MEP for predicting poststroke hand motor recovery. Studies that have analyzed the SP for predicting poststroke motor recovery have rather inconsistent results and suffer from heterogeneity in technical methods, methodology, and patient characteristics. In most studies, prolonged SPs have been found immediately after stroke, whereas in the (sub)acute phase thereafter, different patterns of SP duration have been found. These differences are thought to be related to stroke localization, though contraction-induced reduction phenomena and recovery-related intracortical phenomena may also be responsible. Although the SP might be used to identify clinically silent or minor strokes, in acute stroke patients with initial severe paresis or paralysis, the SP seems to have no additional value to MEP for predicting poststroke motor recovery. Nevertheless, the SP (poststroke-reduced SPs and contraction-induced inhibitory phenomena) has been proposed as a prognostic factor for poststroke spasticity. This review emphasizes the significance of the SP in predicting poststroke motor recovery and spasticity. Although the relation among the SP, recovery-related intracortical phenomena, and spasticity remains unclear, a neurophysiologic model underlying the SP is discussed. However, more research is needed on the value of the SP for predicting poststroke spasticity.

Electric Stimulation↗
PubMed1977

Ischemia of the upper extremity due to noncardiac emboli.

Nine cases of microemboli of arterial origin to the upper extremity are reported. The source of emboli in five of these cases was in the subclavian artery compressed by osseous anomalies in the thoracic outlet. Three aneurysms, one in a subclavian vein graft and two traumatic false aneurysms in the hand, were also noted to be the sources of distal emboli. One unproved case of emboli from an atherosclerotic plaque of the subclavian artery is also reported. Chronicity of symptoms and delay in operation are often noted and lead to difficulties in surgical management. The compressing osseous structures causing the vascular lesion in the thoracic outlet syndrome must be resected, along with removal of the source of emboli. Cervicodorsal sympathectomy is often needed in cases of extensive thrombosis and/or long-standing ischemia. Embolectomy is usually a futile procedure when the main arterial trunk contains old, organized thrombus. Differential diagnostic problems between collagen vascular disease, vasculitis, vasospastic disease, and microembolic disease in cases of unilateral Raynaud's phenomenon are pointed out.

Adult↗