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The purpose of this paper was to provide parameters for the development of a musculoskeletal model of the upper extremity. Five upper extremity specimens were obtained from four fresh cadavers. Anthropometric measures were obtained for each cadaver. Segment inertial parameters were estimated for each specimen from anthropometric measures of the cadaver from which the specimen was obtained. The three-dimensional kinematics of the humerus, ulna, and radius in different movements of the glenohumeral, humeroulnar and ulnoradial joints were measured for each specimen using of the 3Space tracking system (Isotrack, Polhemus). The instantaneous rotation center of the glenohumeral joint and the instantaneous rotation axes of elbow flexion and forearm pronation were determined for each specimen from the kinematic data. The specimens were dissected and the muscle origins and insertions and bony structures needed in upper extremity modeling were digitized using the 3Space system. The shapes of muscle origins and insertions were estimated. Muscle length, volume and pennation angle were measured for the estimation of physiological cross-sectional areas of each muscle. The results, which are given for one specimen, showed that the rotation center of the glenohumeral joint was very close to the geometric center of the joint with a mean distance of 4 mm. The mean angle between the flexion-extension and pro-supination axes of the elbow joint was 94 degrees. The minimum distance between these two axes was about 4 mm.
INTRODUCTION: Steal syndrome is a potentially grave complication of upper extremity hemoaccess (HA) in patients with renal failure. To determine the incidence and risk factors for steal in these patients at the St. Boniface Hospital, Winnipeg, a tertiary care centre for vascular surgery and dialysis, we reviewed data from patients requiring hemodialysis between September 1986 and July 2000. PATIENTS AND METHODS: We excluded all venous catheter and lower extremity procedures. There remained 325 upper extremity procedures in 217 patients. Data were collected from the patients' charts or by interview. First by univariate analysis and then by multivariate analysis for independent risk factors, we studied the effect on the development of steal of age, sex, race diabetes mellitus, hypertension, coronary artery disease or cerebrovascular disease, smoking, proximal procedures based on the brachial artery, distal procedures based on the radial artery, the use of prosthetic graft material and the creation of autologous fistulas. RESULTS: The incidence of steal was 6.2%. The significant independent risk factors were diabetes mellitus (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.39-18.08, p = 0.01) and Aboriginal race (OR 3.59, 95% CI 1.07-12.04, p = 0.04). An increasing risk for each year of advancing age at the time of procedure was suggested but was not significant (OR 1.04, 95% CI 1.00-1.09 p = 0.07). CONCLUSIONS: Patients who are diabetic or Aboriginal are at increased risk for steal with upper extremity HA procedures. This knowledge can guide discussion of dialysis options and informed consent. If upper extremity HA procedures are undertaken in patients at risk, they should be closely monitored and early intervention applied if necessary.
There is little information available of the costs of upper extremity cumulative trauma disorders. Cost data were collected from computerized records of the Liberty Mutual Insurance Company for upper extremity cumulative trauma disorder workers' compensation claims (N = 6,067) and for all claims (N = 731,087) initiated from 45 states during 1989. The data were not analyzed until July 1992, allowing more accurate "closing cost" data to be used in the analysis. Upper extremity cumulative trauma disorder cases represented 0.83% of all claims and 1.64% of all claims costs. The mean cost per case for upper extremity cumulative trauma disorders was $8070; median cost per case was $824. Medical costs represented 32.9% of the total costs; indemnity costs were 65.1%. The total compensable cost for upper extremity cumulative trauma disorders in the United States was estimated to be $563 million.
Current experience in the management of upper-extremity arterial injury in a Level I trauma center between 1992 and 1994 is reported. Arterial trauma was seen in 21 of 643 (3.3%) patients admitted with upper-extremity injury. The mechanism of injury was penetrating in 15 of 21 and blunt in 6 cases. Patient characteristics were: 18 of 21 male, mean age 28, left upper extremity 12 of 21, and 4 patients in shock. Preoperative angiography was performed in 12 of 21 cases (5 of 6 blunt and 7 of 15 penetrating). Involved arteries included: brachial (10), axillary (5), radial (3), and subclavian (3). Associated injuries were common: nerve (9), bone (7), and vein (5). Twenty patients were explored; 18 of 20 underwent arterial repair (16 graft, 2 primary repair), and two proximal arteries were ligated. One intimal flap in the subclavian artery was observed, with a good result. Nerves were repaired in four cases, all with transection, and in four cases there was neurologic deficit without focal transection and no repair was performed. One patient died before his nerve injury could be repaired. Most venous injuries (four of five) were ligated, and three patients with blunt arterial injury underwent forearm fasciotomy. Immediate limb salvage was 100 per cent; there was one in-hospital mortality (4.7%) from exsanguination, and there was one persistent clinically significant late motor nerve deficit. Mean follow-up was 94 days (range, 0-305 days). Upper-extremity arterial injury often can be managed without angiography, particularly in cases of penetrating trauma. Good results can be anticipated with prompt arterial and nerve repair combined with selective use of venous reconstruction and fasciotomy.
Surveys from 40 upper extremity amputees were analyzed to examine factors related to successful use of an upper extremity prosthesis. Factors which were associated with successful rehabilitation were fewer than two complicating factors, completion of high school education, employment at both the time of amputation and review, rapid return to work, acceptance of the amputation by the time of this review, and perception that the prosthesis was expensive. Factors which appeared unrelated to prosthetic success were age, loss of dominant hand, loss of elbow, marital status, use of rehabilitation services, use of a temporary prosthesis, and whether training in prosthetic use was provided. Many of these factors concurred with earlier studies. Previously unreported factors that may be of importance to the long-term success of upper limb amputees are the number of complicating factors and perceptions about the monetary value of the prosthesis.
Upper extremity venous thrombosis is a clinical entity with numerous etiologic factors. Only 2% of all cases of deep venous thrombosis involve the upper extremity, and the incidence of pulmonary embolism related to thrombosis in this location is approximately 12%. Primary or "effort" thrombosis of the upper limb is related to the inherent anatomical structure of the thoracic outlet and axillary region. Secondary thrombosis may have such diverse origins as trauma, infection, congestive heart failure, central venous catheters, neoplasms, septic phlebitis, intravenous drug use, and hypercoagulable states. Patients present with peripheral edema and prominent superficial veins, and neurologic symptoms (pain and paresthesias) are usually present as well. Clinical diagnosis is confirmed by venography or sonography. Treatment regimens include conservative measures, thrombolysis with fibrinolytic agents, and surgical correction of indicated thoracic outlet and axillary structures. We present an unusual case in which upper extremity venous thrombosis in a young healthy female athlete was associated with the presence of cervical ribs. The patient was successfully treated with focal thrombolysis and surgical resection of her ipsilateral cervical rib.
BACKGROUND/OBJECTIVE: Reliable assessment of upper extremity anaerobic power in persons with cervical spinal cord injury (SCI) may indicate the ability to successfully and safely perform many daily activities. PURPOSE: To examine test-retest reliability of upper extremity Wingate anaerobic testing (WAnT) in persons with motor/sensory complete tetraplegia. METHODS: Forty-five persons with cervical-level SCI (15 individuals each at C5, C6, and C7 levels of injury) performed 2-arm WAnT bouts, with 2 to 4 days between bouts. Subjects performed the WAnT seated in their wheelchairs using a tabletop-mounted Monarch 834E ergometer. Resistance loads were applied relative to injury level, with 1%, 2%, and 3% of body mass applied to subjects with C5, C6, and C7 level injuries, respectively. All subjects were directed to crank the ergometer at maximal velocity for a 30-second period. Values of peak power (Ppeak) and mean power (Pmean) were determined using an SMI OptoSensor 2000 system. Ppeak and Pmean were compared between trials and between groups using 2-way analyses of variance for repeated measures. Coefficients of determination (r2) were calculated between trials. RESULTS: There were no significant differences in Ppeak or Pmean detected between the 2 trials of WAnT in the C5, C6, or C7 groups. Regression analyses revealed statistically significant associations between bouts for Pmean and Ppeak in each of the 3 groups (P < 0.05). CONCLUSIONS: Upper extremity WAnT is reliable for upper extremity anaerobic power assessment in persons with cervical SCI at or below the C5 level.
OBJECTIVE: This study tried to isolate critical biomechanical factors in fall arrests using the upper extremity during simulated forward falls. This study also attempted to find the differences in those factors between young and old age groups. BACKGROUND: The role of the upper extremity is not well defined despite its primary usage as a local shock absorber during fall impact. DESIGN: Comparative study in which two age groups underwent motion analysis.Methods. Ten healthy older males (mean age, 66.4 years) and 10 young males (mean age, 24.1 years) volunteered to perform self-initiated and cable-released falls at selected falling distances, while the joint motion and impact forces at the hand were recorded. RESULTS: Significant age differences were demonstrated in joint kinematics and impact force parameters at close distances. Excessive reflexive responses of the upper extremity in cable-released falls for the older adults resulted in 10-15 times higher peak impact forces and 2-3 times shorter body braking time than in self-initiated falls. CONCLUSIONS: Pre-impact activities of the upper extremity predispose the post-impact response during fall arrests. Suppressing excessive pre-impact reflexive activation of the arms could efficiently decrease the risk of fall-related injuries, which calls for securing sufficient arm movement time. Any fall prevention strategy that can increase arm movement time would be effective against injuries of the upper extremity during falling in the older adults. RELEVANCE: The findings will help to understand underlying mechanisms of fall arrest using the upper extremity for prevention of fall-related fractures.
OBJECTIVE: An apparatus and procedure are described to determine position specific normalization coefficients for surface EMG of upper extremity musculature. STUDY DESIGN: Thirty-nine subjects were tested three times. Repeatability of EMG measurements across test sessions was determined by computing intraclass correlation coefficients. Two-way analysis of variance was used to test upper extremity position dependent differences in EMG measurements. BACKGROUND: EMG measurements are susceptible to error from skin movement and muscle length changes, both of which may occur when upper extremity positions vary. Normalization of the EMG signal without consideration for such positional influences may lead to erroneous conclusions regarding muscle activation during functional tasks. METHOD: An apparatus was designed that allowed subjects to perform three repetitions of maximum elbow flexion, forearm pronation, wrist extension, and wrist flexion with the forearm in neutral and pronated positions. Surface EMG was sampled from eight muscles. Mean EMG on maximum voluntary contraction was computed, and resting EMG was subtracted to obtain EMG normalization coefficients. RESULTS: Upper extremity position affected the EMG normalization coefficient for biceps brachii, which was lower in the pronated position, and extensor carpi radialis, which was higher in the pronated position (P<0.00625). CONCLUSIONS: The apparatus accommodates various combined positions of the elbow, forearm and wrist. The normalization procedure is efficient for testing subjects who are being observed during functional tasks. Only two muscles were affected by upper extremity position, but group trends were not always consistent with individual behavior. This method would ensure the use of appropriate EMG normalization coefficients regardless of individual variation. RELEVANCE: This method is effective for normalizing EMG signals using task specific upper extremity positions. It may be used to test isometric exertions of distal upper extremity musculature for clinical and research purposes.
The management of upper-extremity burn contractures is a major challenge for plastic surgeons. After approval by the Food and Drug Administration, artificial skin (Integra) has been available in Taiwan since 1997. From January of 1997 to July of 1999, the authors applied artificial skin to 13 severely burned patients for the reconstruction of their upper extremities, resulting in an increased range of motion in the upper-extremity joints and improved skin quality. An additional benefit was the rapid reepithelialization of the donor sites. There were no complications of infection throughout the therapeutic course, and the overall results were satisfactory. During the 2-year study, scar condition was monitored between 8 and 24 months, and a good appearance and pliable skin were obtained according to the Vancouver Scar Scale. According to this evaluation of Oriental skin turgor, normal pigmentation was restored about 6 months after the resurfacing procedure. For patients with severe burns in whom there is insufficient available skin for a full-thickness skin graft or another appropriate flap for scar revision, Integra is an alternative. The two major concerns in dealing with artificial skin are (1) a 10- to 14-day waiting period for maturation of the neo-dermis, necessitating a two-stage operation, and (2) prevention of infection with antibiotics and meticulous wound care.
OBJECTIVE: To study the incidence and prevalence of neck and upper extremity musculoskeletal complaints in Dutch general practice. METHODS: Data were obtained from the second Dutch national survey of general practice. In all, 195 general practitioners (GPs) from 104 practices across the Netherlands recorded all contacts with patients during 12 consecutive months. Incidence densities and consultation rates were calculated. RESULTS: The total number of contacts during the registration period of one year was 1 524 470. The most commonly reported complaint was neck symptoms (incidence 23.1 per 1000 person-years), followed by shoulder symptoms (incidence 19.0 per 1000 person-years). Sixty six GP consultations per 1000 person-years were attributable to a new complaint or new episode of complaint of the neck or upper extremity (incidence density). In all, the GPs were consulted 147 times per 1000 registered persons for complaints of the neck or upper extremity. For most complaints the incidence densities and consultation rates were higher for women than for men. CONCLUSIONS: Neck and upper extremity symptoms are common in Dutch general practice. The GP is consulted approximately seven times each week for a complaint relating to the neck or upper extremity; of these, three are new complaints or new episodes. Attention should be paid to training GPs to deal with neck and upper limb complaints, and to research on the prognosis and treatment of these common complaints in primary care.
PURPOSE: Injury patterns of occupants in motor vehicle crashes are changing, with upper extremity injury becoming more common in patients treated at trauma centres. Although not life threatening, upper extremity injuries may result in long-term disability, including chronic deformity, neurovascular compromise and degenerative arthritis. The purpose of this study was to compare upper extremity injury in drivers and passengers using the Crash Injury Research Engineering Network (CIREN) database. METHODS: CIREN data were used to compare upper extremity skeletal injury patterns and sources for drivers and passengers in frontal and side impacts. Occupant variables (age, gender, co-morbidity, avoidance maneuvers and restraint use) and crash variables (direction of impact, delta V and vehicle crush) were considered in the analysis. RESULTS: Only 24.8% of all occupants in the CIREN database had upper extremity injuries. One-half of upper extremity injuries to drivers were forearm fractures compared to one-third for passengers. Occupants in side impacts were more likely (OR=5.05) to have clavicle fractures, even while controlling for driver versus passenger status and safety belt use. Air bags were more likely to be a source of forearm fracture (OR=2.31) when controlling for driver versus passenger status, direction of force, sex and age compared to other sources. Only 10% of driver fractures with air bag deployment in frontal impacts were associated with air bag fling. CONCLUSIONS: This study found that drivers and passengers have different upper extremity injury patterns but the direction of impact also plays an important role.
UNLABELLED: Upper-extremity pain is a common and debilitating problem for patients with breast cancer. Although there is considerable literature describing symptoms, little is available on the specific disorders responsible for pain and debility in these patients. Cervical radiculopathy, brachial plexopathy, neuropathy, rotator cuff tendonitis, adhesive capsulitis, epicondylitis, postmastectomy syndrome, swelling, and bone metastases are among the common disorders responsible for upper-extremity pain in breast cancer patients. OVERALL ARTICLE OBJECTIVE: To discuss common upper-extremity pain disorders in patients with breast cancer.
All skiers with upper extremity injuries seen at the Henry Ford Hospital between 1983 and 1986 were evaluated in terms of age, sex, skill of the skier, type of snow conditions, pole type, grip type, direction of fall, and mechanism of injury. Our primary objective was to evaluate whether the type of pole used had an effect on the injury rate. We found that the strap handled pole without any platform had the lowest injury rate. The saber type pole handle had the highest injury rate. Other observations showed ulnar collateral ligament injury of the thumb to be the most common upper extremity injury to skiers. A proportionally high number of skiers with upper extremity injuries were advanced skiers.