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PubMed2006

Osteoid osteoma of the upper extremity. A diagnostic challenge.

Osteoid osteomas are benign tumors that may commonly mimic other entities in the upper extremity. The purpose of this study is to describe the clinical and imaging features of osteoid osteomas involving the upper extremity, highlight the difficulties in the diagnosis in the various areas and propose a diagnostic workup. Fourty-eight patients with histologically confirmed osteoid osteoma of the upper extremity treated at the authors' department from 1985 to 2000 were retrospectively reviewed. Data pertinent on the patients' history, lesion location, clinical and imaging characteristics as well as any unique features of individual patients were collected. There were 29 males and 19 females with a mean age of 28 years (range 20-42). The average duration of symptoms before definite diagnosis was 18 months (range 2-62). Pain was the presenting symptom in 46 of 48 patients, whereas swelling was the main complaint in 2 of the patients. Mean pre-operative visual analogue pain scale (VAS), was 8.8 ranging from 5.1 to 9.3. Eight lesions were located in the humerus, 4 in the ulna and 7 in the radius. In the carpal bones, 4 were located in the scaphoid, 4 in the capitate and 5 in the hamate. Seven lesions were located at the metacarpals and 9 lesions at the phalanges (5 proximal, no middle and 4 distal phalangeal lesions). Radiographs alone were sufficient to establish the diagnosis of osteoid osteoma in 32 cases. Bone scans identified a "hot spot" in 16 patients without previous radiographic evidence of a lesion and furthermore, computed tomography was performed in 32 patients to assist in the intraosseous localization of the lesion, and in the pre-operative planning. All patients underwent operative excision of the lesion and the diagnosis was confirmed by histology. Mean follow-up was 28 months (range 25-42). Fourty-three patients had an uneventful recovery. Mean post-operative VAS value was 1.8 ranging from 0 to 3. Osteoid osteoma of the upper extremity often mimics other etiologies and the complex anatomy of the upper extremity, as well as the tendency of patients to relate their symptoms to trauma are factors that easily lead to misdiagnosis or delay in the diagnosis. A high index of suspicion is essential and the diagnosis is based on an accurate clinical assessment and careful selection of imaging studies.

Adult↗
PubMed1989

Diagnostic imaging of upper extremity trauma.

The radiologic evaluation of upper extremity trauma relies primarily on standard as well as optional radiographic projections. Certain injuries are more fully evaluated with fluoroscopy, arthrography, ultrasound, computed tomography, or magnetic resonance imaging. The imaging approach to upper extremity trauma is presented, with emphasis on subtle or commonly overlooked lesions. The indications for evaluation by fluoroscopy, arthrography, and advanced imaging modalities are discussed.

Arm Injuries↗
PubMed2006

Compression neuropathies of the upper extremity.

Nerve compression syndromes of the upper extremity occur at predicable locations. The diagnosis of nerve compression or nerve entrapment is based on the neurologic and electrodiagnostic examinations. The anatomy, neurophysiology, and electrodiagnosis of nerve compression are discussed. Common and uncommon compression and entrapment syndromes of the upper extremity are described. Errors in diagnosis occur when the neurologic or electrodiagnostic examinations are incomplete or inaccurate.

Carpal Tunnel Syndrome↗
PubMed1997

Anatomy of upper extremity skin flaps.

The design of upper extremity skin flaps is determined by the anatomy and hemodynamics of each donor site. Skin flaps are best characterized by their blood supply into three types--the direct cutaneous, musculocutaneous, and septocutaneous. Because of the predominance of the septocutaneous vascular system in the upper extremity, the majority of useful flaps in that area are derived from this system. Knowledge of the regulatory factors of the cutaneous circulation is critical in understanding the hemodynamic changes associated with flap elevation if the flap is to be successful. By combining careful flap design based on a knowledge of vascular anatomy and the appropriate postoperative regimen, survival of flaps may be increased significantly.

Arm↗
PubMed1990

Vascular problems in the proximal upper extremity.

Vascular problems of the proximal upper extremity present with symptoms and signs of venous and arterial occlusion. They are rare, and sports medicine literature contains only case reports. Blunt trauma and activity requiring repetitive, overhead use of the arm are the usual mechanisms of injury. In athlete who perform repetitive upper-extremity activity, symptoms of easy fatigability of poorly localized pain and paresthesias should alert the treating physician to vascular occlusive disease. Published information suggests a good return-to-sport prognosis, but, because of the small number of cases, this information may be misleading.

Arm↗
PubMed2006

Application of combined botulinum toxin type A and modified constraint-induced movement therapy for an individual with chronic upper-extremity spasticity after stroke.

BACKGROUND AND PURPOSE: Constraint-induced movement therapy (CIMT) is a promising intervention for retraining upper-extremity function after a stroke. The purpose of this case report is to describe the use of a combination of botulinum toxin type A (BtxA) and a modified CIMT program for a patient with severe spasticity who was unable to use his right upper extremity. CASE DESCRIPTION: The 52-year-old patient, who had a stroke 4 years ago, did not meet the minimum motor criteria for CIMT benefit. After receiving BtxA injections targeting the elbow, wrist, and finger flexors, he completed a 4-week program of modified CIMT followed by a 5-month home exercise program. OUTCOMES: The patient exhibited improvement in muscle tone (the velocity-dependent resistance to stretch that muscle exhibits) and in scores on several upper-extremity function tests (Modified Ashworth Scale, Motor Activity Log, Wolf Motor Function Test, Action Research Arm Test, and Fugl-Meyer Assessment of Motor Recovery). He also reported making much progress in the functional use of the involved upper extremity. DISCUSSION: In a patient with severe flexor spasticity and nonuse of the dominant upper extremity after a stroke, a combined treatment of BtxA and modified CIMT may have resulted in improved upper-extremity use.

Botulinum Toxins, Type A↗
PubMed2003

Upper-extremity sarcomas in the United States: analysis of the surveillance, epidemiology, and end results database, 1973-1998.

PURPOSE: Upper-extremity soft-tissue sarcomas are a rare disease with unclear epidemiology and evolving treatment strategies. Our purpose is to evaluate the incidence of upper-extremity soft-tissue sarcomas and the use of adjuvant radiotherapy in this patient population. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, a national population-based database, we identified all cases of primary upper-extremity sarcoma reported to the 9 national SEER registries in the Untied States from 1973 to 1998. RESULTS: Of the 1,286 upper-extremity soft-tissue sarcomas the average incidence rate is 2.2 cases/million/y, which has not changed significantly from 1973 to 1998. Caucasians' average incidence rate is significantly higher than African Americans' (incidence rate ratio [IRR] = 1.3, p =.02); and men are at a significantly higher risk compared with women (IRR = 1.3, p <.01). The use of adjuvant radiotherapy has increased significantly from 17% in 1973 to 47% in 1998 (p <.01). African-Americans, compared with Caucasians, are significantly less likely to receive adjuvant radiotherapy (odds ratio [OR] =.5, p =.01). CONCLUSIONS: The incidence of upper-extremity sarcomas has not changed significantly over the past 3 decades; however, the disease differentially affects the population with higher rates in Caucasians and men. Based on the results of this study the use of adjuvant radiotherapy is increasing but African Americans are less likely than Caucasians to receive this treatment for upper-extremity sarcoma.

Black or African American↗
PubMed2002

A method for determination of upper extremity kinematics.

Kinematic analysis of the upper extremity has been conducted using a wide variety of techniques, philosophies, and analytic methods. We describe a simple, marker-based three-dimensional video analytic technique that borrows concepts from lower extremity kinematic analysis. A sequential rotation order about orthogonal axes is described, although alternate methods are examined as well. The method has been verified by application to a mechanical model. In certain positions, gimbal lock may occur, and a different sequence of rotational decomposition may be required. Agreement on standardization of technique would assist in the dissemination of upper extremity scientific data.

Algorithms↗
PubMedDate not supplied

Epidemiology of occupational disorders of the upper extremity.

The rise in reports of occupational disorders of the upper extremity has been meteoric. This chapter examines the frequency and prevalence of upper extremity disorders, reviews the active surveys of upper extremity disorders in selected occupations, examines current surveillance systems, and discusses the problem of effective case definition.

Arm↗
PubMed2003

Application of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia.

BACKGROUND AND PURPOSE: Constraint-induced movement therapy (CIMT) has been documented to improve motor function in the upper extremity of people with mild hemiparesis. The use of CIMT has not been documented for people with severe hemiparesis. This case report describes a CIMT program for an individual with severe upper-extremity deficits as a result of stroke. CASE DESCRIPTION: The client was a 53-year-old woman who had a stroke 15 years previously and had no isolated movement in her right upper extremity. METHODS: The client completed a 3-week CIMT program during which she restrained her left upper extremity and participated in intensive training of her right upper extremity. Task practice and shaping were the primary techniques used for training. OUTCOMES: Increased scores were noted from pretreatment to posttreatment on the Motor Activity Log, Graded Wolf Motor Function Test (GWMFT), and Fugl-Meyer Evaluation of Physical Performance. Further progress on the GWMFT was noted at the 6-month follow-up. Fugl-Meyer test scores remained higher than at pretreatment, but Motor Activity Log scores returned to near baseline by the 6-month follow-up. The speed of performance on the GWFMT did not change. Although some scores increased, the client reported and demonstrated no progress in functional use of the involved upper extremity at the end of the program. DISCUSSION: This case report describes the use of CIMT with an individual who had severe chronic motor deficits as a result of stroke. Further investigation of CIMT, as well as investigation of CIMT in combination with other motor recovery interventions, is warranted.

Activities of Daily Living↗
PubMed2006

Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To study upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using subjects with a spinal cord injury (SCI) and its relation with lesion characteristics, muscle strength and functional outcome. SETTING: Eight rehabilitation centers with an SCI unit in the Netherlands. METHODS: Using a questionnaire, number, frequency and seriousness of musculoskeletal pain complaints of the upper extremity were measured. A pain score for the wrist, elbow and shoulder joints was calculated by multiplying the seriousness by the frequency of pain complaints. An overall score was obtained by adding the scores of the three joints of both upper extremities. Muscle strength was determined by manual muscle testing. The motor score of the functional independence measure provided a functional outcome. All outcomes were obtained at four test occasions during and 1 year after rehabilitation. RESULTS: Upper extremity pain and shoulder pain decreased over time (30%) during the latter part of in-patient rehabilitation (P<0.001). Subjects with tetraplegia (TP) showed more musculoskeletal pain than subjects with paraplegia (PP) (P<0.001). Upper extremity pain and shoulder pain were significantly inversely related to functional outcome (P<0.001). Muscle strength was significantly inversely related to shoulder pain (P<0.001). Musculoskeletal pain at the beginning of rehabilitation and BMI were strong predictors for pain 1 year after in-patient rehabilitation (P<0.001). CONCLUSIONS: Subjects with TP are at a higher risk for upper extremity musculoskeletal pain and for shoulder pain than subjects with PP. Higher muscle strength and higher functional outcome are related to fewer upper extremity complaints.

Adolescent↗
PubMed1992

Noninvasive vascular studies: a comparison with arteriography and surgical findings in the upper extremity.

Noninvasive vascular studies of the upper extremity were compared with the accepted standards of arteriography and surgical exploration. Results of noninvasive vascular studies and 40 arteriograms in 37 patients revealed agreement in 95% of the cases. Further comparison between results of noninvasive studies and surgical findings in 17 patients revealed a correlation of 100%. Thus, findings from our noninvasive vascular studies agreed with arteriographic and surgical findings with respect to the type, location, and extent of disease in 97% of patients studied. We conclude that noninvasive studies of the upper extremity are accurate, safe, reproducible, inexpensive, and well tolerated by patients. Noninvasive vascular studies also provide information on vascular dynamics that is not available from routine arteriography.

Adolescent↗
PubMed1987

Evaluation of impairment of the upper extremity.

Evaluation of impairment of the upper extremity is the product of a team effort by the physician, occupational therapist, physical therapist, and rehabilitation counselor. A careful recording of the anatomic impairment should be made because this is critical in determining the subsequent functional activities of the extremity. The measurement criteria for clinical and functional evaluation includes condition assessment instruments. Some assess the neurovascular system, others assess movements including the monitoring of articular motion and musculotendinous function. Sensibility assessment instruments measure sympathetic response and detect single joint stimulus, discrimination, quantification, and recognition abilities. A detailed description of each assessment is recorded and physical capacity evaluation is only one component of the entire vocational evaluation. This evaluation answers questions regarding the injured worker's ability to return to his previous job. The work simulator is a useful instrument that allows rehabilitation and testing of the injured upper extremity. Job site evaluation includes assessment criteria for work performance, work behavior, and work environment.

Arm↗
PubMed1997

Prediction of recovery from upper extremity paralysis after stroke by measuring evoked potentials.

Paralysis of the upper extremity is a severe motor impairment that can occur after stroke. Prediction of recovery from paralysis is difficult and is primarily based on subjective clinical evaluation. However, the integrity of the sensorimotor system can be assessed objectively and quantitatively by measuring evoked potentials. In this retrospective exploratory study, we evaluated the predictive value of motor and somatosensory evoked potentials for recovery from paralysis of the upper extremity. Motor and somatosensory evoked potentials were recorded in 29 patients who had had their first-ever infarction in the territory of the middle cerebral artery and who exhibited paralysis of the upper extremity. At follow-up, seven patients showed motor recovery. The evoked potential data were dichotomized into present or absent and related to the occurrence of motor recovery. Analysis revealed a significant association between the presence of evoked potentials early after stroke and the observed occurrence of motor recovery. These results suggest strongly that evoked potentials predict the occurrence of motor recovery of upper extremity paralysis in patients suffering from first-ever infarction in the territory of the middle cerebral artery.

Adult↗
PubMedDate not supplied

Simultaneous bilateral upper extremity venous thrombosis in a factor V Leiden heterozygote: a case report and review.

Primary upper extremity deep venous thrombosis (DVT), or effort thrombosis, typically occurs in young, healthy individuals with a history of repetitive upper extremity movement while secondary upper extremity DVT is associated with a number of predisposing factors. The role of factors such as hypercoagulability in the development of effort thrombosis is less well described. This report describes a previously healthy 21-year-old man who presented with simultaneous bilateral upper extremity DVT after hours of pushing and lifting a heavy wheelbarrow. Treatment included thrombolytic therapy followed by delayed venolysis and vein patch angioplasty. Hypercoagulable screening revealed factor V Leiden heterozygous characteristics.

Adult↗
PubMed1979

Deep venous thrombosis of the upper extremity: a reappraisal.

Deep venous thrombosis (DVT) of the upper extremity is an unusual thrombotic event (1-2% of all DVT) which can be conveniently divided into two categories, traumatic (including "stress") and spontaneous. The spontaneous form is not reported as often in the literature, but occurs more commonly than the traumatic form. There is an increased left-sided predominance in spontaneous DVT compared with the traumatic form, where a right-sided predominance exists. Possible anatomical and physiological explanations are offered for the left-sided predominance in spontaneous DVT of the upper extremity. The thrombogenesis of DVT of the upper extremity is compared with DVT of the lower extremity. An analysis of responses to therapy and considerations for other therapeutic approaches are offered.

Adult↗
PubMedDate not supplied

Effects of central venous catheter placement on upper extremity duplex US findings.

PURPOSE: The upper extremity veins of 17 patients who underwent operative central venous catheter placement were studied prospectively with color duplex sonography to determine which duplex changes, if any, could be due to the presence of the catheter alone and to determine if these waveform changes could mimic the dampened waveform seen peripheral to central nonvisualized or nonocclusive thrombosis or proximal stenosis. PATIENTS AND METHODS: The subclavian, internal jugular, and brachiocephalic veins were examined with color duplex sonography immediately before and after catheter placement. Images obtained before and after catheterization were reviewed by two radiologists for (a) spectral broadening in both the vein of insertion and the brachiocephalic vein, (b) transmission of atrial pulsations, and (c) respiratory phasicity. RESULTS: In all cases, atrial pulsatility and respiratory phasicity were present before and after catheter placement. There was no statistically significant change in the amount of spectral broadening after catheter placement. A mild increase in the peak blood flow velocity of 7 cm/sec (P = .04) in the ipsilateral brachiocephalic vein was demonstrated; however, no significant increase in velocity could be shown in the vein of insertion. CONCLUSION: In this clinical setting, the hemodynamic changes within the vein from the catheter placement are minimal. Any damping of the venous waveform seen with sonography performed to rule out upper extremity deep venous thrombosis secondary to indwelling catheter--for example, loss of atrial pulsatility or respiratory phasicity--is presumably due to the presence of venous thrombosis or stenosis.

Adult↗