Management of distal biceps and triceps ruptures

The management of distal biceps and triceps ruptures is reviewed. Epidemiology, clinical presentation, evaluation, surgical management, nonoperative management, and rehabilitation rationale and techniques are presented. Although various surgical repair techniques are used, none has been shown to produce superior clinical outcomes. The literature is lacking information to provide evidence-based decisions regarding rehabilitation strategies. Prospective studies comparing types and timing of repairs and timing and techniques for a postoperative program are needed. As that information is not yet available, the rehabilitation plan outlined in this article is based on timetables for healing tissue, strength of repair, prevention of complications, consideration of patient's medical history and injury history, and review of the literature. Familiarity with the different treatment options assists the surgeon and therapist tailor a therapy program that is optimal for each individual patient.

Evaluation and Treatment of Medial Ulnar Collateral Ligament Injuries in the Throwing Athlete

Medial ulnar collateral ligament (UCL) injuries are common and are seen most frequently in baseball pitchers. Appropriate recognition, treatment, and rehabilitation are necessary to ensure the best chance for return to preinjury levels of participation. Participation in competitive sports may be disrupted for 6 months to 1 year when treated optimally. Abstinence from play may be prolonged when treatment is delayed or if conservative treatment fails; this delay carries significant consequences to the professional, collegiate, and high school athlete. The orthopedic literature is replete with recommendations for the care of these athletes. These recommendations are generally based on retrospective reviews. The purposes of this paper are 3-fold: to provide background knowledge on this injury, to synthesize the current knowledge on the diagnosis, treatment, and rehabilitation of athletes with medial UCL injuries, and lastly, to provide a treatment algorithm for athletes with UCL injuries.

Occupational and physical therapy for work-related upper extremity disorders: how we can influence outcomes

Upper extremity disorders in the workplace continue to be an economic strain on society. Physical and occupational therapy plays a crucial role in the management of the disorders. Medical providers should use therapists whose treatments demonstrate improvement in function and provide superior outcomes. Skilled therapy intervention requires that a therapist be able to identify and treat an injured worker in a holistic manner by looking at the whole individual, including issues that involve mechanical dysfunctions, psychosocial issues that include job satisfaction, and other age-related organic comorbidities. Therapists who work with injured employees must be highly skilled in identifying behavioral and organic disorders and must be confident in communicating these findings to various members of the health care team to help facilitate further medical testing.

Does functional capacity evaluation predict recovery in workers' compensation claimants with upper extremity disorders?

OBJECTIVES

Functional capacity evaluations (FCEs) are commonly used to determine return-to-work readiness and guide decision making following work related injury, yet little is known of their validity. The authors examined performance on the Isernhagen Work Systems' FCE as a predictor of timely and sustained recovery in workers' compensation claimants with upper extremity disorders. A secondary objective was to determine whether FCE is more predictive in claimants with specific injuries (that is, fracture) as compared to less specific, pain mediated disorders (that is, myofascial pain).

METHODS

The authors performed a longitudinal study of 336 claimants with upper extremity disorders undergoing FCE. FCE indicators were maximum performance during handgrip and lift testing, and the number of tasks where performance was rated below required job demands. Outcomes investigated were days receiving time-loss benefits (a surrogate of return to work or work readiness) in the year following FCE, days until claim closure, and future recurrence defined as whether benefits restarted, the claim reopened, or a new upper extremity claim was filed. Cox and logistic regression were used to determine the prognostic effect of FCE crudely and after controlling for potential confounders. Analysis was performed separately on claimants with specific and pain mediated disorders.

RESULTS

Most subjects (95%) experienced time-loss benefit suspension within one year following FCE. The one year recurrence rate was 39%. Higher lifting performance was associated with faster benefit suspension and claim closure, but explained little variation in these outcomes (r2 = 1.2-11%). No FCE indicators were associated with future recurrence after controlling for confounders. Results were similar between specific injury and less specific groups.

CONCLUSIONS

Better FCE performance was a weak predictor of faster benefit suspension, and was unrelated to sustained recovery. FCE was no more predictive in claimants with specific pathology and injury than in those with more ambiguous, pain mediated conditions.

The efficacy of ice massage in the treatment of exercise-induced muscle damage

The purpose of this investigation was to, firstly, examine the effects of repeated applications of ice massage on the indirect markers associated with muscle damage using a within-subjects cross-over design and secondly, to examine how ice massage affects muscle function in both static and dynamic contractions following unaccustomed eccentric exercise. Twelve males performed damaging exercise on two separate occasions. The protocol consisted of three sets of 10 maximal eccentric repetitions of the elbow flexors using isokinetic dynamometry. Subjects were randomly assigned to an ice massage group or placebo group and received treatments immediately post-exercise, 24 and 48 h post-exercise. Muscle function (maximal isometric, slow and fast isokinetic contractions), creatine kinase, myoglobin, muscle soreness, limb girth and range of motion were measured pre, immediately post, 24, 48, 72 and 96 h post-exercise. Significant time effects were observed for all dependent variables (P<0.05). There were no significant differences between treatments. Ice massage is ineffective in reducing the indirect markers associated with exercise-induced muscle damage and enhancing recovery of muscle function in male exercisers unaccustomed to eccentric biased exercise.

Prevention of delayed recovery and disability of work-related upper extremity disorders

There is always a psychological component to any illness or injury, and unless it is appropriately addressed, such factors can complicate or delay the recovery from a work-related illness or injury. When a worker experiences delayed recovery and unexpected disability, significant contributing psychosocial factors must be assessed for and managed appropriately. A maladaptive belief or understanding about the condition and disability by a patient presents an obstacle to successful treatment. Using cognitive behavioral therapy techniques may be an effective means of managing this challenge for the clinician.

Fitting a Bilateral Transhumeral Amputee With Utensil Prostheses and Their Functional Assessment 10 Years Later: A Case Report

Traumatic transhumeral amputations resulting from electric burn injury are uncommon and present a significant rehabilitation challenge. Compensating for loss of fine, coordinated function of the upper extremities with prostheses is difficult medically, technologically, psychologically, and socially. We followed up a patient with traumatic bilateral transhumeral amputation who was fitted with specially designed bilateral low-temperature utensil prostheses for 10 years. A bilateral utensil prosthesis consists of 2 thermoplastic sockets, an elastic harness, 2 utensil holders, and several different utensils. The characteristics of utensil prostheses are low cost, quick fabrication, and responsiveness to a patient's needs. Ten years after the patient's first prosthesis fitting, he still used these specially designed prostheses. By using these devices and his feet, the patient has regained independence in most activities of daily living and gained a new working skill.

[Rehabilitation patients after fractures of upper limb]

Rehabilitation after fractures of upper limb is very complicated and should be coordinated with orthopedic procedures. A choice of method and schema is depended on general health status of patient and used orthopedic treatment. This process should start immediately after surgeon's intervention. An aim of rehabilitation is improvement of range movement, straight of muscles and acceleration of callus formation. It is very important to restore proprioception in a region of trauma. An intensity and velocity of rehabilitation is the greatest after extra bone consolidation and the slowest after conservative tutor management.

The effectiveness of standard care, early intervention, and occupational management in Workers' Compensation claims: part 2

STUDY DESIGN

A prospective cohort.

OBJECTIVES

To compare the effectiveness of standard care, early intervention treatment, and occupational management in the management of Workers' Compensation injury claims.

SUMMARY OF BACKGROUND DATA

The current management of occupational back pain and work-related upper extremity disorders with either standard care or early intervention treatment appears to be ineffective.

METHODS

A prospective cohort looked at the effect of one company with access to standard care (primary care) changing to occupational management (worksite encouragement to resume activity and work as soon as safely possible) and then to early intervention treatment (offsite work hardening). This information was then compared with the control company with access to early intervention treatment, which later changed to a combined occupational management/early intervention treatment approach. Survival analysis was used to attempt to explain differences in time to injury claim closure.

RESULTS

Occupational management resulted in lower injury claim incidence, duration, and costs than early intervention treatment. Only the covariate of enhanced physical therapist (work hardening) involvement (2001 hazard rate ratio 17.41, 95% confidence interval 3.72-41.51 and 2002 hazard rate ratio 6.22, 95% confidence interval 2.51-15.40) was associated with delayed time to injury claim closure when the company had access to early intervention treatment. Only the covariate of serious injury was associated with delayed time to injury claim closure in the company when it had access to occupational management (hazard rate ratio 1.67, 95% confidence interval 1.05-27.20).

CONCLUSIONS

It is recommended that an occupational management approach, in comparison to early intervention treatment and standard care, be considered for management of occupational injuries.

Custom skiing and trekking adaptations for a trans-tibial and trans-radial quadrilateral amputee

A keen skier who is a trans-tibial and trans-radial quadrilateral amputee sought an improved adaptation for skiing from the Rehabilitation Engineering Service in Edinburgh. The unpredictable nature of the bending moments and loads that can be imposed on the prostheses during skiing raised concern about the suitability of standard prosthetic components for this purpose. The authors report a ski boot modification that incorporates mechanical protection for the standard prosthetic components and a description of the custom-adapted alpine trekking sticks used also as ski poles. Reference is made to the role of risk assessment, the design and manufacture in providing this type of custom-made rehabilitation device.

A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair

The optimal form of rehabilitation after rotator cuff repair has yet to be determined. A randomised clinical trial was undertaken to compare outcomes for two forms of rehabilitation for this condition: individualised supervised physiotherapy treatment, and a standardised unsupervised home exercise regime. Fifty-eight volunteers with all sizes of operatively repaired rotator cuff tears were allocated randomly to one of the two treatment groups. All subjects received a standardised home exercise regime. Subjects who were randomised to the physiotherapy group received additional individualised treatment. Independent, blinded assessments of range of motion, muscle force and functional outcome measures were performed pre-operatively, and at six, 12 and 24 weeks postoperation. At six, 12 and 24 weeks post-operation, comparable outcomes were demonstrated for both rehabilitation groups. By 24 weeks post-operation, most subjects demonstrated outcomes that were consistent with a favourable recovery, regardless of rehabilitation mode. On the basis of these results, outcomes for subjects allocated to individualised physiotherapy treatment after rotator cuff repair are no better than for subjects allocated to a standardised home exercise regime.

Gender differences in recovery from injuries to the extremities in older persons. A prospective study

PURPOSE

This paper examines gender differences in trajectories of basic activities of daily living after fall-related injuries to the extremities in independently living older people in the Netherlands.

METHOD

The study comprised a prospective design. Data were collected from 31 men and 140 women at baseline, when they had not yet sustained injuries (hip fractures, other fractures or contortions and dislocations), and 8 weeks, 5 months and 12 months after their accident. Analysis of variance was used to test for differences in change in basic activities of daily living between baseline and follow-ups for men, for women and for the total study sample while adjusting for several covariates.

RESULTS

The patients did not generally regain their pre-injury levels of functioning 12 months after their event. However, in contrast to the women, older men more closely reached their pre-injury levels of functioning. Although women deteriorated more than men, differences were not statistically significant at 8 weeks and 5 months post-injury. Long-term recovery, however, was significantly associated with gender when the impact of severity seemed to have expired.

CONCLUSIONS

Recovery of basic activities of daily living one year after injuries to the extremities seems to be influenced by gender. Female patients recovered less well compared to males. These gender-related changes warrant concern and attention in clinical practice.

Rehabilitation programs and prevention strategies in adolescent throwing athletes

A specific and early diagnosis must be made in the injured skeletally immature throwing athlete. A well-outlined program of rest, rehabilitation, and proper throwing techniques should be implemented and continued. Overuse injuries are preventable when biomechanics are sound and pitch counts are done with the limits enforced. Guidelines for inning limits, number of pitches, rest intervals, and throwing programs should be followed for adolescent pitchers because adolescents differ from adults. Information is included for specifications of the ball and helmet, as well as chest protective equipment. The goal should be for the Little League players to have fun and be injury free as they are competing, which gives them the best experience and allows continuation of athletic activities for a lifetime.

A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status

BACKGROUND

Rotator cuff tears are among the most common conditions of the shoulder. One of the major difficulties in studying patients with rotator cuff tears is that the clinical expression of these tears varies widely and different practices may have substantially different patient populations. The goals of the present prospective multipractice study were to use patient self-assessment questionnaires (1) to identify some of the characteristics of patients with rotator cuff tears, other than the size of the cuff tear, that are correlated with shoulder function, and (2) to determine whether there are significant differences in these characteristics among patients from the practices of different surgeons.

METHODS

Ten surgeons enrolled a total of 333 patients with a full-thickness tear of the supraspinatus tendon into this prospective study. Each patient completed self-assessment questionnaires that included items regarding demographic characteristics, prior treatment, medical and social comorbidities, general health status, and shoulder function.

RESULTS

As expected, patients who had an infraspinatus tendon tear as well as a supraspinatus tendon tear had significantly worse ability to use the arm overhead compared with those who had a supraspinatus tear alone (p < 0.005). However, shoulder function and health status were correlated with patient characteristics other than the size of the rotator cuff tear. The number of shoulder functions that were performable was correlated with the subscales of the Short Form-36 and was inversely associated with medical and social comorbidities. The patients from the ten different surgeon practices showed significant differences in almost every parameter, including age, gender, method of tear documentation, tear size, prior treatment, medical and social comorbidities, general health status, and shoulder function.

CONCLUSIONS

Clinical studies on the natural history of rotator cuff tears and the effectiveness of treatment must control for a wide range of variables, many of which do not pertain directly to the shoulder. Patients from the practices of different surgeons cannot be assumed to be similar with respect to these variables. Patient self-assessment questionnaires appear to offer a practical method of uniform assessment across different practices.

Clinical and workplace factors associated with a return to modified duty in work-related upper extremity disorders

Return to work following treatment for a work-related upper extremity disorder (WRUED) is affected by a variety of medical, workplace, and personal factors, and returning to modified duty may ease the transition to normal work activities. This study surveyed 165 federal government employees (127 females, 38 males) who were unable to resume their normal work after filing a workers' compensation claim for a WRUED (<90 days from claim filing) and who volunteered for a randomized study of alternative case management strategies. Before randomization, participants completed a baseline survey of upper extremity (UE) symptoms, functional limitations, and workplace factors. At baseline, 58 participants (35%) were working modified duty and 107 participants (65%) were not working. Compared with participants working modified duty, those who were not working were more likely to report: (a). a diagnosis of mononeuropathy, odds ratio (OR)=3.16 (95% confidence interval (CI)=1.37-7.14) versus enthesopathy, (b). higher pain ratings, OR=1.43 (95% CI=1.01-2.01), (c). greater functional limitations, OR=1.63 (95% CI=1.11-2.38), and (d). higher level of ergonomic stressors, OR=1.62 (95% CI=1.09-2.43) in a multivariable logistic regression. Measures of high risk work styles (fast pace and working despite pain) were associated with greater perceptions of ergonomic exposure, but not with work status. The model had 87.9% sensitivity and 43.1% specificity to correctly classify those not working (overall classification 72.1% correct). The results suggest that modified duty for workers with persistent WRUEDs may be enhanced by assessing perceived functional limitation and ergonomic exposure as well as the type and severity of symptoms.

The role of depressive symptoms in recovery from injuries to the extremities in older persons. A prospective study

BACKGROUND

Previous research suggested that depressive symptoms play a role in recovery after hip fracture. However none of these studies were prospective and included only patients with hip fractures.

OBJECTIVE

To examine the effect of depressive symptoms on the recovery of (instrumental) activities of daily living after fall-related injuries to the extremities in older persons.

DESIGN

Prospective cohort study.

METHODS

Data were collected from 168 older persons at baseline, prior to their injuries (hip fractures, other fractures or contortions and dislocations), and 8 weeks, 5 months and 12 months after their accident. Hierarchical multiple regression analysis was used to study the impact of depressive symptoms (as assessed with the Hospital Anxiety and Depression Scale; HADS) on disability (as assessed with the Groningen Activity Restriction Scale; GARS) after the injury while adjusting for several covariates.

RESULTS

Depressive symptoms at baseline were not predictive for disability after the injury when covariates were taken into account. However, depressive symptoms 8 weeks after the fall were significantly related to disability at 8 weeks, 5 months and even 12 months after the injury. In addition, disability levels before the injury were highly predictive for recovery later on. Severity of injury was particularly predictive for disability at 8 weeks while age (which may generally represent the amount of physiological reserve) predicted disability at 5 and 12 months after the injury. Cognitive functioning 8 weeks post-injury was, in contrast to previous research, not predictive for recovery when covariates were taken into account.

CONCLUSIONS

Pre-injury levels of disability and post-injury depressive symptoms are associated with recovery and may warrant concern and special attention in clinical practice.

Postoperative rehabilitation in patients with peripherial nerves injury

Injuries of extremities can be followed by various neuromuscular complications. Injury of peripheral nerves directly depended on the topographic localization of injury (fractures, cuts, contusions). The neuromuscular complications were diagnosed and under follow-up, based on clinical, x-ray, neurologic and neurophysiological findings. The timing of physical treatment and assessment of the necessary neurosurgical intervention depended on the obtained findings. After surgeries, we continued to apply physical treatment and rehabilitation. The aim of the paper was to assess the significance of proper timing for surgery and adequate postoperative rehabilitation, as well as treatment results, depending on the extent of peripheral nerve injury. Material and methods: Based on the study condocted in the period from 2000-2002, most surgeries were done on the ulnar nerve (4 pts), median nerve (4 pts), radial nerve (3 pts), peroneal nerve (2 pts) and plexus brachialis (3 pts). Paresis and peripheral nerve paralysis, associated with sensibility disorders, predominated in clinical features. In most patients surgery was done during the first 3 - 6 months after injury. In early postoperative treatment positioning of extremities with electrotherapy were most often used in early postoperative treatment, Bioptron and dosed kinesitherapy. Depending on the neurophysiological findings, in later treatment stage we included electrostimulation, thermotherapy, kinesitherapy and working therapy, with the necessary application of static and dynamic orthroses. Study results showed that the success of treatment depended on the extent of injury, i.e. whether suture of liberalization of the nerve had been done, on the adequate timing of surgery, as well as on the adequate timing and application of physical therapy and rehabilitation. More rapid and complete functional recovery was achieved if the interval between injury and surgery was shorter, as well as physical therapy was applied early. Based on the analysis of the achieved results, we concluded that peripheral nerve lesions after fractures and contusions had better prognosis in relation to isolated sections of peripheral nerves, having in mind that these were mostly conductive block transfer and nerve stretching lesion, which do not leave sequelae after completed treatment After neurorrhaphies and applied therapy, motor and sensitive deficit mostly depended on good timing of surgery and continual physiatric treatment. It is also important to point out the significance of team-work among neurosurgeon, neurologist and physiatrist necessary in early detection and successful treatment of numerous sequelae and invalidity in patients with peripheral nerve lesions.

[Standardisation and validation of the German version 2.0 of the Disability of Arm, Shoulder,Hand (DASH) questionnaire]

The Disability of Arm, Shoulder, Hand (DASH) Version 2.0 questionnaire captures the subjective experience of patients regarding their own health. This 78-item instrument was developed by the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies and the Institute for Work and Health,Toronto and measures components of health-status relevant to upper-extremity conditions. We translated and validated DASH with the aim of producing a tool which could also be used in German-speaking countries. The paper reports the method of translation and cross-cultural adaptation which was carried out according to the AAOS guidelines. The result was a standardised German version of DASH. Psychometric testing of the translated questionnaire was carried out with 6 samples (n=342) who had undergone hand surgery for a variety of conditions. The study yielded good results across all groups with regard to the construct, criterion and content validity. We confirm that the German version is suitable for use in future studies.

[Rehabilitation of war injuries of the upper extremities with peripheral nerve lesions at the and Praxis Clinic for physical medicine and rehabilitation in Sarajevo]

The war injuries are the most frequent multiple, with the difficult distructions of the tissue and the lesions of the peripheral nerves. By the injuries, the lesions of the nerv system represent the delicate problem for the physical medicine and the rehabilitation during the siege of Sarajevo (1992-1995), in the injuries with the lesions of the peripheral nerves, if they are not treated in the frame of the multiple las urgent, they are postponed the operative treatments longer than three months. This is from the aspect of the successfullness, prognostically and therapeutically, the limiting moment. The successfullness of the operative treatment of the lesions of the peripheral nerves significantly depends on that whether the operation was performed incide tree months. The more difficult consequences in these injuries can appear if simultaneously with the taking care of war injuries does not perform adequately surgical treatment adn the in time physical therapy trough the sufficient long time period. On the four year sample was analyzed the success fullness of the rehabilitation of the injuries of the upper extremities with the lesions of the peripheral nerves. Clinically, uniform, we valorized the success fullness of the treatment of all the patients by the marks from 0.5. In the complete sample the excellent success of the rehabilitation we confirmed in more than a half of patients. The better results show the group of the operated patients, in which is performed neuropathia or neurolisis. The capability of the regeneration of the injured peripheral nerves offers the real possibility for extraordinary recovery also in the most difficult injuries, then the preventions of the significant number of the consequences.