Splinting for peripheral nerve injury in upper limb

The prognosis and speed of peripheral nerve recovery depend very much on the level of injury, severity of injury, the surgical intervention and the subsequent rehabilitative process. Many high level injuries may take years or months for the affected peripheral nerve to recover. Prolonged muscle imbalance causes joint contractures and over-stretching of denervated muscles. Without proper care, hand function recovery may be limited even the nerve regenerated afterwards. During the nerve regeneration period, splinting is one of the most useful modality to minimise deformities, prevent joint contractures and substitute loss motor control. Proper splinting encourages early use of the injured hand in daily activities. There are different types of splinting design for median nerve palsy, ulnar nerve palsy and radial nerve palsy. Dynamic splinting techniques are frequently employed to allow early prehension activities. Other therapeutic techniques, including pressure garment and sensory re-education are useful to enhance better functional return after nerve repair.

[Range of motion in the joints of the upper extremity at different stages of sympathetic reflex dystrophy (SRD)]

Sympathetic reflex dystrophy of the upper extremity is among the most serious complications of trauma injuries. The aim of this paper was to assess the effectiveness of mobilization treatment, augmented by cryogenic temperatures of post trauma SRD of the upper extremity. The material comprised 113 patients treated at the Orthopedic Outpatient Clinic of the J. Babiński Hospital in Breslau during the years 1987-1995. All patients underwent conservative treatment because of post trauma SRD. The effectiveness of cryo-therapy was based on pre- and post-therapy ROM examination. These results were compared to the ROM of the healthy extremity and the degree of ROM limitation was hence calculated. Limitation of ROM was found in all joints of the upper extremity regardless to the stage of the disease. The greatest limitations were found in the joints directly adjacent to the area were the disease was most pronounced. The applied therapy in these cases was found to increase ROM in all patients, with the greatest increase of ROM during stage I and II of the disease.

Pedicled groin flaps for upper-extremity reconstruction in the elderly: a report of 4 cases

The pedicled groin flap is a useful, versatile flap for coverage of wounds of the hand and distal forearm. It produces predictable results with a procedure that is much less difficult to perform and takes less time than a free-tissue transfer. Contrary to the general belief that the groin flap should not be used in the elderly because of the risk of shoulder stiffness, we found satisfactory results with this procedure in 4 elderly patients (age range, 59-75 y) when immediate shoulder mobilization was instituted and physical therapy was continued during flap maturation and pedicle division.

Musculoskeletal recovery 5 years after severe injury: long term problems are common

Five years after severe injury (ISS>15), usually involving several body regions, 158 patients were assessed regarding their musculo-skeletal recovery. An earlier paper in this journal about this study 'Injury 29 (1998) 55' showed that when considering the main body regions causing long term disability, 45% were due to bony injuries to the extremities, pelvis and shoulder girdle. We analysed these body areas regarding the degrees of disability and pain and also for problems with activities of daily living, work, sport and mobility. All patients with unstable pelvic fractures had moderate or severe persisting disability and chronic pain. Functional problems with activities of daily living, work, sport and mobility were reported in 28, 86, 100 and 100% of patients, respectively. Patients with stable pelvic fractures had persisting disability in 54% of cases, which was mild in 42% and moderate or severe in 12% of patients. In patients with stable pelvic fractures 54% had chronic pain, which was mild in 24% of patients and moderate or severe in 30% of patients. Functional problems with mobility, work and sport were reported in 38, 19 and 19% of patients, respectively. Patients with shoulder girdle injuries had persisting disability in 48% of cases which was mild in 24% and moderate or severe in 24% of patients. In patients with shoulder girdle injuries 45% had chronic pain, which was mild in 14% and moderate or severe in 31% of patients. Functional problems with activities of daily living, work, sport and mobility were reported in 38, 28, 38 and 38% of patients respectively. Patients with upper limb fractures had persisting disability in 66% of cases which was mild in 34% of patients and moderate or severe in 32% of patients. Chronic pain was present in 62% of these cases, which was mild in 32% and moderate or severe in 34% of patients. Functional problems with activities of daily living, work, sport and mobility were reported in 31, 45, 48 and 66% of patients, respectively. Patients with lower limb fractures had persisting disability in 84% of cases, which was mild in 16% and moderate or severe in 68% of patients. Chronic pain was present in 80% of these cases, which was mild in 24% and moderate or severe in 56% of patients. Functional problems with activities of daily living, work, sport and mobility were reported in 40, 56, 64 and 76% of patients, respectively. Patients with multiple extremity injuries or combinations of pelvic and lower extremity or shoulder girdle and upper extremity injuries were much more likely to have continuing disability compared with those sustaining single bone injuries of that limb. This high disability rate reflecting treatment in 1989-1990, raises the question of whether our present policy of earlier and better fixation and rehabilitation of fractures in severely injured patients (ISS>15) can improve these results.

Industrial medicine and acute musculoskeletal rehabilitation. 3. Cumulative trauma disorders of the upper limb in computer users

This self-directed learning module highlights various cumulative trauma disorders of the upper limb that may be seen in computer users. The biomechanics and ergonomics of computer users are addressed in relationship to specific neurologic and musculoskeletal conditions within the neck and upper limbs. In addition to a general overview of these conditions, a case presentation is used to show the evaluation and treatment of a computer user who has carpal tunnel syndrome and concomitant de Quervain tenosynovitis.

OVERALL ARTICLE OBJECTIVES

(a) To review the important anatomic and ergonomic basis for upper limb cumulative trauma disorders in computer users and (b) to provide an example of evaluation and treatment.

Impact of case manager training on worksite accommodations in workers' compensation claimants with upper extremity disorders

Management of the return-to-work process in claimants with work-related upper extremity disorders often poses challenges to the health care provider, claimant, and employer. Modifying workplace ergonomic risk factors as a component of the workplace accommodation process may improve return-to-work outcomes by reducing recurrent pain and discomfort. The present study is a case-control evaluation of the effects of a 2-day training program for nurse case managers that was designed to facilitate the implementation of workplace accommodations within a workers' compensation health care delivery system. After the training, 101 claimants with compensable upper extremity disorders were randomly assigned to case managers with and without training. Overall, 208 accommodations were recommended and 155 of these were implemented (75%). Claimants of trained nurses received 1.5 times as many recommendations for accommodations as claimants managed by nurses not trained in the process, and 1.4 times as many accommodations were implemented, although no differences were found between the two groups in implementation rates. Trained nurses were more likely to recommend accommodations addressing workstation layout, computer-related improvements, furnishings, accessories, and lifting/carrying aids, whereas the untrained nurses were more likely to suggest light duty and lifting restrictions. This study indicates that the training was associated with a change in the practice behavior of case managers regarding the workplace accommodation process. More research is needed to identify barriers to implementation and develop more effective approaches to facilitate worksite accommodations in disabled workers with carpal tunnel syndrome and other persistent upper extremity disorders.

The military upper extremity amputee

Throughout the course of military history, soldiers have continued to sustain amputation injuries during war times and during peacetime and training missions. What has changed over time is the etiology of, indication for, and management of the amputations. Technology has advanced significantly, often with some military connection. More work still needs to be done, especially in the areas of greater prosthetic limb function and usage as well as phantom pain and sensation management. Collaborative efforts among physiatrists, surgeons, prosthetists, and therapists can only benefit the patient.

Tragic case of a dog bite in a young child: the dog stands trial

The authors present the tragic case of an 18-month-old child who was bitten by a dog, causing amputation of the forearm and substantial damage to the cutaneous muscle on his back, shoulder, thorax, and neck. A free latissimus dorsi flap was performed to preserve the humerus from which the periosteum had been torn away. A series of cutaneous expansions were then undertaken to graft skin back onto the back, the armpit, and the shoulder stump, to allow for a mechanical prosthesis. A study of the literature on this subject proves that dog bites are more frequent and serious (sometimes even fatal) in young children than in adults. In view of the current legislation, it would seem that the public health authorities are doing little to resolve this distressing problem.

Safety to drive after common limb fractures

One hundred Orthopaedic Consultants in the UK were randomly selected and asked to complete a postal questionnaire indicating when they felt patients with treated, pain free, common limb fractures could return to driving. Seventy-two questionnaires were returned. Six were not completed leaving 66 completed questionnaires. Analysis revealed a clear mandate to allow or prevent driving in patients with certain treatment modalities and stages of union. In the lower limb there was majority agreement of suitability to drive in 61% of the 28 presented scenarios. Opinion was more divided for the upper limb, with only 43% of the scenarios having majority agreement. Our results show that while for some common limb fractures there is a clear body of opinion supporting safety to drive, for other common fractures opinion is less clear cut. This has important financial, medico-legal and legal implications that could be resolved by formal testing.

The use of manual edema mobilization for the reduction of persistent edema in the upper limb

Management of persistent edema with the common treatment methods reported in the literature is not always successful. Manual edema mobilization (MEM) is a relatively new treatment regimen derived from established European and Australian lymphedema reduction regimens. It includes the use of exercises, light skin-tractioning massage techniques following the lymphatic pathways, and the use of low-compression garments. The typical patient who may benefit from the use of MEM has a presumed healthy lymphatic system, is an active participant, and performs some of the techniques independently between therapy sessions. This case report describes the use of MEM on a patient with multiple trauma, which resulted in a significant reduction--78%--of the persistent edema in the affected upper limb. A theoretic rationale is offered for each MEM technique.

Social predictors of recovery in late middle-aged and older persons after injury to the extremities: a prospective study

OBJECTIVES

The impact of educational level and social support on short-term and long-term recovery of activities of daily living and instrumental activities of daily living after injuries to the extremities was examined in a prospective study concerning late middle-aged and older persons.

METHODS

Patients (N = 171) who had sustained fall-related injuries (hip fractures, other fractures, or sprains and dislocations) participated in the study. Disability scores were collected at baseline (before the injury) and 8 weeks, 5 months, and 12 months after the injury. The authors used analysis of variance to assess possible differences between 3 levels of education and social support with respect to changes in disability scores from baseline to the 3 follow-up measurements while adjusting for covariates.

RESULTS

Preinjury assessed educational level or social support did not play a role in short-term changes in disability. In the long term (5 and 12 months after the injury), recovery was significantly associated with social support: Those with higher levels of support had a better recovery. Although patients with high levels of education most closely approached their pre-event level of disability as well, differences did not reach statistical significance. Short-term changes in disability appeared to be determined by the severity of the injury. Social support began to influence recovery only when the impact of severity expired.

DISCUSSION

Patients recovering from fall-related injuries who had reported high levels of social support before their injury had recovered better at 5 and 12 months. Encouragement and special attention given by health professionals to maintain social support may be beneficial for rehabilitation after fall-related injuries in older persons.

Overuse injuries of the upper extremity in tennis players

Several overuse injuries can affect the upper extremity of tennis players. A thorough understanding of anatomy and knowledge of these common conditions and their treatment facilitates the management of these athletes.

Rehabilitation concepts and supportive devices for overuse injuries of the upper extremities

Rehabilitation of overuse injuries requires the health care professional to understand normal and common pathologic mechanics of the patient's sport or physical activity. Evaluation of the total mechanics of the body, not just the local area presenting with discomfort, is important. [figure: see text] The cause of the presenting injury can be a dysfunction at a distant site. Rest and supportive devices are helpful in allowing the athlete to return to a normal activity level. A progressive reconditioning program needs to address strength and flexibility issues and endurance and eccentric exercises.

Complex regional pain syndrome (type I) after electrical injury: a case report of treatment with continuous epidural block

A 26-year-old man presented with severe complex regional pain syndrome type I of the affected limb after a work-related electrical injury. He suffered causalgia-like pain with no electrodiagnostic evidence of nerve injury. Early steroid and analgesic regimens did not adequately relieve these symptoms. His symptoms were temporarily relieved several times with stellate ganglion blocks. The patient underwent a cervical epidural block with a local anesthetic as well as a narcotic agonist over a 4-day period, which resulted in prompt, remarkable pain relief. Vocational rehabilitation was instituted as the pain subsided.

Multidisciplinary team evaluation of upper extremity injuries in a single visit: the UPPER Program

Musculoskeletal disorders are the leading cause of disability among people between 18 and 64 years of age. Patients with musculoskeletal injuries of the upper extremities are usually evaluated and treated by an individual physician and therapist. However, for patients who have problems, especially after being treated by a hand surgeon and a certified hand therapist, there are few other management options. A multidisciplinary assessment program for patients with chronic upper limb pain has not been described in the literature. As part of The University of Michigan RERC (Rehabilitation Engineering Research Center), the UPPER Program (UPper extremity Protocol Evaluation in Rehabilitation) was developed to evaluate patients who have disabling upper limb musculoskeletal disorders. At the center of the program is a multidisciplinary team composed of a physiatrist (physical medicine and rehabilitation specialist), occupational therapist, physical therapist, exercise physiologist, vocational counselor and pain psychologist. The UPPER Program elements include a pre-evaluation questionnaire, individual team member assessments and a team meeting. It is followed by a patient appointment with the team physician to review the results and recommendations. The essential details of the program are presented in this article so it can be reproduced elsewhere.

[Failure of upper limb macro-implantations: surgery and outcome. 11 cases]

The failure of macro-implantation of the upper limb must not be considered as the end of a therapeutic method, but instead as a step in the functional rehabilitation of the upper limb. From a group of 24 patients that have been operated with a macro-implantation of the upper limb, we have seen 11 patients for who the reimplantation had failed. We have studied the surgical procedure of those failures, the mid-term evolution (prosthesis and operations), and a long-term evolution with the functional future of those patients. A surgical procedure with latissimus dorsi flap was necessary in six cases, in one hand to maintain a sufficient length of the stump for prosthesis and the other hand to preserve the articulation of the elbow. Nine patients on 11 were able to be "apparated" by a myoelectric prosthesis for the amputation below the elbow (seven cases), by prosthesis for the amputation above the elbow (two cases). On a long period of time (average time 51 months) only four patients had a permanent use of their prosthesis (myoelectric type). For us, the functional rehabilitation of the upper limb need two important elements: first a good quality of the stump with a sufficient length, and second an important motivation from the patient to live with his "new hand".

Measurement of scapular asymetry and assessment of shoulder dysfunction using the Lateral Scapular Slide Test: a reliability and validity study

BACKGROUND AND PURPOSE

The Lateral Scapular Slide Test (LSST) is used to determine scapular position with the arm abducted 0, 45, and 90 degrees in the coronal plane. Assessment of scapular position is based on the derived difference measurement of bilateral scapular distances. The purpose of this study was to assess the reliability of measurements obtained using the LSST and whether they could be used to identify people with and without shoulder impairments. Subjects. Forty-six subjects ranging in age from 18 to 65 years (X=30.0, SD=11.1) participated in this study. One group consisted of 20 subjects being treated for shoulder impairments, and one group consisted of 26 subjects without shoulder impairments.

METHODS

Two measurements in each test position were obtained bilaterally. From the bilateral measurements, we derived the difference measurement. Intraclass correlation coefficients (ICC [1,1]) and the standard error of measurement (SEM) were calculated for intrarater and interrater reliability of the difference in side-to-side measures of scapular distance. Sensitivity and specificity of the LSST for classifying subjects with and without shoulder impairments were also determined.

RESULTS

The ICCs for intrarater reliability were .75, .77, and .80 and .52, .66, and .62, respectively, for subjects without and with shoulder impairments in 0, 45, and 90 degrees of abduction. The ICCs for interrater reliability were .67, .43, and .74 and .79, .45, and .57, respectively, for subjects without and with shoulder impairments in 0,45 and 90 degrees of abduction. The SEMs ranged from 0.57 to 0.86 cm for intrarater reliability and from 0.79 to 1.20 cm for interrater reliability. Using the criterion of greater than 1.0 cm difference, sensitivity and specificity were 35% and 48%, 41% and 54%, and 43% and 56%, respectively, for 0, 45, and 90 degrees of abduction. Sensitivity and specificity based on the criterion of greater than 1.5 cm difference were 28% and 53%, 50% and 58%, and 34% and 52%, respectively, for the 3 scapular positions.

CONCLUSION AND DISCUSSION

Our results suggest that measurements of scapular positioning based on the difference in side-to-side scapular distance measures are not reliable. Furthermore, the results suggest that sensitivity and specificity of the LSST measurements are poor and that the LSST should not be used to identify people with and without shoulder dysfunction.

The platform transfer splint: 2 case reports of a mobility aide for persons with arm injuries or conditions

Limited or impaired mobility is a major obstacle to maximizing length of stay efficiency for inpatient rehabilitation. Trauma patients and others with multiple limb impairments present a mobility challenge to all rehabilitation centers. Of particular concern are patients with forearm fractures who are nonambulatory. With shorter inpatient stays, patients are being discharged home or to other settings with continued weight-bearing restrictions. These patients put great demands on their caregivers as a result of their limited mobility. The Platform Transfer Splint (PTS) has been developed to overcome limitations seen in this patient population. It is an upper extremity splint that allows weight bearing through the humerus for patients with impairments of the forearm or hand. With use of the PTS, patients can become independent in transfers and wheelchair propulsion. Two case studies are presented to show the impact of the PTS on patient mobility and discharge disposition. Fabrication of the splint is also discussed.

[The musician's hand: aspects of music physiology and performing arts medicine]

Musicians are particularly demanding hand patients. Increased expectancy towards the hand surgeon as well as principle aversion to any kind of operative treatment of the musician's hand impede the relationship between hand surgeon and patient. Knowledge and experience of the specific demands towards the musician's hand--including the background of basics in physiology of music making and instrumental techniques--facilitate history taking, examinations, diagnosing as well as the selection of therapy. Besides tendinitis and tendovaginitis, pathologies of the musician's hand are not more frequent compared to the entire population. Still several pathologies reach a significantly pronounced importance through the specific professional requirements. This is true especially for peripheral nerve compression syndromes, arthritis, ganglia, contractures, joint laxity and focal dystonias. The treatment of these disorders and hand trauma require, besides an utmost of hand surgical care, creativity and the implementation of the professional musical surroundings in therapy and rehabilitation, including also the musical instruments. The indication for surgery might be restrained in certain cases, although there are, without doubt, situations, when a professional musician should be operated on at an early stage. This should enhance a rapid return to play the musical instrument and to exercise delicate and demanding skilled movement patterns of his hand.

Rehabilitation of the burned upper extremity

With the advancement in medical technology and more effective life-sustaining measures, the rehabilitation therapist is faced with the immense task of effectively restoring functional ROM, strength, and mobility and producing a cosmetic result acceptable to the patient. Rehabilitation therapists have a very significant role to play in achieving these goals. The patients and their families come to rely very heavily on the therapists for advice, support, and information both in the acute phase of burn management and, potentially, for years to follow. A concerted team approach is necessary for a satisfactory functional outcome following burn injury.