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Wellington IJ, Garvin PM, Stelzer JW, Morgan C, Alessi A, Hall M, Rodner C, Edgar C. Transient Exertional Compressive Radial Neuropathy in a Collegiate Baseball Pitcher: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00043. [PMID: 36820758 DOI: 10.2106/jbjs.cc.22.00352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/06/2022] [Indexed: 02/24/2023]
Abstract
CASE A 21-year-old collegiate baseball pitcher presented with transient lateral arm pain and wrist extension weakness after pitching more than 1 inning. Physical examination was unremarkable at rest. Ultrasound-guided injection of the radial nerve at the level of the lateral intramuscular septum improved his symptoms. After decompression of the radial nerve, the patient noted resolution of his symptoms while pitching. CONCLUSION Atraumatic radial neuropathy is a rare but documented phenomenon. As far as we know, this is the first reported case of a transient exertional radial neuropathy in an athlete at the level of the lateral intermuscular septum.
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Affiliation(s)
- Ian J Wellington
- UConn Health, Department of Orthopaedic Surgery, Farmington, Connecticut
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Regas I, Pluvy I, Sakek F, Tuphe P, Ortega P, Guinchard B, Obert L, Lepage D. Epidemiology of upper limb chronic exertional compartment syndrome (CECS) in the French Motorcycle Federation racers: Results of a national questionnaire-based study. HAND SURGERY & REHABILITATION 2021; 40:268-276. [PMID: 33667652 DOI: 10.1016/j.hansur.2020.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022]
Abstract
Upper limb chronic exertional compartment syndrome (CECS) has been described in amateur and professional motorcycle racers, but there is no published data about its prevalence. The purpose of this study was to define the awareness, prevention and prevalence of this syndrome in licensed motorcycle racers in competition in France. Secondary purposes were to determine the functional impact of CECS and post-treatment outcomes. The 20,641 licensed racers in competition of the French Motorcycle Federation were sent a self-assessment questionnaire about upper limb pain and CECS physical examination findings, functional impact and treatment outcomes. The satisfaction level was assessed after each type of treatment. Acceptability rate was 6.35% with 1311 racers responding. CECS was unknown by 29% of racers. Prevention methods were unknown by 10% of racers. Less than 50% of racers modified their bikes. The prevalence of upper limb CECS in competitive racers was 9%: 8.7% forearm, 0.2% thenar, 0.1% hypothenar and 0.4% first dorsal interosseus compartments. The prevalence was 16% in international level racers, 11% in national level racers and 7.3% in regional level racers. A quarter of racers were satisfied or very satisfied with the outcomes of conservative therapy and rehabilitation. Only 67 racers underwent surgical treatment for their upper limb CECS: 31 by open fasciotomy, 23 by minimally invasive fasciotomy and 13 by endoscopy-assisted compartment release. In these 67 racers, the mean visual analog score for pain improved significantly (p < 0.001 95% CI [3.1-4.5]) with 81% satisfied or very satisfied with surgery outcomes. This epidemiologic self-assessment questionnaire for upper limb CECS is a new concept. This study screened for CECS and offer information regarding evaluation, treatment, and management.
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Affiliation(s)
- Inès Regas
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU Minjoz de Besançon, 3, boulevard Alexandre Fleming, 25033 Besançon, France; Université de Franche-Comté Sciences médicales et pharmaceutiques, 19, rue Ambroise Paré, 25000 Besançon, France; Nano médecine, imagerie, thérapeutique-EA 4662 Université de Franche-Comté Sciences médicales et pharmaceutiques, 19 rue Ambroise Paré, 25030 Besançon cedex, France.
| | - Isabelle Pluvy
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU Minjoz de Besançon, 3, boulevard Alexandre Fleming, 25033 Besançon, France; Université de Franche-Comté Sciences médicales et pharmaceutiques, 19, rue Ambroise Paré, 25000 Besançon, France; Nano médecine, imagerie, thérapeutique-EA 4662 Université de Franche-Comté Sciences médicales et pharmaceutiques, 19 rue Ambroise Paré, 25030 Besançon cedex, France
| | - Fiona Sakek
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU Minjoz de Besançon, 3, boulevard Alexandre Fleming, 25033 Besançon, France; Université de Franche-Comté Sciences médicales et pharmaceutiques, 19, rue Ambroise Paré, 25000 Besançon, France; Nano médecine, imagerie, thérapeutique-EA 4662 Université de Franche-Comté Sciences médicales et pharmaceutiques, 19 rue Ambroise Paré, 25030 Besançon cedex, France
| | - Pierre Tuphe
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU Minjoz de Besançon, 3, boulevard Alexandre Fleming, 25033 Besançon, France; Université de Franche-Comté Sciences médicales et pharmaceutiques, 19, rue Ambroise Paré, 25000 Besançon, France; Nano médecine, imagerie, thérapeutique-EA 4662 Université de Franche-Comté Sciences médicales et pharmaceutiques, 19 rue Ambroise Paré, 25030 Besançon cedex, France
| | - Pierre Ortega
- Médecin du sport et Président du comité médical de la Fédération Française de Motocyclisme, France
| | - Bruno Guinchard
- Médecin du sport et membre du comité médical de la Fédération Française de Motocyclisme, Besançon, France
| | - Laurent Obert
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU Minjoz de Besançon, 3, boulevard Alexandre Fleming, 25033 Besançon, France; Université de Franche-Comté Sciences médicales et pharmaceutiques, 19, rue Ambroise Paré, 25000 Besançon, France; Nano médecine, imagerie, thérapeutique-EA 4662 Université de Franche-Comté Sciences médicales et pharmaceutiques, 19 rue Ambroise Paré, 25030 Besançon cedex, France
| | - Daniel Lepage
- Service d'orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU Minjoz de Besançon, 3, boulevard Alexandre Fleming, 25033 Besançon, France; Université de Franche-Comté Sciences médicales et pharmaceutiques, 19, rue Ambroise Paré, 25000 Besançon, France; Nano médecine, imagerie, thérapeutique-EA 4662 Université de Franche-Comté Sciences médicales et pharmaceutiques, 19 rue Ambroise Paré, 25030 Besançon cedex, France
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Guerzider Regas I, Pluvy I, Tuphe P, Sakek F, Fuchs B, Haight H, Schmitt E, Michel F, Obert L, Lepage D. Long term functional outcomes after minimally invasive surgical decompression in upper limb chronic exertional compartment syndrome in 30 patients. HAND SURGERY & REHABILITATION 2021; 40:32-39. [DOI: 10.1016/j.hansur.2020.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/30/2022]
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Abstract
Chronic exertional compartment syndrome (CECS) is an overuse injury characterized by increased intracompartmental pressure during exercise. CECS has been described in the foot, thigh, and trunk, but 95% of cases occur in the lower leg. Interestingly, CECS may also affect the upper extremities and has been best described in the forearms. Unfortunately, due to the rarity of this condition, there is no consensus regarding its diagnosis and treatment. This review seeks to discuss the prevalence, etiology, diagnosis, and treatment of CECS of the forearms, which has been described in the literature.
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Affiliation(s)
- Kunal Sindhu
- a Department of Radiation Oncology , Mount Sinai Hospital, Icahn School of Medicine , New York , NY , USA
| | - Brian Cohen
- b Department of Orthopaedic Surgery, Warren Alpert School of Medicine , Brown University , Providence , RI , USA
| | - Joseph A Gil
- b Department of Orthopaedic Surgery, Warren Alpert School of Medicine , Brown University , Providence , RI , USA
| | - Travis Blood
- b Department of Orthopaedic Surgery, Warren Alpert School of Medicine , Brown University , Providence , RI , USA
| | - Brett D Owens
- b Department of Orthopaedic Surgery, Warren Alpert School of Medicine , Brown University , Providence , RI , USA
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Upper Extremity Compartment Syndrome in a Patient with Acute Gout Attack but without Trauma or Other Typical Causes. Case Rep Orthop 2018; 2018:3204714. [PMID: 29796328 PMCID: PMC5896219 DOI: 10.1155/2018/3204714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/13/2017] [Indexed: 12/27/2022] Open
Abstract
We report the case of a 30-year-old Polynesian male with a severe gout flare of multiple joints and simultaneous acute compartment syndrome (ACS) of his right forearm and hand without trauma or other typical causes. He had a long history of gout flares, but none were known to be associated with compartment syndrome. He also had concurrent infections in his right elbow joint and olecranon bursa. A few days prior to this episode of ACS, high pain and swelling occurred in his right upper extremity after a minimal workout with light weights. A similar episode occurred seven months prior and was attributed to a gout flare. Unlike past flares that resolved with colchicine and/or anti-inflammatory medications, his current upper extremity pain/swelling worsened and became severe. Hand and forearm fasciotomies were performed. Workup included general medicine, rheumatology and infectious disease consultations, myriad blood tests, and imaging studies including Doppler ultrasound and CT angiography. Additional clinical history suggested that he had previously unrecognized recurrent exertional compartment syndrome that led to the episode of ACS reported here. Chronic exertional compartment syndrome (CECS) presents a difficult diagnosis when presented with multiple symptoms concurrently. This case provides an example of one such diagnosis.
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Winkes MB, Teijink JA, Scheltinga MR. Motorcycle racer with unilateral forearm flexor and extensor chronic exertional compartment syndrome. BMJ Case Rep 2016; 2016:10.1136/bcr-2016-214739. [PMID: 27080851 DOI: 10.1136/bcr-2016-214739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We discuss a case of a 26-year-old man, a motorcycle racer, who presented with progressive pain, weakness and swelling of his right forearm and loss of power in his index finger, experienced during motor racing. Chronic exertional compartment syndrome (CECS) of both flexor and extensor compartments of his forearm was diagnosed by dynamic intracompartmental muscle pressure measurements. After fasciotomies, all symptoms were resolved and the patient was able to improve on his preinjury racing skills, without any limitations. A literature review and a surgical 'how-to' for correct release of the extensor and deep flexor compartments of the forearm are provided.
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Affiliation(s)
- Michiel B Winkes
- Department of General Surgery, Máxima Medical Center, Veldhoven, The Netherlands
| | - Joep A Teijink
- Department of General Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Marc R Scheltinga
- Department of General Surgery, Máxima Medical Center, Veldhoven, The Netherlands
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Abstract
Often considered no more than an historical curiosity, writer’s cramp remains an important disability in the workplace and the mechanism, which has puzzled the best medical minds for generations, remains contentious. A remarkable range of hypotheses has been put forward to try and explain a disability which periodically reached epidemic and economically worrying levels, but in the end medical opinion has accepted the explanation put forward by neurologists Sheehy and Marsden in 1983 that this was caused by a form of focal dystonia. However, the majority of the historical descriptions of writer’s cramp do not fit the classical parameters of focal dystonia and are more accurately described as a progressive forearm muscle fatigue. Today’s keyboard operators continue to complain of symptoms identical to their clerical forebears demonstrating that this is a problem which has evolved but not disappeared; this has the paradoxical advantage that modern research techniques enable this complaint to be revisited. The result shows that two varieties of writer’s cramp have always existed and while focal dystonia remains a valid explanation for a minority of cases, the much more common fatigue-based complaint is better explained by chronic compartment syndrome of the forearm.
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Affiliation(s)
- Michael H Pritchard
- Consultant Rheumatologist, Cardiff, Wales, UK (retired, University Hospital of Wales, Cardiff)
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Brown JS, Wheeler PC, Boyd KT, Barnes MR, Allen MJ. Chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy. J Hand Surg Eur Vol 2011; 36:413-9. [PMID: 21339238 DOI: 10.1177/1753193410397900] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic exertional compartment syndrome of the forearm is rare in the published literature. We report the outcome of a series of 12 patients treated with fasciotomy over a 14 year period. All patients underwent dynamic intra-compartmental pressure testing using a slit catheter technique before surgery. Raised intra-compartmental pressures on exercise, typical symptoms and the absence of other diagnoses were criteria for offering surgical intervention. The superficial flexor, deep flexor and extensor compartments were released. Median follow-up was 9.5 years (range 7 months to 12 years). Median patient-reported percentage improvement after surgery was 88% (range 0%-100%). Median time to return to full activity was 9 weeks. Eleven out of 12 patients were satisfied, very satisfied or extremely satisfied with the outcome of surgery. Fasciotomy can be an effective treatment for chronic exertional compartment syndrome of the forearm.
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Affiliation(s)
- J S Brown
- Department of Sport and Exercise Medicine, University Hospitals of Leicester, Leicester, UK
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Moreno-Torres A, Rosset-Llobet J, Pujol J, Fàbregas S, Gonzalez-de-Suso JM. Work-related pain in extrinsic finger extensor musculature of instrumentalists is associated with intracellular pH compartmentation during exercise. PLoS One 2010; 5:e9091. [PMID: 20161738 PMCID: PMC2817730 DOI: 10.1371/journal.pone.0009091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 01/19/2010] [Indexed: 11/17/2022] Open
Abstract
Background Although non-specific pain in the upper limb muscles of workers engaged in mild repetitive tasks is a common occupational health problem, much is unknown about the associated structural and biochemical changes. In this study, we compared the muscle energy metabolism of the extrinsic finger extensor musculature in instrumentalists suffering from work-related pain with that of healthy control instrumentalists using non-invasive phosphorus magnetic resonance spectroscopy (31P-MRS). We hypothesize that the affected muscles will show alterations related with an impaired energy metabolism. Methodology/Principal Findings We studied 19 volunteer instrumentalists (11 subjects with work-related pain affecting the extrinsic finger extensor musculature and 8 healthy controls). We used 31P-MRS to find deviations from the expected metabolic response to exercise in phosphocreatine (PCr), inorganic phosphate (Pi), Pi/PCr ratio and intracellular pH kinetics. We observed a reduced finger extensor exercise tolerance in instrumentalists with myalgia, an intracellular pH compartmentation in the form of neutral and acid compartments, as detected by Pi peak splitting in 31P-MRS spectra, predominantly in myalgic muscles, and a strong association of this pattern with the condition. Conclusions/Significance Work-related pain in the finger extrinsic extensor muscles is associated with intracellular pH compartmentation during exercise, non-invasively detectable by 31P-MRS and consistent with the simultaneous energy production by oxidative metabolism and glycolysis. We speculate that a deficit in energy production by oxidative pathways may exist in the affected muscles. Two possible explanations for this would be the partial and/or local reduction of blood supply and the reduction of the muscle oxidative capacity itself.
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Affiliation(s)
- Angel Moreno-Torres
- Research Department, Centre Diagnòstic Pedralbes, Esplugues de Llobregat, Spain.
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Chronic exertional compartment syndrome of the forearm in motocross racers: findings on MRI. Skeletal Radiol 2009; 38:1153-61. [PMID: 19609523 DOI: 10.1007/s00256-009-0746-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 05/11/2009] [Accepted: 06/08/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this prospective study was to demonstrate the findings of MRI in motocross racers with chronic exertional compartment syndrome (CECS) of the forearm. MATERIALS AND METHODS Racers with proven CECS and without CECS and male individuals not involved in strenuous activities with the forearm were included. Signal intensity (SI) and signal-to-noise ratio (SNR) obtained before and after exercise were compared (D-SNR). RESULTS Magnetic resonance imaging after exercise showed an increase in SI and SNR in the muscles on T2-WI. The SI increase was obvious in the flexor digitorum superficialis (FDS) and profundus (FDP) in all CECS patients. In addition, a minor SI and SNR increase in the extensor carpi radialis longus (ECRL) was noted. In the non-symptomatic group of motocross racers, there was only a minor increase in SI and the SNR, which was similar in the FDP and ECRL muscles. In the untrained individuals a remarkable increase in the SI and SNR of the FDS/FDP-ECRL was noted. This increased SI and SNR was not present in the majority of non-symptomatic racers. CONCLUSION Post-exertional MRI produces significant findings in CECS of the forearm. The motocross racers without post-exertional oedema in the FDP/FDS had no CECS.
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Jowett A, Birks C, Blackney M. Chronic exertional compartment syndrome in the medial compartment of the foot. Foot Ankle Int 2008; 29:838-41. [PMID: 18752784 DOI: 10.3113/fai.2008.0838] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic exertional compartment syndrome of the foot has been previously described. There has been debate over the exact number and location of compartments. The involvement of the medial compartment has been consistently described in case reports; however, there is little in the orthopaedic literature on the exact anatomy for the fasciotomy and the resultant long term outcomes. MATERIALS AND METHODS We present the results of five patients (seven feet) who were surgically treated by medial compartment decompression, releasing both superficial and deep fascial layers. There were three females and two males, average age of 23 (17 to 34) years. Decompression was bilateral in one, sequential in one, and unilateral in three. Three patients also had surgical treatment of chronic compartment syndrome elsewhere in their lower limbs. RESULTS Preoperative post exertional compartment pressure measurements were 67.8 (32 to 114) mm at 1 minute and 50.2 (28 to 97) mm at 5 minutes. At an average of 21 (9 to 57) month followup, all but one patient had significant relief of their symptoms. CONCLUSION Chronic exertional compartment syndrome may affect multiple compartments in the lower limb of a single patient. When affecting the medial compartment of the foot, release of the superficial and deep fascia is a reliable treatment. It is safe to perform bilaterally and in association with other lower limb decompressions as required.
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Affiliation(s)
- Andrew Jowett
- Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, United Kingdom.
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Jepsen JR, Laursen LH, Hagert CG, Kreiner S, Larsen AI. Diagnostic accuracy of the neurological upper limb examination II: relation to symptoms of patterns of findings. BMC Neurol 2006; 6:10. [PMID: 16504144 PMCID: PMC1483836 DOI: 10.1186/1471-2377-6-10] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2005] [Accepted: 02/27/2006] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In a sample of patients in clinical occupational medicine we have demonstrated that an upper limb neurological examination can reliably identify patterns of findings suggesting upper limb focal neuropathies. This further study aimed at approaching the diagnostic accuracy of the examination. METHODS 82 limbs were semi-quantitatively assessed by two blinded examiners (strength in 14 individual muscles, sensibility in 7 homonymous territories, and mechanosensitivity at 10 locations along nerves). Based on the topography of nerves and their muscular and sensory innervation we defined 10 neurological patterns each suggesting a localized nerve affliction. Information on complaints (pain, weakness and/or numbness/tingling) collected by others served as a reference for comparison. The relation between the presence of pattern(s) and complaints was assessed by kappa-statistics. Sensitivity, specificity, and positive/negative predictive values were calculated, and pre-test odds were compared to post-test probability. RESULTS The two examiners identified pattern(s) suggesting focal neuropathy in 34/36 out of 38 symptomatic limbs, respectively (kappa = 0.70/0.75), with agreement in 28 limbs. Out of 44 non-symptomatic limbs the examiners agreed on absence of any pattern in 38 limbs. With concordance between the examiners with regard to the presence or absence of any pattern, the sensitivity, specificity, positive and negative predictive values were 0.73, 0.86, 0.93 and 0.90, respectively. While the pre-test odds for a limb to be symptomatic amounted to 0.46 the post-test probability was 0.81. For each examiner the post-test probability was 0.87 and 0.88, respectively. CONCLUSION The improved diagnostic confidence is an indication of one aspect of construct validity of the physical examination. For determination of clinical feasibility of the examination further studies are required, most importantly 1) studies of validity by means of comparison with additional references and 2) studies of the potential benefit that can be attained from its use.
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Affiliation(s)
- Jørgen R Jepsen
- Department of Occupational Medicine, Sydvestjysk Sygehus, Østergade 81–83, DK-6700 Esbjerg, Denmark
| | - Lise H Laursen
- Department of Occupational Medicine, Sydvestjysk Sygehus, Østergade 81–83, DK-6700 Esbjerg, Denmark
| | - Carl-Göran Hagert
- Department of Orthopaedic Surgery, University Hospital, S-22185 Lund, Sweden
| | - Svend Kreiner
- Department of Biostatistics, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Anders I Larsen
- Occupational Health Services, Novozymes, DK-2880 Bagsværd, Denmark
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Bird HA. Unravelling the mystery of work-related upper limb disorder. Rheumatology (Oxford) 2005; 44:1335-6. [PMID: 16244101 DOI: 10.1093/rheumatology/kei038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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