Greater length of hospital stay for concurrent hip and upper limb fractures compared to isolated hip fractures: a systematic review of 13 studies including 210,289 patients and meta-analysis

BACKGROUND

The impact of concurrent upper limb and fragility hip fractures has not been well defined. A greater understanding of this can guide decision making in the early peri-operative period and subsequent rehabilitation of such patients.

AIMS

To identify if patients with concurrent upper limb and fragility hip fractures have different outcomes and demographics than those with an isolated hip fracture.

METHODS

A search of MEDLINE and EMBASE was performed to identify cohort and case-control studies, comparing concurrent hip and upper limb fractures with isolated hip fractures. Meta-analysis was conducted using RevMan 5.4. Subgroup analyses were performed for concurrent distal radius and concurrent proximal humerus fractures.

RESULTS

13 studies were included reporting on 196,916 patients with an isolated hip fracture and 13,373 with concurrent hip and upper limb fractures. Patients with concurrent upper limb fractures had a significantly longer length of hospital stay (mean difference: 3.97 days, 95% CI: 1.36, 6.57, P=0.003) as compared to those with isolated hip fractures. Patients with concurrent upper limb fractures were significantly more likely to be female (OR: 0.57, 95% CI: 0.46, 0.70, P<0.00001), reside at home pre-injury (OR: 0.6, 95% CI: 0.37, 0.96, P=0.03) and have no cognitive impairment (OR: 0.54, 95% CI: 0.35, 0.84, P=0.006). Patients with concurrent distal radius fractures had significantly lower 90-day mortality (OR: 0.70, 95% CI: 0.49, 0.99, P=0.04) and 1-year mortality (OR: 0.68, 95% CI: 0.51, 0.90, P=0.008).

CONCLUSIONS

Concurrent fragility hip and upper limb fractures are associated with increased length of hospital stay. We recommend early, aggressive, individualised rehabilitation to help improve outcomes and early hospital discharge in this highly vulnerable patient group.

The Use of Psychosocial Services Post Hand and Upper Limb Injury and Trauma: A Pilot Study

BACKGROUND

Research demonstrates that hand injuries may cause psychological difficulties. To enhance recovery, therapists must provide appropriate referrals. The purpose of this study was to explore the use of psychosocial services by occupational therapists (OTs) and certified hand therapists (CHTs) post hand and upper limb injury or trauma.

METHODS

A quantitative survey design was implemented using a self-made questionnaire, which consisted of questions regarding demographic information, types and frequency of hand and upper limb injuries, psychiatric diagnoses, frequency of psychosocial service referrals, frames of references used, types of psychosocial assessments and interventions employed, and barriers to psychosocial services. The questionnaire was randomly distributed to 29 therapists.

RESULTS

The most frequently recorded frame of reference was the Biomechanical. Only 17.2% participants implemented psychosocial assessments. Sixteen of the 29 participants referred to 9 possible psychosocial services; however, majority of referrals were "occasionally." OTs specialized in mental health, behavioral specialists, and social workers were recorded with the least amount of referrals. A Spearman rank correlation found a weak, but significant inverse relationship between referrals by therapists and years of experience as an OT or CHT (-0.322 and -0.351, P < .05, respectively).

CONCLUSIONS

Therapists appear to be biomechanically oriented which may impact outcomes. An inverse correlation was found where the less experience participants had, the more likely they were to refer to psychosocial services. The results emphasized the lack of psychosocial assessments, interventions, and referral services being used by therapists. Further education to therapists, third parties, and other health professionals is warranted.

Vocational rehabilitation for enhancing return-to-work in workers with traumatic upper limb injuries

BACKGROUND

Traumatic upper limb injury is a leading cause of work-related disability. After return-to-work (RTW), many survivors of injuries are able to regain a quality of life (QoL) comparable with the normal population. Since RTW plays an important role in economic productivity and regaining health-related QoL, enhancing RTW in workers with traumatic limb injuries is the primary goal of rehabilitation. Vocational rehabilitation has been commonly employed in the field of occupational safety and health to increase the number of injured people returning to the labour market, prevent illness, increase well-being, and reduce disability.

OBJECTIVES

To assess the effects of vocational rehabilitation programmes for enhancing RTW in workers with traumatic upper limb injuries.

SEARCH METHODS

This is an update of a Cochrane review previously published in 2013. We updated our searches of the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 9), MEDLINE (to 30 August 2017), EMBASE (to 3 September 2017), CINAHL (to 6 September 2017), and PsycINFO (to 6 September 2017), and we handsearched the references lists of relevant review articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials (RCTs) comparing vocational rehabilitation with an alternative (control) intervention such as standard rehabilitation, a limited form of the vocational rehabilitation intervention (such as advice on RTW, referral information, or liaison with employer), or waiting-list controls.

DATA COLLECTION AND ANALYSIS

Two authors independently inspected abstracts, and we obtained full papers when necessary. When the two authors disagreed about the inclusion of a study, we resolved disagreements by discussion. A third author arbitrated when necessary.

MAIN RESULTS

Our updated search identified 466 citations. Based on assessments of their titles and abstracts, we decided to evaluate the full texts of five records; however, none met our inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no high-quality evidence to support or refute the efficacy of vocational rehabilitation for enhancing RTW in workers with traumatic upper limb injuries. Since injured people in occupational settings frequently receive vocational rehabilitation with the aim of decreasing work disability, enhancing RTW, increasing productivity, and containing the welfare cost, further high-quality RCTs assessing the efficacy of vocational rehabilitation for workers with traumatic upper limb injury are needed to fill this gap in knowledge.

Postoperative healing patterns in elbow using electromyography: Towards the development of a wearable mechatronic elbow brace

Musculoskeletal (MSK) conditions are the most common cause of severe long-term pain and physical disability. Current postoperative treatment for patients requires them to follow a long-term physiotherapy program customized for each specific case; however, this process can be complex, time-consuming and without the right therapy it may end up being ineffective. A possible solution involves the development of wearable mechatronic elbow braces that use electromyography (EMG) to identify patient intent. However, EMG characteristics change based on the health of the individual and therefore require further investigation. In order to quantify the progress of MSK injury patients and assess their neuromuscular health, EMG signals from 16 healthy individuals and 15 postoperative patients were collected and analyzed. The experiments conducted show that EMG can be used as a method for assessing MSK health. A normal range across the muscle groups has been identified to which the patient population was compared. This showed statistically significant differences in the magnitudes of muscle recruitment and activation between the two groups. Furthermore, a comparison within the patient population at the beginning of their therapy versus at the end of their therapy was conducted. Statistical differences arose in this second analysis further proving that patients' signals tend to change and show trends closer to those of the healthy population.

Rasch Analysis of the General Self-Efficacy Scale in Workers with Traumatic Limb Injuries

Purpose The purpose of this study was to apply Rasch analysis to examine the unidimensionality and reliability of the General Self-Efficacy Scale (GSE) in workers with traumatic limb injuries. Furthermore, if the items of the GSE fitted the Rasch model's assumptions, we transformed the raw sum ordinal scores of the GSE into Rasch interval scores. Methods A total of 1076 participants completed the GSE at 1 month post injury. Rasch analysis was used to examine the unidimensionality and person reliability of the GSE. The unidimensionality of the GSE was verified by determining whether the items fit the Rasch model's assumptions: (1) item fit indices: infit and outfit mean square (MNSQ) ranged from 0.6 to 1.4; and (2) the eigenvalue of the first factor extracted from principal component analysis (PCA) for residuals was <2. Person reliability was calculated. Results The unidimensionality of the 10-item GSE was supported in terms of good item fit statistics (infit and outfit MNSQ ranging from 0.92 to 1.32) and acceptable eigenvalues (1.6) of the first factor of the PCA, with person reliability = 0.89. Consequently, the raw sum scores of the GSE were transformed into Rasch scores. Conclusions The results indicated that the items of GSE are unidimensional and have acceptable person reliability in workers with traumatic limb injuries. Additionally, the raw sum scores of the GSE can be transformed into Rasch interval scores for prospective users to quantify workers' levels of self-efficacy and to conduct further statistical analyses.

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.

Vocational rehabilitation for enhancing return-to-work in workers with traumatic upper limb injuries

BACKGROUND

Traumatic upper limb injury is a leading cause of work-related disability. After return-to-work (RTW), many survivors of injuries are able to regain a quality of life (QoL) comparable with the normal population. Since RTW plays an important role in economic productivity and regaining health-related QoL, enhancing RTW in workers with traumatic limb injuries is the primary goal of rehabilitation. Vocational rehabilitation has been adapted in the field of occupational safety and health to enhance the number of injured people returning to the labour market, prevent illness, increase well-being, and reduce disability.

OBJECTIVES

To assess the effects of vocational rehabilitation programs in enhancing RTW of workers with traumatic upper limb injuries.

SEARCH METHODS

We searched OSH UPDATE databases (CISDOC, HSELINE, International Bibliographic, NIOSHTIC, NIOSHTIC-2, RILOSH) (up to 10 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11), MEDLINE through PubMed (up to 15 November 2012), EMBASE (up to 28 November 2012), CINAHL (up to 5 May 2013), PsycINFO (up to 7 December 2012), and handsearched the reference lists of relevant review articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials (RCTs) comparing vocational rehabilitation with an alternative (control) intervention such as standard rehabilitation, an incomplete form of the vocational rehabilitation intervention (such as with limited advice on RTW, referral information, or liaison with employer), or waiting-list controls.

DATA COLLECTION AND ANALYSIS

Two authors independently inspected abstracts and we obtained full papers when necessary. When the two authors disagreed about the inclusion of a study, we resolved disagreements by discussion. A third author arbitrated when necessary.

MAIN RESULTS

Our search identified 332 citations. Based on assessments of their titles and abstracts, we decided to evaluate the full texts of 15 citations. In the end, none of these 15 citations met our inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no high-level evidence to support or refute the efficacy of vocational rehabilitation in enhancing RTW in workers with traumatic upper limb injuries. Since vocational rehabilitation has frequently been provided to injured people in occupational settings with the aim of decreasing work disability, enhancing RTW, increasing productivity, and containing the welfare cost, further high-quality RCTs assessing the efficacy of vocational rehabilitation for workers with traumatic upper limb injury are needed to fill this gap in knowledge.

[Hinged external fixation in orthopaedic and trauma surgery of the elbow]

PURPOSE OF THE STUDY

A hinged external fixator of the elbow provides stable fixation of the joint while maintaining the range of its motion. The aim of the study was to evaluate a group of patients in whom an external fixator was used to manage severe injuries to the elbow, namely, traumatic unstable dislocation, unstable fracture-dislocation, and elbow fractures not permitting management by primary osteosynthesis. This also involved assessment of early elbow mobilisation and a comparison of this group with a group of patients treated conservatively for less severe elbow injuries.

MATERIAL AND METHODS

A group of 25 patients were evaluated at a follow-up of 18 months. There were 10 women and 15 men; the average age was 48 years (range, 20 to 76). The external fixator was applied in 13 patients, of whom eight had unstable elbow dislocation, three had unstable fracture-dislocation and two suffered a comminuted supracondylar fracture of the distal humerus. The hinged fixator was removed at an average of 7.6 weeks (range, 3 to 9 weeks). In the group of 12 patients treated conservatively by plaster cast application and subsequent rehabilitation, five had elbow dislocation without ligament injury and seven had elbow dislocation with ulnar collateral ligament injury. None of them showed any instability. The patients were evaluated on the basis of clinical and radiological findings, with the Mayo elbow performance (MEP) score being used for clinical assessment.

RESULTS

At a follow-up of 18 months, the patients with the external fixator showed the average range of motion at the elbow joint of 127° (105° to 140°), the MEP score of 92 points (75 to 100) and restriction of elbow extension by 8° (0° to 40°). In the conservatively treated patients, the range of motion was 133° (112° to 145°), the MEP score was 95 points (85 to 100) and extension restriction by 8° (0° to 22°). X-ray examination showed a congruent joint in both groups. The use of external fixator was associated with minor complications: transient radial nerve irritation in one case, and pin-tract infection in two cases (23%) which healed spontaneously after screw removal.

DISCUSSION

The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent consequence of severe elbow injury.

CONCLUSIONS

Elbow injuries differ from patient to patient and therefore the approach to their treatment has to be individual in every patient. A hinged external fixator provides stable fixation and allows for early movement of the elbow. Maintenance of the range of motion facilitated by the hinged fixator is not at the expense of joint stability or fracture non-union. Based on the results presented here, we recommend the use of external fixation in severe unstable elbow fractures and in fractures in which primary osteosynthesis cannot be used because of soft tissue injury.

Injuries among powered two-wheeler users in eight European countries: a descriptive analysis of hospital discharge data

Powered two-wheelers (PTWs--mopeds, motorcycles, and scooters) remain the most dangerous form of travel on today's roads. This study used hospital discharge data from eight European countries to examine the frequencies and patterns of injury among PTW users (age≥14 years), the predicted incidence of the loss of functional ability, and the mechanisms of the head injuries observed (all in light of increased helmet use). Of 977,557 injured patients discharged in 2004, 12,994 were identified as having been injured in PTW collisions. Lower extremity injuries accounted for 26% (25.6-26.7, 95% C.I.) of the total injuries, followed by upper extremity injuries (20.7%: 20.3-21.2), traumatic brain injuries (TBI) (18.5%: 18-19), and thoracic injuries (8.2%: 7.8-8.5). Approximately 80% of the lower extremity injury cases were expected to exhibit some functional disability one year following discharge (predicted Functional Capacity Index, pFCI-AIS98<100), compared to 47% of the upper extremity injury cases and 24% of the TBI cases. Although it occurred less frequently, patients that were expected to experience some functional limitation from TBI were predicted to fair worse on average (lose more functional ability) than patients expected to have functional limitations from extremity injuries. Cerebral concussion was the most common head injury observed (occurring in 56% of head injury cases), with most concussion cases (78%) exhibiting no other head injury. Among the AIS3+ head injuries that could be mapped to an injury mechanism, 48% of these were associated with a translational-impact mechanism, and 37% were associated with a rotational mechanism. The observation of high rates of expected long-term disability suggests that future efforts aim to mitigate lower and upper extremity injuries among PTW users. Likewise, the high rates of concussion and head injuries associated with a rotational mechanism provide goals for the next phase of PTW user head protection.

Influence of pain associated with musculoskeletal disorders on grip force timing

STUDY DESIGN

Retrospective repeated-measures design.

INTRODUCTION

Pain is a common symptom associated with musculoskeletal conditions.

PURPOSE

This study examined if pain resulting from a unilateral upper extremity musculoskeletal injury compromises the person's ability to rapidly initiate and release handgrip.

METHODS

Delays in initiating and releasing a handgrip were determined for 28 individuals with "low pain" and 12 individuals with "high pain" in the injured upper extremity. All participants had no pain in the uninjured upper extremity.

RESULTS

The high-pain group was 10% slower in initiating and releasing a grip than the low-pain group, in both injured and uninjured upper extremities, for both maximal and submaximal grips. In addition, delay in grip initiation was, on average, 8% longer for the injured than for the uninjured upper extremity.

CONCLUSIONS

Unilateral musculoskeletal pain appears to delay grip initiation and relaxation bilaterally, perhaps due to a centrally mediated mechanism.

LEVEL OF EVIDENCE

n/a.

[Dutch military casualties of the war in Afghanistan--quality of life and level of participation after rehabilitation]

OBJECTIVE

To describe the distribution of injuries and the quality of life and functioning at activity and participation level of rehabilitated Dutch military personnel who were wounded during the mission to Afghanistan.

DESIGN

Retrospective, descriptive.

METHOD

The study population consisted of military war casualties who followed multidisciplinary rehabilitation treatment for injuries sustained in combat in Afghanistan. Distribution and degree of injuries were classified according to the 'Abbreviated Injury Scale' (AIS) and the 'Injury Severity Score' (ISS). Quality of life and functional disabilities were assessed with a semi-structured interview, and the following questionnaires: EuroQol-5D with an extra dimension 'cognition' (EQ-6D), the 'Assessment of Life Habits' shortened version 3.0 (LIFE-H 3.0) and the 'Lower Extremity Functional Scale'(LEFS). Coping style was assessed with the Cognitive Emotion Regulation Questionnaire' (CERQ).

RESULTS

A total of 48 servicemen cooperated. A total of 248 injuries; 54% of which affected the extremities. In 9 victims an amputation of the lower extremity was performed; 4 of them had to have a double amputation. 31 servicemen were still receiving specialist medical care at the time of the interview. 39 servicemen had to adjust their career plans. The mean quality of life, measured by EQ-5D, had an index score of 0.72 (Dutch population norm: 0.88). The mean score on the LEFS was 58 (maximum score 80). Changes in mobility and occupation appeared to be predictive factors for quality of life.

CONCLUSION

The quality of life and functional level of Dutch military personnel who were injured in combat in Afghanistan seemed to be lower than in the general population after 2.3 years. For a large part this could be explained by the level of mobility and occupation.

A robotic & virtual reality orthopedic rehabilitation system for the forearm

We describe a robotic and virtual reality system for the rehabilitation of the forearm. It consists of a robotic arm and VR scenarios with a dynamic model of the human upper limb. The system allows to assign specific tasks to perform within the virtual environments. The system simulates the actions of the patient limb and allows exhaustive exercising and motor control, giving visuomotor and haptic feedback and trajectory positioning guidance. The system aids to evaluate the mobility condition of the patient, to personalize the difficult level of the therapy and provides kinematic measures of the patient evolution. The patients recruitment phase has already started for clinical pilot studies.

[Long-term results after polytrauma]

Rehabilitation treatment, which is necessary in the majority of polytrauma patients, is long-lasting and even after several years the final result is frequently not reached yet. Our study is the first in which a population of 510 patients were followed up for 10 years and more and in which many clinical and social parameters were determined. Our study showed that even after a period of 10 years and more the quality of life in several patients is still obviously impaired, according to the parametes "financial losses", "decreased net income", "loss of social services", "credit loan" and "loss of friends". In our study, differences according to financial and professional perspectives between injuries of the lower and upper extremities or combination injuries of the extremities were statistically significant. For the everyday clinic it is important to reintegrate children and young patients into a strong social network because there is a higher percentage of young patients who are socially impaired, even many years after trauma. Adult patients should get strong support to return to their original profession and financial status.

Measuring shoulder injury function: common scales and checklists

The increasing shift towards patient-centred healthcare has lead to an emergence of patient-reported outcome instruments to quantify functional outcomes in orthopaedic patients. Unfortunately, selecting an instrument for use in a shoulder trauma population is often problematic because most shoulder instruments were initially designed for use with chronic shoulder pathology patients. To ensure an instrument is valid, reliable, and sensitive to clinical changes, it is important to obtain psychometric evidence of its use in the target population. Four commonly used shoulder outcome instruments are reviewed in this paper: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES); Constant-Murley shoulder score (CMS); Disabilities of Arm, Shoulder, and Hand (DASH); Oxford Shoulder Score (OSS). Each instrument was reviewed for floor or ceiling effects, validity, reliability, responsiveness, and interpretability. Additionally, evidence of each instrument's psychometric properties was sought in shoulder fracture populations. Based on the current literature, each instrument has limited amounts of evidence to support their use in shoulder trauma populations. Overall, psychometric evaluations in isolated shoulder fracture populations remain scarce, and clinicians must remember that an instrument's properties are defined for the population tested and not the instrument. Therefore, caution must always be exercised when using an instrument that has not been fully evaluated in trauma populations.

Skill generalization relevant to robotic neuro-rehabilitation

Upper limb extremity rehabilitation practices are increasingly involving robotic interaction for repetitive practice, and there is increasing skepticism whether such systems can provide the relevant practice that can be generalized (or transferred) to functional activities in the real world. Most importantly, will patients be able to generalize in three critical ways: (1) to unpracticed directions, (2) to unpracticed movement distances, and (3) to unpracticed weight-eliminated conditions? Rather than presuming that patients could generalize in three conditions, this study tested whether there was any evidence of such generalization ability in healthy individuals. We found that there was some evidence in all conditions except for the ability of healthy subjects to generalize to large movements after practicing small. Such results suggest that larger robotic systems are advantageous for training the functional motions that can include large actions.

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)

PURPOSE

To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries.

METHOD

All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist.

RESULTS

Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status.

CONCLUSIONS

Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.

Sports and performing arts medicine: 1. Upper extremity injuries

OBJECTIVE

This self-directed learning module highlights upper limb sports and performing arts injuries. It is part of the study guide on sports and performing arts medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on shoulder, elbow and finger pain in athletes and wrist pain in musicians. The goal of this article is to enhance the learner's understanding on how to approach common upper limb pain conditions and injuries in these populations.

The impact of early workplace-based return-to-work strategies on work absence duration: a 6-month longitudinal study following an occupational musculoskeletal injury

OBJECTIVES

To examine, using administrative and self-reported data, the relationship between early return-to-work (RTW) strategies and work absence duration.

METHODS

Using a cohort of 632 claimants with work-related musculoskeletal injuries, Cox proportional hazard analyses were performed with RTW strategies measured 1 month after injury as predictors. Outcomes were 6-month self-reported work absence duration and time receiving wage replacement benefits from an administrative database.

RESULTS

Work accommodation offer and acceptance and advice from health care provider (HCP) to the workplace on re-injury prevention were significant predictors of shorter work absence duration indexed by both self-report and administrative data. Receiving an ergonomic visit was a significant predictor of shorter duration receiving benefits only.

CONCLUSIONS

Analyses using administrative and self-reported indices of work absence generally converged. Work accommodation and targeted HCP communication with the workplace are critical for effective early RTW interventions.

'Hybrid-PLEMO', rehabilitation system for upper limbs with active / passive force feedback mode

Several rehabilitation robots for upper limbs have been proposed so far, and clinical effectiveness was reported in several studies for the aged people or patients with stroke. However most of them have only 2-DOF for its active motion. It is important for designing a rehabilitation system which trains in the 3-DOF space because the upper limbs of humans works in 3-DOF space even expect for the wrist. We developed the quasi 3-DOF rehabilitation system which has 2-DOF force-feedback function in working plane but its working plane can be adjusted the inclination. And we named it Hybrid-PLEMO for it can be switched between active type and passive type. Hybrid-PLEMO is a compact, low-cost rehabilitation system for upper limbs with high safety by using ER brakes or ER actuators. Additionally, in Hybrid-PLEMO, we take direct-drive linkage mechanism by adding sub links. In this paper, we describe the mechanism and haptic control of Hybrid-PLEMO.

Rehabilitation of children after elbow injuries

OBJECTIVES

To review the efficiency of early physical therapy to achieve successful rehabilitation after elbow injuries in children.

SETTING

Tertiary medical institution, Department of Physical Therapy, University Clinical Center of Kosovo, rr. Spitalit pn. 10000 Prishtina, Kosovo.

METHODS

We retrospectively reviewed the patients with elbow injuries, (ICD, Rev. 10, Elbow Fractures code) merely as a consequence of trauma, who had undergone rehabilitation program from June 2000 December 2001.

RESULTS

In this study 140 cases with elbow injuries are analyzed. The majority of the injured are with fracture 132 cases (94.29%), whereas only 8 cases or 5.72% are with non displaced fracture or dislocation. Analysis based on the most frequent injury localization in the elbow region, among all fractures, supracondylar fracture is present with 78 cases or 56%. The majority of cases, 49 or 35% have had injuries caused by fall from height, up to 6 cases or 4.3% injured in MVA. Timely initiation of rehabilitation program is influential factor in successful rehabilitation, whereas correlation between time of initiation and rehabilitation success have demonstrated important statistical significance, very high correlation r = 0.75 p < 0.01.

CONCLUSION

The children that did not have continuous rehabilitation program, due to huge interruptions during rehabilitation, have not achieved excellent success in rehabilitation. Early start of rehabilitation, since the arm is immobilized, can cause complete regaining of elbow functions, therefore any delay in the beginning of rehabilitation will leave consequences, from the must minor ones up to disability.

ARMin: a robot for patient-cooperative arm therapy

Task-oriented, repetitive and intensive arm training can enhance arm rehabilitation in patients with paralyzed upper extremities due to lesions of the central nervous system. There is evidence that the training duration is a key factor for the therapy progress. Robot-supported therapy can improve the rehabilitation allowing more intensive training. This paper presents the kinematics, the control and the therapy modes of the arm therapy robot ARMin. It is a haptic display with semi-exoskeleton kinematics with four active and two passive degrees of freedom. Equipped with position, force and torque sensors the device can deliver patient-cooperative arm therapy taking into account the activity of the patient and supporting him/her only as much as needed. The haptic display is combined with an audiovisual display that is used to present the movement and the movement task to the patient. It is assumed that the patient-cooperative therapy approach combined with a multimodal display can increase the patient's motivation and activity and, therefore, the therapeutic progress.

Actualities in big segments replantation surgery

Replantation of an amputation is no longer a difficult technical problem. Indeed, the experience gathered over the last few decades, right from the first concepts posed by the pioneers up to the present era and the improved technical aids, all go to suggest that the majority of amputated segments may now be reconstructed. However, what we really want from a replant is not just survival but function. Indications for replantations must follow careful and objective patient selection together with the evaluation of type and site of lesion and possible complications. Furthermore, the important role of emergency organization in this type of surgery is to be emphasized. Nowadays, clean cut injuries are rarer and are being substituted by high energy trauma which may produce extensive tissue lesions that increase complications and lead to poor functional results. Consequently, some authors were induced to describe evaluation systems for decision making which still present problems which are in part due to the large number of parameters to be taken into consideration as well as to the complex functionality of the upper limb. This led us to evaluate our case series of 52 major replantations of the upper limb over the last 10 years and to compare it with other published series. The best form of reconstruction following total amputation of a major limb segment is still its replantation. The highly significant increase in the quality of life is able to justify the higher social costs and the number of operations required.

Rational flap selection and timing for coverage of complex upper extremity trauma

Reconstruction of complex extremity trauma continues to be a challenging task for plastic surgeons. Characteristics of such injuries include destruction of functional structures, often due to high energy trauma that causes significant invalidity. Before the era of free flaps, pedicled fasciocutaneous and muscle flaps were the only option for reconstruction of the severely injured upper extremity. The management of complex injuries of the upper extremity has changed with the development of reconstructive microsurgery. Nowadays, we have a great variety of different free flaps to cover defects of the upper extremity and restore function by innervated free flaps. Sensibility, skin thickness, texture, colour, durability, binding of the flap to the underlying structures, donor site morbidity, possibility of secondary reconstructive procedures, the surgeon's experience and operative facilities must all be taken into consideration for choosing the optimal reconstructive procedure. Not only the reconstructive und functional requirements but the timing of reconstruction is extremely important for final result. The purpose of this paper is to define the principles of flap selection and timing of flap reconstruction, according to the assessment of trauma in the upper limb.

Proximal biceps rupture: management of an unusual injury in an arm wrestler

Arm wrestling may cause unusual injuries, which may require operative repair in the sporting individual. Injury to the proximal biceps as a consequence of arm wrestling has not been reported previously. The diagnosis and treatment of a 36-year-old man who sustained a proximal biceps rupture while arm wrestling and his operative management are described.

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.

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.