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PubMedDate not supplied

The Pediatric Outcomes Data Collection Instrument (PODCI) and functional assessment of patients with unilateral upper extremity deficiencies.

The Pediatric Outcomes Data Collection Instrument (PODCI) questionnaire was used to quantify functional abilities of a group of unilateral upper extremity deficiency (U-UED) patients and compare them with "normal" control children. Sixty-four consecutive patients with U-UED were assessed. Parents and adolescent (ages 11-21) patients responded. Underlying diagnosis, amputation level, and type of prosthesis were recorded. Scores were compared for congenital versus traumatic etiologies for patients with various amputation levels, and for patients using prostheses versus those not using prostheses. In both parent and patient responses, PODCI scores were significantly lower than "normal" for upper extremity function and sports. Scores were similar for congenital and acquired amputees. Responses from adolescent patients showed progressively decreasing scores for upper extremity, transfers, sports, and global function with progressively proximal amputation levels. Patients using prostheses with different terminal devices did not significantly differ. Parent responses for prosthesis wearers showed lower comfort/pain scores (ie, increased pain) than non-prosthesis wearers, but no significant differences in function, including upper extremity function.

Adolescent↗
PubMed2005

Preoperative vs postoperative radiation therapy for extremity soft tissue sarcoma: controversy and present management.

PURPOSE OF REVIEW: The 5-year results of the Canadian multicenter prospectively randomized phase III trial that compared preoperative with postoperative radiotherapy for patients with extremity soft tissue sarcomas were recently presented at the 2004 meeting of the American Society of Clinical Oncology. These latter findings serve as an impetus for this current review to assess the optimal sequencing of adjuvant radiotherapy for such patients undergoing limb-preserving surgery. RECENT FINDINGS: The recent studies, including the 2004 American Society of Clinical Oncology presentation, described in this paper show no significant rise in the incidence of long-term side effects, such as delayed wound healing and subcutaneous tissue damage, in patients with extremity soft tissue sarcomas who receive once-daily preoperative irradiation followed by limb-preserving surgery. Postoperative radiotherapy may be best reserved for patients who are most likely to undergo a wide local excision with adequate (>10 mm) tumor-free margins (such as low-grade lesions in the lower extremities). There is an increasing use of neoadjuvant chemoradiation in this group of patients, especially for high-grade and large lesions. SUMMARY: Further investigations regarding the preoperative management of extremity soft tissue sarcomas are continuing in an attempt to optimize the survival and functional status of these patients, while minimizing the permanent side effects resulting from such treatment.

Extremities↗
PubMed2005

Return to play issues in upper extremity injuries.

OBJECTIVE: The purpose of this paper is to outline general treatment and return to play (RTP) strategies as they pertain to athletes with various upper extremity injuries. It is not intended to be a comprehensive review of these injuries. DATA SOURCES/SYNTHESIS: A review of the literature plus expert opinion served as the basis for recommendations made regarding management strategies for returning the athlete to play after upper extremity injury. A Medline search was performed using the following key words: upper extremity injury, return to play, glenohumeral dislocation, acromioclavicular joint sprains, elbow dislocation, scaphoid fracture, metacarpal fracture, finger dislocation, tendon injury, hand, mallet finger, and jersey finger. These and other related terms were crossed using the Medline database from 1966 to 2005. RESULTS: Review of book chapters, articles generated from the Medline search, and expert opinion led to the recommendations that are presented here. There is general agreement regarding the treatment of many of the injuries discussed, but controversies do exist. RTP guidelines are largely dependent on the severity of initial injury, rates of healing, and return of strength. CONCLUSIONS: Each athlete with a particular injury to the upper extremity needs to be approached as an individual as no single set of treatment or RTP guidelines applies to all injuries or all individuals. Factors such as age, injury severity, hand dominance, type of sport participation, method of treatment, and chronicity of injury are among the many issues that must be considered when developing a treatment and RTP strategy for a particular athlete.

Acromioclavicular Joint↗
PubMed2006

Extremity vascular injuries on the battlefield: tips for surgeons deploying to war.

BACKGROUND: Recent events have refocused attention on certain principles regarding the surgical management of casualties on the battlefield. Extremity vascular injuries predominate, representing 50 to 70% of all injuries treated during Operation Iraqi Freedom, and exsanguination from extremity wounds is the leading cause of preventable death on the modern battlefield. Recent advances in military medicine have translated into a greater percentage of wounded soldiers surviving during Operations Enduring and Iraqi Freedom than in any other previous American conflict. The combat-experienced military surgeon, a fraction of those in uniform until recently, rarely has had the opportunity to convey lessons learned to the newly indoctrinated war surgeon. The purpose of this review is to do exactly that. METHODS: We collectively reviewed the experience and opinions of five U.S. Army surgeons with regard to management of extremity vascular injuries in a combat zone RESULTS: The modern battlefield has a staunch reputation of being unclean, noisy, and lacking of valuable resources. High-kinetic energy injuries such as those resulting from high explosives, munitions, and high-velocity missiles often cause soft-tissue destruction that is not routinely seen in civilian settings. Military-specific considerations in the management of these injuries are reviewed. CONCLUSIONS: The management of extremity vascular injuries on the modern battlefield presents many unique and demanding challenges to even the most seasoned of surgeons. Preparation goes a long way in overcoming some of the obstacles to seamless patient care.

Amputation, Surgical↗
PubMedDate not supplied

Two simple leg net devices designed to protect lower-extremity skin grafts and donor sites and prevent decubitus ulcer.

Burn therapists routinely are tasked to position the lower extremities of burn patients for pressure ulcer prevention, skin graft protection, donor site ventilation, and edema reduction. We developed two durable and low-maintenance devices that allow effective positioning of the lower extremities. The high-profile and low-profile leg net devices were simple to fabricate and maintain. The frame was assembled using a three-quarter-inch diameter copper pipe and copper fittings (45 degrees, 90 degrees, and tees). A double layer of elasticized tubular netting was pulled over the frame and doubled back for leg support to complete the devices. The devices can be placed on any bed surface. The netting can be exchanged when soiled and the frame can be disinfected between patients using standard techniques. Both devices were used on approximately 250 patients for a total of 1200 treatment days. No incidence of pressure ulcer was observed, and graft take was not adversely affected. The devices have not required repairs or replacement. Medical providers reported they are easy to apply and effectively maintain proper positioning throughout application. Neither device interfered with the application of other positioning devices. Both devices were found to be an effective method of positioning lower extremities to prevent pressure ulcer, minimize graft loss and donor site morbidity, and reduce edema. The devices allowed for proper wound ventilation and protected grafted lower extremities on any bed surface. The devices are simple to fabricate and maintain. Both devices can be effectively used simultaneously with other positioning devices.

Burns↗
PubMed2006

Peripherally inserted central catheters and upper extremity deep vein thrombosis.

The purpose of the study was to determine the incidence and risk factors for venous thrombosis in patients with a peripherally inserted central catheter (PICC). A retrospective study of all upper extremity venous duplex scans was carried out in the Vascular Medicine department from year 2000 to 2002 inclusive. A chart review of positive scans was undertaken to identify possible thrombotic risk factors. Of 317 upper extremity venous duplex scans carried out, 115, or 32%, were positive for upper extremity deep vein thrombosis. Three main risk factors were identified - presence of a central line, malignancy and administration of chemotherapy. PICC were the most common central line present. Symptomatic thrombosis occurred in 7% of PICC inserted for chemotherapy compared with 1% of PICC inserted for other reasons. Ten per cent of the patients receiving chemotherapy through a PICC developed a thrombosis. The post-thrombotic syndrome was infrequent following upper extremity deep vein thrombosis. Patients receiving chemotherapy through a PICC are at increased risk of thrombosis. There may be a role for prophylactic low-dose anticoagulation in these high-risk patients.

Adolescent↗
PubMed2002

A review of functional status measures for workers with upper extremity disorders.

In order to identify functional status measures for epidemiological studies among workers with mild to moderate disorders of the neck and upper extremity, a literature search was conducted for the years 1966 to 2001. Inclusion criteria were: (1) relevance to neck and upper extremity; (2) assessment among workers; and (3) relevance to mild to moderate disorders. Of 13 instruments reviewed, six measures were tested among workers. The three best measures, depending on the purpose of research, included the standardised Nordic Musculoskeletal Questionnaire, the Upper Extremity Questionnaire, and the Neck and Upper Limb Instrument. Development of a functional protocol is regarded as a realistic enhancement for research of neck and upper extremity disorders in the workplace. For research and clinical practice, measures of functional status, sensitive enough to measure the subtle conditions in mild to moderate disorders, may provide prognostic information about the risk of developing musculoskeletal disorders in apparently healthy patients. Appropriate use of functional status questionnaires is imperative for a meaningful portrayal of health.

Disability Evaluation↗
PubMed1988

Peripheral nerves of the extremities: imaging with US.

High-resolution real-time ultrasonography (US) was used to evaluate peripheral nerves of the extremities in healthy subjects and in 11 patients with a mass developed from a peripheral nerve. The normal median and ulnar nerves in the upper extremity and the normal sciatic and external popliteal nerves in the lower extremity were seen, all having an echogenic fibrillar echotexture. Pathologic findings included nine cases of benign tumor (four schwannomas, three neurofibromas, two traumatic neuromas), one of neurilemmitis, and one of tuberculoid leprosy. All lesions were hypoechoic. Three of the four schwannomas had well-defined contours, and two were associated with a typical distal sound enhancement. Neurofibromas and traumatic neuromas were less sharply delineated. Inflammatory conditions were characterized by a hypoechoic, thickened nerve. US was effective in imaging nerve masses in the extremities, and large normal nerves can now be demonstrated with high-resolution US.

Extremities↗
PubMed2006

Histopathologic changes in laryngeal mucosa of extremely low-birth weight infants after endotracheal intubation.

OBJECTIVES: Advances in medicine have improved the survival of infants with increasingly lower birth weights. The histopathologic changes of intubation-related laryngeal injury in extremely low-birth weight infants (less than 1,000 g) have not been well known. We examined histopathologic changes in infant larynges, including extremely low-birth weight infants, after endotracheal intubation. METHODS: Forty-four infants, including 21 extremely low-birth weight infants, who had been intubated for periods ranging from 10 minutes to 138 days, were examined in a whole organ serial section study. RESULTS: As the duration of intubation increased, the ulceration was found to be larger and deeper. The injury at the subglottis and posterior glottis was greater than that at other portions. The perichondrium of the cartilage was exposed in many cases intubated longer than 8 days. Repaired epithelium that was composed of squamous epithelium was present in 6 of 7 larynges that had been intubated more than 20 days, indicating that not only injury but also the healing process occurred during long intubation. There were no obvious relationships between the degree of intubation injury and the birth weight of the infants. CONCLUSIONS: Prolonged intubation is better tolerated by infants than adults. The intubation-related laryngeal injuries of extremely low-birth weight infants were histopathologically the same as those of infants of other birth weights.

Disease Progression↗
PubMedDate not supplied

Effects of parenteral nutrition on whole body and extremity composition in children and adolescents with active inflammatory bowel disease.

The effect of parenteral nutrition (PN), combined with corticosteroid therapy, on body composition was evaluated in 22 pediatric patients with active and complicated inflammatory bowel disease (IBD). The patients were divided into two groups according to the duration of PN. Group A consisted of 14 patients who received PN for an average of 43 days (short term) whereas eight patients received PN for an average of 104 days (long term); group B. Nutritional assessments were performed before and following the PN periods. In addition, a follow-up assessment was performed 50 days after the cessation of PN for group A. Serial evaluations included; weight, height, disease activity score, arm anthropometry, subscapular skinfold (SSSF) thickness, 24-hr urinary creatinine, and computed tomography (CT) scan of the thigh. Following PN with a glucose-fat mixture used as a nonprotein energy source, there were significant (p less than 0.05) increases in weight, SSSF, and muscle mass (MM) in both groups. Disease activity declined in both groups and height increased in group B and at the follow-up assessment for group A. Considering extremity composition, both groups exhibited increases in midarm muscle area, midarm fat area, thigh muscle area, and thigh fat area. However, a differential distribution of incremental change was observed depending on the duration of PN. Fat deposition predominated in both the upper and lower extremities for group A. Group B patients, however, although showing a predominance of fat accumulation in the upper extremities, gained muscle and fat components equally in the lower extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2006

Severe vascular gunshot injuries of the extremities: a ten-year nation-wide analysis from Finland.

BACKGROUND AND AIMS: Gunshot wounds affecting the main vessels of the extremities mostly threaten limb salvage. The purpose of this study was to analyse the nature and severity of civilian vascular gunshot injuries of the extremities using a nation-wide database. MATERIAL AND METHODS: Retrospective analysis of the Finnish Hospital Discharge Register, hospital records and death certificates over a 10-year period from January 1, 1990 to December 31, 1999. RESULTS: Thirty-two individuals with the mean age of 33 years (17-68) sustained 43 severe vascular injuries to the extremities caused by gunshots. The incidence was 6.0 (95% CI: 4.1-8.5) per 10,000,000 person-years and did not change significantly during the period. Four of the injured died. The most common anatomical locations of vascular injuries were the femoral artery (6 lesions), popliteal artery (6) and superficial femoral artery (5). Use of alcohol was detected in ten cases (32% of patients) and of illegal drugs in seven cases (22%). Five patients (18% of non-fatal injuries) required vascular re-operation caused by post-operative problems. Five amputations were performed as primary treatment. CONCLUSIONS: Severe vascular gunshot injuries of the extremities are not common in Finland. The need for primary amputation or vascular re-operations is noteworthy.

Adolescent↗
PubMed2004

Clinical pathology and therapeutic results of neurilemmoma in the upper extremity.

PURPOSE: To evaluate the clinical pathology and postoperative outcomes of patients with neurilemmoma in the upper extremity who underwent tumour enucleation, and the correlation factors for neurological deficits apart from enucleation of nerve fascicles. METHODS: Magnetic resonance imaging was used to evaluate the state of lesions of the patients with upper-extremity neurilemmoma who underwent tumour enucleation. To find out the correlation factors for neurological deficits, the patients were then divided into 2 groups based on their recovery period-group A (shorter than 6 months) and group B (at 6 months or longer). Duration of the illness, the affected nerve, and the size and histological type of the tumour were then compared between the 2 groups. RESULTS: Of the 20 patients who underwent tumour enucleation for neurilemmoma in the upper extremity, 19 had a single nerve affected and one had multiple lesions involving two nerves. The tumours in 6 patients were of Antoni A type histology and in the remaining 14 patients were of a mixed type. Antoni B type alone was not observed. 15 patients showed postoperative neurological deficits. No neurological deficits were observed in 5 patients. Neurological deficits were fully recovered in all patients except the one with a lesion in the digital nerve. Apart from enucleation of nerve fascicles, the period required for the recovery of neurological deficits was correlated to the duration of the illness (p=0.04) and the histological type of the tumour (p=0.03). CONCLUSION: Most of the patients with neurilemmoma (95%) had a single nerve affected. A majority of patients (70%) had the mixed type of Antoni A and Antoni B histology; Antoni B type alone was not observed. Neurological deficits were observed in 75% of patients. In patients with neurilemmoma developing in the upper extremity, the period required for recovery from postoperative neurological deficits was short when the duration of illness was short and when Antoni A type histology was present.

Adolescent↗
PubMed2002

Responsiveness of two upper extremity function instruments for stroke inpatients receiving rehabilitation.

OBJECTIVE: To compare the responsiveness of the Action Research Arm test (ARAT) and the upper extremity section of the Motor Assessment Scale (UE-MAS) in assessing the recovery of upper extremity function in stroke inpatients receiving rehabilitation. SUBJECTS: Forty-eight stroke inpatients. SETTING: The physical medicine and rehabilitation department of a medical centre. DESIGN: The patients were tested at admission and at discharge from the department. METHODS: Various indices, including effect size d, Wilcoxon test and Spearman's rho, were used to assess responsiveness. The change in score of the upper extremity subscale of the Fugl-Meyer scale was used as the external criterion. RESULTS: The responsiveness indices of both total scores of the ARAT and UE-MAS are generally moderate and similar (d = 0.52, Wilcoxon Z = 5.03, p < 0.001 and rho = 0.66 for the ARAT; d = 0.45, Z = 4.54, p < 0.001 and rho = 0.7 for the UE-MAS). Responsiveness indices are small to moderate and similar in each of the subscales of both instruments. CONCLUSION: The results of this study support the value of the ARAT and UE-MAS for measuring recovery of upper extremity function in stroke patients.

Aged↗
PubMed1998

Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity.

PURPOSE: This randomized, prospective study assesses the impact of postoperative external-beam radiation therapy on local recurrence (LR), overall survival (OS), and quality of life after limb-sparing resection of extremity sarcomas. PATIENTS AND METHODS: Patients with extremity tumors and a limb-sparing surgical option were randomized to receive or not receive postoperative adjuvant external-beam radiotherapy. Patients with high-grade sarcomas received postoperative adjuvant chemotherapy whereas patients with low-grade sarcomas or locally aggressive nonmalignant tumors were randomized after surgery alone. RESULTS: Ninety-one patients with high-grade lesions were randomized; 47 to receive radiotherapy (XRT) and 44 to not receive XRT. With a median follow-up of 9.6 years, a highly significant decrease (P2 = .0028) in the probability of LR was seen with radiation, but no difference in OS was shown. Of 50 patients with low-grade lesions (24 randomized to resection alone and 26 to resection and postoperative XRT), there was also a lower probability of LR (P2 = .016) in patients receiving XRT, again, without a difference in OS. A concurrent quality-of-life study showed that extremity radiotherapy resulted in significantly worse limb strength, edema, and range of motion, but these deficits were often transient and had few measurable effects on activities of daily life or global quality of life. CONCLUSION: This study indicates that although postoperative external-beam radiotherapy is highly effective in preventing LRs, selected patients with extremity soft tissue sarcoma who have a low risk of LR may not require adjuvant XRT after limb-sparing surgery (LSS).

Extremities↗
PubMed2003

Delayed harvesting of sentinel lymph nodes after previous wide local excision of extremity melanoma.

BACKGROUND: Harvesting the sentinel lymph node (SLN) is important in the management of patients with primary cutaneous melanoma. Selective sentinel lymphadenectomy (SSL) is generally performed at the time of wide local excision (WLE). The aim of our study was to determine whether delayed SSL is useful in detecting micrometastasis to the regional basin in patients with previous WLE of an extremity melanoma. METHODS: Of 203 patients with a primary melanoma site located on the upper or lower extremity seen at the University of California, San Francisco/Mount Zion Melanoma Center from May 17, 1994, to March 23, 1999, 24 patients had a WLE of their extremity melanoma with adequate margins before referral. SSL was performed to assess micrometastasis in the regional lymph node basin after preoperative lymphoscintigraphy. RESULTS: At least 1 SLN was identified in all 24 patients. At a median follow-up of 3 years, two patients showed micrometastasis in the SLNs. One of these two patients developed recurrence, and all remaining patients showed no evidence of disease. CONCLUSIONS: Although it is generally advised that WLE should be performed simultaneously with SSL, delayed SSL after WLE of an extremity melanoma can still provide valuable staging information, which is critical for management of the patient.

Adult↗
PubMed2006

Functional evaluation after reconstruction with myocutaneous and fasciocutaneous flaps for conservative oncological surgery of the extremities.

BACKGROUND: Limb-preservation surgery has evolved during the last two decades through application of pedicled and free flaps and has obtained oncological results similar to those with amputation for malignant neoplasms of the extremities. However, functional evaluation has not been performed comprehensively after these advanced reconstructive procedures. The aim of this study was to describe the oncological, surgical, and functional outcomes achieved in these patients. METHODS: Patients had malignant neoplasms of the extremities and/or shoulder and hip girdle, underwent resective surgery and reconstruction with limb-preservation purposes, and were treated from 1997 to 2002. Survival analysis was performed, and functional evaluation after resection was performed with the Enneking system 1 year after surgery. RESULTS: Thirty-two patients were included. The mean overall survival of the cohort was 5.6 years. Functional evaluation mean rating percentages for the upper and lower extremities were 86.5% and 75.2%. Functional outcomes were better for reconstruction with free flaps than with pedicled flaps in the lower extremities (rating percentages, 67% and 79.6%, respectively; P = .018). CONCLUSIONS: Limb-preservation surgery is a safe treatment for malignant neoplasms. It can be performed with low morbidity and good oncological outcomes. Functional results in our series were good. Lower limb preservation has superior scores with free flap reconstructions because of their potential to cover extensive defects, and better results were obtained in walking, gait, and weight bearing.

Adolescent↗
PubMedDate not supplied

Arterial reconstruction after mangled extremity: injury severity scoring systems are not predictive of limb salvage.

The Vascular Unit at Suez Canal University Hospital in Egypt covers a wide area with high rates of severe injuries. This is a prospective study of mangled extremities to identify risk factors associated with limb loss in these patients. Between December 2000 and August 2003, a prospective study on all patients with arterial injuries in mangled extremities was undertaken. All patients were scored using the Mangled Extremity Severity Score (MESS) and the Mangled Extremity Severity Index (MESI). During this period, arterial reconstruction was performed in 62 patients. Primary patency, secondary patency, and limb salvage rates were 81%, 85.5%, and 93.5%, respectively. The only factor affecting limb salvage (statistical trend) was the site of trauma (upper limb 100% vs lower limb 89%; p = .08%). There was no significant effect related to the mechanism of trauma (blunt 90% vs stab 100%; p = .125), MESS (< 7, 100% vs > 7, 91%; p = .22), and MESI (< 20, 100% vs > 20, 90.5%; p = .154). Upper limb injuries were the least likely to lead to amputation. We recommend that all injuries, whatever their score, should be surgically explored before treatment decisions are made.

Adolescent↗
PubMed1992

Type A-insulin resistance with lipopexia on extremities: a case report.

We present the unusual case of a 17-year-old female with insulin-resistant diabetes, acanthosis nigricans, hirsutism, amenorrhea, dental dysplasia and lipopexia on the extremities. She had been diagnosed as having border line diabetes with hyperinsulinemia at age 12 when she was not obese and diabetes mellitus at age 13. On admission, she was obese and had lipopexia only on the extremities. The presence of hyperinsulinemia and poor response to exogenous insulin suggested severe insulin resistance. Insulin binding to transformed B-lymphoblasts derived from her was extremely low compared to the normal control, showing decreased receptor affinity. Her parents and sister exhibited hypersecretion of insulin in response to a 75 g oral glucose tolerance test. Her mother was diabetic, and her father and sister had border line diabetes, whereas her brother had a normal response. These findings support strongly the diagnosis of a type A syndrome with severe insulin resistance associated with lipopexia on the extremities. A genetic defect in the insulin receptor gene may be responsible.

Absorptiometry, Photon↗