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PubMed2005

The effect of wrist guard use on upper-extremity injuries in snowboarders.

The objective of this investigation was to determine the effect of wrist guard use on all upper-extremity injuries in snowboarders. This matched case-control study was conducted at 19 ski areas in Quebec, Canada. Cases were 1,066 injured snowboarders who reported upper-extremity injuries to the ski patrol during the 2001-2002 season. Controls were 970 snowboarders with non-upper-extremity injuries who were matched to cases on ski area and the nearest date, age, and sex, in that order. The response rate was 71.8% (73.5% for cases and 70.1% for controls). Cases were compared with controls with regard to wrist guard use. The prevalence of wrist guard use among snowboarders with hand, wrist, or forearm injuries was 1.6%; for those with elbow, upper arm, or shoulder injuries, it was 6.3%; and for controls, it was 3.9%. Thus, wrist guard use reduced the risk of hand, wrist, or forearm injury by 85% (adjusted odds ratio = 0.15, 95% confidence interval: 0.05, 0.45). However, the adjusted odds ratio for elbow, upper arm, or shoulder injury was 2.35 (95% confidence interval: 0.70, 7.81). These results provide evidence that use of wrist guards reduces the risk of hand, wrist, and forearm injuries but may increase the risk of elbow, upper arm, and shoulder injuries.

Adolescent↗
PubMed1996

Myxoid/round cell liposarcoma of the extremities. A clinicopathologic study of 29 cases with particular attention to extent of round cell liposarcoma.

Round cell liposarcoma, a high-grade sarcoma, is a poorly differentiated form of myxoid liposarcoma, which is low grade. It is not known, however, how much of a round cell component within an otherwise typical myxoid liposarcoma results in a neoplasm that behaves as a high-grade sarcoma. Twenty-nine cases of myxoid liposarcoma of the extremities with or without a component of round cell liposarcoma were studied to semiquantitate the amount of round cell component needed to adversely affect prognosis. An estimate of the percent of necrosis, round cell liposarcoma, myxoid liposarcoma, and transitional areas was obtained for each slide on all cases. Transitional areas were defined as those that displayed an increased cellularity compared with typical myxoid liposarcoma, but in which the cells remained spindled, did not have overlapping nuclear borders, and retained an easily discernible plexiform vascular pattern. The amount of necrosis was subtracted from the total material available for evaluation, and a composite estimate of the percent of round cell, myxoid, and transitional areas was obtained. Two tumors were located on the upper extremity, 27 on the lower extremity; tumor size ranged frm 3 to 30 cm (median, 14 cm). All 29 tumors had a myxoid component, with a range from 12 to 100% (median, 73%). The range of transitional component for all 29 tumors was 0 to 88% (median, 11%). Twenty-one tumors had transitional areas (range, 4-88%). The range of round cell component for all 29 tumors was 0 to 58% (median, 0%). Twelve tumors had round cell areas (range, 1-58%). Seventeen patients are either alive without disease, or died from unrelated causes at 24-202 months (median, 96 months). Twelve patients are either alive with metastases or died of disease at 10 to 180 months (median, 53 months). Patients with > 5% round cell component in their initial tumor had a statistically significant higher rate of metastasis or death due to disease than those with < or = 5% round cell liposarcoma (p = 0.05). In addition, patients with myxoid liposarcoma with transitional areas did not fare worse than those with myxoid liposarcoma alone. In conclusion, we found that a round cell component of > 5% portends a higher risk of metastasis or death from disease. Furthermore, transitional areas alone do not appear to alter the prognosis of myxoid liposarcoma. Thus, only those areas that are unequivocally round cell liposarcoma should be designated as high grade.

Adolescent↗
PubMed1976

Limb salvage from a multidisciplinary treatment approach for skeletal and soft tissue sarcomas of the extremity.

Multimodality management of extremity skeletal and soft tissue sarcomas with preoperative intra-arterial Adriamycin and radiation therapy, radical surgical resection and postoperative chemotherapy or chemo-immunotherapy has resulted in preservation of a functional extremity in 13 or 14 patients. Seven of 8 patients with Stage IIIA and IIIB soft tissue sarcomas, managed with preoperative intra-arterial Adriamycin and radiation therapy, followed by en bloc soft tissue resection and 6 patients with bone sarcomas managed by preoperative treatment, followed by bone resection and replacement with cadaver bone allografts, remained free of disease from 4 to 34 months. The results of the combined modality approach were significantly better than the results obtained in patients managed by surgical resection alone, or by combination of operation with another single modality, both in terms of short term-recurrence free survival and salvage of a functional extremity.

Bone Neoplasms↗
PubMed1982

The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy.

Between May 1975 and April 1981, 43 adult patients with high-grade soft tissue sarcomas of the extremities were prospectively randomized to receive either amputation at or above the joint proximal to the tumor, including all involved muscle groups, or to receive a limb-sparing resection plus adjuvant radiation therapy. The limb-sparing resection group received wide local excision followed by 5000 rads to the entire anatomic area at risk for local spread and 6000 to 7000 rads to the tumor bed. Both randomization groups received postoperative chemotherapy with doxorubicin (maximum cumulative dose 550 mg/m2), cyclophosphamide, and high-dose methotrexate. Twenty-seven patients randomized to receive limb-sparing resection and radiotherapy, and 16 received amputation (randomization was 2:1). There were four local recurrences in the limb-sparing group and none in the amputation group (p1 = 0.06 generalized Wilcoxon test). However, there were no differences in disease-free survival rates (71% and 78% at five years; p2 = 0.75) or overall survival rates (83% and 88% at five years; p2 = 0.99) between the limb-sparing group and the amputation treatment groups. Multivariate analysis indicated that the only correlate of local recurrence was the final margin of resection. Patients with positive margins of resection had a higher likelihood of local recurrence compared with those with negative margins (p1 less than 0.0001) even when postoperative radiotherapy was used. A simultaneous prospective randomized study of postoperative chemotherapy in 65 patients with high-grade soft-tissue sarcomas of the extremities revealed a marked advantage in patients receiving chemotherapy compared with those without chemotherapy in three-year continuous disease-free (92% vs. 60%; p1 = 0.0008) and overall survival (95% vs. 74%; p1 = 0.04). Thus limb-sparing surgery, radiation therapy, and adjuvant chemotherapy appear capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremity.

Adolescent↗
PubMed1989

A phase II study of the efficacy of diamminedichloroplatinum (cisplatin) for the control of locally recurrent and intransit malignant melanoma of the extremities using tourniquet outflow-occlusion techniques.

A phase II trial was conducted with 15 patients (mean age of 65.7 years) with locally recurrent or intransit melanoma of the extremities. After total outflow occlusion with pneumatic tourniquet, the cell-cycle nonspecific anti-neoplastic agent cis-diamminedicholoroplatinum (CDDP) was infused intra-arterially in a mean dose of 26.7 mg/m2 per infusion (2.6 infusions per patient). The aim of this study was to determine the efficacy of CDDP infusion for control of intransit and recurrent melanoma of the extremities. Three to four weeks postinfusion, all visible residual disease was resected. Partial remissions were observed in ten patients (67%); five patients achieved stable disease status. No patient had complete regression of disease. At an average follow-up interval of 18.3 months (range 4-44 months), the mean local/regional disease-free survival was 14.8 months. Eighty per cent of patients (twelve of 15) had local/regional control of disease at an average follow-up of 14.8 months after CDDP infusion and surgical resection. Of five melanoma-related deaths, three patients had had no local/regional recurrence at the time of their demise. Three compartment syndromes resulted as a complication of the infusional therapy and occurred within 1-3 days of the treatment. In vitro growth of melanoma from lymph nodes draining the infused area was seen in all subjects studied. Outgrowth from tumor within the tourniquet infusion area was observed in two patients, both of whom experienced recurrences clinically at 24-months' postinfusion. Pharmacokinetic data of total CDDP concentrations from tissue and blood (n = 4) were available from pretreatment to 1 hour post-therapy. Biopsy data from patients pre- and post-treatment suggest substantial tumor uptake of CDDP as compared to local or distal normal skin, with minimal CDDP loss to the systemic circulation. Pharmacologic and clinical data of this phase II trial suggest that intraarterial infusion with tourniquet outflow-occlusion augments tumor tissue levels of CDDP within the infused extremity and enhances local control of high-risk and intransit disease.

Adult↗
PubMed1991

Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?

Although highly accurate, contrast arteriography is a costly, invasive, and time-consuming method to rule out occult arterial damage in injured extremities. Accordingly the authors assessed the sensitivity and specificity of Doppler-derived arterial pressure measurements in trauma victims undergoing evaluation for possible extremity arterial damage. Arterial pressure index (API) was calculated (Doppler arterial pressure distal to injury/Doppler arterial pressure in uninvolved arm), but not used in clinical decision making in 100 consecutive injured limbs in 93 trauma victims. All patients then underwent contrast arteriography. Twenty limbs had an API less than 0.90 and an abnormal arteriogram, whereas 75 had both a normal API and a normal contrast study. One limb had a significant angiographic abnormality with an API greater than 0.90; two others had API less than 0.90 but normal arteriograms. Two limbs with a normal API had false-positive arteriograms. When compared with arteriography, an API less than 0.90 had a sensitivity of 87% and a specificity of 97% for arterial disruption in this series. Sensitivity and specificity rose to 95% and 97% when API was compared with clinical outcome. In the absence of obvious signs of arterial injury, API may be a reasonable substitute for screening arteriography in the traumatized extremity, particularly if close follow-up observation can be assured.

Adolescent↗
PubMed1993

Development and treatment of pulmonary metastases in adult patients with extremity soft tissue sarcoma.

OBJECTIVE: The authors reviewed a series of adult patients with extremity soft tissue sarcoma to determine the incidence of pulmonary metastases and outcome after treatment. METHODS: Of 716 patients admitted between January 1983 and December 1990, 135 (19%) had isolated pulmonary metastases as the initial site of distant recurrence. Fifty-eight percent (78 of 135) of the patients were treated surgically, and 83% of them had their tumors completely resected. RESULTS: The median survival after complete resection was 19 months; incomplete resection, 10 months; and no operation, 8 months (p = 0.005). The 3-year survival rate after complete resection was 23%, compared with a 2% rate (1 of 57) in those treated nonsurgically (p < 0.001). Factors associated with an increased risk of pulmonary metastases included high tumor grade, tumor size greater than 5 cm, lower extremity site, and histologic type (spindle cell, tendosynovial, and extraskeletal osteosarcoma). Factors associated with complete resectability were the histologic types of spindle cell and extraskeletal osteosarcoma. CONCLUSIONS: Complete surgical resection remains the only possibility for cure from pulmonary metastases in soft tissue sarcoma; however, only 11% of the 19% of patients with an extremity sarcoma whose first distant recurrence is in the lung will be alive at 3 years, despite therapy. Complete resection and the development of more effective adjuvant treatments are imperative to improve outcome for this group of patients.

Adolescent↗
PubMed1994

Prognostic factors predictive of survival and local recurrence for extremity soft tissue sarcoma.

OBJECTIVE: The authors sought to identify prognostic factors in the management of extremity soft tissue sarcoma. SUMMARY BACKGROUND DATA: The surgical management of soft tissue sarcoma has evolved because of advances in therapy, resulting in increased limb preservation and quality of life. However, identifying a subset of patients most likely to benefit from adjuvant chemotherapy has been difficult to achieve. METHODS: A retrospective analysis of a prospective data base of 182 patients with extremity sarcomas from 1970 to 1992 was performed. RESULTS: A histologic diagnosis of Ewing's sarcoma, synovial sarcoma, and angiosarcoma was associated with a 13-fold increased risk of death compared with liposarcoma, fibrosarcoma, and malignant peripheral nerve sheath histologic types after having adjusted for the other prognostic factors (p < 0.001). In addition to histologic type, high-grade sarcomas (p = 0.018), sarcomas greater than 10 cm in size (p = 0.006), and age at diagnosis (p = 0.016) were found to be important prognostic factors for survival but not for local recurrence. For the first time to their knowledge, the authors showed that mean mitotic activity has prognostic value after having adjusted for other prognostic factors, such as grade (p = 0.005). The only prognostic factors predictive for local recurrence were whether the patient presented with locally recurrent disease (p = 0.0001) or had microscopically positive margins (p = 0.052). CONCLUSIONS: The use of mitotic activity along with grade, size, histologic type, and age at diagnosis is prognostic for survival in extremity soft tissue sarcoma. The use of an objective pathologic feature, such as mean mitotic activity, is also useful in selecting patients for future systemic neoadjuvant or adjuvant trials and primary therapy.

Adolescent↗
PubMed1981

Degloving injuries of the extremities and torso.

Degloving injuries of the extremities and torso occur with relative frequency and are associated with a high morbidity and mortality. The common aim of all surgical approaches is to reestablish skin coverage over the injured area, but therapies differ in both technique and results. This survey evaluates the management and results of 21 patients sustaining degloving injury of at least 2/3 the circumference of the torso or an extremity. Initial surgical techniques which employ application of the skin as a full- or split-thickness graft were contrasted with those in which salvage of the entire flap with its subcutaneous tissue was attempted. The results suggest that immediate use of the degloved skin as a full-or split-thickness skin graft gives the most satisfactory coverage to the denuded areas. Other important features in management include frequent observation and immobilization of the extremity postoperatively, and use of mesh grafts when necessary to cover large areas. Recent emphasis on the blood supply of the skin underscores the importance of its circulation as the determinant of flap survival. Daily observation until the flap becomes fixed is mandatory. Primary reattachment of the full-or split-thickness flap by suture or use of compression dressings without grafting is unsuccessful and should be abandoned as an acceptable approach to this problem.

Abdominal Injuries↗
PubMed1984

Experience with 112 shotgun wounds of the extremities.

Although shotgun and gunshot injuries are frequently grouped together, shotgun injuries are ballistically and clinically very different from gunshot wounds. Because of the differences between gunshot and shotgun injuries, the clinical records of 85 patients with 112 extremity shotgun wounds treated over a 6-year period were reviewed: 11% had Type I injuries; 30% and 59%, respectively, had Type II and Type III injuries. Overall, 59% had major soft-tissue injuries and 44% had bone or joint injuries, and nerve and vascular injuries were documented in 21% and 26%. The major cause of a prolonged hospital stay was the presence of a major soft-tissue injury, while the presence or absence of a neural injury was the most important determinate of whether the extremity would be functional. In contrast, neither skeletal nor vascular injuries resulted in long-term extremity disability. Thus, we recommend an aggressive operative approach towards early wound closure in these patients to decrease hospitalization time. Further, we believe that the operative determination of the presence or absence of anatomic damage of the nerves in patients with neural deficits is an important component in the long-term management of these patients.

Adolescent↗
PubMed1994

The role of heparin in the prevention of extremity and digit necrosis in meningococcal purpura fulminans.

In order to gather data regarding the utility of heparin therapy in limiting digit and extremity necrosis resulting from meningococcal purpura fulminans in children, we reviewed the charts of 24 pediatric patients with PF associated with meningococcal disease. Our study population was comprised of the 13 patients who survived more than 2 days. Clinical and outcome data were compared between the group of patients who received therapeutic heparin treatment in the initial 72 hours (> or = 50 units/kg bolus followed by an infusion, three patients) and the group who did not (10 patients). Demographic and initial clinical and laboratory findings were similar between groups (P > 0.15). When the two groups were compared for dermatologic and orthopedic sequelae, the mean number of digits (6.3 vs. 11.1; P = 0.35) and extremities (1.7 vs. 3.0; P = 0.17) with necrosis was less in those patients who received therapeutic doses of heparin, although the differences were not statistically significant. When only those patients on whom diffuse purpura were noted on admission were compared, these differences were greater. This small, retrospective series suggests that heparin therapy may limit digit and extremity necrosis when used early and in therapeutic doses in meningococcal purpura fulminans. Therefore, a larger, prospective controlled trial is warranted.

Child, Preschool↗
PubMed1987

Lymphatic drainage in patients after replantation of extremities.

Lymph drainage was studied by means of lymph scintigraphy in eight patients in whom successful replantation of a totally or subtotally amputated extremity had been performed. Scintigrams were made after subcutaneous injection of technetium-99m in the replanted part of the patient and the contralateral, normal extremity. In all scintigrams, axillary or inguinal lymph node activity is seen, implying drainage of lymph by means of the lymph vessels. Retention of colloid in the replanted part (79 to 94 percent) shows no significant difference with the contralateral, normal side (86 to 94 percent). Unquestionable evidence of regeneration of lymphatics in humans is delivered in the three patients, in whom lymph node activity and normal retention percentages are seen on the scintigrams after total amputation of an extremity followed by replantation without anastomosing of interrupted lymph vessels.

Extremities↗
PubMed2000

Free filet extremity flap: indications and options for reconstruction.

Radical and extended forequarter and hind limb amputations have been used for curative and palliative intents. Concerns regarding wound healing and closure, especially in irradiated fields, have occasionally limited the extent of ablation. This article reports an experience with coverage of these large defects by using the free filet extremity flap. A retrospective review was performed of 11 patients who had undergone immediate reconstruction with free filet extremity flaps between 1991 and 1998. There were nine men and two women with an average age of 43.9 years. All except three patients received preoperative radiotherapy. Resections included four hindquarter and seven forequarter amputations for palliation of intractable pain, tissue necrosis, and infections. Donor vessels included the brachial artery, its venae comitantes, cephalic and basilic veins, and common femoral and popliteal vessels. Immediate reconstruction was successful in all cases by the use of the amputated limb as the free filet flap. All wounds healed despite irradiation inclusive of defects up to 50 cm x 70 cm (3500 cm2). The average follow-up time was 5 months with a mean survival of 3.5 months. Four patients currently are alive, and one patient died within 30 days of surgery. The remaining six patients have died of their disease within 9 months of the palliative procedures. Pain, tissue necrosis, and infections were improved in all patients after hospital discharge. Extensive defects can be reconstructed and healed successfully, even in irradiated wounds, with the use of the free filet extremity flap. Appropriate advanced preoperative and intraoperative planning is essential. Although survival was unchanged, this technique allowed healed wounds with an improvement in the quality of life.

Adult↗
PubMed2003

Assessment and management of patients with venous, arterial, and diabetic/neuropathic lower extremity wounds.

Most healthcare providers recognize that management of lower extremity wounds presents a difficult challenge. These chronic wounds significantly impact the quality of life for individuals and have implications for costs and utilization of healthcare resources. Lower extremity wounds can be due to a myriad of different diseases, but the primary causes are chronic venous insufficiency, lower extremity arterial disease, and diabetes/neuropathy. Differential assessment is necessary prior to implementation of management strategies in order to address the etiology and pathogenesis factors that are related to each type of leg wound. This article presents an overview of the risk and predisposing factors for venous, arterial, and diabetic/neuropathic wounds. Additionally, it addresses issues of differential assessment including typical locations, common clinical characteristics, typical wound appearance, key management issues, considerations for alternative treatments, collaborative care, and patient/family education.

Diabetic Neuropathies↗
PubMed2003

Solitary fibrous tumor in the extremity: case report and review of the literature.

A solitary fibrous tumor is a relatively unusual neoplasm first described as a distinctive tumor arising from pleura. Some reports have shown that solitary fibrous tumors also affect extrathoracic regions. The current study presents a literature review with four additional patients with solitary fibrous tumor arising from the extremities to clarify clinicopathologic features. The current four patients were two males and two females, ranging from 17 to 60 years of age. Magnetic resonance imaging scans of the current patients showed inhomogeneous low to intermediate intensity signal on T1-weighted images and inhomogeneous intermediate to high intensity signal on T2-weighted images. Histologically, the tumors were composed of a haphazard proliferation of spindle cells, although cellularity was variable in each case. Two of the four tumors showed hypercellularity of spindle cells with focally myxomatous or hyaline changes, whereas myxomatous patterns with scattered spindle cells throughout the specimens were observed in the other two tumors. Immunohistochemically, all four patients showed positive immunoreactivity for CD34, and two tumors showed focally positive immunoreactivity for bcl-2 protein. During the followup of 12 to 54 months, neither local recurrence nor distant metastasis was detected after wide resection. Examination of the literature and the current patients suggests that solitary fibrous tumors in the extremities are likely to have a malignant potential, although most patients have a benign clinical course. Local wide resection and careful long-term followup are necessary for patients with solitary fibrous tumor in the extremities.

Adolescent↗
PubMed2004

Lymph node metastasis in soft tissue sarcoma in an extremity.

For patients with soft tissue sarcoma in an extremity, the outcome is thought to be poor if lymph node metastasis develops. The purpose of this study was to examine the impact of lymphatic involvement from soft tissue sarcoma on patient survival. Thirty-nine (3.7%) of 1066 patients who had surgery for soft tissue sarcoma in an extremity had lymph node metastases develop. Three (20%) of 15 patients with epithelioid sarcoma, four (19%) of 21 patients with rhabdomyosarcoma, two (11.1%) of 18 patients with clear cell sarcoma, and two (11.1%) of 18 patients with angiosarcoma had lymphatic involvement. Thirty patients who had resection of involved lymph nodes had an estimated 5-year survival of 57%, whereas nine patients treated without surgery all died within 30 months. An estimated 4-year survival of 71% for patients with isolated lymph node metastases was significantly better than 21% for patients with synchronous systemic and lymph node involvement. There was no difference in outcome for patients with isolated lymphatic involvement compared with patients with American Joint Committee on Cancer Stage III extremity sarcomas. These results suggest that long-term survival is possible after surgical resection of lymphatic metastases from soft tissue sarcoma. The American Joint Committee on Cancer should consider separating isolated nodal metastases from systemic involvement in patients with Stage IV sarcoma.

Adolescent↗
PubMed2005

Telemedicine consultation for patients with upper extremity disorders is reliable.

UNLABELLED: Telemedicine is a valuable resource for the delivery of health care to patients in underserved areas. The purpose of this study was to assess the reliability of asynchronous teleconsultation in the diagnosis and establishment of treatment plans for patients with disorders of the upper extremity. One hundred patients with disorders of the upper extremity were prospectively evaluated. Initial patient evaluations, done by an independent evaluator, involved a medical history, physical examination, digital images of the patient, and digitized radiographic studies. This patient information was presented electronically to two hand surgeons 6 months after one surgeon independently evaluated the patients in the outpatient clinic. The physicians formulated diagnosis and treatment plans for the patients based on the blinded electronic information. These findings then were compared with the treatment plans made by the physicians at the time of the patients' visits. Telemedicine consultation resulted in excellent agreement within observers (kappa = .92) and between observers (kappa = .86). Telemedicine consultation seems to be a reliable method for diagnosis and establishment of treatment plans in the management of upper extremity disorders. LEVEL OF EVIDENCE: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consecutive patients--with universally applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Adolescent↗
PubMed2006

Enlargement of cervical spinal cord correlates with improvement of motor function in upper extremities after laminoplasty for cervical myelopathy.

OBJECTIVE: The correlation between postoperative spinal cord enlargement at the most compressive disc level and clinical outcome is controversial. The relationship between spinal cord enlargement at neurologically symptomatic disc level and clinical recovery has not been explored. The purpose of this study was to clarify the relationship between postoperative spinal cord enlargement at neurologically symptomatic disc level and neurologic outcome. METHODS: We studied 55 consecutive patients between 1995 and 2002. All patients underwent preoperative neurologic examination to determine the neurologically symptomatic disc level of the spinal cord and computed tomographic myelography twice before and 4 weeks after laminoplasty. The cross-sectional areas of both spinal cord and dural sac from C3/4 to C7/T1 disc levels were measured on computed tomographic myelography images. The Japanese Orthopedic Association scoring system was used for clinical evaluation before and 1 year after surgery. RESULTS: Total score improved significantly from 10.2+/-2.8 (SD) to 13.0+/-3.0 after operation. Motor and sensory function scores of upper and lower extremities also improved significantly. The enlargement of spinal cord area at the neurologically symptomatic disc level correlated significantly with improvement in motor function scores of upper extremities (rs=0.421 P=0.0052). However, there were no significant relationships between the enlargement of the spinal cord at the most compressive disc level or that at the dural sac and any categories of Japanese Orthopedic Association scoring system. CONCLUSION: Postsurgical enlargement of the cervical spinal cord at the neurologically symptomatic disc level at 4 weeks postoperatively correlated with recovery of motor function of the upper extremities at 1 year.

Cervical Vertebrae↗