Tetraplegia and functional surgery of the upper limb: what anesthesia for what surgery?

Needle aspiration for the treatment of peritonsillar abscess was assessed in 43 consecutive children aged 7 to 18 years (mean age, 13.9 +/- 2.5 years) during the 3-year period from 1988 through 1991. A positive aspirate was obtained in 31 (76%) of the 41 patients who cooperated for needle aspiration; a mean of 2.9 +/- 1.9 mL of pus was withdrawn. Of the 31 children with a positive aspirate, in 27 (87%) the abscess resolved, two (6%) required a second aspiration for resolution, and two (6%) underwent immediate tonsillectomy for persistent abscess. Of the 10 children (24%) with negative aspirations, in six (60%) the abscess resolved with antibiotic treatment alone, three (30%) underwent immediate (quinsy) tonsillectomy, and in one (10%) the abscess spontaneously drained. No bleeding, airway obstruction, or anesthetic complications occurred. Needle aspiration of peritonsillar abscess in children, with tonsillectomy reserved for nonresponders, appears to be an efficacious and safe method of treatment.     

The use of microvascular free flaps in the repair of the skin of the upper limb

Between 1980 and 1992 microsurgical free flaps were used in 35 patients for the repair the of skin defects in the upper limb. Twenty six patients were male and nine female. The scapular flap was done in 16 cases, the lateral flap in seven, the dorsalis pedis in four, the neurovascular first web space in four, the latissimus dorsi in two, the radical forearm flap in one and the gracilis in other one. The survival rate in this series was 88.57%. Early free flaps were performed in 12 patients of whom one developed infection at the recipient site. Two-point discrimination was achieved in four thumbs reconstructed with the neurovascular first web flap. No complications occurred at the donor areas.     

Intrauterine vascular deficiency of the upper limb

We report six cases of intrauterine vascular deficiency of the upper limb, presenting over a 12-year period, with established areas of necrosis at the time of birth. Three of the six mothers were diabetic. An urgent examination of the neonate should be done to exclude occult systemic thomboses, as early anticoagulation or thrombolytic therapy may be indicated. The majority of cases were managed conservatively with dressings and splintage of the limb; exceptionally surgical intervention was required. Long-term sequelae included flexion contractures and shortening of the forearm bones.     

Occupational "cramps" of the upper limb

Problems involving the coordination of movements of the hand analogous to the "writers cramp" have been seen in musicians and other professions. They occur in individuals with muscular imbalance, who assume abnormal body postures affecting not only the involved limb but also the spine and pelvis. These patients also often have a particular psychological make up. Treatment is based on the re-training of their muscular actions and on teaching the patients to avoid assuming abnormal stances or postures.     

Digital necroses of the upper limb. 86 cases

The authors study 86 cases of ischaemic problems affecting the upper limb associated with digital necrosis. They emphasise the wide range of aetiologies encountered and discuss the relationship between this syndrome and the main forms of arterial disease, principally inflammatory, scleroderma appearing to be the dominant though not sole aetiology. The aetiological results are also studied in relation to the extent of the necrosis and the sex of the patient. These data are compared with those found in the literature.     

Dislocations in the upper limb. Traps, tricks and treatment

Dislocations in the upper limb are not always straightforward--they are often poorly diagnosed and managed. Careful examination to detect the total injury and awareness of the pitfalls should ensure that mistakes are avoided.     

Neurologic evaluation of the upper extremity

Symptoms and disease processes can overlap, and neurologic symptoms of the hand or arm are not necessarily due to local pathology. To combat these difficulties, the authors present a basic review of neuroanatomy, the neurologic examination, the principles of electromyography, and the process of formulation.     

Longitudinal sliding of the median nerve during movements of the upper limb

Repeated transfusion of small increments of blood are frequently required for the sick and premature newborn infant to correct endogenous hypovolemia and/or to replace blood obtained for laboratory monitoring purposes. Previously fresh group and type specific whole blood was used. To eliminate waste of fresh whole blood, maintain fresh red blood cell properties, eliminate the hazards of transfusing plasma and to provide a more efficient system, a pediatric frozen red cell pack (PFRCP) has been developed. Units of group O rr red blood cells are glycerolized using a high glycerol method. The glycerolized red blood cells are separated into three equal aliquots and frozen. When needed, the PFRCP are deglycerolized by a modified procedure using the IBM Cell Processor. During a six month period, 71 infants were given 153 separate transfusions of deglycerolized red blood cells using 102 PFRCP prepared from 34 units of red blood cells. Red blood cell recovery, hematocrit, white blood cell removal, residual glycerol, total protein, and supernatant hemoglobin levels were measured. Clinical response was followed and found to be excellent.     

Biomechanical pathology of the upper limb: a new epidemic?

Work-related upper limb disorders are one leading occupational diseases in many industrialized countries. The paper reviews the evidence of work-relatedness of the most common upper limb disorders (namely carpal tunnel syndrome, hand-wrist and shoulder tendinitis, trapezius myalgia, hand hammer syndrome). Attention is drawn to the difference in the number of reported cases in Italy and other countries, assuming, as an underlying cause, underreporting of such conditions in Italy.     

Impairments and compensation in mouth and limb use in free feeding after unilateral dopamine depletions in a rat analog of human Parkinson''s disease

The Montoya Staircase Test has been designed as a simple objective way of measuring changes in skilled movements following motor system damage. In the test, rats reach from a central platform for food pellets located on adjacent staircases and the measure of success is the number of food pellets obtained. As there has been no detailed behavioral analysis of how animals reach in this task, the present study evaluates reaching in the test by combining end point measures (success) with movement analysis based on video recordings. It is found that control rats locate food using olfaction and then reach using an identifiable sequence of movements, including (1) aiming the limb, (2) opening the digits in preparation for grasping, (3) grasping, and (4) supinating the paw, during limb withdrawal, to place food in the mouth. The nonreaching limbs adjust posture during the reaching sequence. Rats with unilateral DA-depletions show (1) severe impairments in success when using their contralateral-to-lesion limb (bad limb), (2) moderate impairments in using their ipsilateral-to-lesion limb (good limb), (3) abnormal reaching movements and posture, and (4) a variety of compensatory movements so as to enhance success. When success produced by compensatory adjustment is subtracted from total success, the DA-depleted rats show no recovery. The results confirm that the Staircase Test is a sensitive measure for motor system damage and demonstrate that when movement analysis is combined with end point measures, the test can dissociate impairment, recovery, and compensation.     

Radiographic and endoscopic evaluation of the upper GI tract

As the U.S. population grows increasingly diverse, health care professionals will need to develop skills that allow them to provide quality care to patients from a variety of racial and ethnic backgrounds. Chief among these skills is the ability to communicate effectively. This article discusses the demographic shifts occurring in the United States today and reviews the concept of cultural diversity. It also presents information about how to communicate with patients from diverse cultural backgrounds.     

The use of implant-supported titanium prostheses for treatment of periodontally compromised patients including functional and orthodontic therapy. Report of 2 cases

Due to its corrosion resistance and biocompatibility, titanium appears to be an alternative material for implant-supported restorations. However, due to technological difficulties, the clinical application of titanium in implant restorations has been limited. Only after recent progress in technology could the clinical use of ceramo-metal titanium restorations be recommended. The therapeutic repertoire for treating patients with missing teeth has been significantly expanded by modern implant methods. Osseointegrated prostheses have become an integral part of restorative therapy also for periodontally compromised dentitions. This article presents 2 case reports for the use of ceramo-metal implant-supported titanium cast prostheses for restorative treatment of periodontally compromised patients requiring comprehensive treatment involving periodontal, functional, orthodontic and prosthodontic therapy. Favourable clinical results have been obtained and a complication-free service of these reconstructions has been documented throughout a 12- to 24-month observation period. These observations suggest that implant-supported ceramo-metal titanium prostheses may be a valuable part of restorative therapy for periodontally compromised dentitions in that they facilitate restorations with optimal biocompatibility. However, controlled clinical studies are needed to establish the long-term serviceability of these titanium restorations.     

Reversible changes of motor cortical outputs following immobilization of the upper limb

Dopa-responsive dystonia (DRD) is no longer a rare oddity. For the clinician, DRD poses a diagnostic challenge as its clinical presentation can be quite diverse. Marked and sustained response to L-dopa is the most crucial and absolute hallmark in confirming a diagnosis. Absence of degenerative nigral cell loss underlies the remarkable L-dopa response. The broadening spectrum of the clinical presentations, progress in molecular genetics with evidence of incomplete penetrance and phenotypic variability, biochemistry, utility of nuclear imaging in differential diagnosis, and treatment are discussed. I propose the concept of DRD as a syndrome, defined as selective nigrostriatal dopamine deficiency caused by genetic defects in dopamine synthesis without degenerative cell loss. I further propose the term DRD-plus, defined as inherited metabolic disorders which have symptomatic features of DRD, and those features not seen in DRD as well.     

Effects of postural changes of the upper limb on reflex transmission in the lower limb. Cervicolumbar reflex interactions in man

The influence of passive changes in upper limb position on the excitability of three myotatic arc reflexes (soleus, quadriceps, and biceps femoris) of the lower limb has been explored on 42 volunteers. The results indicate that the excitability of the three myotatic arcs can be influenced at a distance by postural modifications of the upper limb. When the ipsilateral upper limb is forwards or the contralateral backwards, a facilitation of both soleus and quadriceps tendon reflexes is observed while the biceps femoris reflexes are reduced. This pattern of facilitation and inhibition is reversed when the ipsilateral upper limb is backwards or the contralateral forwards. The facilitations as well as inhibitions of proximal myotatic arc reflexes are quantitatively more marked than that of the soleus reflex. Facilitation and inhibition are not linearly related to the angle of the arm with the trunk. Effects begin at a considerable angle, become maximal at 45 degrees, and progressively disappear for greater values. It is suggested that the distinct pattern of facilitation and inhibition which is exerted in reciprocal fashion on extensor and flexor motor nuclei might depend on the long propriospinal neurones connecting cervical and lumbar enlargements.