Use of digital images to aid in the decision-making for acute upper extremity trauma referral

This study evaluated the use of digital smartphone images in the decision-making for acute upper extremity trauma referrals. Surgeons (n = 15) were presented with ten upper limb trauma scenarios for consideration of immediate transfer. Based on verbal history and with additional images, participants were asked questions regarding diagnosis, injured tissues, recommended management and diagnostic and treatment confidence. Statistical analyses evaluated confidence level changes and relationships between confidence levels and independent variables. Confidence levels for diagnosis and treatment were increased with the provision of smartphone images, and this was statistically significant. The decision to transfer was changed in 22%. The photographs were more useful for amputation versus non-amputation injuries (diagnosis and treatment) and hand versus forearm injuries (diagnosis), and these differences reached statistical significance. Smartphone digital images were shown to be useful for decision-making in acute upper extremity trauma referrals. This improved communication may have implications for health cost savings and patient burden by minimizing unnecessary acute transfers.

LEVEL OF EVIDENCE

Diagnostic Level III.

Patient outcome following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion

This study reports patient outcome following a thoracodorsal to musculocutaneous nerve transfer. We retrospectively reviewed the charts of six patients who had undergone transfer of the thoracodorsal nerve to the musculocutaneous nerve for reconstruction of elbow flexion. The mean age was 47 years (standard deviation: 24 years; range: 17-72 years). The mean time from injury to surgery was 3 months (standard deviation: 2 months; range: 1-5 months). In all cases, the biceps muscle was successfully reinnervated; in one case the Medical Research Council (MRC) muscle grade was grade 5, in four cases it was grade 4, and in one case it was grade 2. No patients complained of functional weakness with shoulder adduction and/or internal rotation. In the majority of cases, transfer of the thoracodorsal nerve to the musculocutaneous nerve provides excellent recovery of elbow flexion.

Evaluation of hand sensibility: a review

Many assessment devices and measures have been described to evaluate sensibility, with little consensus on the optimal measurement tool. The purpose of this paper is to review the assessment methods and devices used in the evaluation of hand sensibility. Consideration is given to the characteristics of each measurement tool, the information necessary for complete patient evaluation, and the battery of valid and reliable measurements that provide the most complete and accurate patient assessment.

Clinical outcome following nerve allograft transplantation

The clinical outcome of seven patients who underwent reconstruction of long upper- and lower-extremity peripheral nerve gaps with interposition peripheral nerve allografts is reported. Patients were selected for transplantation when the nerve gaps exceeded the length that could be reconstructed with available autograft tissue. Before transplantation, cadaveric allografts were harvested and preserved for 7 days in University of Wisconsin Cold Storage Solution at 5 degrees C. In the interim, patients were started on an immunosuppressive regimen consisting of either cyclosporin A or tacrolimus (FK506), azathioprine, and prednisone. Immunosuppression was discontinued 6 months after regeneration across the allograft(s) was evident. Six patients demonstrated return of motor function and sensation in the affected limb, and one patient experienced rejection of the allograft secondary to subtherapeutic immunosuppression. In addition to providing the ability to restore nerve continuity in severe extremity injuries, successful nerve allografting protocols have direct applicability to composite tissue transplantation.

Current approach to cubital tunnel syndrome

The choice for surgical treatment of cubital tunnel syndrome is no clearer today than when it was reviewed 10 years ago. There continue to be no significant prospective randomized trials to adequately compare the different surgical techniques. Even if such a trial were performed, most hand surgeons would probably continue to be skeptical. In the end, each surgeon must rely on his or her own personal experience or judgment. Based on the authors' experience in the treatment of cubital tunnel syndrome, they are confident that anterior transmuscular transposition of the ulnar nerve obtains the best results when the preoperative algorithm is properly applied and early postoperative physical therapy is instituted.

Outcome following implantation of a peripheral nerve stimulator in patients with chronic nerve pain

This study evaluated the usefulness of the implanted peripheral nerve stimulator in patients with pain following injury to a peripheral nerve. The patient sample (n = 17) consisted of 7 men and 10 women with a mean age of 48 years (SD = 18 years). The mean follow-up time since implantation of the stimulator was 21 months (SD = 15 months). Workers' compensation and/or litigation were involved in 11 cases. Peripheral nerve stimulators were placed in the upper extremity in 12 patients and in the lower extremity in 5 patients. Pain relief following implantation was rated as excellent by five patients, good by six patients, fair by four patients, and poor by two patients. A statistically significant decrease in reported pain level was found postoperatively (p < 0.0003). There was no statistically significant difference in postoperative pain level between men and women (p = 0.30), between cases involving workers' compensation or litigation and those not involving these issues (p = 1.0), or between patients who received an upper-extremity implant and those who received a lower-extremity implant (p = 0.56). Of the 12 patients who were unable to work before the operation, 6 returned to work after the operation. In conclusion, peripheral nerve stimulators can be useful in decreasing pain in carefully selected patients with severe neurogenic pain.

Subjective recovery of nerve graft donor site

Nerve graft procedures require the use of a donor nerve to supply the graft material. This results in an area of numbness in a less critical region. The purpose of this study was to assess donor site recovery using patient subjective evaluation. Thirty-one patients (mean age, 38 years) who were at least 2 years past a nerve graft procedure participated in the telephone survey. The mean time since surgery was 65 months. Donor nerves from the lower extremity were utilized in 16 patients and from the upper extremity in 15 patients. The subjective patient evaluations indicated low levels of pain, numbness, and cold sensitivity in the donor nerve sensory distribution. Patient factors, including workers' compensation and legal involvement, did not have a significant effect on recovery at the donor site. Function and daily activity were not affected significantly by donor site factors. Satisfaction with nerve graft recovery was related significantly to reported patient satisfaction of the donor site (p = 0.002).

Nerve transfers. New options for reconstruction following nerve injury

Surgical reconstruction of proximal level nerve repair or long nerve grafts have provided less than optimal results, presenting the opportunity for investigation of alternate reconstructive techniques. Good motor function following an injury to a motor nerve requires a maximal number of motor axons reaching the motor end plate within a critical time period. Nerve transfers eliminate the need for a nerve graft by allowing a direct end to end nerve repair without tension. This article reviews surgical options using nerve transfers for patients with upper and lower extremity nerve injuries.

Utility of vibration thresholds in patients with brachial plexus nerve compression

The diagnosis of brachial plexus nerve compression is controversial due to the subjective nature of patient symptoms and the lack of objective, quantifiable tests. It has been hypothesized that quantitative sensory evaluation of sensory threshold is the most sensitive method of evaluating nerve compression, particularly in the early stages. This study evaluated the sensitivity and specificity of vibration thresholds for detection of brachial plexus nerve compression. A multiple-frequency vibrometer was used to evaluate 40 control subjects and 35 patients with brachial plexus nerve compression. Calculated sensitivity values were modest (0.49 at 63, 250, and 500 cps) with high specificity values (0.98 at 8 cps) for individual frequencies using a fifth percentile criterion. The low sensitivity values indicate that this instrument is not adequate as a screening device.

Multiple nerve entrapment syndromes in office workers

Reports of nerve compression syndromes have been increasing in frequency. The authors discuss evaluation, management, and surgical repair of these multifactorial disorders.

Evaluation of hand sensibility with single and double latex gloves

The purpose of this study was to examine hand sensibility of surgeons wearing single and double latex gloves. Evaluation of hand sensibility, including cutaneous pressure thresholds, moving two-point discrimination, and static two-point discrimination, was performed on 25 surgeons (mean age 45 years). The dominant hand index finger was assessed with no glove, single glove, and double glove. The majority of surgeons had a moving and static two-point discrimination of 2 or 3 mm. The lowest cutaneous pressure thresholds were found when measured with no gloves and increased with single and double gloves. Statistically significant differences in cutaneous pressure thresholds using Semmes-Weinstein monofilaments were found for gloves versus no gloves (p < 0.0003) and single versus double gloves (p = 0.0003). Statistically significant differences in moving two-point discrimination were found for no gloves versus double gloves (p = 0.05) and single versus double gloves (p = 0.02). In conclusion, we found significant differences in hand sensation when measured with single and double gloves.

Surgeons' concern and practices of protection against bloodborne pathogens

OBJECTIVE

To evaluate surgeons' concern regarding risk awareness and behavioral methods of protection against bloodborne pathogen transmission during surgery.

METHODS

A 29-item questionnaire was sent to 914 surgeons from two universities and two surgical societies.

RESULTS

The questionnaire was returned by 768 active surgeons. Slight or moderate concern about contracting human immunodeficiency virus (HIV) was reported by most surgeons; 8% reported extreme concern and 4% reported no concern. In total, 605 surgeons reported having been vaccinated against hepatitis B; surgeons in practice <7 years were most likely to be vaccinated. Most surgeons did not routinely use double gloves: 92 of 768 surgeons reported that they always use double gloves when performing surgery, and 83 reported that they usually use double gloves. There was a statistically significantly higher proportion of surgeons who always or usually use double gloves who also had hepatitis B vaccinations. Most surgeons incorrectly estimated the seroconversion rates with exposure to a patient with HIV (66% incorrect), hepatitis B (88% incorrect), or hepatitis C (84% incorrect). Most surgeons never or rarely report needle-stick injuries, and only 17% always report needle-stick injuries.

CONCLUSIONS

Most surgeons underestimate the risk of bloodborne pathogens and do not routinely use double gloves.

Nerve injury in repetitive motion disorders

Nerve compression in repetitive motion disorders is being recognized with increasing frequency. The pathophysiology of chronic nerve compression spans a broad spectrum beginning with subperineurial edema and progressing to axonal degeneration. These changes depend on the amount and duration of the compressive forces. Certain postures or positions in the upper extremity will increase pressures around certain nerves increasing pressure exposure. Evaluation of these patients with chronic nerve compression should include examination at all levels of potential entrapment in the upper extremity to identify all sites of compression.

Pain responses in patients with upper-extremity disorders

The purpose of this study was to evaluate the relationship between pain response factors and upper-extremity disorders associated with work-related compensable disorders. In this retrospective study, the charts of 113 patients were examined. Compensation was not found to have any statistically significant association with pain levels. The degree of functional overlay in these patients, indicated by pain questionnaire scores, differed only slightly between compensated and noncompensated patients and indicated no significant difference between the 2 groups, except that the compensated group used a higher number of descriptors to describe their pain (p = .0143). These results indicate that compensation affects the verbalization of pain but does not affect the degree of pain experienced. Working status was found to be significantly correlated with a better ability to cope with stress at home, suggesting that employment status may be a more important factor than compensation status in the presentation of these patients.

Evaluation of cutaneous vibration thresholds in medical transcriptionists

This study was designed to determine whether vibration thresholds of transcriptionists varied significantly from the thresholds of individuals not exposed to keyboard activities. Using a multifrequency vibrometer, we obtained vibration threshold values from 31 medical transcriptionists who perform work on computer keyboards and compared them to values obtained from 40 control subjects. Thresholds tended to become more abnormal at higher frequencies, although this difference was statistically significant only at frequencies of 125 Hz, 250 Hz, and 500 Hz in the index and small fingers. Vibration thresholds were not found to increase significantly with age or years of occupation. Vibration thresholds were significantly increased in medical transcriptionists at the higher frequencies, suggesting subtle neural dysfunction.

Quality of life and functional outcome following brachial plexus injury

Thirty-two patients (3 women, 29 men) participated in a mailed questionnaire survey to evaluate long-term subjective, employment, and functional outcome following surgical treatment for brachial plexus injury. The mean age was 37 years and mean postinjury time was 7 years. The main outcome measures were overall life satisfaction, employment status, and the impact of the brachial plexus injury on life domains. Quality-of-life questions were adapted from the interviewer form of the U.S. General Social Survey. Considering overall life satisfaction, 25 patients (78%) reported at least moderate satisfaction and no patients reported extreme dissatisfaction. Ten patients reported that their injury did affect to a great deal their overall quality of life and slightly more than half the patients were employed at the time of the study. These outcomes were not affected by such patient factors as coverage by workers' compensation, litigation, pain, marital status, number of children, educational status, and the degree of functional recovery. These patient factors also did not alter the impact of the injury on overall life satisfaction. In spite of the devastating nature of these injuries, this patient population for the most part reported good quality of life with employment status predicted within the first year following injury.

Repetitive use and static postures: a source of nerve compression and pain

Nerve compression or musculoskeletal diagnoses require consideration of both the repetitive movements and static postures that may be contributing to the problem. Certain postures and positions assumed at home, at work, and during sleep will have three major influences: (1) directly increasing pressure on nerves at entrapment sites; (2) placing muscles in shortened positions so that adaptive muscle shortening may then secondarily compress nerves; and (3) placing some muscles in elongated and weakened positions, resulting in other muscles being over-used, thus creating the cycle of muscle imbalance. Successful management of the patient with upper extremity pain, paresthesia, and numbness should begin with initial identification of all sites that are contributing to the presenting symptoms. Treatment must then be directed toward the sources of nerve compression and musculoskeletal dysfunction. Upper quadrant symptomatology can be alleviated with an appropriate therapy program, even in the patient with chronic symptoms, but only with patient education, compliance with an exercise program, and behavioral modification at home, work, and during sleep.

Long-term follow-up evaluation of cold sensitivity following nerve injury

This article reports the long-term follow-up evaluation (mean, 10 years) findings of 50 patients with upper-extremity peripheral nerve injuries. The most common persistent symptom was cold sensitivity (n = 38), and 33 of 38 patients rated its intensity as moderate or severe. Cold sensitivity typically developed within months after initial injury and resolved in only 2 patients. No significant difference in the incidence of cold sensitivity was found between patients with subjectively normal hand sensation (7 of 11) and those who reported abnormal hand sensibility (31 of 37). A cold sensitivity severity score (CSSS) was determined; a significant relationship was found between the CSSS and the patient's subjective rating of cold sensitivity intensity and change in job status or occupation due to injury (p < or = .02). No significant relationships were found between incidence of cold sensitivity and age, mechanism of injury, smoking, or level of nerve injury. A significant relationship was found between cold sensitivity and digital amputation injuries (p < or = .05). Thus, cold sensitivity is a common sequela following nerve injury and does not decrease over time.

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is the term commonly used to describe patients with symptoms attributed to compression of the brachial plexus and subclavian vein and artery in the region of the thoracic inlet/outlet. TOS remains extremely controversial with respect to its existence, diagnosis, conservative management, and surgical treatment. The diagnosis is based upon clinical evaluation, reproduction of patient symptoms with arm elevation, and the absence of other relevant pathology. Conservative management should be directed towards correction of postural abnormalities and muscle imbalance in the cervicoscapular region. Patient education compliance to a home exercise program and behavioral modification at home, work, and sleep is necessary for a successful outcome. Surgical decompression of the brachial plexus is best achieved through a supraclavicular approach and should be reserved for the few patients in which conservative management has failed to improve symptoms.

Somatosensory evoked potentials fail to diagnose thoracic outlet syndrome

Somatosensory evoked potentials (SEPs) are used in the diagnosis of thoracic outlet syndrome (TOS), even as an indication for surgery. The purpose of this study was to evaluate the use of SEPs in the diagnosis of TOS. Twenty-one patients (mean age, 37 years) with TOS and 23 control subjects (mean age, 34 years) were included. Somatosensory evoked potentials of median and ulnar nerves were measured bilaterally in patients in both a relaxed and arms-elevated provocative position. A three-way analysis of variance showed no significant difference between the interpeak latencies of the TOS and control groups (p = .352). Significant differences were found in testing positions (p = .0014) and nerve tested (p = .001) in both groups. Therefore, this study suggests that SEPs are not helpful in the diagnosis of TOS.

Thoracic outlet syndrome: a current overview

Thoracic outlet syndrome and the surgery associated with this diagnosis have a controversial reputation. The majority of patients with thoracic outlet syndrome seen in the context of the work place will have a multiplicity of components to their symptomatology, including multilevel nerve compression and muscle imbalance of the neck, shoulder, and back. Identification and conservative management of these problems make the necessity for surgery for thoracic outlet syndrome a rare event. Decompression of the brachial plexus, with or without first rib resection, is a technically demanding surgical procedure requiring expertise in peripheral nerve, vascular and thoracic surgery. Evaluation of these patients requires an understanding of neuromuscular physiology and chronic pain syndromes.

Evaluation of the patient with thoracic outlet syndrome

Clinical evaluation is paramount in making the diagnosis of thoracic outlet syndrome. Complaints of paresthesia and numbness will relate to the nerve compression component of thoracic outlet syndrome, whereas the pain associated with this syndrome is largely caused by muscle imbalance in the neck, shoulders, and upper back. Utilization of a pain evaluation scale assists in assessing a functional overlay to the pain complaints. Detailed sensory testing at rest and after provocation of the patient's symptoms with overhead activity will assist in the diagnosis. Radiographic test results are frequently normal in this patient population. By contrast, vascular testing results are frequently abnormal in a normal patient population. Electrodiagnostic tests are useful in ruling out other, more distal nerve entrapments.

Conservative management of thoracic outlet syndrome

Conservative management of thoracic outlet syndrome requires accurate evaluation of the peripheral nervous system, posture, and the cervico-scapular muscles. Patients should be instructed in postural correction in sitting, standing and sleeping, stretching exercises (ie, upper trapezius, levator scapulae, suboccipitals, scalenes, sternocleidomastoid and pectoral muscles), and strengthening exercises of the lower scapular stabilizers beginning in gravity-assisted positions to regain normal movement patterns in the cervico-scapular region. Patient education, compliance to an exercise program, and behavioral modification at home and work are critical to successful conservative management.

Establishing normal values of moving two-point discrimination in children and adolescents

To establish normal values of moving two-point discrimination (2pd) in children and adolescents, bilateral median and ulnar nerve distribution in 313 subjects aged 4 to 18 years was evaluated. A moving 2pd of 2 to 3mm for both the median and ulnar nerve distributions bilaterally was found in 270 subjects. 2% (N = 5) had moving 2pds of 4mm for both right and left median nerve distributions. There was a significant increase in mean age with 2, 3 and 4mm of moving 2pd for median and ulnar nerves bilaterally. There was no significant difference between sexes for ulnar nerves bilaterally or left median nerve. A borderline difference was found between the sexes for the right median nerve. Multivariate logistic regression revealed age as a significant predictor of discrimination for all variables. Significantly more subjects had a moving 2pd of 4mm in the ulnar nerve distribution than in the median nerve distribution.

Hand sensibility measures used by therapists

Sensory evaluations are frequently used to assess patients with functional loss resulting from nerve injury. The results of these tests are routinely utilized by hand surgeons as an indication for conservative management or surgical intervention in the evaluation of surgical outcome and in the determination of disability ratings. Reports in the literature regarding specific tests for sensibility show variation in their application. The purpose of this study was to evaluate which tests are used to evaluate hand sensibility and the techniques of application currently used by hand therapists. Two hundred members of the American Society of Hand Therapists were randomly selected and a survey was sent to these members. The results of this study identify the need to develop standardized protocols for sensory evaluations and the need for therapists to follow the standardized methods for administration of moving and static two-point discrimination, and Semmes-Weinstein monofilaments, if comparisons of results between centers are to be meaningful.

Outcome following conservative management of thoracic outlet syndrome

Conservative management of thoracic outlet syndrome is recommended as the initial treatment of choice, and yet few studies have evaluated patient outcome. This study evaluates patient subjective outcome following conservative management of thoracic outlet syndrome. Forty-two patients (37 women, 5 men), mean age 38 years, participated in a telephone questionnaire. Patients clinically diagnosed with thoracic outlet syndrome who had participated in physical therapy at least 6 months prior to the study were selected. Mean duration of symptoms before treatment was 38 months, and mean follow-up time after therapy was 1 year. Twenty-five patients reported symptomatic improvement, 10 were the same, and 7 had worse symptoms. Sixteen patients reported full work and recreational activities, and 8 patients reported restrictions in both work and recreational activities. Poor overall outcome was related to obesity (p < .04), workers' compensation (p < .04), and associated carpal or cubital tunnel syndrome (p < .04). Neck and shoulder symptoms were improved in 38 patients. Improvement in hand and arm pain was significantly better in those without concomitant distal nerve compression (p < .006).

Subjective outcome following surgical management of lower-extremity neuromas

This study evaluated the long-term subjective outcomes of 19 patients (13 females, six males), following surgical resection and proximal transposition of lower-extremity neuromas. The patient mean age was 49 years (S.D.: 18), with a mean post-injury time of 8 years and post-surgery follow-up of 4 years. Thirteen patients reported symptomatic improvement in pain, and six reported no improvement. Of ten subjects who were unemployed prior to surgery, two returned to work and four retired postoperatively. Preoperatively, 13 patients used analgesic medication and postoperatively, eight reported taking less medication; four had completely stopped taking pain medication. Symptomatic pain relief apparently can be achieved with surgical management of lower-extremity neuromas.

Subjective outcome following surgical management of upper extremity neuromas

Our study used a telephone survey to evaluate long-term subjective outcome of 70 patients with 112 upper extremity neuromas treated surgically. The mean postinjury time before surgery was 9 years. The mean postsurgical followup was 5 years. Fifty-one of the patients were involved with workers' compensation (WC). Forty-five patients reported good relief of pain. Preoperatively, 46 patients were unemployed because of pain; following surgery 18 of these patients returned to work. Of the 54 patients taking analgesic medication preoperatively, 19 reported less and 10 reported no postoperative analgesic use. No significant difference was found in gender, postinjury time, postsurgical followup time, number of previous surgeries for pain relief, or site of nerve injury between patients who reported improvement versus no symptomatic improvement. Poor subjective outcome occurred in patients (p < .03), with 16 out of 19 of those not involved with WC reporting good pain relief as compared to 29 out of 51 of WC patients.

Provocative testing for cubital tunnel syndrome

This prospective study evaluated the clinical usefulness of provocative testing in 32 subjects with electrodiagnostically proven cubital tunnel syndrome and 33 control subjects. Four provocative tests were included: Tinel's sign, elbow flexion, pressure provocation, and combined elbow flexion and pressure provocation. The mean age of the control group was 41 years and 46 years for the group with cubital tunnel syndrome. In the control group, provocative tests were rarely positive. In 44 extremities with cubital tunnel syndrome, 31 had a Tinel's sign, 33 had a positive elbow flexion test, 39 had symptoms with pressure only, and 41 had symptoms with a combination of pressure provocation and elbow flexion testing. The sensitivity of the Tinel sign was 0.70, and at 30 seconds, the sensitivities of the other provocative tests were: elbow flexion (0.32), pressure provocation (0.55), and pressure-flexion test (0.91). The most sensitive provocative test in the diagnosis of cubital tunnel syndrome was elbow flexion when combined with pressure on the ulnar nerve.

Subjective and employment outcome following secondary carpal tunnel surgery

Forty-five patients (50 hands) who had undergone secondary carpal tunnel surgery participated in a telephone questionnaire survey. The mean follow-up time from the second carpal tunnel surgery was 31 months (range, 9-92 mo). Only 24 patients (53%) reported significant improvement in their symptoms. Thirty-nine patients were unemployed workers who had experienced an average time off work of 28.7 months (+/- 4) before their secondary carpal tunnel surgery. Eleven of the 39 previously unemployed workers (28%) returned to work after the secondary carpal tunnel surgery. Factors associated with poor subjective and employment outcome included worker's compensation case involvement (p < 0.003). Occupations associated with repetitive hand movements or vibrating tools were associated with poor employment outcomes (p < 0.006). Although secondary surgery for carpal tunnel syndrome can be effective in relieving symptoms, patients and surgeons must have realistic expectations of the procedure, especially with respect to long-term employment goals.

Correlation of two-point discrimination and hand function following median nerve injury

Two-point discrimination (2pd) (moving and static) and object identification were assessed in 43 patients after median nerve repair and graft in the middistal forearm. The mean age was 37 years (range, 16-78 yr). Twenty-six patients underwent primary median nerve repair and 17 had secondary median nerve grafts. The minimum follow-up time was 2 years. The values of moving 2pd and static 2pd ranged from 2 to > 16 mm. Both moving 2pd and static 2pd had strong correlational relationships with hand function as measured by object identification. Correlation coefficients for the relationship between 2pd (moving and static) and total objects identified ranged from 0.66 to 0.74.

Occupational exposure to hand vibration in northern Ontario gold miners

Nineteen underground gold mine drillers who operate vibration equipment and a control group of 16 gold mill workers without vibration exposure were evaluated. Assessment included static two-point discrimination, moving two-point discrimination, vibration threshold, and cutaneous pressure threshold. Provocative tests, including Tinel, pressure, and Phalen signs, were performed at the carpal and cubital tunnels. Mean age of the miners was 35 years, and the mean age of the control group was 31 years. The mean time of vibration exposure was 14 years. Numbness, pain, and weakness was reported in 12 miners and 1 control subject. Symptoms of vibration white finger were found in 16 miners and 3 control subjects. The miners had a higher incidence of positive provocative tests at the carpal and cubital tunnels and higher cutaneous pressure thresholds than the control group. Significantly higher vibration thresholds were found in the miners versus the control subjects. A correlation between years of vibration exposure and vibration threshold was found.

Duration of contact time alters cutaneous pressure threshold measurements

Semmes-Weinstein monofilaments (SWMs) are standard measures used to assess hand sensibility. The purpose of this study was to evaluate the effect of varying contact time on the measurement of cutaneous pressure thresholds. Thirty-two healthy adult subjects were evaluated with a 20-filament SWM test kit. The index finger of the dominant hand was assessed with the following four distinct monofilament contact times: 0.5, 1.5, 5.0, and 30.0 seconds. With increased duration of monofilament contact time, there was a significant increase in the cutaneous pressure threshold measures (p < 0.05). That is, to perceive a stimulus for a longer period of time, a heavier filament was required. With increasing age, significantly higher pressure thresholds were obtained particularly for the sustained contact time (> 5.0 seconds). Pressure thresholds vary significantly with SWM contact time, emphasizing the importance of maintaining a consistent SWM application protocol.

Facial sensibility in patients with unilateral facial nerve paresis

This study evaluated facial sensibility in 29 patients with unilateral lower motoneuron facial nerve paresis using standard clinical tests of sensory evaluation used at other anatomic sites, most commonly the hand. Vibratory and cutaneous pressure thresholds and moving and static two-point discrimination were measured. Statistically significant differences were found between the affected and unaffected sides of the face, with vibration threshold, cutaneous pressure threshold, and static two-point discrimination being greater on the affected side. Vibration thresholds and two-point discrimination (moving and static) progressively decreased, moving down the face from the forehead to the cheek, chin, and then the lip. Sensibility thresholds are altered in patients with unilateral lower motor neuron facial nerve paresis. These findings document a relationship between sensory disturbance and lower motoneuron facial nerve paresis. The potential functional significance of this relationship has clinical significance for patients undergoing rehabilitation training.

Establishment of reliability in the evaluation of hand sensibility

Evaluation of hand sensibility using measures of threshold and tactile discrimination are standard assessment methods following nerve injury. Many of the available sensory measures for the quantification of hand sensibility lack verification of intertester reliability. Intertester reliability of vibration threshold, cutaneous pressure threshold, two-point discrimination, object identification, and texture identification was established. The intraclass correlation coefficient ranged from 0.96 to 0.99 for all variables except texture identification (r = 0.77). Comparisons were made between the sensory measures and each functional measure. The strongest correlational relationship was between two-point identification and object identification. Based on the results of this study, evaluation of hand sensibility may be attained with measurement of vibration and cutaneous pressure threshold, two-point discrimination, and object identification.

Development of a new measure of fine sensory function

With the loss of sight, the blind individual must rely on tactile senses for function, and yet assessment of hand sensibility is not routinely integrated into evaluations of the blind. The available sensory measures lack the sensitivity to differentiate higher levels of hand sensibility, and therefore, a new more sensitive measure of fine sensory function was developed. A 3 x 3 braille dot cell was developed, and pattern variation was utilized to assess higher discriminatory abilities. Thirty blind and sighted subjects were evaluated, and intertester reliability of fine sensory function (braille pattern identification) was established (r = 0.95). Comparison between braille identification and measures of threshold and innervation density revealed the strongest correlational relationship with two-point discrimination. This study supports the assessment of fine sensory function with braille pattern identification.

Evaluation of patients with thoracic outlet syndrome

This prospective study evaluated 50 patients with thoracic outlet syndrome. Detailed history and pain scale evaluation preceded physical examination, which included provocative tests (positional and compressive) and sensory evaluation (baseline and postprovocative vibration thresholds and two-point discrimination). Only one patient had a positive nerve conduction study/electromyograph at the brachial plexus level. Thirty-two percent of the patients had a compressive anatomic abnormality as seen on a computed tomography scan. Ninety-four percent had positive provocative position and compression test results. Two-point discrimination was normal in 98%. Clinical assessment of thoracic outlet syndrome is best achieved by reproduction of symptoms with compression and positional provocative testing. Results of the majority of tests (nerve conduction studies/electromyographs, x-ray films, sensory tests) will be normal. Measurements of changes in sensory thresholds during provocation of symptoms may be useful.

Verification of the pressure provocative test in carpal tunnel syndrome

Three provocative tests (pressure, Phalen's test, and Tinel's sign) were studied in 30 patients with carpal tunnel syndrome and 30 control subjects. The pressure provocative test had a sensitivity of 100%. In contrast, Phalen's test was 88% sensitive and Tinel's sign only 67% sensitive. The pressure provocative test is a sensitive indicator of median nerve compression at the wrist with a faster reaction time than Phalen's test (mean time of 9 seconds vs 30 seconds). It is an appropriate provocative test in patients with stiff or painful wrists when wrist flexion is restricted.

Provocative sensory testing in carpal tunnel syndrome

This study reports the relationship between three clinical tests in the diagnosis of carpal tunnel syndrome and the stages of nerve compression. Assessments of 158 patients with carpal tunnel syndrome were reviewed retrospectively. 77% of patients had at least one of the clinical signs present. The incidence of positive pressure-provocative and Phalen's tests were similar and more likely to occur in combination than separately. Tinel's sign was more likely to be positive in the later stages of nerve compression. Our results suggest that the presence or absence of a provocative test is dependent upon the severity of the nerve compression.

Sensory recovery after median nerve grafting

Fourteen patients were evaluated prospectively after median nerve grafts. Twelve male and two female patients with a mean age of 41 years were included. Mean time since surgery was 4 years. Detailed sensory evaluations were completed. Statistical evaluation analyzed relationships between object identification, sensory tests, and graft length. According to the S-0 to S-4 grading system, 11 patients were considered to be S-3+ or greater. Recovery of moving two-point discrimination of 2 to 3 mm. was achieved by 50% of the patients. Strong correlations were found between object identification and static two-point discrimination, moving two-point discrimination, and graft length. Cutaneous pressure threshold and vibration threshold correlated weakly with object identification.