Effects of standing on typing task performance and upper limb discomfort, vascular and muscular indicators

Standing is a popular alternative to traditionally seated computer work. However, no studies have described how standing impacts both upper body muscular and vascular outcomes during a computer typing task. Twenty healthy adults completed two 90-min simulated work sessions, seated or standing. Upper limb discomfort, electromyography (EMG) from eight upper body muscles, typing performance and neck/shoulder and forearm blood flow were collected. Results showed significantly less upper body discomfort and higher typing speed during standing. Lower Trapezius EMG amplitude was higher during standing, but this postural difference decreased with time (interaction effect), and its variability was 68% higher during standing compared to sitting. There were no effects on blood flow. Results suggest that standing computer work may engage shoulder girdle stabilizers while reducing discomfort and improving performance. Studies are needed to identify how standing affects more complex computer tasks over longer work bouts in symptomatic workers.

Postural Compression of Subclavian Vein in Droopy Shoulder Syndrome

A patient with droopy shoulder syndrome (DSS) presented postural symptoms of venous compression of the left upper limb, in addition to those of traction at the brachial plexus. An antegrade phlebography clearly demonstrated impaired patency of the subclavian vein on neck extension. Recognition and management of the compromised venous drainage in patients with DSS is important in preventing vascular complications of the upper limbs.

Determination of Functional Outcome Following Upper Extremity Arterial Trauma

Upper extremity arterial trauma may lead to significant disability with a poor functional outcome. This study represents a retrospective review of all trauma patients presenting to a university-affiliated medical center. Patients suffering from upper extremity arterial injuries requiring treatment were identified. The injured vessels were identified along with the mechanism of injury and method of repair. The degree of functional disability was evaluated by using a previously validated questionnaire, the Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure. Between September 1999 and December 2004, 17 patients presented with traumatic arterial injury to the upper extremity, with 9 and 8 patients suffering from blunt and penetrating traumas, respectively. One patient required amputation representing a limb salvage rate of 94%. The mean length of hospitalization was significantly shorter for penetrating trauma (5.1 vs 12 days, P = .03), with blunt trauma victims being more prone to coexisting orthopedic injuries ( P = .009). Length of follow-up did not differ between the 2 groups and ranged from 1-60 months. Patients with blunt trauma tended, although not statistically significant, to have higher DASH scores (61.8 vs 22.8, P = .08), indicating a greater degree of disability. By utilizing a validated disability questionnaire, this study confirms that patients suffering from blunt injuries to upper extremity arteries are more likely to have greater degrees of disability affecting everyday activities.

The Sternomastoid Branch of the Occipital Artery: A Surgical Landmark for the Spinal Accessory Nerve in Selective Neck Dissections

OBJECTIVE: To evaluate the anatomic relationship between the spinal accessory nerve (SAN) and the sternomastoid branch of the occipital artery (SBOA) and its utility as a surgical landmark during a selective neck dissection (SND).

STUDY DESIGN AND SETTINGS: Consecutive patients undergoing SND for squamous cancer from October 1, 2004 to February 28, 2005 were enrolled in this study. During surgery the distance between the SBOA and the point of insertion of the SAN into the sternomastoid muscle (SMM) was measured.

RESULTS: Twenty-four patients underwent 33 SND. The distance between the SBOA and SAN ranged between 1 and 11 mm, with a mean of 6.2 mm and a median of 6 mm.

CONCLUSION: The relationship between these 2 structures has a range and constancy that is acceptable as a landmark.

SIGNIFICANCE: This article presents a useful adjunct for location of the SAN in the anterior neck during SND.

EBM RATING: C

The variable morphology of suprascapular nerve and vessels at suprascapular notch: a proposal for classification and its potential clinical implications

PURPOSE

The most common place for suprascapular nerve entrapment is the suprascapular notch. The aim of the study was to determine the morphological variation of the location of the suprascapular nerve, artery and vein, and measure the reduction in size of the suprascapular opening in each type of the passage.

METHODS

A total of 106 human formalin-fixed cadaveric shoulders were included in the study. After dissection of the suprascapular region, the topography of the suprascapular nerve, artery and vein was evaluated. Additionally, the area of the suprascapular opening was measured using professional image analysis software.

RESULTS

Four arrangements of the suprascapular vein, artery and nerve were distinguished with regard to the superior transverse scapular ligament: type I (61.3 %) (suprascapular artery was running above ligament, while suprascapular vein and nerve below it), type II (17 %) (both vessels pass above ligament, while nerve passes under it), type III (12.3 %) (suprascapular vessels and nerve lie under ligament) and type IV (9.4 %), which comprises the other variants of these structures. Statistically significant differences regarding the suprascapular opening were observed between the specimens with types II and III. Anterior coracoscapular ligaments were present in 55 from 106 shoulders.

CONCLUSION

The morphological variations described in this study are necessary to better understand the possible anatomical conditions which may promote suprascapular nerve entrapment (especially type III). They may be useful during open and endoscopic procedures at the suprascapular notch to prevent such complications as unexpected bleeding.

[Anatomy typological and clinical parallels in case of disturbance of soft tissue formations of shoulder girdle]

The influence of anthropology on topographical anatomical structure peculiarities of soft tissue formations of shoulder girdle has been investigated. The dependence of anatomical structure and topography of muscles, ligaments, tendon sheaths, synovial bursae, rotator cuffs on patient's body constitution type has been examined. The influence of a somatotype on topical damage of soft tissue structures of shoulder girdle has been proved. The so-called "holes" or weak areas, joint capsules, places where ligaments attach to bones and cartilages, where vascular formations also take place have been revealed. It is in these areas that degenerative inflammatory process begins. First of all this process influences hemolymph circulation, then it results in disturbance in production and resorption of synovial fluid and causes destructive processes in ligaments, tendons and osteochondral tissue. Due to research the ability to conduct differential diagnosis has been determined, methods of modality treatment and prevention of periarticular tissue diseases have been optimized.

Isolated shoulder palsy due to infarction of the cortical branch of the middle cerebral artery

A 71-year-old man with hyperlipidemia abruptly developed left-sided isolated shoulder palsy. Cranial magnetic resonance imaging demonstrated infarction of the cortical branch of the right middle cerebral artery (MCA). In the primary motor cortex, there is broad somatotopic representation of various body parts in a particular arrangement, and the area corresponding to the shoulder is very small. Consequently, there have been only 3 reported cases of isolated shoulder palsy due to cerebral infarction, and its vascular supply remains uncertain. The present case indicates that the corresponding area to the shoulder receives its blood from the cortical branch of the MCA.

A rare case report of subscapular artery

Axillary artery is one of the most important arteries of the upper limb, which is a continua- tion of the subclavian artery. It begins at the lateral border of the first rib and ends at the inferior border of the teres major where it becomes the brachial artery. Axillary artery has six important branches included: 1) Superior thoracic artery 2) Thoracoacromial artery 3) Lateral thoracic artery 4) Subscapular artery 5) Posterior circumflex humeral artery 6) Anterior circumflex humeral artery. Subscapular artery arises from the third part of axillary artery normally and then divides into cir- cumflex scapular artery that extremely enters the triangular space. The other branch of subscapular artery, the thoracodorsal artery, accompanies thracodorsal nerve to lateral border of scapula and supplies and innervates that region. In this case the subscapular artery was absent in both sides and instead of that the circumflex scapular artery was directly derived from axillary artery and the thoracodorsal artery is separated from circumflex scapular artery as a thin and short branch, too. It seemed that the lateral thoracic artery, which was thicker than its normal condition, supplied the muscles of the lateral part of scapula and the thoracodorsal muscle. Other branches of the axillary artery demonstrated without any abnormally. Since axillary artery has the highest rate of rapture and damage coming after the popliteal artery, knowing the variations is important and essential for surgeons, radiologist and anatomist.

[Selectivity of photothermolysis in the treatment of port wine stains using multiple pulses with a pulsed dye laser]

BACKGROUND

In 25 % to 50 % of patients with port wine stains treated with pulsed dye laser (even in multiple sessions), only a partial improvement is obtained that is often unsatisfactory for the patient. Various factors have been proposed to explain the resistance to treatment, such as the presence of deep, small-caliber, or very thick vessels that cannot be coagulated with a single laser pulse. Certain mathematical models suggest that multiple pulses would be effective in coagulating those vessels without losing the selectivity of photothermolysis, since more energy could be delivered to the target structures without damaging the surrounding tissue. The aim of this study was to assess the efficacy and selectivity of photothermolysis with multiple laser pulses.

METHODS

Twelve patients with port wine stains were included in the study. Various areas of each lesion were treated with pulsed dye laser (Candela V-beam, 595 nm) using different parameters. Immediately afterwards, the treated areas were biopsied.

RESULTS

The risk of exceeding an appropriate dose was greater with small spot size, long pulse duration, short intervals between pulses, and high fluences. Heat damage was less with spots of 10 mm, short pulses, intervals of 1 minute between pulses, and low fluences. In selected cases, multiple pulses were effective and selective where single pulses did not successfully coagulate the vessels.

CONCLUSIONS

Our results indicate the enormous possibilities of multiple laser pulses for the treatment of refractory vascular lesions. In addition, we have addressed the variables defining the complex thermodynamic interaction between the laser and the cutaneous tissue and indicated the safest parameters. We discuss the possible usefulness of this approach with other lasers and skin diseases.

The subscapular artery and the thoracodorsal branch: an anatomical study

The motive for this research was the use of the muscles of the scapular region in transposition, transplantation and reparative surgery and the need for more detailed knowledge of the blood supply to these muscles. In addition, the subscapular arterial tree may be used as a source of microvascular grafts to replace damaged or diseased portions of arteries, particularly in the hand and forearm. The research was conducted on 60 sides of corpses of adults of both sexes. It was noticed that the subscapular artery was present in 96.7% of cases and originated laterally to the pectoralis minor muscle in 76.7% of cases. The average calibre was 5.0 mm, and in 73.2% of cases it measured between 4.0 and 5.9 mm. The average length was 18.0 mm, ranging from 10.0 to 29.9 mm (76.7%). It presented in its course important relations with the axillary nerve (69%) and with the radial nerve (82.8%). Its branches were collateral (subscapular muscle - 61.3%) and terminal (except for the circumflex scapular artery), leading to the following muscles: serratus anterior (43.9%), latissimus dorsi (27.6%), and subscapular (23.3%). The thoracodorsal artery, one of the terminal branches, most frequently showed a calibre of between 2.0 and 3.9 mm (70.3%), collateral branches in 85.0%, was mainly distributed to the subscapular muscle (36.7%) and to the serratus anterior muscle (29.0%) and had terminal branches to the following muscles: latissimus dorsi (44.1%), serratus anterior (40.5%) and the subscapular (12.5%). The serratus anterior muscle received one branch in 39.5% and two branches in 41.9%, while the latissimus dorsi muscle received one branch in 66.7% and two branches in 23.1%.

The clinical anatomy of the cephalic vein in the deltopectoral triangle

Identification and recognition of the cephalic vein in the deltopectoral triangle is of critical importance when considering emergency catheterization procedures. The aim of our study was to conduct a cadaveric study to access data regarding the topography and the distribution patterns of the cephalic vein as it relates to the deltopectoral triangle. One hundred formalin fixed cadavers were examined. The cephalic vein was found in 95% (190 right and left) specimens, while in the remaining 5% (10) the cephalic vein was absent. In 80% (152) of cases the cephalic vein was found emerging superficially in the lateral portion of the deltopectoral triangle. In 30% (52) of these 152 cases the cephalic vein received one tributary within the deltopectoral triangle, while in 70% (100) of the specimens it received two. In the remaining 20% (38) of cases the cephalic vein was located deep to the deltopectoral fascia and fat and did not emerge through the deltopectoral triangle but was identified medially to the coracobrachialis and inferior to the medial border of the deltoid. In addition, in 4 (0.2%) of the specimens the cephalic vein, after crossing the deltopectoral triangle, ascended anterior and superior to the clavicle to drain into the subclavian vein. In these specimens a collateral branch was observed to communicate between the cephalic and external jugular veins. In 65.2% (124) of the cases the cephalic vein traveled with the deltoid branch of the thoracoacromial trunk. The length of the cephalic vein within the deltopectoral triangle ranged from 3.5 cm to 8.2 cm with a mean of 4.8+/-0.7 cm. The morphometric analysis revealed a mean cephalic vein diameter of 0.8+/-0.1 cm with a range of 0.1 cm to 1.2 cm. The cephalic vein is relatively large and constant, usually allowing for easy cannulation.

Initial post-fracture humeral head ischemia does not predict development of necrosis

We evaluated the functional outcome and the occurrence of avascular necrosis in 51 consecutive patients (26 women) with intracapsular fractures of the proximal humerus treated with open reduction and internal fixation between February 1998 and December 2001. Mean age was 44 years (range, 21-60 years). Forty-one heads were initially perfused (group A), and 10 were ischemic (group B). Seven patients were lost to follow-up. Forty-four were evaluated using the Constant-Murley score and the Subjective Shoulder Value; 40 patients consented to a radiographic evaluation. The mean follow-up was 5 years (range, 3.3-7.3 years). In group A, 20 of 30 heads had no sign of structural alterations, 6 had signs of structural alterations of the cancellous bone, and 4 showed collapse of the subchondral bone plate of varying degrees. In group B, 8 of 10 heads were structurally altered, and 2 had collapsed. The median uncorrected Constant-Murley score was 80 (range, 37-98) for patients without structural alterations, 81 (range, 53-93) for patients with structural alterations, and 68 (range, 48-74) for patients with collapsed heads. The median Subjective Shoulder Value was 95 (range, 50-100), 90 (range, 50-100), and 55 (range, 40-80), respectively. Eight of 10 initially ischemic heads did not develop avascular necrosis, indicating that revascularization may indeed occur. The reason for late necrosis in some of the initially perfused heads remains unclear. Collapse was associated with a significantly worse clinical outcome. We conclude that osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained.

Effect of mechanical compression due to load carrying on shoulder muscle fatigue during sustained isometric arm abduction: an electromyographic study

The use of surface electromyography (EMG) for studying the effect of mechanical compression of occupational origin on muscle fatigue has been the subject of poor attention in ergonomic research. This study examined the effect of backpack carrying on fatigue of two shoulder muscles during sustained low force static contraction: the middle deltoid (MD) muscle and the upper trapezius (UT) muscle on which the backpack strap exerted direct compressive force. EMG activities of MD and UT muscles, of the dominant and non-dominant sides, were studied on eight subjects during two tasks, a maximal and an exhausting submaximal bilateral isometric 90 degrees arm abduction, which were performed while carrying a backpack load of 0, 10, and 20 kg, respectively. EMG amplitude (root mean square, RMS) and spectral (mean power frequency, MPF) parameters were computed from the recorded signals. No significant differences between the dominant and non-dominant sides were found for none of the parameters whatever the load-carrying mass. Load-carrying masses which were tested did not influence significantly the maximal bilateral arm abduction performance contrary to the time to exhaustion during the submaximal task, which decreased significantly with increasing load-carrying mass. A significant increase in fatigability, defined by the slope of MPF decrease, was observed for both muscles when load-carrying mass increased; but only UT presented a significant increase in muscle fatigue level, defined by the MPF value with respect to its initial value, at the end of the exhausting submaximal task. Furthermore, the increase in muscle activation of UT, quantified by RMS, during the exhausting task was not significantly higher with increasing load-carrying mass. So, the increased signs of local fatigue of UT may be interpreted by a localised blood flow impairment resulting from the direct compressive force exerted by backpack on this muscle.

Combined approach to a peripheral congenital arteriovenous malformation: surgery and embolization

A 28-year-old woman with a complex peripheral congenital arteriovenous malformation in the left shoulder and left upper arm was treated by a combination of surgery and embolization. In the consecutive four operations, the major feeding arteries of the arteriovenous malformation were ligated, but as her complaints increased, transcatheter embolization was planned for releaving the symptoms in the first aspect. A total of eight embolization sessions were performed with Onyx during the 3-year period. The arteriovenous communications were occluded by embolization, with approximately more than an 80% decrease in the lesion size angiographically. After these interventions, the patient's symptoms improved clinically and dyspnea was lessened. Peripheral congenital arteriovenous malformation is a rare and therapeutically challenging condition in which a combination of surgery and embolization would be necessary to obtain a good result.

Arterial supply of the glenoid: an anatomic study

Surgery is performed on the glenoid for a variety of pathologic conditions, and an adequate blood supply is required to achieve good healing of soft tissue and bone. The objective of this investigation was to study the arterial supply of the glenoid in 24 fresh human cadaveric specimens. The vascular supply originates from branches of the anterior and posterior circumflex arteries and the suprascapular artery and branches directly from the infraspinatus and teres minor muscles. The antero-superior portion of the glenoid is poorly vascularized, with a specific area that is completely devoid of blood supply. In addition, circumferentially around the glenoid rim, there is an area of approximately 5 mm from the edge that is completely devoid of vascularity. Adequate bone and soft-tissue healing in the glenoid, particularly in its anterosuperior portion, after fracture repair, osteotomy, total shoulder arthroplasty, and capsular procedures may be compromised by the demonstrated hypovascularity.

Low-energy arterial injury at the shoulder with progressive or delayed nerve palsy

We describe 20 patients, aged between 43 and 88 years, with delayed nerve palsy or deepening of an initial palsy caused by arterial injury from low-energy injuries to the shoulder. The onset of palsy ranged from immediately after the injury to four months later. There was progression in all the patients with an initial partial nerve palsy. Pain was severe in 18 patients, in 16 of whom it presented as neurostenalgia and in two as causalgia. Dislocation of the shoulder or fracture of the proximal humerus occurred in 16 patients. There was soft-tissue crushing in two and prolonged unconsciousness from alcoholic intoxication in another two. Decompression of the plexus and repair of the arterial injury brought swift relief from pain in all the patients. Nerve recovery was generally good, but less so in neglected cases. The interval from injury to the repair of the vessels ranged from immediately afterwards to 120 days. Delayed onset of nerve palsy or deepening of a nerve lesion is caused by bleeding and/or impending critical ischaemia and is an overwhelming indication for urgent surgery. There is almost always severe neuropathic pain.

Anatomy of Y-Shaped Configurations in the Subscapular Arterial System and Clinical Application to Harvesting Flow-Through Flaps

BACKGROUND

A flow-through flap is useful in cases where the recipient artery must not be sacrificed. The aim of this study was to investigate Y-shaped configurations in the subscapular arterial system that can safely be used in harvesting a flow-through flap from the scapular region.

METHODS

Sixteen dissections of the subscapular arterial system were carried out in eight embalmed cadavers. The origins and external diameters of branches in the subscapular arterial system were recorded. The distances between the origins of each branch were measured.

RESULTS

The branches that showed a consistent presence and had a reliable diameter of more than 1.0 mm were the circumflex scapular artery, the bony branch of the circumflex scapular artery, the thoracodorsal artery, the angular branch, and branches to the serratus anterior and latissimus dorsi muscles. It was demonstrated that using the Y-shaped configuration between these branches enables the harvesting of a flow-through flap in various length versions of the Y-shaped vascular pedicles. A significant anatomical variation (i.e., both the thoracodorsal and circumflex scapular artery arose directly from the axillary artery) was found in three of 16 dissections. In this vascular variation, sacrificing the axillary artery must be avoided, so Y-shaped pedicles using the origin of the thoracodorsal or circumflex scapular artery cannot be created. On the basis of these results, flow-through flaps using this arterial system were applied in 10 patients for reconstruction of lower extremities, and satisfactory results were obtained.

CONCLUSIONS

The results of our study are available for determining preoperatively and intraoperatively which Y-shaped configuration to use in harvesting a flow-through flap from the scapular region.

The Effects of Interscalene Brachial Plexus Block on Humeral Arterial Blood Flow: A Doppler Ultrasound Study

In this study we investigated and quantified the effects of interscalene block (ISB) on humeral arterial blood flow (HBF). Eleven patients scheduled for shoulder arthroscopic surgery under ISB were prospectively studied. A Doppler ultrasound of the humeral artery was performed before, and 30 min after, the ISB. The resistance index and the HBF were measured at the level of the midpoint of the upper arm. The median (interquartile range) of resistance index decreased from 0.98 (0.95-1.00) to 0.81 (0.77-0.91) (P < 0.01). The median HBF increased from 32 (18-46) to 88 (59-98) mL/min (P < 0.01). We conclude that ISB enhances arterial blood flow and decreases arterial resistance.

Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work-related trapezius myalgia

Needle stimulation (acupuncture) has recently been shown to increase blood flow in the tibialis anterior muscle and overlying skin in healthy subjects (HS) and patients with fibromyalgia (FM). The aim of the present study was to examine the effect of needle stimulation on local blood flow in the trapezius muscle and overlying skin in HS and two groups of patients suffering from chronic pain in the trapezius muscle, i.e., FM and work-related trapezius myalgia (TM) patients. Two modes of needling, deep muscle stimulation (Deep) and subcutaneous needle insertion (SC), were performed at the upper part of the shoulder and blood flow was monitored for 60 min post-stimulation. Blood flow changes were measured non-invasively by using a new application of photoplethysmography. Increased blood flow in the trapezius muscle and overlying skin was found in all three groups following both Deep and SC. In HS, Deep was superior to SC in increasing skin and muscle blood flow, whereas in FM, SC was as effective as, or even more effective, than Deep. In the severely affected TM patients, no differences were found between the stimuli, and generally, a lesser blood flow response to the stimuli was found. At Deep, the muscle blood flow increase was significantly larger in HS, compared to the two patient groups. Positive correlations were found between muscle blood flow at Deep and pressure pain threshold in the trapezius muscle, neck movement and pain experienced at the stimulation, and negative correlations were found with spontaneous pain-related variables, symptom duration and age, pointing to less favorable results with worsening of symptoms, and to the importance of nociceptor activation in blood flow increase. It was hypothesized that the different patterns of muscle blood flow response to the needling may mirror a state of increased sympathetic activity and a generalized hypersensitivity in the patients. The intensity of stimulation should be taken into consideration when applying local needle stimulation (acupuncture) in order to increase the trapezius muscle blood flow in chronic pain conditions.

Downhill running: a model of exercise hyperemia in the rat spinotrapezius muscle

To utilize the rat spinotrapezius muscle as a model to investigate the microcirculatory consequences of exercise training, it is necessary to design an exercise protocol that recruits this muscle. There is evidence that the spinotrapezius is derecruited during standard treadmill exercise protocols performed on the uphill treadmill (i.e., 6° incline). This investigation tested the hypothesis that downhill running would effectively recruit the spinotrapezius muscle as assessed by the presence of an exercise hyperemia response. We used radioactive 15-μm microspheres to determine blood flows in the spinotrapezius and selected hindlimb muscles of female Sprague-Dawley rats at rest and during downhill (i.e., −14° incline; 331 ± 5 g body wt, n = 7) and level (i.e., 0° incline; 320 ± 11 g body wt, n = 5) running at 30 m/min. Both level and downhill exercise increased blood flow to all hindlimb muscles ( P < 0.01). However, in marked contrast to the absence of a hyperemic response to level running, blood flow to the spinotrapezius muscle increased from 26 ± 6 ml·min−1·100 g−1 at rest to 69 ± 8 ml·min−1·100 g−1 during downhill running ( P < 0.01). These findings indicate that downhill running represents an exercise paradigm that recruits the spinotrapezius muscle and thereby constitutes a tenable physiological model for investigating the adaptations induced by exercise training (i.e., the mechanisms of altered microcirculatory control by transmission light microscopy).

Technique of forequarter (interscapulothoracic) amputation

In the anterior approach to forequarter amputation, a segment of clavicle is removed and early dissection and division of the subclavian vessels are done. In the posterior approach after division of the trapezius and muscles attached to the vertebral border of the scapula, the trunks of the brachial plexus and the subclavian vessels are serially ligated and divided, while the pectoral muscles are intact. In both approaches, the dissection around the subclavian vessels can be slow and tedious to avoid bleeding, which could be difficult to control because the vessels have not been cleared circumferentially for application of a vascular clamp. Our technique combines an anterior and a posterior approach, which rapidly divides all the relevant muscles and clavicle, and leaves at the end the division of the nerves and subclavian vessels as the extremity is gently supported to avoid undue traction on the vessels. The trunks of the brachial plexus are divided posteriorly and the subclavian vessels at the thoracic inlet, allowing a greater proximal margin than that achieved by the anterior or posterior approach. When extra skin has to be removed from the axilla because of tumor involvement, a fasciocutaneous deltoid flap may provide coverage of the defect.

Clinical and Basic Research on Occipito-cervico-dorsal Flaps: Including a Study of the Anatomical Territories of Dorsal Trunk Vessels

The authors have carried out a clinical study of all the patients who underwent reconstructions with occipito-cervico-dorsal flaps in their department between 1994 and 2003 and analyzed the outcomes of the surgery. The reconstructed areas ranged from the cheek to the anterior chest. Twenty-eight cases underwent reconstruction with microvascular augmented occipito-cervico-dorsal flaps, and four were reconstructed with single pedicle occipito-cervico-dorsal flaps. In five cases, distal partial necrosis was observed. The largest flap size was 43 x 23 cm (5 x 5-cm pedicle). In the microvascular augmented occipito-cervico-dorsal flaps, the circumflex scapular artery and veins were used in 28 cases, and dorsal intercostal perforators were used together with circumflex scapular artery and veins in five cases. The follow-up term was between 1 and 8 years. Neck scar contractures were released in all cases, and good results were obtained not only functionally but also aesthetically. In an anatomical study, the authors used 20 preserved cadavers and took angiograms of the dorsal region. Five cadavers were used to confirm the territory of each of the vessels that have close relations to the occipito-cervico-dorsal flap (the occipital artery, transverse cervical artery, circumflex scapular artery, and dorsal intercostal perforator artery). Each anatomical territory was clearly seen and its area identified.

[Evaluation of clinical reports in treating periarthritis of shoulder by manipulation with the theory of evidence based medicine]

OBJECTIVE

To explore the effect of treating periarthritis of shoulder with manipulation through evaluating clinical reports with the theory of evidence-based medicine (EMB).

METHODS

By retrieval of some main medical literature databases in the past 5 years, 242 articles on treating periarthritis of shoulder with manipulation were available. Selected by admission standard, 10 of them were evaluated with EBM theory.

RESULTS

Both single-application and union-application of manipulation were effective to periarthritis of shoulder, but the evaluated articles were all low-quality articles.

CONCLUSION

Because of low quality clinic test and larvaceous publication bias, the extant evidence is not enough to recommend replacing other therapeutic methods by manipulation. The low quality of evaluated articles suggests that there exist some methodology problems in the clinic test on treating periarthritis of shoulder with manipulation.

[Combined injuries of arteries, nerves and tendons of the forearm]

Combined injuries of the forearm occupy an important place in modern structure of functionally severe traumas. Discussions concerning the best time for nerve reconstructions and unsolved questions of a necessity to restore one of the arteries if the other is safe confirms the importance of the problem. An analysis of the domestic and foreign literature data on diagnosing and treatment of the traumas in question is given. Main specific features of treatment depending on the time, character of injuries and functional role of the injured structures are described.

Enlarged spinoglenoid notch veins causing suprascapular nerve compression

OBJECTIVE

To report the magnetic resonance (MR) imaging findings of enlarged veins in the spinoglenoid notch as a cause of suprascapular nerve compression.

DESIGN AND PATIENTS

Six patients presented to MR imaging for evaluation of chronic shoulder pain. Clinical information and MR imaging studies were reviewed. The spinoglenoid notch vascular structures were compared with measurements made in 10 age-matched controls.

RESULTS

Spinoglenoid notch vascular structures measured in 10 asymptomatic age-matched control patients ranged from 1 to 4 mm in diameter with an average of 2.2 mm. The six study patients had vascular structures that ranged from 6 to 10 mm in diameter with an average of 8.4 mm. Atrophy and fatty infiltration of the infraspinatus muscle was noted as an associated finding at MR imaging in all six patients. Surgery was performed in three of the six patients, at which time a venous varix was identified in the spinoglenoid notch in all three patients.

CONCLUSION

We describe distended veins in the spinoglenoid notch. These may be readily apparent at MR imaging and should be distinguished from paralabral ganglion cysts compressing the suprascapular nerve in the absence of labral tears, especially if percutaneous aspiration of a ganglion cyst is entertained.

Study of the relationship between the suprascapular artery and the brachial plexus

The literature concerning the relationship of the suprascapular artery with the brachial plexus is quite limited. The aims of this study were to investigate the different types of relationships between the suprascapular artery and the brachial plexus trunks and to try to clarify their prevalence in the European population. Our study involved the dissection of 100 upper extremities from adults, all of European origin (55 women, 45 men). In the classic description, the suprascapular artery passes in front of the brachial plexus (group A) in the majority of cases, then behind the omohyoid before reaching the superior border of the scapula. There are two other types of relationship with the brachial plexus: the suprascapular artery can pass between the trunks of the brachial plexus (group B) or the artery can pass behind the brachial plexus (group C). To our knowledge there has been only one study on the subject, carried out by Kosugi et al. Our results show a not inconsiderable number of variations in the relationships between the suprascapular artery and the brachial plexus (29%). Although no differences were noted between the sexes, a significant number of individual variations were revealed by the comparative study of dissections performed on both upper extremities of the same individual. Our results suggest that new studies are required to complete these initial anatomical results observed on a small sample of subjects of European origin. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0026-5.

Axillary artery injury: report of two cases and review of the literature

These are the cases of two young men, 21- and 28-year old, who sustained penetrating stab injuries to their axillary arteries. Both patients presented initially with profuse bleeding and were in a state of shock. The first patient underwent initial emergency surgery to control his bleeding whereby deep stitches were inserted around the axillary vessels and nerves and ended up with permanent iatrogenic Median nerve palsy. The bleeding in the second patient was controlled initially by compression dressing and he underwent successful vascular repair of the axillary artery with full recovery of his upper limb function. In this paper, we are discussing the initial management problem of these cases and the results of similar injuries and their repair in the literature.

[Rare variants of formation of human brachial nerves and arteries]

In the course of preparing muscular and neurovascular specimen of human right arm a combination of several rare anatomic variants was discovered which, to the authors opinion, are worth attention. 1. Formation of the median nerve at the border between middle and inferior thirds of brachium. 2. Variant of n. musculocutaneus origination from the lateral fascicle of plexus brachialis by several branches. 3. Variant of n. antebrachii cutaneous lateralis origination from the lateral fascicle by two branches. 4. Radial artery branching from humeral artery at the level of middle third of the brachium. 5. Three heads were discovered in m. biceps brachii. The variants described are interesting from scientific and clinical interest: they contribute to general conception of human anatomy and clinical manifestations of injuries of brachial nerves and arteries.

Potential complications of intralesional laser photocoagulation for extensive vascular malformations

Vascular anomalies remain a challenge for both patients and plastic surgeons. Recently, promising results have been reported using intralesional photocoagulation (ILP) to treat extensive vascular lesions. At the authors' center, they have treated more than 300 patients with vascular anomalies in different parts of the body between 1996 and 1999. They describe their operative techniques of ILP. Laser pulses of a 1,064-nm wavelength from the Nd:YAG laser were delivered to the target tissues with a 600-microm optical fiber. They report 2 patients who developed complications after a single session of ILP therapy for their extensive vascular malformations. The first patient had Klippel-Trenaunay syndrome (capillary-lymphaticovenous malformations) with widespread involvement of her buttocks and left lower limb. She had severe leukocytosis, thrombocytosis, and hyperkalemia that resolved with intravenous hydration, antibiotics, and sodium bicarbonate. In their second patient, the entire left upper limb was affected. Her total red cell count diminished by a quarter and her hemoglobin concentration dropped by more than 3 g%. This was corrected gradually with supplemental oral hematinics. Although these complications resolved uneventfully in their patients, they hope that their possible development will caution anyone who may wish to attempt this new method of therapy.

Anatomical relationship between arteries and veins in the scapular region

Veins in the scapular region were investigated in five fresh cadavers, in which radiopaque materials were injected into both the arterial and the venous systems, to determine their locational relationship to the arteries. This radiographic technique is very useful for comparing veins and arteries. Many veins not accompanying arteries were observed, and veins in the skin and subcutaneous tissue were considered to consist of venae comitantes and non-venae-comitantes. The non-venae-comitantes formed a mainly polygonal venous network in the skin layer, and large communicating veins connected the venous network to the scapular or parascapular veins. These veins played a role in the drainage of venous blood that had perfused the dermis and, in this sense, they should be named cutaneous veins.

Supraclavicular artery in Japanese: an anatomical basis for the flap using a pedicle containing a cervical, non-perforating cutaneous branch of the superficial cervical artery

We investigated the morphology of the non-perforating cervical cutaneous branch in the lateral cervical triangle using 65 (130 sides) donated cadavers. We found the branch in 104 of the entire 130 sides (80.0%). In the majority (72.1%), the cutaneous branch did not cross the clavicle or acromion but supplied the dorsolateral cervical area. The branch was originated from the superficial cervical artery close to the posterior belly of the omohyoideus muscle and immediately lateral to the external jugular vein. The comitant vein, if present, drained into the external jugular vein. Our observations and measurements (length and diameter) suggested that the non-perforating cutaneous branch is useful for a pedicle of the dorsolateral cervical flap in Japanese people. However, detailed morphologies differ from the previous studies published in western countries.

Quadrilateral space syndrome: case report and review of the literature

The quadrilateral space syndrome is defined as tenderness over the quadrilateral space and shoulder pain radiating to the arm, secondary to compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space. The symptoms are aggravated by forced abduction and extrenal rotation of the arm. The diagnosis is clinical and is documented by arteriography or angio-MR imaging with dynamic maneuvers. A 30-year-old woman presenting with this syndrome is described here, the differential diagnosis discussed, and the literature reviewed.

Variation in the branching of the axillary artery. A description of a rare case

A case is described in which a rare variation of a branch arising from the axillary artery is defined as a thoracoepigastric artery. This variation was observed in the cadaver of a 72-year-old man. This artery branched from the axillary artery, passing as a common trunk between the roots of the median nerve, and divided into two branches. The lateral one gave rise to muscular branches supplying the shoulder and fasciae, while the medial one descended on the anterior aspect of the axillary fossa, reaching the hypogastric region, and anastomosed with the superficial epigastric artery, which is a branch of the femoral artery. To our best knowledge, no variation similar to this one has been described. We suggest naming this artery the thoracoepigastric artery.

An anatomic examination of the suprascapular flap

To investigate the potential utility of a suprascapular flap, the authors examined dissected cadavers to identify the ramification of the suprascapular artery, and directly injected 2.5% patent blue dye to observe the distribution of its cutaneous perforators. Results indicate that a suprascapular flap is not practicable. The branching pattern of the suprascapular artery from the subclavian artery varies widely, making dissection of the vessels highly problematic. Moreover, no constant presence of cutaneous perforators from the artery could be identified in either the suprascapular fossa or the shoulder.

Vascular pathology in the throwing athlete

Vascular pathology in the upper extremity of a throwing athlete comprises a spectrum of serious disorders apt to threaten the patient's career and the viability of the involved parts. Such pathology includes digital vessel thrombosis, proximal thrombosis with distal embolization, vessel aneurysm, and vessel compression, such as in thoracic outlet syndrome and quadrilateral space syndrome. This article provides a description of vascular disorders prone to result from sports activities and a review of published data relevant to throwing athletes. Recognition of vascular compromise as a cause for dead arm syndrome or painful digital dysfunction among athletes is essential to prevent the grave consequences of progressive ischemia.

Spontaneous brachial plexus hemorrhage-case report

BACKGROUND

Shoulder hemorrhage resulting in brachial plexus neuropathy is a rare occurrence most often seen in cases of traumatic injury or anticoagulation therapy. We report a unique case of spontaneous brachial plexus hemorrhage.

CASE DESCRIPTION

This is the first report of a spontaneous shoulder hemorrhage in which a 48-year-old jackhammer operator presented to the emergency department with a sudden onset of right shoulder pain and upper extremity pain and numbness. Imaging studies revealed a hematoma in the right axilla and chest wall. Without evidence of active bleeding or worsening neurologic deficit, this patient was treated conservatively with pain control and observation and eventually experienced a full recovery. Had there been persistent neurologic deficit, however, surgical evacuation would have been indicated.

CONCLUSIONS

Cases of nerve compression caused by a hematoma should be analyzed on the basis of the severity of the neurologic deficit and not on the underlying cause of bleeding. Conservative treatment may be indicated in cases of mild or improving neurologic deficit, but regardless of its etiology, a hematoma that results in severe or worsening neurologic symptoms must be surgically evacuated to prevent permanent nerve damage.

Quadrilateral space syndrome: diagnosis, pathology, and treatment

Quadrilateral space syndrome is an infrequent, recently established neurovascular compression syndrome affecting young active adults. With this syndrome, the neurovascular bundle, consisting of the posterior humeral circumflex artery (PHCA) and the axillary nerve, is compressed by fibrotic bands as it traverses the quadrilateral space. Symptoms result from compression of the axillary nerve, not from PHCA occlusion. Because of the vague, often nonspecific, clinical presentation of patients with quadrilateral space syndrome, diagnosis is challenging and requires a high index of suspicion from the orthopedist. Subclavian arteriography confirms the diagnosis. Treatment is usually conservative; operative management is reserved for selected patients. A posterior approach with detachment of the deltoid and teres minor muscles is recommended for surgical decompression and for lysis of fibrous tissue. We report two cases of persistent quadrilateral space syndrome in young adults, treated surgically, with 2-year follow-up. In the present report, diagnostic criteria, pathology, management, operative technique, and recent literature are also reviewed.

Anatomical study of the blood supply in the human shoulder region

The blood supply of the shoulder muscles, ligaments and joint capsule was investigated by injection of silicone rubber into the arteria subclavia of postmortem cases. We show that the a. suprascapularis forms important anatomoses with other arteries in the region and is of greater importance for the blood supply of the rotator cuff as hitherto believed. We also describe the a. subcoracoidea as a so far unknown branch of the a. axillaris.

Surgical anatomy of the posterior shoulder: effects of arm position and anterior-inferior capsular shift

The purposes of this study were to evaluate anatomically various surgical intervals to the posterior shoulder and to determine the effects of varying arm positions and anterior-inferior capsular shift (AICS) on the relation of the posterior neurovascular structures to fixed bony landmarks. Fourteen cadaveric shoulders were dissected. The posterior surgical anatomy was defined, and the distances from fixed bony landmarks to neurovascular and musculotendinous structures were determined with digital calipers. Measurements were made with the arm in various positions and repeated after AICS. The most direct anatomic approach to the posterior shoulder was through a deltoid split in the raphe from the posterolateral corner of the acromion (PLCA), followed by an infraspinatus (IS) splitting incision. The IS/teres minor interval was at the inferior aspect of the glenoid rim and was difficult to locate in all specimens. The distance to the axillary nerve from the PLCA averaged 65 mm and decreased by an average of 14 mm (22%) with abduction and by 19 mm (29%) with extension. The posterior humeral circumflex artery was located along the humeral neck and was vulnerable to injury during lateral capsular dissection. The suprascapular nerve had multiple branches to the IS with most penetrating the muscle at its inferior portion. The closest branch to the glenoid rim was an average of 20 mm medial from it. No branch entered at the level of the IS raphe. The anatomic relations of the suprascapular nerve were unchanged after AICS. On the basis of this study, surgical exposure of the posterior shoulder with a deltoid split from the PLCA, followed by an IS split, appears to be anatomically safe. The arm position should be in neutral rotation, especially if previous anterior capsular procedures have been performed, which can alter the posterior neurovascular anatomic relations.

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.

Arthroscopic capsular release for the stiff shoulder. Description of technique and anatomic considerations

The anatomic proximity of several neurovascular structures remains a major concern to the surgeon interested in performing arthroscopic capsular release. We evaluated the anatomic relationships between the released capsule and the axillary nerve, posterior circumflex humeral artery, and brachial artery in a frozen cadaveric model. With the aid of electrocautery, seven cadaveric shoulders underwent complete arthroscopic capsular release. The release was performed circumferentially, approximately 1 cm lateral to the glenoid rim. All shoulders were subsequently frozen and sectioned through the plane of the capsular release while the shoulder was maintained in the lateral arthroscopic position (45 degrees of abduction and 20 degrees of flexion). Anatomic dissection revealed an average distance from the capsular release to the axillary nerve of 7.04 mm (95% confidence interval, 5.62, 8.47), to the posterior circumflex humeral artery of 8.2 mm (95% confidence interval, 6.41, 9.99), and to the brachial artery of 15.97 mm (95% confidence interval, 9.85, 22.09). As the axillary nerve was followed medially from the released capsule, the inferior border of the subscapularis muscle became interposed between the capsule and the axillary nerve. This limited anatomic study shows that a relatively safe margin between the capsule and the neighboring neurovascular structures can be obtained by releasing the capsule within 1 cm of the glenoid rim.

Treatment of high-flow vascular malformations by venous embolization aided by flow occlusion techniques

PURPOSE

Transvenous embolization techniques may be helpful as alternatives to the arterial route when treating high-flow vascular malformations. We present our experience using these techniques in four patients.

METHODS

In one patient the venous portion of the arteriovenous malformation (AVM) was punctured directly; in the other three patients it was catheterized via a retrograde venous approach. Flow occlusion techniques were utilized in all patients during embolization, which was performed with absolute alcohol or N-butyl-2-cyanoacrylate.

RESULTS

Excellent clinical and angiographic results were obtained, with obliteration of arteriovenous shunting in all patients. There were no complications.

CONCLUSION

The embolization of certain AVMs using a venous approach is a safe and effective treatment.

A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study

This prospective study assessed the role of Doppler pressure indices (Ankle-Brachial Index [ABI] or Brachial Brachial Index [BBI]) in the evaluation for occult arterial injury from penetrating proximity extremity trauma (PET). A total of 258 patients with 323 PETs were evaluated by physical examination and Doppler pressure (ABI/BBI) determination. An ABI/BBI of < 0.9 was considered abnormal. The findings were compared with those of arteriography in all patients. Eleven injuries (3.4%) found on arteriography were associated with normal indices. Five of these injuries were treated by repair (4 patients) or angiographic embolization of a bleeding vessel (1 patient), all in lesions proximal to the knee or elbow joints. The other six lesions were observed without intervention. All of the 29 injuries associated with abnormal indices had positive arteriographic findings. The 4 lesions that were treated operatively were proximal and the remaining 25, all with distal penetration, were observed without observation. As compared to angiography, Doppler indices yielded the following results: 283 true-negative, 11 false-negative, 29 true-positive, and 0 false-positive, for a sensitivity of 72.5%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 96%. These data suggest that Doppler indices should be an integral part of the physical examination and can screen patients with proximal injuries for further studies such as duplex sonography or arteriography.

Transverse cervical artery fasciocutaneous free flap for head and neck reconstruction: initial anatomic and dye studies

METHOD

The bilateral transverse cervical arteries of 16 fresh cadavers were exposed by an infraclavicular midline approach. Each artery was cannulated, and methylene blue dye was infused to delineate the skin territory subserved by the vessel. The two major infusion skin patterns obtained allowed fashioning of a thin fasciocutaneous flap incorporating supraclavicular skin, which was based on the transverse cervical artery; or a larger flap additionally incorporating upper back skin and varying amounts of trapezius muscle, when the artery had a dorsal scapular artery branch. Depending on the skin pattern, either scapula or clavicle could be transferred with the other soft tissues.

RESULTS

The skin territory of the transverse cervical artery is caused to vary by the presence or absence of its dorsal scapular artery branch. The supraclavicular portion of the flap is recommended for repair of facial and nasal lesions because of its close match in color and texture to facial skin. Oral lesions can also be reconstructed with this flap because of its pliability.

CONCLUSION

The free flap based on the transverse cervical artery pedicle appears to be a useful addition to the armamentarium of flaps for head and neck reconstruction. Clinical use of the flap is ongoing and will be subsequently reported.