Stephen H. Lacey

Functional range of motion of the elbow

One hundred normal upper extremities in 50 adults were sequentially studied in a Bledsoe brace, which limited elbow motion. The amount of flexion and extension of the elbow was serially limited by 15 degree increments. At each setting, the subjects were asked to perform 12 activities of daily living. The percentage of subjects who completed each task with the specified range of motion was determined. Overall, 49 of the subjects performed all of the tasks with extension limited at 75 degrees and flexion limited at 120 degrees. By isolating the allowable range of motion of the elbow and allowing for compensatory motions and strategies of the normal adjacent joints, the functional elbow range of motion is established as 75 degrees-120 degrees flexion. Thus, the functional status of a patient with a specific elbow range of motion can be predicted more accurately.

The posterior deltoid to triceps transfer: A clinical and biomechanical assessment

Transfer of the posterior deltoid muscle to the triceps insertion for elbow extension provides improved function in patients with C5 and C6 level tetraplegia. We have modified the surgical technique using the tibialis anterior tendon as a graft. The length-tension characteristics and available amplitude of the posterior deltoid muscle were determined with intraoperative electrical stimulation. The excursion of the posterior deltoid muscle was 7.31 cm with a standard deviation of 1.23 cm. Postoperative mean torque measurements of elbow extension power were 36.4 kg cm with a standard deviation of 15 kg cm. All patients had maximal strength between 90 degrees and 120 degrees of elbow flexion. Length-tension curves for the posterior deltoid muscle showed a large range of effective strength and helped confirm optimum tension of the posterior deltoid muscle and proper shoulder and elbow positions at surgery. Clinical results in 10 patients were excellent.

Surgical Rehabilitation of the Tetraplegic Upper Extremity

cal skeletal injury. Hand rehabilitation once focused exclusively on the application of splints or the surgical conversion of the hand to provide equivalent internal splinting by extensive use of arthrodeses at the expense of joint motion. Surgical reconstruction of the upper extremity was once limited to passive tenodeses, arthrodeses of major joints (1), and internalization of the flexor hinge splint concept. These procedures yielded stiff yet functional hands (2). The lessons learned in this early experience were that gravity assists and immobility limits function. Tendon transfer surgery of the hand has constantly evolved based on clinical experience and the advancement of technology (3,4). Classification of the residual potential for surgical reconstruction and evaluation of new surgical procedures have evolved over the past decades, based on the inspirational work of Moberg and elaborated by members of an international study group (5). Recent experience and refine-

Multiplicity of neurilemomas in the upper extremity

Multiple neurilemomas in two patients show that these tumors may indeed be multiple, may involve the same nerve trunk, may occur over a period of years, and may involve different regions of the body. Twelve neurilemomas were removed from the right upper extremity of a patient over a 3-year period. They varied in size from 0.5 cm to 4 cm in diameter and had the typical histopathologic appearance of neurilemomas. The second patient had median nerve compression and at operation a neurilemoma was found compressing the nerve. Two years later, the patient had evidence of median nerve compression in the opposite extremity, and again a neurilemoma was found. Both of these patients had evidence of peripheral nerve compression, but the existence of multiple neurilemomas was not apparent on initial examination. These cases show that patients with neurilemomas may have additional sequential tumors discovered at a later date that were not apparent initially.

Carpal Instability in the Weight-Bearing Upper Extremity*

The prevalence of carpal instability in a paraplegic population was investigated to establish an association between chronic repetitive stress on the wrist and the development of such instability. Nine of 162 paraplegic patients had static carpal instability and no history of an acute injury of the wrist. The predominant pattern of instability, found in eleven wrists (six patients), was non-dissociative volar intercalated segmental instability. The prevalence of carpal instability increased with the duration of weight-bearing on the upper extremity. Eighteen per cent of the patients in whom the spinal cord injury had occurred more than twenty years before the study had carpal instability. Carpal instability in these weight-bearing upper extremities and the increase in its prevalence with the duration of the forces across the wrist demonstrate an association between chronic repetitive stress on the wrist and carpal instability.

Recurrent histoplasmosis of the wrist : A case report

Histoplasmosis of the extremities is rare. A case of recurrent histoplasmosis with a 10-year latency between initial presentation and clinical recurrence is reported. Prolonged antibiotic treatment and debridement of bony involvement led to clinical resolution of this fungal infection after a follow-up period of 20 months.

Recovery and determination of 3H-tetracycline from whole bones.

Abstract A method has been described for quantitatively extracting and analyzing 3H-tetracycline from whole dog and rat bones. This method depends upon the complete decalcification of bone with cold dilute hydrochloric acid and liquid scintillation counting of the radioactivity. The assay has a 100-fold increase in sensitivity over fluorometric measurements. The quantification was independent of the age of the bone and the elapsed time after labeling. It was demonstrated in bones doubly labeled with 3H-tetracycline and 3H-proline that the two isotopes were quantitatively separated without cross contamination.

Bilateral pronator syndrome associated with anomalous heads of the pronator teres muscle: A case report

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AMPUTATION AS A SALVAGE FOR PATIENTS WITH INCAPACITATING INFECTED FRACTURES OF THE LOWER LIMBS

: Most serious lower-limb injuries with severe bone and soft tissue damage heal when treated wisely by techniques available today. Unfortunately, a small percentage of patients face prolonged physical and economic disability as a result of extensive damage to bone and soft tissue, nonunion of fractures with infection, nerve and blood-vessel injury, and complications of surgical treatment. Every effort should be made to effect union by established methods but a small percentage of fractures do not heal satisfactorily. Failure of infected lower-limb fractures to unite after prolonged treatment or the prospect of prolonged treatment or the prospect of prolonged morbidity and disability occasionally justify amputation in one lower limb. When a lower-limb prosthesis can provide stability support, and mobility painlessly, and overcome the morbidity and disability of an infected ununited fracture, amputation may be the treatment of choice. In the present review of our experiences in the past 17 years with patients having severly injured and diseased lower limbs where little chance existed for rehabilitation to acceptable levels of function by various methods of treatment, open amputation through infected bone followed by secondary closure was chosen to salvage the unfortunate patient with littlw chance of achieving acceptable function after infected ununited fractures of the lower limbs.