Shoulder girdle elevation during neurodynamic testing: an assessable sign?

One of the signs advocated for monitoring during neurodynamic testing in the assessment of patients with upper quadrant disorders, is the response of the shoulder girdle. It is stated that a protective rising of the shoulder girdle is present when patients with neurogenic disorders are assessed and that the elevation is absent in asymptomatic subjects. As sensory responses are elicited in the majority of asymptomatic subjects and as the range of motion (ROM) is often limited during neurodynamic testing, it is questionable whether the elevation of the shoulder girdle would be absent in asymptomatic subjects. The aim of this study was to measure the shoulder girdle elevation force during five variants of the neural tissue provocation test for the median nerve. Thirty-five asymptomatic male subjects were assessed. A load cell was used to measure the amount of shoulder girdle elevation force and two electrogoniometers were used to measure the ROM at the elbow and wrist. When the ROM at the end of the test was restricted, a gradual increase in shoulder girdle elevation force could be observed throughout the test. Compared to the initial force at the start of the test, all variants resulted in a significant increase in force. It is concluded that a gradual increase in shoulder girdle elevation force should not be regarded as an abnormal sign in the interpretation of neurodynamic tests.

Addition of test components during neurodynamic testing: effect on range of motion and sensory responses.

STUDY DESIGN: Single session, repeated-measures design. OBJECTIVES: To analyze the impact of different components of the neural tissue provocation test for the median nerve (NTPT1) on the range of motion (ROM) of the elbow and wrist and the sensory responses elicited by the test. BACKGROUND: The assessment of minor peripheral nerve injuries by neurodynamic tests is becoming more integrated in physical therapy practice. The influence of different test components on the nervous system has been analyzed in numerous in vitro studies, but in vivo studies are still lacking. METHODS AND MEASURES: Five test variations were performed on 35 asymptomatic men (23.5 +/- 2.3 years). Elbow extension was performed (1) without additional components (NTPT1NEUTRAL), (2) with wrist extension (NTPT1WE), (3) with cervical contralateral lateral flexion (NTPT1CLLF), and (4) with both wrist extension and cervical contralateral lateral flexion (NTPT1WE+CLLF). In the fifth variant, the wrist was extended from a preloaded position (WENTPT1). The range of elbow and wrist extension when a submaximal discomfort was elicited was measured with 2 electrogoniometers. RESULTS: The addition of each test component resulted in a significantly reduced ROM (NTPT1NEUTRAL: 179.5 +/- 8.8 degrees, NTPT1WE: 169.0 +/- 13.9 degrees, NTPT1CLLF: 154.7 +/- 13.2 degrees, NTPT1WE+CLLF: 143.9 +/- 16.1 degrees; WENTPT1: 67.1 +/- 11.0 degrees). Sensory responses were predominantly evoked at the region of the added component. CONCLUSIONS: The different test components, whose mechanical influence on the nervous system has been demonstrated in anatomical studies, also have an effect on joint ROM and sensory responses during neurodynamic testing, when individually or simultaneously added. If the nerve bedding is elongated throughout its whole length, the available ROM is markedly reduced and sensory responses can be elicited throughout the entire arm.

Measuring small linear displacements with a three-dimensional video motion analysis system: determining its accuracy and precision.

OBJECTIVES: To determine accuracy, precision, and smallest detectable difference for a three-dimensional (3D) video motion analysis system specifically configured for measuring small and slow displacements within a small measurement volume (0.7 x 0.5 x 0.3 m). DESIGN: Repeated measurements with random sequence of conditions. SETTING: Rehabilitation research laboratory. INTERVENTION: A reference sliding device was used to control cyclic displacements of two reflective markers over 5 calibrated ranges (1, 3, 10, 30, and 60 mm). Nine cycles were performed for each of 9 conditions (3 directions x 3 zones). Four cameras recorded all trials on tapes, which were digitized with a Kinemetrix system. MAIN OUTCOME MEASURES: Change in distance of the moving markers relative to a third static marker was averaged over 50 frames per trial. Mean error, mean absolute error, and intertrial and intratrial standard deviations (SDs) were calculated for each zone and direction. RESULTS: For 810 trials, mean error and absolute error were, respectively, .034 mm and .094 mm. The mean intertrial and intratrial SDs and 99% confidence interval were .047 mm (CI = +/- .121 mm) and .030 mm (CI = +/- .077 mm). The corresponding smallest detectable differences were .171 mm and .109 mm. CONCLUSION: Motion analysis configured for registration within small volumes allows measurement of minuscule displacements with great accuracy and may therefore be suitable for many applications in rehabilitation research other than gait analysis.

A qualitative assessment of shoulder girdle elevation during the upper limb tension test 1.

The 'feel through range' and the 'end-feel' of the elbow extension, and the elevation of the shoulder girdle during the upper limb tension test for the median nerve are considered important in clinical decision making. As no objective measurements have been published regarding these parameters, a special device was designed in order to obtain objective information on the force by which the shoulder girdle is elevated during the test. The purpose of this technical note is to describe the technical aspects of the device and its practical application. In a pilot study, five asymptomatic subjects have been assessed. The relationship between the elevation of the shoulder girdle and the range of elbow extension has been analysed. The data of five subjects and representative curves of one subject are presented. All five subjects demonstrate a considerable increase in force elevating the shoulder girdle. The results show that the device can be used to measure the force by which the shoulder girdle is elevated throughout the test. Although the number of subjects and the number of repetitions is limited, the data suggest that the method is accurate and that the phenomenon of shoulder girdle elevation during the upper limb tension test in asymptomatic subjects is consistent.

Unstable femoral neck fractures in young adults: treatment with the AO 130-degree blade plate.

OBJECTIVE: To evaluate the clinical outcome of the treatment of unstable femoral neck fractures using the AO 130-degree blade plate. DESIGN: Between 1980 and 1994, thirty-four consecutive patients younger than age fifty years with an unstable intracapsular femoral neck fracture (Garden Types III-IV) were treated with internal fixation. SETTING: University Hospital Gasthuisberg, Leuven, Belgium. INTERVENTION: The AO 130-degree blade plate with an antirotation, 6.5-millimeter, partially threaded cancellous lag screw was used. RESULTS: Nineteen (63.3 percent) patients had an excellent result, seven (23.3 percent) had a good result, three (10 percent) had a fair result, and one (3.3 percent) had a poor result. Delayed union was observed in one case, and avascular necrosis was observed in two cases. Two implants perforated the subchondral bone. CONCLUSION: Stable fixation with the AO 130-degree blade plate avoids damage to the adjacent blood supply to the femoral head and appears to guarantee a good final outcome of unstable intracapsular femoral neck fractures in young adults.

Reliability of manual skinfold tests in a healthy male population.

OBJECTIVE: To assess the intra- and interexaminer agreement of a manual skinfold thickness test and a manual skinfold compliance test. The relation between the weekly routine of the examiners and the intraexaminer reliability was also assessed for both tests. DESIGN: This is a reliability study of a common palpatory procedure to assess skinfold thickness and skinfold compliance. Twelve healthy subjects were palpated twice in two sessions by 12 examiners. SETTING: The study was conducted at the Polytechnic of Utrecht (the Netherlands), Faculty of Health Care, Department of Physiotherapy. SUBJECTS: Healthy male subjects recruited from students of the Polytechnic of Utrecht (the Netherlands), Department of Physiotherapy. RESULTS: The intraexaminer agreement Intraclass Correlation Coefficient [ICC(3.1)] was .25 for skinfold thickness and .28 for skinfold compliance. The interexaminer agreement [ICC(2,1)] ranged from .01 to .24. The Pearson correlation coefficient between the examiners age and routine vs. intraexaminer agreement ranged from -.41 to .23 (nonsignificant). CONCLUSIONS: The intra- and interexaminer agreement of the manual skinfold test produced poor-to-fair reliability. The correlation between the examiners' weekly routine and the intraexaminer reliability ranged from low negative to little (if any). This study shows a lack of reliability of palpatory tests for skinfold thickness and skinfold compliance. This outcome agrees with results of previous studies found in the literature.

Peripheral cutaneous nerve distribution to the fingers.

Both sensory distribution charts and the unaffected side, are used as reference points in the assessment of cutaneous innervation. Sensory nerve conduction studies, in particular, often use comparison between sides. However, remarkable differences can be found between various sensory innervation maps, and no evidence was found in the literature for the assumption that the pattern of cutaneous sensory distribution of the peripheral nerves between the left and right limbs is symmetrical. The purpose of this study was to investigate variations in the sensory innervation of the fingers by means of a neurophysiological method, and to compare the results for the left and right hands. The subjects of this study were 31 young women. Percutaneous peripheral nerve stimulation was performed on the four nerve branches providing sensory innervation to the fingers, and action potentials were sought from the fingers by use of annular surface electrodes. Variations in the cutaneous innervation of the fingers between individuals often occurred and were found more frequently on the dorsal than the palmar aspect. The distribution of sensory innervation may even differ markedly between hands in the same individual. The cutaneous innervation of all peripheral nerves supplying the fingers may differ from the innervation patterns described in the various distribution charts. Prudence is called for when applying sensory distribution charts as absolute references for the assessment of cutaneous sensation in patients. Caution should also be applied when comparing one hand with the other when assessing the cutaneous innervation of the fingers.

Treatment of unstable peritrochanteric fractures in elderly patients with a compression hip screw or with the Vandeputte (VDP) endoprosthesis: a prospective randomized study.

A prospective randomized study was set up, comparing a compression hip screw with the Vandeputte (VDP) endoprosthesis treatment for fresh, unstable peritrochanteric fractures, according to the Evans-Jensen and AO systems. Ninety patients, ages > or = 70 years, 47 of whom were treated with a compression hip screw and 43 with a VDP endoprosthesis, were included. All patients were being followed for 3 months. No difference between the two groups was found for operating time, wound complications, and mortality rate, but there was a higher transfusion need in VDP treatment. Severe fracture redisplacement or total collapse of the fracture occurred in 11 (26%) compression hip screw patients, two of whom had revision surgery. Only one patient needed reintervention after VDP treatment. Functional capacity of preoperative independent patients at hospital discharge did not differ for the two groups. In conclusion, the compression hip screw seemed to be an appropriate implant for most of the peritrochanteric fractures, but for very old patients with advanced osteoporosis, with a complex, unstable peritrochanteric fracture, and who are eligible for early mobilization, primary cemented endoprosthesis might be the best treatment.

[Therapeutic procedure and long-term results in tibial pilon fracture in relation to primary soft tissue damage]. / Therapeutisches Vorgehen und Langzeitergebnisse bei der Pilonfraktur in Abhängigkeit vom primären Weichteilschaden.

Between 1980 and 1990, 81 fractures of the pilon tibial of type B or C in the AO classification, presenting in 78 patients, were treated operatively in the Department of Traumatology and Emergency Surgery of the University Hospitals of Leuven. One-fourth of the fractures were open, 36 had second- or third-degree soft tissue damage according to the Tscherne classification system. The relationship between the fracture type and soft tissue damage was significant: the more severe the soft tissue damage, the more complex the fracture type. Screw osteosynthesis was performed mostly in fractures without soft tissue damage; plate osteosynthesis was used more frequently than external fixation in fractures with severe soft tissue damage. The number of late complications was much higher when the fracture was combined with severe soft tissue lesions. The number of secondary operative procedures on the soft tissue and bones was especially elevated in fractures primarily stabilized with a plate osteosynthesis. Sixty-four patients were reviewed clinically and radiologically after a mean time of 52.7 months. The subjective and objective end results were classified in accordance to the scales of Ovadia. Of the patients without soft tissue lesions, 86.4% showed excellent or good subjective and 74.6% excellent or good objective end results; 55.6% of the patients with severe soft tissue damage had excellent or good subjective and 48.1% excellent or good objective end results. In pilon fractures with severe soft tissue damage, bony consolidation can only be reached after several operative steps. In the primary procedure, only minimal osteosynthesis, combined with medial external fixation should be performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care.

From 1978 to 1991, 126 multiply-injured patients of 65 years and over were admitted to the Department of Traumatology and Emergency Surgery of the University Hospitals of Leuven. The seriousness of the injury was evaluated using the Injury Severity Score (ISS) and the Glasgow Coma Scale (GCS). Traffic accident (57 per cent) and a simple fall at home (30 per cent) were the main causes of injury. The overall mortality rate within 6 months was 17 per cent. Multiple system organ failure (MSOF) was responsible for the fatal outcome in 48 per cent of the cases and in 71 per cent of the deaths more than 7 days after trauma. Of the survivors still living at home before injury, 78 per cent were able to go back to their normal surroundings. Survivors were compared with non-survivors. There was no significant difference in age or in ISS, nor in pre-existing diseases. On the other hand, the GCS was of important prognostic value, both for survival and functional recovery (P < 0.001). Also, the need for early intubation and continued ventilation were predictive of survival (P < 0.001). Nevertheless, this need for respiratory assistance was not an indication for withdrawing support as 9 per cent of the survivors also required endotracheal intubation for 5 days or longer. In our opinion, aggressive trauma care for the elderly is justified.

Multiple trauma in patients of 65 and over. Injury patterns. Factors influencing outcome. The importance of an aggressive care.

In a first study of 416 polytrauma patients, 49 were aged 65 years or older. These "old patients" (mean age 72.1) were compared with the remaining 367 "young patients" (mean age 31.3). In a second study concerning 126 polytrauma patients of 65 and over, the survivors and non survivors were profiled and compared. The typical injured old patient was a pedestrian hit by a car or a motorbike or someone who had simply fallen at home. Despite the fact that the mean Injury Severity Score (ISS) was significantly lower in the old patients' groups (33.2 versus 42.1 degrees) (p < 0.0001) the mortality rate was higher (18% versus 7.6%) (p < 0.05). In old trauma victims multiple system organ failure (MSOF) was responsible for the fatal outcome in 48% of the cases and in 71% of the deaths more than 7 days after trauma. Seventy eight percent of the surviving old patients still living at home pre-injury were able to go back to their normal surroundings. In the old patients groups there was no significant difference in age nor in ISS nor in pre-existing diseases between survivors and non-survivors. On the other hand the Glasgow Coma Scale (GCS) was of important prognostic value, as well as to survival as to functional recovery (p < 0.001). Also the need for early intubation and continued ventilation were predictive of survival (p < 0.001). Nevertheless this need for respiratory assistance was not an indication for withdrawing support as also 9% of the survivors required endotracheal intubation for 5 days or longer.(ABSTRACT TRUNCATED AT 250 WORDS)

Pertrochanteric fractures in the elderly. Is the Belgian VDP prosthesis the best treatment for unstable fractures with severe comminution?

During a ten year period (1978-1988) 565 patients, aged 70 years and over, suffering a fresh pertrochanteric fracture have been treated in the Department of Traumatology at the University Hospitals of Leuven, Belgium. According to the system of Evans and Jensen, 388 fractures were classified as unstable. Special attention was given to the 324 cases of type I C and I D fractures. The method of treating greatly changed during the period of study. All patients were followed up prospectively during one year. Our study showed that for these unstable fractures, fixation with an angled plate or Ender nails should be forsaken. The overall results of the dynamic hip screw treatment were good (reoperation rate 2%, good functional results in 64%), but as this treatment has a risk for serious collapse and pain in about 80% of all type I D fractures, one could suggest to treat these complex multifragment fractures primarily with an endoprosthesis. This treatment needs no longer to be considered as a severe intervention, as the danger of mechanical complications being very minimal (less than 1%).

Pertrochanteric fractures in the elderly: are there indications for primary prosthetic replacement?

During a 10-year period (1978-1988), 565 patients, aged greater than or equal to 70 years, who sustained a fresh pertrochanteric fracture, were treated in the Department of Traumatology at the University Hospitals of Leuven, Belgium. Three hundred eighty-eight fractures were complex and unstable, according to the Evans-Jensen system and the AO system. Special attention was given to the 324 cases of type IC and ID in Evans' system, type A2 in the AO system. The method of treatment changed greatly during the period of study. All patients were followed prospectively during 1 year. Our study showed that for these unstable fractures, fixation with an angled plate or Ender nails should be forsaken. The overall results of the compression hip screw treatment were good (reoperation rate 2%, good functional results in 64%), but as this treatment has a risk for serious collapse and pain in about 80% of all type ID fractures, one could suggest treating these complex multifragment fractures primarily with an endoprosthesis. This treatment need no longer be considered severe intervention, as the danger of mechanical complications is minimal (less than 1%).

[Hip fractures in the elderly; mortality, functional results and probability of returning home]. / Heupfracturen bij bejaarden; sterfte, functionele resultaten en kans op huiswaarts keren.

767 patients over the age of 70 with a fracture of one hip were studied prospectively. The results were compared with the literature. The overall mortality rate within 3 months was 24%. This mortality was significantly influenced by the general health condition of the patient at the time of the injury, his living quarters and the ability to walk again after operation (p less than 0.001). For 38% of the survivors, able-bodied before the injury, the fracture meant an important loss of functional independence. The degree of impairment was closely related to the patient's age and fracture type (p less than 0.05). Of patients living in their own homes before injury only 60% were able to go back home. In predicting the probability of going back home, the functional status before injury and the ability to walk again at the time of discharge from the surgical department were highly important (p less than 0.001).

[Indications, dangers and results of surgical treatment of humeral shaft fractures]. / Indikationen, Gefahren und Ergebnisse der operativen Behandlung von Oberarmschaftfrakturen.

A series of 78 fractures of the humeral shaft is presented that were treated operatively between 1978 and 1987. Open fractures, fractures with primary palsy of the radial nerve, distal fractures with an intraarticular component, fractures in polytraumatized patients and non-unions were absolute indications for operative stabilization in this series. In 71 fractures, internal stabilization was performed and in 7 fractures external fixation. In 16 fractures (20.6%), primary palsy of the radial nerve was present. In 10 patients (12.8%), radial nerve palsy appeared postoperatively. Nonunions and deep infections did not occur. In two cases, a second osteosynthesis was necessary after loosening of the implants. The humeral shaft fracture shows normal bony consolidation after conservative treatment as well as appropriate plate osteosynthesis. Nine of the 16 patients with primary radial nerve palsy (56.2%) and 6 of the 10 patients with secondary radial nerve palsy (60%) had total functional recovery. In our series, intraoperative palsy of the radial nerve was the most frequent complication after dissection of spiroid fractures in the middle or lower third of the humeral shaft. In this fracture form, a more unstable osteosynthesis, such as intramedullary pinning in accordance to Hackethal, should be chosen.

Hip fractures in the elderly. Mortality, functional results and social readaptation.

Six-hundred and fourteen aged over 70 and presenting hip fractures have been studied prospectively. The results were compared with the literature. The overall mortality rate within three months was 24%. This mortality was significantly influenced by the general health condition of the patient at the time of the injury, his living conditions and the possibility of walking again after the operation (p less than 0.001). For 38% of the survivors, the fracture means a considerable loss of functional independence. The adjacent impairment was in close relationship with patient's age and fracture-type (p less than 0.05). Sixty per cent of the patients were able to return home. In predicting the probability of returning home, the functional status before injury and the possibility of walking at the moment of discharge were particularly important (p less than 0.001).

Pertrochanteric fractures in elderly patients. Treatment with a long-stem/long-neck endoprosthesis.

The long-stem, long-neck endoprosthesis is used in the treatment of pertrochanteric hip fractures in the elderly. Between 1978 and 1984, 157 patients 70 years of age and over were treated at our clinic for fresh unstable pertrochanteric hip fractures. Fifty-five patients had internal fixation. Because of the high incidence of mechanical complications, the long spherostem endoprosthesis became the treatment of choice between 1980 and 1984. Thus, 102 patients were treated with this type of arthroplasty. They were compared with the 55 patients treated with osteosynthesis, and we concluded that: (1) in comparison with osteosynthesis, the procedure of endoprosthetic replacement is no more extensive and the mortality is no higher; (2) the incidence of mechanical complications is significantly lower in the endoprosthesis group; (3) even if the dynamic hip screw is now the treatment of choice for pertrochanteric fractures, the long spherostem endoprosthesis is still indicated in arthrotic hip fractures or in the case of reintervention after implant failure.

Home-going: prognostic factors concerning the major goal in treatment of elderly hip fracture-patients.

Two hundred and forty-one hip fracture patients over 70 years of age still living at home at the moment of the accident were followed prospectively until three months postoperatively. The patients were admitted to the department over a five year period (1978-1983). One hundred and forty-four patients returned home. In order to predict whether an elderly hip fracture patient will be able to return home within three months, the following prognostic factors will have to be taken into account: pre-operative functional status (p = 0.0001), ambulatory capacity at discharge (p = 0.0001), age (p = 0.001), presence of relatives at home to return to (p = 0.02) and general medical postoperative complications (p = 0.0006). In this respect it was noted that sex, fracture type or mechanical complication with possible operation do not significantly influence the home-going rate within three months after surgery (p greater than 0.05).