Ulnar stress reaction in an axillary crutch user.

Ulnar stress fractures have been reported in athletes performing repetitive, high-impact activities, such as baseball pitchers and gymnasts. Crutch-assisted walking also results in cyclical forearm loading. We report the first case of ulnar stress reaction due to axillary crutch use. A 23-year-old right-handed woman experienced right forearm pain and imaging confirmed a right ulnar stress injury. The patient was also found to have mild hypercortisolism, low bone mass and vitamin D deficiency. Crutches were discontinued and physical therapy to normalise weight bearing through the left leg was prescribed. The patient's right forearm symptoms resolved and she was started on oral vitamin D supplementation. Axillary crutch use may result in ulnar stress injury, particularly in vulnerable populations. The addition of an upper extremity injury to someone with impaired mobility may compound disability. As such, clinicians should be aware of the clinical presentation of ulnar stress fractures in the long-term axillary crutch user.

Different walk aids on gait parameters and kinematic analysis of the pelvis in patients with Adult Neuromuscular Disease.

OBJECTIVE: To investigate the effects of different walking aids (single cane, bilateral forearm crutch and walker) on gait parameters and kinematic analysis of pelvis in patients having adult neuromuscular diseases. METHODS: The study design was a self-controlled study. The study was conducted in the Department of Physiotherapy and Rehabilitation, Hacettepe University in Ankara, Turkey, between 2014-2015. The study included 18 adult patients with neuromuscular disease. The manual muscle test, the Rivermead mobility index, the motor function assessment scale, and the trunk control test were used as descriptive measurements. The 2-minute walking test, the modified Borg scale and the G-Walk gait analysis system (BTS Bioenginering S.p.A., Italy) were used as the outcome measures. The outcome measures were performed randomly during normal gait without walking aids (self control group), then during walking with single point cane, bilateral forearm crutch and walker. RESULTS: It was observed that the walking aids have decreased the walking speed, walking distance and cadence. When the pelvis kinematic was analyzed, there was only a significant difference in the extension of the pelvis between the groups (p<0.05). The most useful (61%), most comfortable (44.4%) and the most preferred (61%) walking aid was determined as single cane by patients and the safest (55%) one was determined as a walker. CONCLUSION: In the decision-making process for walking aids, the patient`s biomechanical, physiological and psychosocial needs, expectations, satisfactions and levels of independence should be considered before providing patients with aids for walking.

Reduction in ulnar pressure distribution when walking with forearm crutches with a novel cuff design: Cross-sectional intervention study on the biomechanical efficacy of an ulnar recess.

Walking with crutches is an effective way of reducing the load on the lower extremity and is often indicated after injury or surgery. However, walking with forearm crutches with conventional cuffs can trigger symptoms including tenosynovitis in the biceps tendon, ulnar neuropraxia at the wrist, pain, or skin hematoma. The purpose of this study was to test the hypothesis that a crutch cuff design with an ulnar recess reduces ulnar pressure during walking with forearm crutches. The pressure distribution between the forearm and crutch cuff was measured in 15 healthy participants for crutch walking with conventional and novel cuffs, respectively. Relative peak pressure in the proximal medial region compared to the overall peak pressure was reduced by 8.6% when walking with crutches with the novel cuff design compared to conventional cuffs (p < 0.001). Relative peak pressure in the distal intermediate and lateral regions were increased by 3.3% and 3.7% for the novel compared with conventional cuffs, respectively (p < 0.001 for both). Hence, the novel crutch cuffs shifted regions of high pressure away from the proximal ulnar region towards more distal regions that are covered by more soft tissue.

The impact of non weight bearing: A prospective cohort study.

BACKGROUND: Patients with lower limb injuries are commonly advised to non weight bear (NWB) on their injured limb as part of treatment. Occasionally, patients complain that offloading one limb, associated with the use of crutches or other mobility aids, may lead to pain on one of the other supporting limbs. This has led to compensation claims (1) but has never been the subject of formal research. METHODS: A prospective cohort trial was undertaken to address this question. Patients were recruited from two Metropolitan Hospital Orthopaedic Fracture Clinics and Orthopaedic Wards. A survey was administered at two time points; the first at the point of definitive orthopaedic treatment and commencement of the NWB phase. The second after the NWB phase was completed. The surveys included a pain Visual Analogue Scale (VAS), Short Form (SF)12, a pain body chart and a health questionnaire. RESULTS: A total of 55 patients were enrolled in the study. Seven patients developed new joint pain after a period NWB. These patients scored significantly lower on the follow up SF12 when compared to those who did not develop new pain (p=0.045). Follow up phone calls at least 6 months following completion of the second survey revealed that all initial and new pain areas in these participants had resolved. The main limitation of this study was the limited numbers. CONCLUSION: This study supports the idea that crutches, prescribed in the short term to allow a limb to be NWB, achieve this aim with minimal impact. Their use may be associated with new other joint pain however it can be anticipated this will resolve after cessation of crutch use.

Outcomes of Rotator Cuff Repair in Patients with Comorbid Disability in the Extremities.

BACKGROUND: Rehabilitation and overuse of the shoulder after rotator cuff repair are a concern in patients with comorbid disability in other extremities. Improvement of outcomes can be hampered in this situation. This study was to describe the clinical outcomes of rotator cuff repair in patients with comorbid disability in other extremities. METHODS: In two tertiary institutions, 16 patients with comorbid disability (9 men and 7 women; mean age of 57.1 years [range, 45 to 71 years]; 14 dominant arms; mean follow-up of 18 months [range, 12 to 38 months]) underwent rotator cuff repair. There were 5 massive tears, 1 large tear, 9 medium tears, and 1 small tear. Open repair was performed in 3 patients and arthroscopic repair in 13. The most common comorbid condition was paralysis (n = 7). Eight patients walked with crutches preoperatively. Anatomical outcome was investigated in 12 patients using either magnetic resonance imaging or ultrasonography at least 6 months postoperatively. RESULTS: Range of motion, visual analogue scale for pain and satisfaction, and all functional scores improved significantly. Healing failure occurred in 4 patients (2 large-to-massive and 2 medium size tears), but none required revision surgery. All 4 retears involved the dominant side, and 3 patients were crutch users. CONCLUSIONS: The current data suggested favorable outcome of rotator cuff repair in patients with comorbid disability. Careful surgical planning and rehabilitation is particularly important for crutch users and in the case of dominant arm involvement in disabled patients.

Persistent anterior interosseous nerve palsy following forearm crutch use.

A 43-year-old man presented with weakness of the interphalageal joint of his right thumb following the use of forearm crutches. On examination he was unable to oppose his thumb and index finger to form the 'ok' sign. Nerve conduction showed anterior interosseous nerve (AIN) damage along its path to the flexor pollicis longus. The patient was managed conservatively with little clinical improvement seen at 4 months. AIN palsies are very rare and account for <1% of all upper limb lesions. Although AIN palsies resulting from other causes such as surgery and blunt trauma are more common, we report the second case of AIN palsy following crutch use, and the first case in which clinical identification was confirmed using electrodiagnosis. Usual clinical practice recommends a prolonged period of conservative management with surgical management withheld for a minimum of 12 months. Correct crutch fitting and early identification of signs of associated injuries are of paramount importance.

Crutch-related acute arterial thrombosis in upper limb: case report / Oclusão arterial aguda de membro superior associada à utilização de muleta: relato de caso

Case report of an acute arterial obstruction in the upper limb secondary to thrombosis of the axillary artery caused by chronic use of crutches. The authors make a brief review of the literature and discuss it in relation to the present case.

Relato de caso de obstrução arterial aguda do membro superior por trombose da artéria axilar secundária ao uso crônico de muleta. Os autores fazem uma breve revisão da literatura, discutindo o presente caso.

Forearm pressure distribution during ambulation with elbow crutches: a cross-sectional study.

BACKGROUND: Increasing numbers of patients require permanent walking aids to maintain mobility. Current elbow crutches are not designed for long-term use, and overuse is often associated with hematoma formation and pain along the forearm. We therefore hypothesized that the highest pressures between the forearm and crutch cuff during walking and stance are located in the ulnar region and that the level of weight-bearing, forearm circumference and kinematic parameters influence peak pressure values and pressure distribution. METHODS: Ten healthy adults participated in a cross-sectional study. A pressure sensor array was attached to the forearm of each participant separating the forearm into four quadrants (lateral, ulnar, intermediate and medial). Measurements were taken during crutch gait and during partial and full weight-bearing stance. A three-dimensional motion analysis system with reflective markers attached to the subject's body and to the crutches was used to obtain kinematic data. RESULTS: The mean pressure on the forearm during crutch gait was 37.5 kPa (SD 8.8 kPa). Highest mean pressure values were measured in the ulnar (41.0 kPa, SD 9.6 kPa) and intermediate (38.0 kPa, SD 9.0 kPa) quadrants. The center of pressure was mainly located in an oblique lamellar area in these two quadrants. With increasing weight-bearing on the crutches during stance, we observed a shift of the peak pressures towards the ulnar quadrant. The circumference of the forearm correlated with the peak pressure in the medial and intermediate quadrants during crutch gait (P < 0.05). Peak pressures on the forearm showed a trend towards correlation with crutch abduction, but no association with other kinematic parameters was detected. CONCLUSION: The pressure load on the forearm during crutch-assisted gait is located predominantly over the ulna and may be linked to a range of secondary conditions caused by crutch use including hematoma formation and pain.

Recurrent brachial artery embolism caused by a crutch-induced axillary artery aneurysm: report of a case.

We report a case of axillary artery aneurysm with brachial artery embolism in a 60-year-old man who had walked with the assistance of axillary crutches all of his life since poliomyelitis during infancy had left him with lower limb paralysis. We performed bypass grafting from the axillary to brachial artery with exclusion of the aneurysm. An axillary artery aneurysm is rare, but potentially lethal for the upper extremity; therefore, surgical treatment should be considered.

Experimental characterization of axillary/underarm interface pressure in swing-through crutch walking.

Supporting weight on the upper support of crutches is not recommended because it can lead to axillary nerve damage. Despite this warning, improper axillary loadings may still occur because of a lack of arm strength or fatigue. It is generally accepted that improper use of conventional axillary crutches contributes to axillary nerve damage, but surprisingly there are no studies characterizing axillary support/underarm configurations. In this study, we compared traditional and horizontal axillary support designs by measuring various biomechanical parameters on the axillary support during a swing-through gait while supporting weight on the axillary support. Subjects found the axillary support that remains horizontal to be more comfortable than the axillary support of axillary crutches. The higher perceived comfort may be attributed to the lower force and contact area, both average and maximum, developed on the horizontal axillary support and/or shorter excursion of the position of the center of force during a stride. These findings suggest that avoiding all weight bearing on the axillary support may be an overly conservative recommendation for supports that remain horizontal. Individuals with insufficient arm strength may benefit by considering this type of support, but because further study is needed, a physical therapist should be consulted.

Bilateral wrist drop complicating axillary crutches mobilization in a young adult / Mano péndula bilateral que complica la movilización con muletas axilares en un adulto joven

OBJECTIVE: Axillary crutches are simple rehabilitative devices that are globally used temporarily or permanently to assist in ambulation of patients and rarely present with complication. This report is about bilateral wrist drop incidentally noticed in a young adult patient mobilized on axillary crutches after internal fixation of a simple right tibia fracture. METHODS: The fracture was fixed by intramedullary nailing and the patient was mobilized on axillary crutches. At six weeks, patient fearfully refused to be commenced on partial weight bearing and at 12 weeks after surgery he was noticed to be totally weightbearing on the bars of the appropriately long axillary crutches and had developed bilateral wrist drop. There was radiological evidence of healing at the fracture sites. Treatment included mobilization on one elbow crutch on the left, physical therapy and nerve stimulation. RESULTS: At six weeks of physiotherapy, the power of the dorsiflexors of the wrists had recovered completely. CONCLUSION: Bilateral posterior cord palsy of brachial plexus could occur even in young healthy patients but total recovery could occur if the diagnosis and treatment are prompt. Patients should be told in unequivocal terms not to weight bear directly on axillary bars.

OBJETIVO: Las muletas axilares son simples dispositivos de rehabilitación que se utilizan en todo el mundo de manera temporal o permanentemente para ayudar a caminar a los pacientes, y raramente presentan complicación. Este trabajo trata de la mano péndula o mano caída, observada incidentalmente en un paciente adulto joven movilizado en muletas axilares, después de la fijación interna de una fractura simple de la tibia derecha. MÉTODOS: La fractura fue fijada mediante clavo intramedular, y el paciente fue movilizado con muletas axilares. A las seis semanas, el paciente se negó temeroso a la iniciación para sostener parcialmente todo su peso con ayuda de muletas, y a las 12 semanas después de la cirugía, se le vio sostener todo su peso sobre las barras de las muletas axilares de longitud adecuada, y había desarrollado mano péndula bilateral. Había evidencia radiológica de curación en los sitios de fractura. El tratamiento incluyó la movilización con una muleta de codo a la izquierda, terapia física, y estimulación nerviosa. RESULTADOS: A las seis semanas de fisioterapia, la capacidad de los dorsiflexores de las muñecas se había recuperado completamente. CONCLUSIÓN: La parálisis del fascículo posterior bilateral del plexo braquial podría ocurrir incluso en pacientes jóvenes sanos, pero la recuperación total podría ocurrir si el diagnóstico y el tratamiento se hacen a tiempo. A los pacientes se les debe decir en términos inequívocos que no deben soportar todo su peso directamente en las barras axilares.

Recurrent upper limb ischaemia due to a crutch-induced brachial artery aneurysm.

An 83-year old man who had used bilateral axillary crutches for 67 years was referred to our hospital for acute left upper limb ischaemia. He underwent successful recanalization through emergent catheter thromboembolectomy. However, a crutch-induced left brachial artery aneurysm was subsequently detected by computed tomography. Therefore, we performed aneurysm exclusion and subsequent saphenous vein bypass grafting. When a crutch user presents with upper limb ischaemia, a high index of suspicion and early identification of the crutch induced vascular injury are mandatory for appropriate treatment.

Bilateral wrist drop complicating axillary crutches mobilization in a young adult.

OBJECTIVE: Axillary crutches are simple rehabilitative devices that are globally used temporarily or permanently to assist in ambulation of patients and rarely present with complication. This report is about bilateral wrist drop incidentally noticed in a young adult patient mobilized on axillary crutches after internal fixation of a simple right tibia fracture. METHODS: The fracture was fixed by intramedullary nailing and the patient was mobilized on axillary crutches. At six weeks, patient fearfully refused to be commenced on partial weight bearing and at 12 weeks after surgery he was noticed to be totally weightbearing on the bars of the appropriately long axillary crutches and had developed bilateral wrist drop. There was radiological evidence of healing at the fracture sites. Treatment included mobilization on one elbow crutch on the left, physical therapy and nerve stimulation. RESULTS: At six weeks of physiotherapy, the power of the dorsiflexors of the wrists had recovered completely. CONCLUSION: Bilateral posterior cord palsy of brachial plexus could occur even in young healthy patients but total recovery could occur if the diagnosis and treatment are prompt. Patients should be told in unequivocal terms not to weight bear directly on axillary bars.

Isquemia arterial aguda del miembro superior por uso de muletas / Isquemia arterial aguda do membro superior por uso de muletas / Crutches induced acute arterial ischemia of the upeer limb

La compresión axilar por el uso de muletas es una causa infrecuente y subdiagnosticada de isquemia arterial aguda del miembro superior. Se presenta el caso de un paciente con isquemia aguda debido a trauma en la confluencia de las arterias axilar y humeral inducido por el uso de muletas. Dicha lesión fue el foco de microembolias que ocluyeron el arco palmar y la arteria humeral. Se diagnosticó con una arteriografía selectiva de la arteria axilar, y se tratómediante un bypass axilo-humeral con prótesis de PTFE anillado de 6 mm, con resultado satisfactorio en el seguimiento clínico a cinco años del postoperatorio.

A compressão axilar devido ao uso de muletas é uma causa pouco frequente e subdiagnosticada de isquemia arterial aguda do membro superior. Apresenta-se o caso de um paciente com isquemia aguda por trauma da confluência das artérias axilar e femoral induzido pormuletas. Esta lesão foi o foco de microembolias que provocaram a oclusão do arco palmar e da artéria femoral. Foi diagnosticado com uma arteriografia seletiva da artéria axilar, e tratado com um bypass axilo-femoral com prótese de capas de PTFE de 6 mm, com resultado satisfatório no seguimento clínico, cinco anos depois do pós operatório.

Crutch induced axillary trauma represents an infrequent but underdiagnosed cause of acuteischemia to the upper limb. We present a case of acute arterial ischemia caused by trauma of the confluence of the axillary and brachial arteries induced by the use of crutches. This lesion was the origin of microembolisms that occluded both the palmar arch and the brachialartery. The diagnosis was made by a selective arteriography of the axillary artery. An axillobrachial bypass with a 6 mm ringed PTFE prosthesis was performed showing satisfactory resultson his 5 year postoperative clinical follow up.

Mobility aid-related accidents in children.

During the period 1991-2008, more than 63 000 children were examined in US emergency rooms following an accident related to a mobility aid: 40% of the children were less than 10 years old; 60% of the accidents occurred at home; and 4.4% of the children were hospitalised. Wheelchairs were the devices most often involved (67%), followed by crutches and walkers. Most accidents involving children under 10 years old were linked to a walker or wheelchair, and mainly resulted in head injuries. Most of the accidents in older children involved crutches and caused lower-limb sprains. In practice, the correct use of mobility aids should be explained to parents and children, and information given about the circumstances most likely to lead to accidents. Children using these devices should be supervised if necessary.

Sternotomy and crutches.

The use of crutches following a sternotomy raises the concern of sternal dehiscence. We discuss secure reinforced sternal closure, classify sternal distractional forces and discuss the postoperative mobilization process.

[The upper extremities revascularization in patients with brachial artery thrombosis due to its chronic damaging by crutches: new approaches to the treatment].

An optimal tactics of treatment of patients, suffering the upper extremities (UE) ischemia, caused by arterial thrombosis, occurred due to subclavian artery damage in those patients, who apply crutches for a long period of time, was elaborated. In modern medicine in patients with the UE arterial bed thrombosis with affection of its peripheral, and more in terminal, portion the possibilities of direct revascularization performance are significantly restricted, especially in patients, suffering from constant mechanical injury of armpit and its vascular content, caused by crutches. Application of the method, consisting of automyelotransplantation of the bone marrow aspirate, have permitted to regulate the disorders of microhemodynamics, using stimulation of angiogenesis and development of a collateral blood flow.

Recurrent upper extremity embolism due to a crutch-induced arterial injury: a different cause of upper extremity embolism.

Acute embolism of the upper extremity is a relatively infrequent event compared to the lower extremity, but it will affect the function of the limb involved and may occasionally lead to amputation. Most upper extremity emboli are of cardiac origin, with the remainder arising from subclavian aneurysm, occlusive disease, or iatrogenic causes. Rarely, crutch-induced repetitive trauma of an upper extremity can produce recurrent embolic events. Frequently, this process is initially diagnosed and treated as a brachial artery embolism; such a misdiagnosis is associated with recurrent embolism. We report herein two uncommon cases of axillobrachial arterial injuries secondary to crutch trauma as a source of recurrent emboli to an upper extremity.

Crutch-induced bilateral brachial artery aneurysms.

A 57-year-old man, who was a chronic axillary crutch user as a result of childhood poliomyelitis, was referred to our hospital because of a sudden onset of right forearm ischemia. The right forearm had no pulse, and three-dimensional computed tomography (3DCT) showed an aneurysm of the right brachial artery associated with arterial occlusion. The thrombosed aneurysm of the brachial artery was resected and the brachial artery was successfully revascularized by interposing a saphenous vein graft. Postoperative 3DCT revealed an asymptomatic left brachial artery aneurysm. His postoperative course was uneventful under warfarin anticoagulation therapy.