Transferencia dinámica de latissimus dorsi para restauración funcional de la flexo-extensión del codo / Dynamic transfer of latissimus dorsi for functional restoration of elbow flexion-extension

Introducción y objetivo: La pérdida de función o la ausencia congénita de músculos del miembro superior puede afectar seriamente a la calidad de vida del paciente, limitando actividades cotidianas que requieren flexión o extensión del codo. Describimos nuestra experiencia con la técnica para reconstrucción dinámica de la flexión y extensión del codo mediante transferencia pediculada del músculo latissimus dorsi (LD). Material y métodos: Empleamos esta técnica en 2 casos y presentamos el protocolo de rehabilitación kinesiológica subsiguiente. Este protocolo se inicia de manera inmediata tras la cirugía con apoyo de férulas de inmovilización para la extremidad superior y progresa gradualmente hacia la movilización autoasistida según tolerancia del paciente. Después, se avanza a la movilización activa sin carga, dirigida a mejorar las actividades de la vida diaria y aumentar la movilidad articular del codo, cuantificada a través de goniometría. Finalmente, progresa hacia la movilización contra resistencia. Resultados: Los pacientes operados que sufrían pérdida traumática del músculo bíceps brachii y del tríceps brachii respectivamente, mostraron rápida recuperación funcional y satisfactoria reinserción laboral y social. Conclusiones: En nuestra experiencia, esta técnica ha sido una opción efectiva y segura en la restauración de la función del codo y la cobertura de extensos defectos cutáneos, evitando la necesidad de recurrir a colgajos libresNivel de evidencia científica 4d Terapéutico.(AU)

Background and objective: Loss of function or congenital absence of upper limb muscles can significantly impact a patient's quality of life, limiting everyday activities that require elbow flexion or extension. We describe the technique for dynamic reconstruction of elbow flexion and extension using pedicled transfer of the latissimus dorsi (LD) muscle. Methods: We present our experience with the use of this technique in 2 cases and describe the subsequent kinesiological rehabilitation protocol. This protocol is initiated immediately post-surgery, with the support of immobilization splints for the upper limb and gradually progresses to self-assisted mobilization based on patient tolerance. Subsequently, advancement is made to active load-free mobilization, aimed at enhancing daily life activities and increasing elbow joint mobility, quantified using goniometry. Finally, the rehabilitation regimen progresses to resistance-based mobilization. Results: Operated patients suffering traumatic loss of the biceps brachii and triceps brachii muscles respectively, exhibited rapid functional recovery and satisfactory reintegration into work and social life. Conclusions: In our experience, this surgical technique has demonstrated itself to be an effective and safe option in restoring elbow function and providing coverage for extensive cutaneous defects, eliminating the need for free flaps. Level of evidence 4d Terapeutic.(AU)

Caracterización clínica y sociodemográfica de la población infantojuvenil entre 2 y 17 años con diagnóstico de deficiencia de extremidades superiores adquirida y/o congénita, en el Instituto Teletón Santiago / Clinical and sociodemographic characterization of the child and youth population between 2 and 17 years old with a diagnosis of acquired or congenital upper limbs deficiency at Instituto Teletón Santiago

INTRODUCCIÓN: Las deficiencias congénitas y adquiridas de extremidades superiores son una condición importante en la población pediátrica, existe poca información respecto de sus características clínicas, sociodemográficas y las asociadas al uso de prótesis. OBJETIVO: Describir las características clínicas y sociodemográficas de la población infantojuvenil entre 2 y 17 años con diagnóstico de deficiencia de extremidades superiores adquirida y/o congénita, pertenecientes al Instituto Teletón Santiago (IT-S). METODOLOGÍA: Estudio transversal, en población infantojuvenil entre 2 y 17 años, con diagnóstico de deficiencia de extremidades superiores, adquirida y congénita, que se atienden en el IT-S. Se realizó una revisión de fichas clínicas y encuesta para la obtención de datos de características sociodemográficas, clínicas y asociadas al uso de prótesis. RESULTADOS: Se incluyeron 215 pacientes, 93,9% de etiología congénita y 6,1% adquirida. El nivel de la deficiencia más frecuente fue parcial de mano con 51,6%, seguido del transradial con 33,1%. El 33% de los 215 pacientes estudiados tuvieron prescripción de prótesis. De los pacientes con prescripción de prótesis, 78,9% correspondía a mecánica y 18,3% a prótesis 3D. El 53,5% usaba su prótesis y el 46,4% no la usaba. Respecto a las prótesis 3D, el 84,6% no la usaban. En el nivel parcial de mano, el 83,3% no usaban su prótesis. CONCLUSIONES: Este estudio aporta datos de importancia clínica, destacando, una prescripción protésica de inicio temprano y asociada a las características clínicas de los pacientes. Así mismo, existe una alta tasa de no uso de las prótesis 3D, en el nivel parcial de mano.

INTRODUCTION: Congenital and acquired deficiencies of the upper extremities are an important condition in the pediatric population, however, there is almost no information regarding the clinical and sociodemographic characteristics and those associated with the use of prostheses. OBJECTIVE: Describe the clinical and sociodemographic characteristics of the child and adolescent population between 2 and 17 years old with a diagnosis of acquired and/or congenital upper limb deficiency, belonging to the Instituto Teletón Santiago (IT-S). METHODS: A cross-sectional study was conducted in child and adolescent population between 2 and 17 years old, with a diagnosis of acquired and/ or congenital upper limb deficiency treated in the IT-S. A review of clinical records and a survey were carried out to obtain data on sociodemographic and clinical characteristics and characteristics associated with the use of prostheses. RESULTS: 215 patients were included, 93.9% of congenital and 6.1% of acquired etiology. The most common level of deficiency was partial hand with 51.6%, followed by transradial with 33.1%. 33% of the 215 patients included had a prescription for a prosthesis. 78.9% of the patients with a prosthesis prescription had a mechanical prosthesis and 18.3% had a 3D prosthesis. 53.5% used their prosthesis and 46.4% did not use it. 84.6% of the patients with 3D prostheses did not use them and an 83.3% of the patients with a partial hand level deficiency did not use their prosthesis. CONCLUSION: This study provides data of clinical importance, highlighting an early-onset prosthetic prescription associated with the clinical characteristics of the patients. Likewise, there is a high rate of non-use of 3D prostheses at the partial hand level.

Effect of prostheses on children with congenital upper limb deficiencies.

BACKGROUND: Individual weaknesses in motor skills are a characteristic of children with congenital upper limb deficiencies. These weaknesses increase with age. In Japan, however, prosthetic prescription and subsequent rehabilitation approaches for children with upper limb deficiencies are insufficient and often delayed. This study aimed to elucidate whether rehabilitation approaches, including prostheses prescription and occupational therapy, improve these children's adaptive behaviors, especially their motor skills. METHODS: The study included nine children, aged 0-6 years, with unilateral transradial or transcarpal upper limb deficiencies. We measured their adaptive behaviors and motor skills at the beginning of prosthetic therapy and after 1.5 years, using the Vineland Adaptive Behavior Scales - Second Edition. RESULTS: The score for the motor skills domain was significantly lower than the median score of the domains at the beginning of prosthetic therapy. The motor skill weaknesses significantly improved after 1.5 years of prosthetic therapy. CONCLUSIONS: Although children with congenital upper limb deficiencies have individual weaknesses in their motor skill behavior, it was shown that these weaknesses can be improved through rehabilitation approaches, including occupational and prosthetic therapies. Issuing the appropriate prostheses and implementing the appropriate training to use the prostheses for congenital upper limb deficiencies are reasonable and meaningful interventions to improve quality of life.

Health-related quality of life in adults with congenital unilateral upper limb deficiency in Norway. A cross-sectional study.

PURPOSE: To examine subjective health-related quality of life (HRQoL) in adults with congenital unilateral upper limb deficiency (UULD) in Norway and to explore the associations between demographic and clinical factors and HRQoL. METHOD: Cross-sectional study comparing HRQoL, measured by SF-36, among adults with UULD and an age- and gender-matched control group from the Norwegian general population (NGP). RESULTS: Seventy-seven respondents, median age 42 years (range: 20-82); 71% were women. Most had left-sided (61%), below elbow (53%), transverse (73%) deficiency. Compared to the NGP, the UULD group reported reduced HRQoL on all SF-36 subscales except for the role emotional (RE) scale (p=0.321), mental health (MH) (p=0.055) and mental component summary (MCS) (p=0.064). The greatest difference was on the bodily pain (BP) scale (point difference of 20.0). Multiple linear regression models showed significant association between several physical- and mental SF-36 subscales and occupational status, occurrence of comorbidity and chronic pain. CONCLUSIONS: Persons with UULD reported reduced HRQoL on most SF-36 subscales, mostly in the physical health domain. Employment status, occurrence of comorbidity and chronic pain seem to have a negative impact on the HRQoL. Measures that can reduce pain and loss of function should be given particular attention in UULD rehabilitation. Implications for Rehabilitation Persons with congenital unilateral upper limb deficiency (UULD) who experience pain and discomfort should seek professional help for evaluating their everyday coping strategies. Professionals who meet persons with UULD should examine anomalies, comorbidity, pain and employment status before choosing advices and actions. Individually adapted grip-improving devices, environments, physical exercise and pain management programs should be implemented early to reduce pain, loss of function and decreased HRQoL. A multidisciplinary approach is often necessary when counseling persons with UULD.

Design and evaluation of voluntary opening and voluntary closing prosthetic terminal device.

Body-powered prostheses use a cable-operated system to generate forces and move prosthetic joints. However, this control system can only generate forces in one direction, so current body-powered prehensor designs allow the user either to voluntarily open or voluntarily close the tongs. Both voluntary opening (VO) and voluntary closing (VC) modes of operation have advantages for certain tasks, and many end-users desire a terminal device that can switch between the two modes. However, such a terminal device must maintain the same thumb position (i.e., point of Bowden cable attachment) and movement direction in both modes in order to avoid the need to readjust the harness after every mode switch. In this study, we demonstrate a simple design that fulfills these requirements while allowing the user to switch easily between modes. We describe the design concept, describe a rugged split-hook prototype, provide specifications (size, weight, efficiency, etc.), and present a pilot study in which five subjects with intact arms and two subjects with amputation used the VO and VC split-hook prehensor to perform the Southampton Hand Assessment Procedure. Subjects performed an average of 4 to 7 (+/- 0.2) points better when they could choose to switch between modes on a task-by-task basis than when they were constrained to using only VO or VC modes.

Pediatric limb differences and amputations.

Congenital limb differences are uncommon birth defects that may go undetected even with prenatal screening ultrasound scans and often go undetected until birth. For children with congenital limb differences, a diagnostic evaluation should be done to rule out syndromes involving other organ systems or known associations. The most common etiology of acquired amputation is trauma. Postamputation complications include pain and terminal bony overgrowth. A multidisciplinary approach to management with the child and family can lead to a successful, functional, and fulfilling life.

Prognostic factors of a satisfactory functional result in patients with unilateral amputations of the upper limb above the wrist that use an upper limb prosthesis.

PURPOSE: The purpose of this study is to determine the prognostic factors of a satisfactory functional outcome in patients using upper extremity prosthetics with a proximal third forearm stump, and above, level of amputation. MATERIALS AND METHODS: All patients with longitudinal deficiencies and traumatic amputations of upper extremity with a level of amputation of proximal third forearm and above were included. A total of 49 patients with unilateral upper extremity amputations that had used the prosthetic for a minimum of 2 years were included in the protocol. The Disability arm shoulder hand (DASH) scale was used to determine a good result with a cut-off of less than 40%. The independent variables were the level of amputation, the etiology for its use, initial age of use and number of hours/day using the prosthesis. RESULTS: It was found that patients with a congenital etiology and those that started using the prosthetic before 6 years of age had better functional results. DISCUSSION: It was found that when adapting a patient with an upper extremity prosthetic, which has a high rejection rate of up to 49%, better functional outcomes are found in those who started using it before 6 years of age, and preferably because of a congenital etiology. It was also found that the number of hours/day strongly correlates with a favorable functional outcome.

Opinions of youngsters with congenital below-elbow deficiency, and those of their parents and professionals concerning prosthetic use and rehabilitation treatment.

BACKGROUND: Youngsters with unilateral congenital below-elbow deficiency (UCBED) seem to function well with or without a prosthesis. Reasons for rejecting prostheses have been reported earlier, but unfortunately not those of the children themselves. Furthermore, reasons for acceptance are underexplored in the literature. OBJECTIVES: To investigate opinions of children and early and late adolescents with UCBED, and those of their parents and healthcare professionals, concerning (1) reasons to wear or not to wear prostheses and (2) about rehabilitation care. METHODS: During one week of online focus group interviews, 42 children of 8-12 y/o, early and late adolescents of 13-16 and 17-20 y/o, 17 parents, and 19 healthcare professionals provided their opinions on various topics. This study addresses prosthetic use or non-use of prosthetics and rehabilitation care. Data were analyzed using the framework approach. RESULTS: Cosmesis was considered to be the prime factor for choosing and wearing a prosthesis, since this was deemed especially useful in avoiding stares from others. Although participants functioned well without prostheses, they agreed that it was an adjuvant in daily-life activities and sports. Weight and limited functionality constituted rejection reasons for a prosthesis. Children and adolescents who had accepted that they were different no longer needed the prosthesis to avoid being stared at. The majority of participants highly valued the peer-to-peer contact provided by the healthcare professionals. CONCLUSIONS: For children and adolescents with UCBED, prostheses appeared particularly important for social integration, but much less so for functionality. Peer-to-peer contact seemed to provide support during the process of achieving social integration and should be embedded in the healthcare process.

Kinematic comparison of the wrist movements that are possible with a biomechatronics wrist prosthesis and a body-powered prosthesis: a preliminary study.

PURPOSE: This study examined the kinematic differences between a body-powered prosthesis and a biomechatronics prosthesis as a transradial amputee performed activities that involve flexion/extension and supination/pronation of the wrist. METHOD: The subject's wrist movements were calculated and compared as he completed a wrist range of motion test involving simulated flexion/extension and supination/pronation. RESULTS: The results revealed that, under the test conditions, the body-powered prosthesis limits an individual's ability to complete four different tasks of wrist movement especially when it comes to complete the supination/pronation movement. Conversely, while using biomechatronics wrist prosthesis, the user was able to compensate for limited wrist motion through an ability to achieve a greater range of wrist movement. CONCLUSIONS: The biomechatronics wrist prosthesis provides a greater degree of freedom of wrist flexion/extension and supination/pronation movements.

Body structures and physical complaints in upper limb reduction deficiency: a 24-year follow-up study.

OBJECTIVE: To describe upper body structures associated with upper limb reduction deficiency and the development of these structures over time, to examine the presence of physical complaints in this population, and to compare body structures and complaints between groups based on prosthesis use. DESIGN: Prospective cohort study with a follow-up period of 24 years, with matched able-bodied controls. SUBJECTS: Twenty-eight patients with unilateral below-elbow reduction deficiency fitted with myoelectric prostheses, aged 8-18 years at inclusion. METHOD: Measurements of upper arm, trunk and spine were performed and study-specific questionnaires were answered at baseline and follow-up; the Brief Pain Inventory and the Quick Disability of Arm, Shoulder, and Hand questionnaires were answered at follow-up. RESULTS: Both at baseline and follow-up, within-subjects differences in structures of the arm and trunk were shown in patients but not in controls. Spinal deviations, although small, were greater in patients compared to controls. Self-reported disability was higher in patients compared to controls. Differences in back pain and effect of prostheses use could not be shown. CONCLUSIONS: Patients with unilateral below-elbow reduction deficiency have consistent differences in upper body structures. Deviations of the spine, probably of functional origin, do not progress to clinically relevant scoliosis.

One-handed musicians-more than a gimmick.

There are many musicians with acquired limitations in making music, and there are many people with a disability who would like to play a music instrument in a modified way. There is discouragingly little information about this topic in literature. This article gives an overview of "making music in a modified way." It focuses on the possibilities for musicians with one-handed functionality to overcome problems with regards to their physical condition, insufficient muscle strength, or missing parts of the upper extremity. Five categories of possibilities for the functional one-handed musicians are described: 1. one-hand reconstructed instruments, 2. one-hand compositions, 3. adaptations of the instrument for the other hand, 4. prostheses to make it possible to play with both hands/arms, and 5. other techniques which enable the use of the leg(s). The solutions described make clear that playing music in an adaptive way requires an interdisciplinary approach. The purpose of this article is to inform, and to inspire, the healthcare professional about the many possibilities for functional one-handed musicians.

Evaluation of functionality in acquired and congenital upper extremity child amputees.

OBJECTIVE: The aim of this study was to evaluate the functional level of children with congenital and acquired upper limb loss after a rehabilitation program. METHODS: This study included a total of 40 children, aged 8 to 17 years with upper limb loss. Children were divided into two groups; congenital amputees (n=20) and acquired amputees (n=20). The children underwent prosthetic fitting, prosthetic training and rehabilitation. The Child Amputee Prosthetics Project - Functional Status Inventory (CAPP-FSI) and Prosthetic Upper Extremity Functional Index (PUFI) were used at the initial visit to the prosthetic unit without prosthesis, 3 weeks after the prosthetic training and 6 months after discharge with and without prosthesis. The results with and without the prosthesis were compared between the acquired and congenital amputee groups. RESULTS: There were significant differences in all tests performed at the baseline, at the 3rd week, and at the 6th month without prosthesis and at the 3rd week and at the 6th month with prosthesis (p<0.05). The congenital group received higher scores in the CAPP-FSI and PUFI at the baseline, at the 3rd week and at the 6th month (p<0.05). Patients in the congenital group used their prostheses for 8 hours a day and the acquired group for 4 to 8 hours. CONCLUSION: Daily prosthesis usage time and the child's experience with the prosthesis during daily activities are the determining factors for the functional level in upper limb child amputees. Functionality may improve based on these factors.

Mixed feelings of children and adolescents with unilateral congenital below elbow deficiency: an online focus group study.

The existing literature is inconsistent about the psychosocial functioning of children and adolescents with Unilateral Congenital Below Elbow Deficiency (UCBED). The objective of this qualitative study was to explore the psychosocial functioning of children and adolescents with UCBED in terms of their feelings about the deficiency and what helps them to cope with those feelings. Additionally, the perspectives of prosthesis wearers and non-wearers were compared, as were the perspectives of children, adolescents, parents and health professionals. Online focus group interviews were carried out with 42 children and adolescents (aged 8-12, 13-16 and 17-20), 16 parents and 19 health professionals. Questions were asked about psychosocial functioning, activities, participation, prosthetic use or non-use, and rehabilitation care. This study concerned remarks about psychosocial functioning. Children and adolescents with UCBED had mixed feelings about their deficiency. Both negative and positive feelings were often felt simultaneously and mainly depended on the way people in the children's environment reacted to the deficiency. People staring affected the children negatively, while support from others helped them to cope with the deficiency. Wearing a prosthesis and peer-to-peer contact were also helpful. Non-wearers tended to be more resilient than prosthesis wearers. Wearers wore their prosthesis for cosmetic reasons and to prevent them from negative reactions from the environment. We recommend that rehabilitation teams make parents aware of their great influence on the psychosocial functioning of their child with UCBED, to adjust or extend the currently available psychosocial help, and to encourage peer-to-peer contact.

Comparison of self-reports and parent proxy-reports of function and quality of life of children with below-the-elbow deficiency.

BACKGROUND: The agreement between children's self-reports and parent proxy-reports has not been established for function and quality-of-life measures for children with musculoskeletal diagnoses, including unilateral congenital below-the-elbow deficiency. Factors influencing parent-child agreement in this population have yet to be determined. METHODS: Ten hospitals administered the Pediatric Outcomes Data Collection Instrument (PODCI) and the Pediatric Quality of Life Inventory (PedsQL) prospectively to children and adolescents with a unilateral congenital below-the-elbow deficiency in order to assess their function and quality of life. Two-thirds of the subjects wore a prosthesis. These children's and adolescents' self-reports were compared with their parents' proxy-reports for the PODCI (n = 179) and the PedsQL (n = 364). RESULTS: Parents underestimated their children's/adolescents' self-report scores for the upper extremity physical function domain of the PODCI (p < 0.001) and overestimated the scores for comfort in the pain/comfort domain of the PODCI (p < 0.05). Parents also reported a lower social functioning score on the PedsQL than did the children and adolescents (p < 0.001). Greater agreement with regard to the social functioning domain of the PedsQL was observed between parents and children than between parents and adolescents (p < 0.05) and between parents and subjects who did not wear a prosthesis than between parents and subjects who wore a prosthesis (p < 0.01). CONCLUSIONS: Although the absolute differences are small, children with a unilateral congenital below-the-elbow deficiency report better upper-extremity function and quality of life than their parents perceive, but they may also be experiencing more pain. Factors influencing parent-child agreement on measures of quality of life include age and use of a prosthesis. Parents' reports of function may provide a helpful counterbalance to children's and adolescents' reports, but because quality of life is subjective by nature, the child's or adolescent's report is the gold standard. As a result of variability in agreement, PODCI and PedsQL parent reports cannot be considered true proxies for the self-reports of children or adolescents with unilateral congenital below-the-elbow deficiency or, possibly, of those with other musculoskeletal diagnoses.

[Prosthesis for upper extremity congenital deformities]. / Appareillage des malformations congénitales du membre supérieur.

Prosthetic fitting, in the case of upper extremity congenital deformity, is still subject to controversy. While some authors recommend early systematic fitting, others are not in favour of doing this systematically, denying any advantage in fitting a prosthesis early on. As always, the truth is located between these two extremes. We are not in the logic of the restoration of a lost function. The present situation must be taken into account, but above all, it is necessary to think about the future not to compromise the socialization of these children when they become adults. The proposal of a fitting should never be seen as a constraint by the parents, and even less so by the child. The decision will result from a multidisciplinary reflection with the parents and together with the surgeon, the physical and rehabilitation medicine (PRM) doctor, the physiotherapist and the prosthetist. The fitting can be either aesthetic or functional. Aesthetic fitting is not totally without function, and the child quickly integrates the prosthesis into his daily activities. Functional fitting may only be considered using powered equipment and electric motorization. Early fitting (before four years old) allows the child to build his schema by integrating the prosthesis without it being seen as a constraint. The future desire of wanting a prosthesis is thus safeguarded. A child who has already been fitted can, in adulthood, choose freely to either continue to wear the prosthesis throughout the day or punctually, on certain occasions, or refuse fitting with full knowledge of the facts.

Multivariate prediction of upper limb prosthesis acceptance or rejection.

OBJECTIVE: To develop a model for prediction of upper limb prosthesis use or rejection. DESIGN: A questionnaire exploring factors in prosthesis acceptance was distributed internationally to individuals with upper limb absence through community-based support groups and rehabilitation hospitals. SUBJECTS: A total of 191 participants (59 prosthesis rejecters and 132 prosthesis wearers) were included in this study. METHODS: A logistic regression model, a C5.0 decision tree, and a radial basis function neural network were developed and compared in terms of sensitivity (prediction of prosthesis rejecters), specificity (prediction of prosthesis wearers), and overall cross-validation accuracy. RESULTS: The logistic regression and neural network provided comparable overall accuracies of approximately 84 +/- 3%, specificity of 93%, and sensitivity of 61%. Fitting time-frame emerged as the predominant predictor. Individuals fitted within two years of birth (congenital) or six months of amputation (acquired) were 16 times more likely to continue prosthesis use. CONCLUSIONS: To increase rates of prosthesis acceptance, clinical directives should focus on timely, client-centred fitting strategies and the development of improved prostheses and healthcare for individuals with high-level or bilateral limb absence. Multivariate analyses are useful in determining the relative importance of the many factors involved in prosthesis acceptance and rejection.

Evaluation of arm and prosthetic functioning in children with a congenital transverse reduction deficiency of the upper limb.

OBJECTIVE: To assess upper extremity functioning of children with unilateral transverse upper limb reduction deficiency, using standardized instruments, and to investigate their validity and reliability. DESIGN: Cross-sectional study. SUBJECTS: Twenty subjects aged 4-12 years; 9 prosthetic users and 11 non-users. METHODS: The Assisting Hand Assessment, Unilateral Below Elbow Test, Prosthetic Upper extremity Functional Index and ABILHAND-Kids were assessed in all children. Users were tested with and without their prosthesis. We compared results of users and non-users, and of users with and without their prosthesis. Validity was determined by testing hypotheses and correlations with other measures. Test-retest reliability was assessed from repeated measurements in 10 children. RESULTS: Children with an upper limb reduction deficiency performed well on daily activities. They could use their prosthesis in 68% of the activities, but were currently using it in only 30%. Children find their prosthesis useful for specific activities, rather than for daily activities in general. The Assisting Hand Assessment and Prosthetic Upper extremity Functional Index showed best validity; test-retest reliability was good to excellent. CONCLUSION: The use of standardized instruments adds relevant information on functioning of children with an upper limb reduction deficiency. We found additional support for validity and reliability of, in particular, the Assisting Hand Assessment and Prosthetic Upper extremity Functional Index.

[Management of upper limb deformities. Treatment concepts through the years]. / Hilfsmittel bei Fehlbildungen der oberen Extremitäten. Versorgungskonzepte im Wandel der Zeit.

The provision of aids and prostheses for patients with upper limb deficiencies has to be based on comprehensive knowledge in the field of orthopaedic technology. Taking into account the patient's complete background, evaluation of the possible functional benefit is mandatory in order to achieve good acceptance of a prosthesis in the long term. The extent of extremity "loss" and the remaining function of the deficient limb have an impact on the success of prosthetic fitting. Furthermore, there is a trend towards myoelectric prostheses, which seem to improve prosthetic acceptance. Bilateral congenital deficiency of the upper limbs cannot be equated with amputations. Most people affected do not push for a prosthesis, but should be provided with one, if the need arises. Decades of overuse of the deficient limbs often take their toll in terms of decreasing function as degenerative changes occur. As a consequence, artificial upper limbs may be obligatory to prevent loss of independence.

Prescription of the first prosthesis and later use in children with congenital unilateral upper limb deficiency: A systematic review.

BACKGROUND: The prosthetic rejection rates in children with an upper limb transversal reduction deficiency are considerable. It is unclear whether the timing of the first prescription of the prosthesis contributes to the rejection rates. OBJECTIVE: To reveal whether scientific evidence is available in literature to confirm the hypothesis that the first prosthesis of children with an upper limb deficiency should be prescribed before two years of age. We expect lower rejection rates and better functional outcomes in children fitted at young age. METHODS: A computerized search was performed in several databases (Medline, Embase, Cinahl, Amed, Psycinfo, PiCarta and the Cochrane database). A combination of the following keywords and their synonyms was used: "prostheses, upper limb, upper extremity, arm and congenital". Furthermore, references of conference reports, references of most relevant studies, citations of most relevant studies and related articles were checked for relevancy. RESULTS: The search yielded 285 publications, of which four studies met the selection criteria. The methodological quality of the studies was low. All studies showed a trend of lower rejection rates in children who were provided with their first prosthesis at less than two years of age. The pooled odds ratio of two studies showed a higher rejection rate in children who were fitted over two years of age (pooled OR = 3.6, 95% CI 1.6 - 8.0). No scientific evidence was found concerning the relation between the age at which a prosthesis was prescribed for the first time and functional outcomes. CONCLUSION: In literature only little evidence was found for a relationship between the fitting of a first prosthesis in children with a congenital upper limb deficiency and rejection rates or functional outcomes. As such, clinical practice of the introduction of a prosthesis is guided by clinical experience rather than by evidence-based medicine.

The axillary arch: anatomy and suggested clinical manifestations.

The purpose of this commentary is to describe bilateral anomalous bands of the latissimus dorsi muscle observed in an 81-year-old male embalmed cadaver, and to discuss the possible clinical implications of this anomaly. The musculotendinous bands tautened and compressed the underlying axillary vessels, and the musculocutaneous, median, and ulnar nerves during passive abduction/external rotation of the shoulder. Similar variations found in the latissimus dorsi muscles in this commentary have been reported in the anatomical and surgical literature. These reports include descriptions of the anomalous bands of the latissimus dorsi attaching to the coracoid process, pectoralis major muscle, and fascia of the coracobrachialis muscle. The potential presence of an axillary arch presents several clinical considerations for the physical therapist. The existence of an axillary arch should be considered in patients with signs and symptoms consistent with upper extremity neurovascular compromise similar to thoracic outlet syndrome. Including this variant in the differential diagnostic process may assist physical therapists in the management of patients with signs and symptoms consistent with thoracic outlet syndrome.