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Concept: Limb


Lower limb injuries in sport are increasingly prevalent and responsible for large economic as well as personal burdens. In this review we seek to determine which easily implemented functional neuromuscular warm-up strategies are effective in preventing lower limb injuries during sports participation and in which sporting groups they are effective.

Concepts: Effectiveness, Limb, Sport, Stadium


The concept of reachable workspace is closely tied to upper limb joint range of motion and functional capability. Currently, no practical and cost-effective methods are available in clinical and research settings to provide arm-function evaluation using an individual’s three-dimensional (3D) reachable workspace. A method to intuitively display and effectively analyze reachable workspace would not only complement traditional upper limb functional assessments, but also provide an innovative approach to quantify and monitor upper limb function.

Concepts: Programming language, Lambda calculus, Upper limb, Limb, Limbs


The suprascapular notch is the most common site of suprascapular nerve entrapment, which can manifest in disability and pain of the upper limb. Here, we present three cases of a very rare anatomical variation in the suprascapular region: the coexistence of the suprascapular notch and the suprascapular foramen. The variation was found during radiological and anatomical investigations. The suprascapular foramen was situated inferior to the suprascapular notch. A bony bridge lay between them, likely created by an ossified anterior coracoscapular ligament (ACSL). This anatomical variation probably increased the risk of suprascapular nerve entrapment by nerve irritation of the bony margins during passsage through the foramen and by a lack of the elasticity that the ACSL normally demonstrates. Also, a bony bridge passing through the middle part of the suprascapular notch reduces the space available for nerve passage (bony bridge decreases the space by about 36.5-38.6 %). One patient who underwent the radiological study had typical symptoms of suprascapular nerve entrapment. Based on his medical history and the presence of this rare variation of the suprascapular notch at the suprascapular region we suspect this neuropathy.

Concepts: Pain, Radiology, Anatomy, Upper limb, Limb, Supraspinatus muscle, Suprascapular nerve, Suprascapular notch


The lower extremity has received its fair share of attention as a vascular access site in patients who have exhausted their upper arm vessels. However, experiences with lower extremity arteriovenous grafts (AVGs) have so far been disappointing because of high infection rates and severe limb ischemia. We report our experience with hemodialysis access from the lower extremity.

Concepts: Hemodialysis, Upper limb, Limb


The evolution of the human upper limb involved a change in function from its use for both locomotion and prehension (as in apes) to a predominantly prehensile and manipulative role. Well-preserved forelimb remains of 1.98-million-year-old Australopithecus sediba from Malapa, South Africa, contribute to our understanding of this evolutionary transition. Whereas other aspects of their postcranial anatomy evince mosaic combinations of primitive (australopith-like) and derived (Homo-like) features, the upper limbs (excluding the hand and wrist) of the Malapa hominins are predominantly primitive and suggest the retention of substantial climbing and suspensory ability. The use of the forelimb primarily for prehension and manipulation appears to arise later, likely with the emergence of Homo erectus.

Concepts: Human, Human anatomy, Upper limb, Limb, Human evolution, Limbs, Australopithecus, Homo erectus


AIM: Botulinum toxin A (BoNT-A) combined with occupational therapy is effective in improving upper limb outcomes in children with unilateral cerebral palsy (CP). It is now essential to identify the most effective therapies following BoNT-A. Given the added burden for children and families, the aim of this study was to explore whether modified constraint-induced movement therapy (mCIMT) leads to sufficiently superior gains compared with bimanual occupational therapy (BOT) in young children with unilateral CP following BoNT-A injections. METHOD: In this randomized, controlled, evaluator-blinded trial, 34 children (20 males, 14 females; mean age 3y, SD 1y 4mo, range 18mo-6y) with unilateral CP were randomized using concealed allocation to one of two 8-week interventions. The experimental group (n=17) received BoNT-A and mCIMT. The comparison group (n=17) received BoNT-A and BOT. Participants were recruited from a physical rehabilitation clinic and randomized between August 2003 and May 2009. Primary outcome was measured using the Assisting Hand Assessment at 3 months. Secondary outcomes were measured at 3 months and 6 months using the Quality of Upper Extremity Skills Test, the Pediatric Evaluation of Disability Inventory, Canadian Occupational Performance Measure, and the Goal Attainment Scale. RESULTS: There were no clinically important differences between groups at baseline. Immediately following intervention, there was no evidence of a superior effect for BoNT-A + mCIMT as determined by the Assisting Hand Assessment (estimated mean difference [EMD] 0.81, upper 95% confidence limit 3.6; p=0.32) or secondary outcomes. However, both groups showed improvement over time (BoNT-A + mCIMT: EMD 2.7, 95% confidence interval [CI] 0.7-5.2; BONT-A + BOT: EMD 4.7, 95% CI 2.1-8.6). Follow-up at 6 months also demonstrated no superior effect for BoNT-A + mCIMT. INTERPRETATION: Following upper limb injection of BoNT-A, there was no evidence that mCIMT, despite the significantly increased intensity of the home programme, produced a superior effect across a range of outcomes compared with a structured programme of BOT in young children with unilateral CP.

Concepts: Statistics, Measurement, Confidence interval, Cerebral palsy, Upper limb, Limb, Canadian model of occupational performance, Interval estimation


BACKGROUND: In 2008, we showed that incomplete or delayed extremity fasciotomies were associated with mortality and muscle necrosis in war casualties with limb injury. Subsequently, we developed an education program focused on surgeon knowledge gaps regarding the diagnosis of compartment syndrome and prophylactic fasciotomy. The program included educational alerts, classroom training, video instruction, and a research publication. We compared casualty data before and after the program implementation to determine whether the education altered outcomes. METHODS: Similar to the previous study, a case series was made from combat casualty medical records. Casualties were US military servicemen with fasciotomies performed in Iraq, Afghanistan, or Germany between two periods (periods 1 and 2). RESULTS: In both periods, casualty demographics were similar. Most fasciotomies were performed to the lower leg and forearm. Period 1 had 336 casualties with 643 fasciotomies, whereas Period 2 had 268 casualties with 1,221 fasciotomies (1.9 vs. 4.6 fasciotomies per casualty, respectively; p < 0.0001). The mortality rate decreased in Period 2 (3%, 8 of 268 casualties) from Period 1 (8%, 26 of 336 casualties; p = 0.0125). Muscle excision and major amputation rates were similar in both periods (p > 0.05). Rates of casualties with revision fasciotomy decreased to 8% in Period 2, (22 of 268 casualties) versus 15% in Period 1 (51 of 336 casualties; p = 0.009). CONCLUSION: Combat casualty care following implementation of a fasciotomy education program was associated with improved survival, higher fasciotomy rates, and fewer revisions. Because delayed fasciotomy rates were unchanged, further effort to educate providers may be indicated. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Concepts: Education, Limb, Human leg, Compartment syndrome, War casualties


Pirogow’s amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers numerous advantages for the patient, such as the ability to stay mobile without the use of a prosthesis, it is rarely performed (0.1% of all lower limb amputations). The results of the operations on 20 patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score), and these results were then compared to those of 20 pa-tients who underwent lower leg amputation. Using a point system the criteria pain, functional and radiological assessment, difference in leg length, and mobility without prosthesis were recorded and evaluated. 65% of those questioned who were amputated following the Pirogow method indicated an excellent or very good result, in the control group 60% of those having undergone a lower leg amputation responded similarly, indicating an excellent or very good result.In 30% in the Pirogow group in contrast to 20% after lower leg amputation postoperative complications lead to a revision-operation. In patients suffering from diabetes or restricted perfusion of the lower extremity an amputation at the level of the ankle has to be considered critically keeping the necessity of a revision-operation in mind. However, if it can be carried out successfully, the benefits of Pirogow-amputation are found in the significantly reduced difference in leg length and the increase in mobility without prosthesis.

Concepts: Cancer, Patient, Patience, Amputation, Prosthesis, Limb, Human leg, Gangrene


Proprioceptive inputs from the plantar sole contribute to balance control during normal quiet standing. This study investigated the cooling of plantar sole mechanoreceptors through ice immersion and its effects on balance control and lower leg muscle activity. Ten healthy males participated in this study. Plantar sole sensitivity was tested using the two point discriminatory test and the Semmes-Monofilament test. Plantar sole cooling was achieved through foot immersion in ice water. Balance control was measured using a force platform with seven trials (30s) performed before and after ice water foot immersion. Lower limb balance control muscle activity was measured with electromyography. Ice cooling reduced the plantar sole sensitivity of the foot. A short term alteration in balance control was observed with only the first trial showing significantly greater speed and RMS of the velocity of the centre of pressure in the cooling condition when compared to control trials before cooling. Muscular activity increased following the first trial. The adaptation observed after the short term alteration of balance control, could result from sensory reweighting processes. It is suggested that the muscular activity increase is evidence of sensory reweighting and contributes to the regulation of balance control when the plantar sole sensation is partially inhibited.

Concepts: Foot, Sensory system, Sense, Electromyography, Muscle spindle, Limb, Human leg, Mechanoreceptor


The aim of this review was to identify and summarise publications, which have reported clinical applications of upper limb accelerometry for stroke within free-living environments and make recommendations for future studies. Data was searched from MEDLINE®, Scopus, IEEExplore and Compendex databases. The final search was 31st October 2013. Any study was included which reported clinical assessments in parallel with accelerometry in a free-living hospital or home setting. Study quality is reflected by participant numbers, methodological approach, technical details of the equipment used, blinding of clinical measures, whether safety and compliance data was collected. First author screened articles for inclusion and inclusion of full text articles and data extraction was confirmed by the third author. Out of 1375 initial abstracts, 8 articles were included. All participants were stroke patients. Accelerometers were worn for either 24 hours or 3 days. Data were collected as summed acceleration counts over a specified time or as the duration of active/inactive periods. Activity in both arms was reported by all studies and the ratio of impaired to unimpaired arm activity was calculated in six studies. The correlation between clinical assessments and accelerometry was tested in five studies and significant correlations were found. The efficacy of a rehabilitation intervention was assessed using accelerometry by three studies: in two studies both accelerometry and clinical test scores detected a post-treatment difference but in one study accelerometry data did not change despite clinical test scores showing motor and functional improvements. Further research is needed to understand the additional value of accelerometry as a measure of upper limb use and function in a clinical context. A simple and easily interpretable accelerometry approach is required.

Concepts: Clinical trial, Ratio, Upper limb, Accelerometer, Limb, Arm