Arm Abduction Research Articles

Fluoroscopic measurements of the glenohumeral joint position and space in true anteroposterior and axillary views – a reliability study

Two-dimensional (2D) fluoroscopy has been used in shoulder pathologies to estimate the humeral head position (HHP) in the true anteroposterior (AP) view. However, there is a lack of evidence regarding the reliability estimating it in the axillary view and in measuring the shoulder joint space width (JSW). True AP view images (n=36) of subjects with adhesive capsulitis were taken in supine in multiple arm abduction positions. The axillary view images (n=48) were taken in supine and prone in 75° of abduction. The HHP was assessed in the glenoid reference frame. The position and radius of the humeral head along with the superior, inferior, anterior, posterior, and middle JSWs were measured in each image. All the images were coded and randomly presented twice to a physiotherapist at a gap of 48-72 h for intra-rater reliability and to 2 therapists and an orthopaedic surgeon for inter-rater reliability. Reliability was expressed using intraclass correlation coefficients (ICC) and standard error of measurement (SEM). In both the views, inter-rater, and intra-rater reliability was excellent for the radius of the humeral head (inter-rater – 0.95-0.97 and intra-rater -0.98)], moderate (ICC: 0.70 and 0.76), and excellent (ICC: 0.89 and 0.93) for HHP. The reliability for JSWs was moderate to good (ICC: 0.66-0.82) for inter-rater and good to excellent (ICC: 0.75-0.95) for intra-rater analysis. The SEM for HHP and JSWs were <0.4 mm for intra-rater analysis, and <0.7 mm for inter-rater reliability in both views. The study demonstrated that the glenohumeral arthrokinematic parameters can be measured with good to excellent levels of reliability when using 2 D fluoroscopy. The study is part of a clinical trial (Clinical Trial Registry India: CTRI/2018/12/016657).

Arthroscopic Trillat technique for chronic post-traumatic anterior shoulder instability: outcomes at 2 years of follow-up.

The purpose of this study was to assess the outcomes of a new arthroscopic Trillat technique at a 2-year follow-up. Our current hypothesis was that this technique could be used for the effective treatment of chronic post-traumatic unidirectional anterior shoulder instability, and that the recurrence and complication rates, external rotation, and functional outcomes would be as good as those of the reference technique. Between April 2012 and August 2016, all patients older than 16 years who underwent the arthroscopic Trillat technique for unidirectional chronic post-traumatic anterior shoulder instability at the Dijon University Hospital (France), after the failure of well-conducted medical and rehabilitation treatment with at least 24 months of follow-up, were included. Criteria for noninclusion were association with posterior and/or inferior instabilities, voluntary instabilities, and glenoid bone loss greater than 20%. Patients attended follow-up with their surgeon before the intervention, in the immediate postoperative period, at 6 weeks, 3 and 6 months, and then by an independent observer for the last evaluation. Patients were then examined clinically with scores such as Constant, Rowe and Walch-Duplay scores, and subjective shoulder value, for shoulder range of motion, and radiographically (anteroposterior and Lamy's lateral x-rays of the operated shoulder). Forty-nine patients and 52 shoulders were included, with a mean follow-up of 40 months (range, 24-71 months). The recurrence rate of instability was 3.8% (2 of 52). No conversion to arthrotomy was necessary. No intraoperative complications, postoperative neurological lesions, or sepsis were observed. The mean Constant score was 92.1 (77.5-100) points, Walch-Duplay 82.9 (40-100), Rowe 81.73 (5-100), and subjective shoulder value 86.1 (50-100) at the last follow-up. The arm at side external rotation limitation averaged 8.4° (-25° to 40°) and the external rotation with 90° arm abduction limitation 0.34° (-5° to 15°). Forty-one patients (79%) resumed their sports activity at the same level. Fifty patients (96%) were satisfied to very satisfied. One patient developed nonunion of the coracoid process and subsequently underwent a Latarjet procedure with a good outcome. The arthroscopic Trillat procedure offers good outcomes as a first-line treatment for chronic anterior post-traumatic glenohumeral instability. It should be excluded in cases of glenoid loss greater than 20%.

Single or Double Plating for Acromial Type III Fractures: Biomechanical Comparison of Load to Failure and Fragment Motion.

Background: Acromial Levy III fractures after inverse shoulder arthroplasty occur in up to 7% of patients. To date, it is not clear how these fractures should be treated as clinical outcomes remain unsatisfactory. The aim of this study was to evaluate the biomechanical performance of three different plating methods of type III acromion fractures. Methods: Levy III fractures in synthetic scapulae were fixed with three different methods. Angular stable locking plates were placed on the spina scapula to bridge the fracture either dorsally, caudally, or on both aspects by double plating. In a biomechanical experiment, the pull of the deltoid muscle at 40° abduction of the arm was simulated by cyclic loading with increasing load levels until failure. Failure load, cycles to failure, and fragment motions were evaluated. Results: The results showed that double plating (350 ± 63 N) withstood the highest loads until failure, followed by dorsal (292 ± 20 N) and caudal (217 ± 49 N) plating. Similarly, double plating showed significantly smaller fragment movement than the other two groups. Conclusions: Double plating appeared to provide the largest biomechanical stability in type III acromion fracture under arm abduction. Caudal plating in contract resulted in insufficient fracture stability and early failure and can thus not be recommended from a biomechanical point of view.

A Novel Augmented Reality Mobile-Based Application for Biomechanical Measurement

Human posture and range of motion (ROM) measurements are important health indicators for identifying abnormalities from various disorders (e.g., scoliosis, musculoskeletal disorders, pain syndromes). A viable real-time mobile application for measuring body posture and ROM is currently lacking. To address this need, a novel Android smartphone augmented-reality-based application was developed and evaluated to enable real-time AprilTag2 marker measurement at the point of patient contact (Biomechanical Augmented Reality-Marker, BAR-M). Mobile app performance was evaluated on a body opponent bag (BOB) and 15 healthy participants by comparing smartphone app and Vicon motion analysis output (pelvis, shoulder, arm, torso angles). A Samsung Galaxy smartphone recorded live video, calculated AprilTag orientations and angle of “a line connecting the center of two tags”, and displayed outcomes in real time. For the BOB test, the absolute difference between Vicon and smartphone angles were 0.09° ± 0.05° for hip, 0.09° ± 0.06° for shoulder, and 0.69° for arm abduction. For the participant test, the absolute mean angle differences were 1.70° ± 0.23° for hip, 1.34° ± 0.27° for shoulder, and 11.18° ± 3.68° for arm abduction. Overall, the app obtained valid and reliable angle measurements for postural and ROM assessments using the smartphone’s front camera. Arm abduction results were affected by clothing movement that caused Vicon markers to move differently from AprilTag markers. Thus, with appropriate measurement methods, this real-time smartphone app is a viable tool to facilitate immediate clinical decision making based on human posture and ROM assessments.

Tumor deformation correction for an image guidance system in breast conserving surgery.

Breast cancer is the most common cancer in women, and surgical resection is standard of care for the majority of breast cancer patients. Unfortunately, current reoperation rates are 10-29%. Uncertainty in lesion localization is one of the main factors contributing to these high reoperation rates. This work uses the linearized iterative boundary reconstruction approach to model patient breast deformation due to abduction of the ipsilateral arm. A preoperative supine magnetic resonance (MR) image was obtained with the patient's arms down near the torso. A mock intraoperative breast shape was measured from a supine MR image obtained with the patient's arm up near the head. Sparse data was subsampled from the full volumetric image to represent realistic intraoperative data collection: surface fiducial points, the intra-fiducial skin surface, and the chest wall as measured with 7 tracked ultrasound images. The deformed preoperative arm-down data was compared to the ground truth arm-up data. From rigid registration to model correction the tumor centroid distance improves from 7.3 mm to 3.3 mm, average surface fiducial error across 9 synthetic fiducials and the nipple improves from 7.4 ± 2.2 to 1.3 ± 0.7, and average subsurface error across 14 corresponding features improves from 6.2 ± 1.4 mm to 3.5 ± 1.1 mm. Using preoperative supine MR imaging and sparse data in the deformed position, this modeling framework can correct for breast shape changes between imaging and surgery to more accurately predict intraoperative position of the tumor as well as 10 surface fiducials and 14 subsurface features.

The Impact of OKC Exercises and TRX Exercises on Shoulder Joint Proprioception in Overhead Athletes With Shoulder Impingement Syndrome: A Randomized Controlled Trial

Purpose: Sub-acromial impingement syndrome (SAIS) is one of the most common causes of shoulder pain and affects shoulder joint proprioception. The closed kinetic chain (CKC) exercises with sling are more effective and safer than open kinetic chain (OKC) exercises. This study aimed to compare the effectiveness of OKC and total-body resistance exercises (TRX) sling training on shoulder joint position sense (JPS) in overhead athletes with shoulder impingement syndrome (SIS). Methods: This article was a randomized control trial (RCT) study conducted in Kerman City, Iran, in 2019. The research sample included 33 overhead athletes with SIS who were randomly classified into three groups: OKC, sling, and control groups. Joint position sense (JPS) was evaluated in external rotation (ER), internal rotation (IR), and abduction of the dominant arm in the target angle concerning the shoulder range of motion with the Leighton flexometer. The obtained data were analyzed using the analysis of covariance (ANCOVA). Results: The post-intervention results showed that a significant difference was observed between groups (ER, P<0.001; IR, P<0.001; abduction P<0.001). The change in the sling exercises group was significantly higher in ER, and IR, except abduction JPS than in OKC (P=0.001, P=0.001, P=0.235, respectively) and control groups (P<0.001, P<0.001, P<0.001, respectively). Change in the OKC group was significantly higher in ER, IR, and abduction JPS (P=0.001, P=0.019, P<0.001, respectively) than in the control group. The OKC and sling exercise improved the shoulder JPS of overhead athletes with SIS. Conclusion: The study results showed that the sling exercises were more effective than the OKC exercise for the shoulder JPS because these exercises were CKC and performed on an unstable level.

The Effect of Gender and Arm Anatomical Position on the Hand Grip Strength and Fatigue Resistance during Sustained Maximal Handgrip Effort.

Background: Handgrip or Grip strength (GS) is a common method used to evaluate muscle strength and affected by different factors, including age, gender, and arm’s positions.Objective: This study aims to investigate the effect of both the gender and arm’s positions on the handgrip strength and the fatigue resistance (FR), which is the time needed for the handgrip strength to drop to 75% (FR75), 50% (FR50), and 25% (FR25) of its maximum strength during sustained maximal handgrip effort.Material and Methods: In this experimental study, 59 male and 41 female participants were asked to grip forcefully on a dynamometer for the longest period. GS and FR75, FR50, and FR25 values were recorded for 7 different arm positions. Factorial ANOVA was used to find the main effect of gender and position and the interaction between them. Sidak and Tukey’s HSD tests were used to find the gender and arm position effects, respectively.Results: The results showed a significant effect for gender and arm position on GS and FR and a significant interaction effect for GS that was significantly higher in males than females for all positions. The gender difference in FR depends on arm’s positions and the level at which the FR was measured. GS was higher when arm adduction with 90 ͦ forward at the elbow as compared to arm abduction with 180 ͦ at the shoulder and 90 ͦ at the elbow.Conclusion: The results confirmed the significant effect of the gender and arm’s positions on the maximal handgrip strength and fatigue resistance during sustained maximal handgrip effort.

Subject-specific model-derived kinematics of the shoulder based on skin markers during arm abduction up to 180° - assessment of 4 gleno-humeral joint models

Accuracy of shoulder kinematics predicted by multi-body kinematics optimisation depend on the joint models used.This study assesses the influence of four different subject-specific gleno-humeral joint models within multi-body kinematics optimisation: a 6-degree-of-freedom joint (i.e. single-body kinematics optimisation), a sphere-on-sphere joint (with two spheres of different radii) and a spherical joint with or without penalised translation. To drive these models, the 3D coordinates of 12 skin markers of 6 subjects performing static arm abduction poses up to 180° were used. The reference data was obtained using biplane X-rays from which 3D bone reconstructions were generated: scapula and humerus were 3D reconstructed by fitting a template model made of geometrical primitives on the two bones’ X-rays. Without any motion capture system, the recording of the skin markers was performed at the very same time than the X-rays with radiopaque markers.The gleno-humeral displacements and angles, and scapula-thoracic angles were computed.The gleno-humeral sphere-on-sphere joint provided slightly better results than the spherical joint with or without penalised translation, but considerably better gleno-humeral displacements than the 6-DoF joint. Considering that it can easily be personalised from medical images, this sphere-on-sphere model seems promising for shoulder multi-body kinematics optimisation.

A Woman With Painful Shoulder

A 24-year-old woman with a previous right shoulder dislocation presented to the emergency department with sudden onset of right shoulder pain after being struck by an open car door 3 days ago. On examination, there was a loss of the deltoid contour with a palpable defect (Figure 1). She had positive Dugas test findings and could perform flexion and abduction of the right arm up to 60 degrees as well as almost full external rotation without pain restraint. Standard projection (Figure 2) radiography and point-of-care ultrasound of the right shoulder were performed (Figure 3).

Non-linear finite element model established on pectoralis major muscle to investigate large breast motions of senior women for bra design

This paper presents a three-dimensional nonlinear biomechanical finite element model to simulate elderly breast deformation under arm abduction. The finite element model was constructed based on complex anatomical structures that consist of the soft tissues including torso, breast, pectoralis major muscle, and rigid bones including humerus, sternum, clavicle and ribs. The elderly breast was defined as material nonlinearity and geometric nonlinearity. The computational model can simulate and illustrate the deformation of soft tissues during arm abduction from 30° to 90°. The finite element model was validated by motion data. The Young’s modulus for the clavicular portion and the sternocostal portion of the pectoralis major muscle was characterized as 0.1 MPa and 0.08 MPa, respectively. Besides this, the finite element model presented here features the musculoskeletal system for breast deformation and reveals the synergistic relationship between the breast and the pectoralis major muscle. A questionnaire was conducted to analyze the importance of purchasing factors and the discomfort positions in a sports bra from the perspective of senior women. Combined with the finite element model results, this study provides a promising basis for the design of sports bras in an ergonomic way.

Relationship Between Inflow Impairment and Skin Oxygen Availability to the Upper Limb During Standardized Arm Abduction in Patients With Suspected Thoracic Outlet Syndrome.

ObjectiveThoracic outlet syndrome (TOS) should be considered of arterial origin only if patients have clinical symptoms that are the result of documented symptomatic ischemia. Simultaneous recording of inflow impairment and forearm ischemia in patients with suspected TOS has never been reported to date. We hypothesized that ischemia would occur in cases of severely impaired inflow, resulting in a non-linear relationship between changes in pulse amplitude (PA) and the estimation of ischemia during provocative attitudinal upper limb positioning.DesignProspective single center interventional study.MaterialFifty-five patients with suspected thoracic outlet syndrome.MethodsWe measured the minimal decrease from rest of transcutaneous oximetry pressure (DROPm) as an estimation of oxygen deficit and arterial pulse photo-plethysmography to measure pulse amplitude changes from rest (PA-change) on both arms during the candlestick phase of a “Ca + Pra” maneuver. “Ca + Pra” is a modified Roos test allowing the estimation of maximal PA-change during the “Pra” phase. We compared the DROPm values between deciles of PA-changes with ANOVA. We then analyzed the relationship between mean PA-change and mean DROPm of each decile with linear and second-degree polynomial (non-linear) models. Results are reported as median [25/75 centiles]. Statistical significance was p < 0.05.ResultsDROPm values ranged −11.5 [−22.9/−7.2] and − 12.3 [−23.3/−7.4] mmHg and PA-change ranged 36.4 [4.6/63.8]% and 38.4 [−2.0/62.1]% in the right and left forearms, respectively. The coefficient of determination between median DROPm and median PA-change was r2 = 0.922 with a second-degree polynomial fitting, but only r2 = 0.847 with a linear approach.ConclusionOxygen availability was decreased in cases of severe but not moderate attitudinal inflow impairments. Undertaking simultaneous A-PPG and forearm oximetry during the “Ca + Pra” maneuver is an interesting approach for providing objective proof of ischemia in patients with symptoms of TOS suspected of arterial origin.

Outcome Comparison of Different Reconstructive Approaches for Axillary Defects Secondary to Radical Excision of Hidradenitis Suppurativa

Background: Radical excision of debilitating hidradenitis suppurativa lesions is the only curative approach in the advanced stages of the disease. Different concepts for axillary reconstruction do exist, but data on their clinical outcome are scarce. Methods: This is a retrospective cohort study of two reconstructive methods (posterior arm flap vs. vacuum-assisted closure [VAC] + split-thickness skin graft [STSG]) for axillary defects in patients with severe axillary hidradenitis suppurativa treated at the University Hospital Zurich between 2005 and 2020. Results: A total of 35 patients (mean age 36 ± 10 years, mean BMI 29 ± 5 kg/m2, Hurley stage II–III) with 67 operated axillae were stratified according to their type of reconstruction. Median operation time in the flap group was 144 min (IQR 114–207) (cumulative 181 min [IQR 124–300]) and 50 min (IQR 40–81) in the VAC + STSG group (cumulative 151 min [IQR 94–194], p < 0.01; p = 0.20 [cumulative time]). The cumulative length of stay was 6 ± 3 days in the flap group and 14 ± 7 days in the VAC + STSG group (p < 0.01). Time to complete wound healing was 27 days (IQR 20–49) in the flap group and 62 days (IQR 41–75) in the VAC + STSG group (p < 0.01). Vancouver Scar Scale score was 6 (IQR 4–9) in the flap group and 11 (IQR 9–12) in the VAC + STSG group (p < 0.01). Protective sensory recovery was most satisfactory in the flap group (p < 0.01). Forty-four percent of patients of the VAC + STSG group demonstrated functional impairment of arm abduction. Time to return to work was less in group A with 42 days (IQR 27–57) needed as compared to group B with 48 days (IQR 34–55) needed (p = 0.32). The average cost saving was 25% higher for the flap group than for the VAC + STSG group. Conclusion: Despite an increased operation time, axillary reconstruction by the posterior arm flap yields a reduced length of stay, less time to complete wound healing along with restoration of a protective sensibility, and less axillary scarring avoiding functional deficits – eventually allowing earlier return to work.

The risk of iatrogenic radial nerve and/or profunda brachii artery injury in anterolateral humeral plating using a 4.5 mm narrow DCP: A cadaveric study.

Fixation of humeral shaft fractures with a plate and screws can endanger the neurovascular structure if proper care is not taken. No studies to our knowledge have studied the risk of iatrogenic radial nerve and/or profunda brachii artery (RNPBA) injury from each screw hole of a 4.5 mm narrow dynamic compression plate (narrow DCP). The purpose of this study is to evaluate the risk of RNPBA injury in anterolateral humeral plating with a 4.5 mm narrow DCP. 18 humeri of 9 fresh-frozen cadavers in the supine position were exposed via the anterolateral approach with 45 degrees of arm abduction. A hypothetical fracture line was marked at the midpoint of each humerus. A precontoured ten-hole 4.5mm narrow DCP was applied to the anterolateral surface of the humerus using the fracture line to position the center of the plate. All screw holes were drilled and screws inserted. The cadaver was then turned over to the prone position with 45 degrees of arm abduction, and the RNPBA exposed. The holes through in which 100% of the screw had contact with or penetrated the RNPBA were identified as dangerous screw holes, while lesser percentages of contact were defined as risky. The relative distance ratios of the entire humeral length from the lateral epicondyle of the humerus to the 4th, 3rd, 2nd and 1st proximal holes were 0.64, 0.60, 0.56 and 0.52, respectively. The most dangerous screw hole was the 2nd proximal, in which all 18 screws had contacted or penetrated the nerve, followed by the risky 1st (12/18), 3rd (8/18) and 4th (2/18) holes. In humeral shaft plating with the 4.5mm narrow DCP using the anterolateral approach, the 2nd proximal screw hole carries the highest risk of iatrogenic radial nerve and/or profunda brachii artery injury.

Effects of passive exoskeleton support on EMG measures of the neck, shoulder and trunk muscles while holding simulated surgical postures and performing a simulated surgical procedure

Exoskeletons have shown significant impact at reducing the biomechanical demand on muscles during repetitive lifting and overhead tasks in non-healthcare industries. However, the benefits of exoskeletons are yet to be realized in the operating room, particularly as work-related musculoskeletal disorders continue to be a concern for surgeons. This study quantified the effect of using neck, arm, and trunk exoskeletons on muscle activity while assuming typical postures held in the operating room. Fourteen participants were recruited to participate in this study. In this two-part experiment participants were asked to 1) hold a series of neck flexion, arm abduction and trunk flexion postures seen in surgical procedures, and 2) perform a simulated surgical task requiring five different trunk flexion posture levels. Participants were required to complete these tasks with and without passive exoskeleton(s). This study showed that even for postures held short time periods, exoskeletons are beneficial at reducing the demand on muscles; however, the reduction in muscle demand depends on body segment and postural angle, as intended with these passive exoskeletons. Furthermore, for the simulated surgical task with awkward trunk flexion postures (10–65°), the trunk exoskeletons showed a significant reduction in the rate of rise in back muscle sEMG (+1.365%MVC/min vs. +0.769%MVC/min for non-dominant lumbar extensor muscles, p = 0.0108; +1.377%MVC/min vs. +0.770%MVC/min for the dominant lumbar extensor muscles, p = 0.0196) over 25 min, consequently resulting in improved trunk subjective discomfort scores (7.34 vs. 4.30, p < 0.05), with no impact on the neck and shoulder biomechanical demand. The results from this study indicate that exoskeletons may be a potential intervention to reduce biomechanical loading during surgery.

From the finger lift to the palm-up open hand when presenting a point: A methodological exploration of forms and functions

There are many studies on the palm-up open hand (PUOH) as a gesture used when the speaker is presenting a point, but many other gesture forms can also accompany this discursive move. While the forms may appear diverse based on traditional means of gesture analysis, the relations between a number of them can be analyzed in a coherent way using the kinesiological system developed by Boutet (2010; 2018; to appear). This system approaches gestural forms not from external criteria based on the viewer’s perspective (involving hand shapes, locations in gesture space, etc.), but rather from the inside; in the present analysis, the focus is on the directions of movements made at joints in producing them (e.g. whether flexion vs. extension was involved, whether any rotation involved was inward or outward, etc.). Four particular gestures are considered as points along a continuum: from the finger extension, to the forearm and wrist turn-out of the hand, to the supination of the PUOH, to an exaggerated form of the PUOH produced with extension and abduction of the upper arm. A multifunctional model is also proposed to analyze the degree of transparency of the different gestures’ representational, pragmatic, and interactive functions. The functional analysis performed with this model is grounded in form features from a combination of the kinesiological and traditional four-parameter form-based systems. This methodological exploration provides a model which could be applied or adapted for the analysis of other groups of gestures that are related in terms of their physiological means of production.

A Matlab toolbox for scaled-generic modeling of shoulder and elbow

There still remains a barrier ahead of widespread clinical applications of upper extremity musculoskeletal models. This study is a step toward lifting this barrier for a shoulder musculoskeletal model by enhancing its realism and facilitating its applications. To this end, two main improvements are considered. First, the elbow and the muscle groups spanning the elbow are included in the model. Second, scaling routines are developed that scale model’s bone segment inertial properties, skeletal morphologies, and muscles architectures according to a specific subject. The model is also presented as a Matlab toolbox with a graphical user interface to exempt its users from further programming. We evaluated effects of anthropometric parameters, including subject’s gender, height, weight, glenoid inclination, and degenerations of rotator cuff muscles on the glenohumeral joint reaction force (JRF) predictions. An arm abduction motion in the scapula plane is simulated while each of the parameters is independently varied. The results indeed illustrate the effect of anthropometric parameters and provide JRF predictions with less than 13% difference compared to in vivo studies. The developed Matlab toolbox could be populated with pre/post operative patients of total shoulder arthroplasty to answer clinical questions regarding treatments of glenohumeral joint osteoarthritis.

Upper arm posture during human embryonic and fetal development.

The upper extremity posture is characteristic of each Carnegie stage (CS), particularly between CS18 and CS23. Morphogenesis of the shoulder joint complex largely contributes to posture, although the exact position of the shoulder joints has not been described. In the present study, the position of the upper arm was first quantitatively measured, and the contribution of the position of the shoulder girdle, including the scapula and glenohumeral (GH) joint, was then evaluated. Twenty-nine human fetal specimens from the Kyoto Collection were used in this study. The morphogenesis and three-dimensional position of the shoulder girdle and humerus were analyzed using phase-contrast X-ray computed tomography and magnetic resonance imaging. Both abduction and flexion of the upper arm displayed a local maximum at CS20. Abduction gradually decreased until the middle fetal period, which was a prominent feature. Flexion was less than 90° at the local maximum, which was discrepant between appearance and measurement value in our study. The scapular body exhibited a unique position, being oriented internally and in the upward direction, with the glenoid cavity oriented cranially and ventrally. However, this unique scapular position had little effect on the upper arm posture because the angle of the scapula on the thorax was canceled as the angle of the GH joint had changed to a mirror image of that angle. Our present study suggested that measuring the angle of the scapula on the thorax and that of the GH joint using sonography leads to improved staging of the human embryo.

Quantifying an Upper Extremity Everyday Task With 3D Kinematic Analysis in People With Spinal Cord Injury and Non-disabled Controls.

Objectives: Upper extremity function after spinal cord injury (SCI) is an important factor for performance of activities of daily living. An objective assessment of upper extremity function preferably in purposeful daily tasks is essential in understanding its impact on real-life activities. This study aimed to identify which movement parameters of upper extremity, measured by kinematic analysis during a purposeful daily task, are impaired in people with cervical or thoracic SCI.Materials and Methods: The study included 29 adults (mean 59.5 years, 9 women and 20 men) with cervical (n = 19) or thoracic (n = 10) established complete (n = 15) or incomplete (n = 14) SCI, and 54 non-disabled controls with commensurable age and sex (mean 59 years, 15 women, 39 men). The 3D kinematic data were captured with a five-camera system during a standardized unilateral daily task (drinking from a glass). In SCI, the upper extremity functioning of each arm was assessed with Action Research Arm Test (ARAT). Having a full score in ARAT indicated full functioning; a score of <57 points indicated limited functioning. Kinematic data from full functioning arms (n = 27) and limited functioning arms (n = 30) in SCI were compared with the non-dominant arms (n = 54) in controls.Results: In the limited upper extremity functioning group, movement time, smoothness, arm abduction, wrist angle, trunk displacement, and inter-joint coordination, but not peak velocity of the hand, angular velocity of elbow, and relative time to peak velocity, all differed from controls. In the full upper extremity functioning group, arm abduction alone was significantly different from controls.Conclusions: The findings demonstrate that apart from measures of peak velocity, kinematic measures of movement quality including movement time, smoothness, trunk displacement, and joint angles are impaired in people with limited upper extremity functioning after SCI. The study provides robust results applicable to a representative population of individuals with established cervical or thoracic SCI. The results suggest that kinematic analysis might be useful for those with limited functioning in order to get a better understanding of the specific movement impairments in daily tasks after SCI.

THE ONE EXCESSIVE EXERCISE CAUSED PULMONARY EMBOLISM!

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: The annual incidence of upper extremity deep venous thrombosis (DVT) is 0.4 in 10,000 people annually accounting for 4-10% of all DVT. Upper extremity DVT is divided into primary and secondary. Around 80% of the cases consist of secondary DVT caused by indwelling catheters, cardiac hardwares, and cancer. One of the primary causes is Paget-Schroetter Syndrome. This is the development of upper extremity clot caused by strenuous activity like rowing, baseball, and heavy lifting. We present a young farmer with acute pulmonary thromboembolism due to Paget-Schroetter Syndrome. CASE PRESENTATION: A 26-year-old male farmer presented with right arm throbbing pain and edema for a week. It was aggravated by abduction and extension above 90 degrees and alleviated by resting. It was associated with weakness resulting in difficulty holding his phone or brushing his teeth. Vital signs were within normal limits. Physical examination significant for 1+ edema on the right upper extremity and right axilla. Pulses were 2+ in all extremities. Pain was reproducible on passive right arm abduction and extension. Chest CTA showed acute thrombus in the segmented vessel of the right lower lobe and pulmonary arterial segment of the right upper lobe. Right upper extremity venous Doppler showed acute occlusive deep vein thrombosis in the right subclavian, axillary, brachial veins. Venogram confirmed axillary vein occlusion. CTA of upper extremity showed focal concentric narrowing of right subclavian artery at the junction of right clavicle and right first rib. Patient underwent balloon angioplasty and catheter directed thrombolysis with EKOS. He was discharged on Rivaroxaban with plans for first rib resection on the outpatient setting. DISCUSSION: Paget-Schroetter syndrome (PSS) also known as Effort thrombosis is an acute thrombosis of the axillary-subclavian vein associated with strenuous activity. Those repetitive movements cause microtrauma on the subclavian vein endothelium triggering the coagulation cascade. This can be accompanied by venous stasis caused by anatomical thoracic outlet obstruction from cervical rib, scalenus tendon hypertrophy, or costoclavicular ligament. The major complication of this disease is Pulmonary Embolism which has been reported up to 10% of the presentations. CONCLUSIONS: It is important to identify PSS as the cause of PE, since it requires a more aggressive treatment beside anticoagulation, which includes catheter directed thrombolysis, thoracic outlet decompression, and physical therapy. Conservative management with anticoagulation by itself could lead to disability. Increasing awareness will ensure early recognition and proper treatment. REFERENCE #1: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. REFERENCE #2: Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A. Deep Vein Thrombosis of the Upper Extremity. Dtsch Arztebl Int. 2017;114(14):244-249. doi:10.3238/arztebl.2017.0244 DISCLOSURES: No relevant relationships by Sarah Nuzzo, source=Web Response No relevant relationships by Joshuam Ruiz Vega, source=Web Response No relevant relationships by Amtul Shafi, source=Web Response

Vascular Thoracic Outlet Syndrome in 3 Pediatric Patients

<h3>Introduction</h3> Thoracic outlet syndrome (TOS) may lead to vascular complication and represents the minority of TOS case in adults. However in the pediatric population TOS vascular complications are morefrequent. Management is commonly described in adult populations, but in children and teenagersdiagnosis and treatment is not as well defined and presents different challenges than in adults. We describe three cases of vascular TOS in a pediatric population and review of the literature.Case <h3>Reports</h3> The first patient is a 14-year-old girl who was a competitive swimmer presented with left arm pain and swelling for several months worse the last 4 weeks. Venogram¹ revealed complete occlusion of the left subclavian and axillary veins and following a course of lytic therapy a 50%axillary vein stenosis with complete occlusion with left arm abduction was noted². She underwent left first rib resection and resumed competitive swimming. Follow up venous duplexshowed no venous compression with the arm adducted and with full abduction.Figure 1.Figure 1Figure 2.Figure 2Figure 3.Figure 3Figure 4.Figure 4Figure 5.Figure 5Figure 6.Figure 6 The second patient is a 13-year-old female who was also a competitive swimmer but who coincidentally had mild scoliosis³. She presented after a 2 day history of left arm swelling. Venogram revealed left subclavian and axillary vein thrombosis and she also underwent a course of lytic therapy. Post-therapy imaging showed an occlusion of the left axillary vein with abduction similar to the first patient⁴ and so she also underwent left first rib resection. Follow up venous duplex showed no venous compression. The third patient is a 16-year-old male who had been weight training presented with sudden onset of left arm pain 1 week prior to admission. Arteriogram revealed occluded left axillary artery⁵. Following combined lytic therapy and open left brachial artery thrombectomy repeat arteriogram revealed a patent left axillary artery⁶ and complete occlusion with left arm abduction. He underwent left first rib resection. At 2 months of follow up he was asymptomatic with normal axillary duplex with the arm adducted and with abduction. <h3>Discussion</h3> Vascular complications of TOS in the pediatric population can be managed in a similar fashionas adults. Return to premorbid activities can be expected. Pediatric patients can present some challenges with timely diagnosis and treatment.