Shoulder Brace Research Articles

Compartment syndrome of the leg associated with lithotomy position for cytoreductive surgery

Compartment syndrome is seen in patients who have ischemic damage to muscle that is contained within a fascial compartment. A pathologic cycle is initiated when tissue injury produces swelling and compromises muscle perfusion. Patients undergoing cytoreductive surgery combined with intraperitoneal chemotherapy are required to be in the lithotomy position for many hours. Compartment syndrome can develop necessitating fasciotomy. In a study of 473 operative procedures to perform cytoreductive surgery and intraperitoneal chemotherapy, eight patients required fasciotomy on an emergency basis to treat compartment syndrome and were recorded in a prospective database over a 4-year time period. During the hospitalization five of the eight patients developed venous thrombotic complications. In order to prevent movement of the patient on the operating table during steep Trendelenburg position, shoulder braces were used in the subsequent 250 patients and no episodes of compartment syndrome occurred. Compartment syndrome in patients undergoing cytoreductive surgery may be related to changes in position on the operating table induced by steep Trendelenburg position. Minimizing this change in position has reduced the likelihood of developing Compartment syndrome.

Laparoscopic positioning and nerve injuries

Injuries to the nerves of the upper and lower extremities are uncommon but potentially avoidable complications during laparoscopic surgery. Brachial plexus nerve injuries have been reported to occur in as many as 0.16% of advanced laparoscopic procedures. To minimize the risk of brachial plexus injuries during laparoscopy, the arms should be tucked at the side of the patient. If the arms are extended on arm boards, they should be abducted less than 90 degrees. Both steep Trendelenburg position with the arms extended and shoulder braces should be avoided. Lithotomy position has been associated with injuries to lower extremity nerves, including the femoral, lateral femoral cutaneous, obturator, sciatic, and common peroneal nerves. These lower extremity nerve injuries result in sensory deficits in 1.5% of cases, and persistent motor deficits in 0.03% of cases. Careful positioning and boot stirrups both appear to decrease the risk of nerve injury, especially for laparoscopic procedures lasting longer than 2 hours. Four important elements of correct lithotomy positioning are: (1) hip flexion of 60 degrees to 170 degrees; (2) knee flexion of 90 degrees to 120 degrees; (3) hip abduction of 90 degrees or less; and (4) minimal external hip rotation. Extrinsic pressure on the legs should be avoided. To minimize the risk of positional nerve injuries, the laparoscopist should verify that each patient is positioned appropriately during surgery. Laparoscopic positioning and nerve injuriesJournal of Minimally Invasive GynecologyVol. 14Issue 5Preview Full-Text PDF The Journal of Minimally Invasive Gynecology, CME Test 017Journal of Minimally Invasive GynecologyVol. 14Issue 5Preview Full-Text PDF

Anaesthesia for Robotic-Assisted Radical Prostatectomy: Considerations for Laparoscopy in the Trendelenburg Position

Two cases of anaesthetic complications after robotic-assisted laparoscopic radical prostatectomy using the da Vinci Remote-Controlled Surgical System are presented. Case 1 describes a patient with post-extubation respiratory distress requiring re-intubation and subsequent ventilation in an intensive care unit. This was attributed to laryngeal oedema, which was most likely due to the reduction in venous outflow from the head caused by the pneumoperitoneum and prolonged, extreme Trendelenburg position. Case 2 describes a patient with mild brachial plexus neurapraxia, which was most likely due to compression by shoulder braces (to prevent cephalad sliding) during the exaggerated head-down tilt. For this procedure, the authors recommend limiting the duration and extent of head-down tilt as much as possible, avoiding excessive intravenous fluids and careful positioning of the patient with avoidance of shoulder braces whenever possible.

The subacromial impingement syndrome of the shoulder treated by conventional physiotherapy, self-training, and a shoulder brace: Results of a prospective, randomized study

This prospective, randomized trial was performed to compare the results of treating subacromial impingement syndrome of the shoulder by a guided self-training program with the treatment by conventional physiotherapy or a functional brace. Sixty patients with the diagnosis of an outlet impingement syndrome of the shoulder (Neer I and II) were treated either by strengthening the depressors of the humeral head with a guided self-training program, by conventional physiotherapy, or by wearing a functional brace. The Constant-Murley score was assessed after 6 and 12 weeks. Shoulder pain was monitored with a visual analog scale. All three groups showed a significant improvement in shoulder function as well as a significant reduction in pain. There were no statistically significant differences among the groups. Guided self-training can lead to results similar to those of conventional physiotherapy. The comparable effect of the functional brace remains unclear and might be explained by an influence on proprioception.

Managing anterior shoulder instability with bracing: an expanded update.

This article provides an updated report on functional bracing for anterior shoulder instability. A classification of shoulder braces is reintroduced into three separate types. Type A braces limit shoulder motion to a "safe zone," whereas types B and C apply indirect and direct stabilizing forces to the joint, respectively. Thirteen of the most widely available braces were surveyed and the parameters of comfort, convenience, construction, cost, potential sport use, and special features were analyzed. Problem areas included poor fit and range of motion restriction. The system of classifying sports based on shoulder demands is reintroduced.

Quantitative analysis of traction in the glenohumeral joint. In vivo radiographic measurements

Purpose: To analyse change in distance between the humeral head and the glenoid fossa during traction in the maximally loose-packed position (MLPP) and the maximally closed-packed position (MCPP) under standardized conditions. Subjects: Six healthy subjects (three male and three female) with a mean age of 40.5 years, volunteered to participate in this study. Materials and methods: Subjects were placed with the right shoulder in a modified shoulder brace (Otto Bock Armabduktions-Orthese in Modular Bauweise ®) in 45° abduction in the plane of the scapula with neutral rotation (MLPP). A standard anterior–posterior radiograph of the glenohumeral joint was made. A 14 kg traction force was applied for 40 s, and a second radiograph was made. The same procedure was repeated with the shoulder placed in the MCPP, which was 90° abduction and 90° external rotation. A radiologist, blinded for the variable traction or no traction, performed all radiographic measurements. Measurements were made on the same radiographs on two separate occasions (O1 and O2) with a 2-month interval. Results: No significant differences were found in mean distance between the humeral head and the glenoid fossa during traction in the MLPP compared to traction in the MCPP (O1: P=1.00) and (O2: P=0.63). Conclusions: Application of a 14 kg force does not result in a significant increase of distance between the humeral head and the glenoid fossa. No significant difference was found between the change in distance of the humeral head and the glenoid fossa after traction in the MLPP compared to traction in the MCPP.

Preventing Perioperative Peripheral Neuropathies: An ASA Practice Advisory. Warner et al. (page 1168)

In this issue, Warner al. and fellow members of the American Society of Anesthesiologists’ (ASA) Task Force on Prevention of Perioperative Peripheral Neuropathies, present a practice advisory generated through a five-step process. Intended as a source of guidance and not a formal set of practice guidelines, the advisory focuses on such preventive strategies as perioperative patient positioning, use of protective padding, and avoidance of contact with hard surfaces or supports that may apply direct pressure on susceptible peripheral nerves.The 10-member task force first conducted a review of the published literature, initially identifying 509 articles that addressed topics related to seven evidence linkages. After a review of the articles, 427 were eliminated because they did not provide direct evidence. Second, consultants who practice in various academic and private practice settings and who have particular expertise in identified subject areas were surveyed regarding their opinions of the effectiveness of positioning and protective strategies to prevent perioperative peripheral neuropathies. These consultants were also asked to comment on the task force’s initial draft report. Third, the task force collected responses from 429 of 1,500 ASA members selected at random to complete surveys regarding their opinions of the advisory’s elements. Fourth, the task force held an open forum at a major national anesthesia meeting to solicit additional input regarding the draft advisory. Finally, all available information was used to build consensus within the task force on the advisory.The task force found strong agreement among surveyed consultants and ASA members that a focused preoperative physical assessment may identify patients with an increased risk of development of peripheral neuropathies during the perioperative period. Eighty-eight percent of the responding consultants and 80% of the ASA member respondents agreed with this statement. In the area of specific positioning strategies for the upper extremities, 92% of the consultant respondents and 96% of the ASA members agreed that limiting abduction of the arms in a supine patient may decrease the risk of brachial plexus neuropathy. There was some disagreement regarding the upper limits of abduction, with 93% of the consultants advising limiting abduction to 90°, and 7% indicating an upper abduction limit of 60°. Further advisories regarding preventive positioning strategies addressed ulnar neuropathies in supine patients with arms on arm boards, with arms tucked at the side, or with the elbow flexed. The task force also addressed specific positioning strategies for the lower extremities, the use of protective padding, automatic blood pressure cuffs, and shoulder braces.

A new type of the jacket-shaped shoulder brace for the patient with shoulder injury caused by wheel chair athletic sports

A new type of the jacket-shaped shoulder brace for the patient with shoulder injury caused by wheel chair athletic sports

Iatrogenic Serratus Anterior Paralysis: Long-term Outcome in 26 Patients

To evaluate the treatment, extent of recovery, and residual disability in 26 iatrogenic cases of serratus paralysis. Seventeen cases of serratus anterior paralysis had occurred following a local invasive procedure along the course of the long thoracic nerve, including seven first-rib resections, four mastectomies with axillary dissection, two scalenotomies, two surgical treatments of spontaneous pneumothorax, and two infraclavicular plexus anesthesia. Eight cases of paralysis had occurred after general anesthesia for patients who had undergone surgery for diverse clinical reasons. One case of paralysis occurred after spinal anesthesia. The length of sick leave, treatment with a shoulder brace, amount of physical therapy, long-term symptoms, and residual disability were evaluated from the medical records and from the questionnaire sent to the patients on average 6 years (range, 2 to 11 years) after the onset of the paralysis. Despite comprehensive and lengthy treatment, all but one had residual symptoms, as well as limitations in the use of the affected limb. Twenty-one (81%) of the patients could not lift or pull heavy objects, 15 (58%) could not play sports, such as tennis or golf, and 14 (54%) found it impossible to work with hands above shoulder level. Serratus anterior paralysis, following anesthesia or local invasive procedures on the anterolateral aspect of the thorax, may cause considerable and long-term dysfunction of the shoulder girdle and affect the function of the whole upper limb.

Brachial plexus neuropathies after advanced laparoscopic surgery

A retrospective review of 3,200 advanced laparoscopic procedures demonstrated five brachial plexus injuries during a 5-month period in 1986 (0.16% incidence rate). Brachial plexus injury can occur during laparoscopic surgery using steep Trendelenburg's position with shoulder braces and the patient's arm extended at 90 degrees. Position modification can reduce the risk for upper extremity neuropathies.

New shoulder brace provides improved bracing positioning

New shoulder brace provides improved bracing positioning

A Case Report of Brachial Plexus Palsy after Laparascopy Assisted Vaginal Hysterectomy

Trendelenburg position has been used for the low abdominal and pelvic surgery or for the management of the hypotensive patients. But, various adverse effects can also occur in steep Trendelenburg position, of which brachial plexus injury has been known as the most common nerve injury during this position under the general anesthesia especiaUy when the shoulder braces are used. We experienced a case of brachial plexus palsy in a 53 year old woman who had a laparas-copy assisted vaginal hysterectomy(LAVH) under the general anesthesia for myoma uteri for four and a half hours. During the operation she was in a 30°-tilting Trendelenburg and combined lithotomy position with her arms tucked at her side with drawsheet and shoulder braces were placed over the acromioclavicular joints bilaterally. In the morning of the postoperative 1st day, she complained the right shouder pain and the right arm tingling sensation and weakness. After needle electromyography and nerve conduction study, it was decided that she got an intraoperative brachial plexus injury mainly involving the lateral cord of the brachial plexus, resulting from the nerve compression caused by shoulder braces in Trendelenburg position. The symptoms were improved after the physical therapy and she was recommended to take more physical therapy after discharge.

The Use of the Varney Brace for Subluxating Shoulders in Stroke and Upper Motor Neuron Injuries

Applying the Varney shoulder brace for painful subluxating shoulders in stroke and head injury patients with or without spasticity has proved to be an extremely effective means of reducing the subluxed shoulder. Other causes for painful shoulders in these patients must be ruled out. Not every shoulder which subluxes with or without spasticity is painful. Correct diagnosis of the etiology of the pain is essential to help the patient. Rotator cuff tendinitis, reflex sympathetic dystrophy, glenohumeral arthritis, shoulder contracture, pain due to central nervous system origin (thalmic pain) and other intrinsic causes of referred pain must be ruled out. Once the subluxed shoulder is proven to be the cause of pain, the Varney brace is an excellent orthosis for the reduction and maintenance of position. Pain usually subsides completely within 5 to 7 days.

Oblique projections in cervical myelography.

Oblique projections of the cervical spine in myelography provide additional data on the nature and severity of defects in nerve-root sleeves. The authors describe an alternative technique of obtaining the desired radiographs without altering the position of the patient or removing the shoulder braces.

Extradural Analgesia for Culdoscopy

150 women (aged 18 to 43) receiving culdoscopy at Pittsburghs Magee-Womens Hospital from May 1967 to April 1968 were observed and interviewed to determine the efficacy of extradural analgesia. 120 patients received lumbar epidural blocks and continuous technique was used in 23 cases 12 of which had intraabdominal surgery following culdoscopic examination. 30 caudal blocks were performed including 2 continuous techniques. Supplemental analgesia was required in 18 out of 150 cases. Lumbar epidural technique elicited 1 paresthesia but the patient displayed no postoperative neurologic sequelae. 6 patients displayed significant hypotension (25% decrease in blood pressure) which was readily corrected with fluids in 5 while 1 required an intravenous vasopressor. 1 patient experienced vomiting and 13 displayed shivering but no convulsions. Only 1 patient had a postdural headache and no treatment was required for 28 mild backaches at the epidural site. Common complaints of pain and discomfort of the shoulder upper chest or epigastric area was thought to reflect either retained free air subdiaphragmatic irritation or soreness from the shoulder braces. Retained air is usually eliminated by gas expulsion induced by manual pressure on the abdomen before withdrawal of the cannula. Contraindications to culdoscopy include vaginal infection acute pelvic inflammation a narrow senile vagina and fixed masses in the cul-de-sac. Pulmonary cardiac or orthopedic diseases may indicate inability to assume the knee-chest position. Culdoscopy was usually completed in 30 minutes which included training and demonstration time. A high degree of patient acceptance combined with low morbidity rates and zero mortality in the study suggest that extradural techniques approach the ideal analgesia for culdoscopy.

Safety straps for myelography.

In order to provide maximum security for the patient from accidents at the time of a myelographic examination, a relatively simple but effective strapping apparatus has been assembled. The need for more protection of the patient against accidents while undergoing myelography has long been recognized. All radiologists are familiar with the problems encountered with the extremely weak or the heavily sedated patient, as well as with the occasional syncopal episode in the healthy subject. The reason for the unpopularity of various safety devices in the past has been, chiefly, the disadvantage of not providing the patient enough freedom to co-operate with the verbal instructions of the examiner. Any safety device that would be successful in meeting the need should (a) support the weight of the patient should any syncopal episode occur, (b) allow sufficient rotation freedom and other movement as directed by the examiner during the study, (c) be quickly and comfortably applied, (d) not contain radiopaque substance that would appear on a radiograph, and (e) lend itself to quick removal. The apparatus described here has met the above requirements in our department for several hundred myelographic studies during a fourteen-month period. As shown in Figure 1, it consists of strap “A,” a 2-inch-wide heavy cotton fabric strap long enough to encircle the chest below the arms of a large patient. The ends of the strap are of Velcro fabric; this makes it possible to fasten the strap securely and quickly in place. This encircling strap passes through a loop in the end of straps “E” and “C,” which are in turn secured to the shoulder braces of the myelogram table by means of a metal buckle attached to each of the straps. In like manner, ankle harness “D” (Fig. 2), made of similar heavy material with Velcro ends, secures the ankles of the patient to the footboard and prevents falling when head is down. With this device in place (Fig. 3), should the patient suddenly become unable to support himself, he will be spared an injury-producing fall. The apparatus also allows the patient enough freedom to easily co-operate with the examiner in assuming oblique positions in both lumbar and cervical studies, so once the device is applied it need not be removed until the study is completed. Since beginning our series of examinations using the above-described strapping device, we have added another feature aimed at avoiding injuries to the upper extremities. This addition was prompted by an incident in which a patient received a crushing injury to a finger after inadvertently placing his hand between the fluoroscopic screen carriage and the myelogram table. In order to prevent further similar incidents, two wrist straps of Velcro fabric have been added to aid in comfortably immobilizing the upper extremities. The necessary materials for the assemblage of an apparatus similar to the one described may easily be obtained from most orthopedic appliance dealers.

The scalenus anticus syndrome as a complication after gynecologic operations

Summary The syndrome of neurocirculatory compression by lesions of the scalenus anticus muscle is reviewed, and four cases illustrating this syndrome are presented. 1. This syndrome may result from the faulty positioning of the patient on the operating table. Injury to the scalenus anticus muscle may be caused by shoulder braces when the patient is maintained in Trendelenburg position, especially when one arm is abducted for intravenous fluid administration and when the head is hyperextended during the administration of the anesthetic. 2. Prophylactic measures relate to protection of the scalenus muscle during the operation.

On a New Form of Shoulder Brace, on the Action of such Appliances, and on the Right Method of Fitting them

On a New Form of Shoulder Brace, on the Action of such Appliances, and on the Right Method of Fitting them