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Primary cutaneous lymphomas rarely present to the hand surgeon. Diagnosis of primary cutaneous lymphoma in the upper extremity can be difficult to make, as they are rare, and may be mistaken for other lesions. We report an unusual case of primary cutaneous lymphoma presenting in the upper extremity. This rare differential should be considered when encountered with a lump of similar appearance in the upper extremity.

Introduction: Carpet weaving is one of the most common occupations in Iran. Studies have shown that the majority of workers in these industries are women and these people are exposed to high occupational risks such as musculoskeletal disorders (MSDs). This study aimed to evaluate the hands activity level and upper extremity work-related musculoskeletal disorders (UEWMSDs) symptoms in female carpet weavers (FCWs).

Methods: This case-control observational study was performed on 150 FCWs of a carpet weaving workshop as a case group and 150 office staff as a control group. In order to assess the risk factors for UEWMSDs, the Hand Activity Level-Threshold Limit Value (HAL-TLV) method was used. The Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used to assess the prevalence of UEWMSDs symptoms in the past year. Data were analyzed using SPSS-V 24.

Results: The mean final scores of the HAL_TLV for the case and control groups were 1.04 and 0.15, respectively. The results of the statistical analysis showed a statistical significant difference between the mean of HAL, NPF, and HAL_TLV variables in case and control groups ($P$$<$ 0.001). Also, the results showed a statistical significant difference between the mean scores of the incidence of discomfort in the Shoulder, Forearm, and Wrist areas in the case and control groups ($P$$<$ 0.001).

Conclusion: The results of this study show the effect of increasing the level of hand activity on UEWMSDs symptoms. To reduce the level of hand activity and UEWMSDs symptoms in FCWs, there should be increased focus on work time, work speed, and the use of ergonomic, lightweight hand tools.

This study investigates upper limb movement and electromyography (EMG) signals during snatch under various loading conditions and discusses results from six lifting phases. Qualisys motion analysis and Noraxon EMG systems were used to record upper limb movement and muscle activity. When lifting heavy weights, the maximum shoulder flexion angle exceeded 180° in the rise phase and thus, was higher than when lifting lower weight categories. The deltoid and biceps muscles exhibited higher activity during this phase when lifting heavy weights. It can be inferred that the deltoid muscle is activated in this phase in order to maintain the shoulder in an abducted position, and to maintain hyperflexion of the biceps. Muscle activity of the deltoid and biceps in the second pull phase also increased significantly during heavy weight lifting. We infer that the effective use of these two muscles in the second pull phase would produce higher peak barbell vertical velocity, increasing the amount of weight can be lifted. Muscle activity for the latissimus dorsi during first pull showed a statistically significant increase when lifting heavy weights. This ability by the latissimus dorsi to generate higher velocities early in the concentric phase (downswing) possibly contributed to the improved final performance during heavy weight lifting.

This study focuses on the functional assessment of the upper extremity of stroke patients via analysis of angular kinematics features. Amplitudes and angular velocities of multi-joint movements more precisely describe functional state at different impairment levels. However, the arm movement as a whole could be analyzed by means of joint angle–angle diagrams, which illustrate the 2D trajectory of upper extremity during movement and show the visual ranges of upper extremity in different cycles of motion. The functional range of motion of each upper extremity segment in all patient groups for more accurate assessment of capability was calculated. Moreover, we calculated the area (S) between two curves in joint angle–angle diagrams as a novel index of the complete upper extremity movement range evaluation. Our findings correspond to clinical rates and upper extremity assessment based on joint angle–angle diagrams seems to be a promising method for accurate assessment and/or predicting the outcomes of rehabilitation programs.

The upper limb of a vehicle driver is vulnerable to injury in a car collision accident. In order to study the injury mechanism and biomechanical response of the upper limb, a finite element model of upper limbs including upper limb bones, muscles, ligaments and skin was established from CT scan data, and was validated by quasi-static and dynamic three point bending tests to the long bones, as well as airbag and forearm impact tests. Further, the influence of airbag parameters and driver’s postures on the upper limb injury were simulated and analyzed. The results showed that the risk of forearm fracture increased with the increase of the forearm radial speed. When the air mass rate of airbag reduced to half of the initial, the forearm distal-end average speed was decreased by 19.1%, and the peak decreased by 9.0% accordingly. When the distance between forearm and the airbag was selected from 0 to 15, 25 and 35mm, respectively, the forearm distal-end average speed was decreased by 23.8%, 45.1% and 56.7% accordingly, and the peak decreased by 1.6%, 28.4% and 42.0%, respectively. The simulation result indicates this model has a good bio-fidelity and can accurately reflect the dynamic response of the upper limb and quantitative injury mechanism, enabling the evaluation of vehicle safety restraint system.

Recently, the functional near-infrared spectroscopy (600–900nm electromagnetic wave) ($f$-NIRS)-based rehabilitation researches have been studied for understanding the human brain. Although $f$-NIRS can successfully measure the relative blood concentration changes of oxy-hemoglobin (HbO) and deoxy-hemoglobin (HbR) as an assessment tool to identify significant clinical intervention during pre- and post-rehabilitation therapy for stroke survivors, there is insufficient information particularly on the use of $f$-NIRS as a clinical translation in upper extremity function rehabilitation. In order to widely utilize the $f$-NIRS for upper extremity rehabilitation, device information, experiment design, measurement procedure, and analyzing method are described for clinician aspect in this study. In addition, further research trend was introduced from previous studies for stroke survivor rehabilitation. The authors believed that the information provided in this study can be a useful guideline to encourage future researchers to focus on upper extremity function rehabilitation of stroke survivors.

Due to the advantages of more intensiveness, long duration, repeatability, and task-orientation, robot-assistant training has become a promising technology in stroke rehabilitation. Regarding the upper extremity, the natural coordination called shoulder rhythm is the most challenge to the design of ergonomic shoulder exoskeleton. Based on kinematic analysis of movement of shoulder complex, a 10-degree-of-freedom (DoF) exoskeleton rehabilitation robot with six-DoF shoulder actuation mechanism driven by pneumatic muscle through Bowden cable transmitting force is proposed. The kinematic relationship between shoulder girdle motion and the humerus flexion/retroflexion and abduction/adduction was described. The compact mechanisms for cable tension and cable disconnect/connect respectively were proposed to realize the cable automatic tension and drive-unit/manipulating-unit detachment. In order to verify the manipulability of the proposed robot during assisting patient with performing activities of daily living (ADLs), the performance criteria, i.e., normalized dexterity measure and manipulability ellipsoid, are used to evaluate and compare with human upper extremity. The evaluated results confirm the ergonomic design of shoulder mechanism of the rehabilitation robot that can provide approximate dexterity of human upper extremity in ADLs.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures.

Methods: A prospective study was conducted (2016–2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations.

Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all).

Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.

Aneurysmal bone cyst (ABC) is a benign expansile bone tumor without metastasis capability. Only 3–4% of ABCs occur in the hand and they mainly take place in metaphysis’ of long bones like metacarpals or phalanges. Carpal ABCs have been reported as individual case reports in the literature due to rarity. A patient presented with pain in her right wrist. Magnetic resonance imaging revealed a well circumscribed one cm sized mass in the pisiform bone that resembled an aneurysmal bone cyst. Total pisiformectomy was performed. Treatment options are total excision or curettaging in ABCs. But rarity of these lesions may delay the diagnosis process for the inexperienced surgeon.

Background: Soft tissue sarcomas (STS) are rare, and little is known about the factors that affect the delays in the initial treatment. The aim of this study is to quantify the period between onset of symptoms and start of treatment of STS and determine the factors affecting delays in initial treatment.

Methods: This is a retrospective study of all STS treated in our institution between October 2009 and March 2019. We analysed patient record to determine the period from onset of symptoms to start of initial treatment. We also collected data with regard to patient characteristics and features of the tumour. Tumours were classified into upper extremity, lower extremity, trunk and others based on location of the tumour. Statistical tests were done to identify factors that affected delay in initial treatment.

Results: The study included 134 patients (76 male and 58 female) with STS with an average age of 56.6 years. The tumours involved the upper extremity in 20 patients, lower extremity and trunk in 50 patients each and other areas in 14 patients. The most frequent histological subtypes were liposarcomas (n = 31, 23.5%) and undifferentiated pleomorphic sarcomas (n = 24, 18.2%). Initial treatment was delayed by an average of 9.9 months for all groups. The period of treatment delay for tumours involving the upper extremity was shorter (7.9 months) and these tumours were smaller at initial presentation (57.6 mm) compared to tumours in other locations (p < 0.05). Other factors that were positively associated with treatment delays were a history of diabetes mellitus (p = 0.037) and smoking (p = 0.026).

Conclusion: Patients with upper-extremity STS may have the benefit of a relatively better prognosis as they present earlier and with a smaller tumour. In addition, factors, such as diabetes and smoking, which indicate a low interest in health also influenced the delay in the initial treatment.

Level of Evidence: Level III (Therapeutic)

Background: The recently validated Hand Questionnaire (HAND-Q) is a multifaceted patient-reported outcome measure (PROM) for hand/upper extremity (UE) pathology and treatment. Here, we conduct a pilot study utilising data collected as a participating site for the Phase II HAND-Q Pilot Multicenter International Validation Study. We hypothesised that self-reported hand functionality, symptom/disease severity, hand appearance, emotional dissatisfaction and treatment satisfaction would be worse in patients who perceived their disease severity to be more severe but would not differ between patients based on prior surgical history.

Methods: Patients were prospectively enrolled for HAND-Q participation from September 2018 to August 2019. Patients were included in this analysis if they responded to the following scales of HAND-Q: Hand Functionality Satisfaction, Symptom Severity, Hand Appearance Satisfaction, Emotional Dissatisfaction and Treatment Satisfaction. Composite scores (CS) were created for each section. Surgical versus non-surgical CS and mild versus moderate/severe CS were compared with t-tests. Bi-variate comparisons of responses were performed between surgical and non-surgical groups, and between mild and moderate/severe groups.

Results: HAND-Q individual question analysis revealed significant differences in functionality and symptom severity for patients with prior surgery (p < 0.047). CS analysis confirmed greater overall impairment in surgical patients, but no overall impact on symptom severity. Regarding disease severity HAND-Q individual question analysis, moderate/severe patients reported worse outcomes for specific aesthetic qualities and symptoms for almost all items (p < 0.05). CS analysis revealed significantly worse overall hand appearance satisfaction, hand functionality, emotional satisfaction and symptom severity for patients with moderate/severe hand conditions.

Conclusions: HAND-Q revealed worsened outcomes for UE patients with self-reported moderate/severe conditions or previous surgical history. Understanding how previous surgery and disease severity may impact clinical outcomes is important for crafting appropriate treatment.

Level of Evidence: Level II (Prognostic Study)

Background: Upper limb traumatic injuries have a significant impact on social and professional life; however, there is still a paucity of studies focusing on the injuries of the ulnar border of the forearm, wrist and hand.

Methods: We designed a retrospective single-blinded study, including all patients with deep traumatic wounds affecting the ulnar side of the forearm, wrist or hand, that received surgical treatment from 2006 until 2016. A characterisation of the sample, assessment of concomitant injuries and clinical outcomes, as well as neurological and functional evaluation were performed.

Results: We obtained a sample of 61 patients, 69% with injuries affecting the wrist and 90% of patients with a neurological lesion, most frequently of the ulnar nerve lesion (UNL). Concomitant injuries included tendinous lesions, more frequently of the flexor carpi ulnaris (64%) and fractures (13%). And 39% of patients presented an ulnar artery lesion, without significant differences in outcomes regarding the completion of arteriorrhaphy or not. At the end of the 8.6 years follow-up, 34% of patients had no deficits; however, patients with UNL showed worse functional scores and greater risk of sequelae. Besides motor function compromise, sensory deficits were also associated with worst functional outcomes.

Conclusions: The UNL subgroup showed important impairment of the first ray, probably related to the level of UNL. Furthermore, besides the implications of the motor sequelae, sensory deficits were also associated with worst functional scores. Due to the high percentage of neurovascular and tendinous lesions in ulnar-sided upper extremity wounds, the authors recommend surgical exploration of these lesions.

Level of Evidence: Level IV (Therapeutic)

Background: Tourniquet use during upper extremity surgery in patients with a history of axillary lymph node dissection (ALND) remains controversial due to the perceived but unproven risk of lymphoedema. We prospectively evaluated upper extremity swelling in patients with a history of unilateral ALND using a standardised tourniquet model.

Methods: A tourniquet was applied to the upper arm bilaterally, with the unaffected side serving as an internal control. Each arm was subsequently held in an elevated position to reduce swelling. Hand volume was measured using an aqueous volumeter.

Results: The patients’ ALND arms experienced slightly greater increases in volume following tourniquet application compared to their healthy control arms. However, this amount of oedema was temporary and reversible, as both arms experienced spontaneous resolution of swelling with no significant difference in residual hand volume at the conclusion of the study.

Conclusions: Tourniquet use may be safe in patients with a history of ALND. Further investigation is needed to verify this in a surgical setting.

Level of Evidence: Level II (Therapeutic)

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES.

Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment.

Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment.

Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS.

Level of Evidence: Level III (Diagnostic)

Background: WALANT has gained much popularity in recent years, especially with COVID-19. However, a recent survey of the American Society for Surgery of the Hand membership (i.e. attendings/consultants) showed that only 17% were exposed to WALANT during residency or fellowship training. There is much interest in WALANT from trainees, but interpretation of the type and volume to be administered is highly varied.

Methods: The aims of this study were (1) to survey a group of plastic surgery trainees in the UK about their knowledge of WALANT formulas, and (2) to compare trainee logbook records of WALANT procedures (if available) with published data from the UK.

Results: All trainees were familiar with the ‘standard’ WALANT formula (1% lidocaine, 1:100,000 adrenaline ± 8.4% NaHCO₃) described by Lalonde. However, because of local formularies, rather than 1:100,000 adrenaline, all used 1:200,000 adrenaline as it comes premixed in the UK. Other formulas used by UK trainees included 0.5% bupivacaine + 1:200,000 adrenaline, and mixing 1% lidocaine + 1:200,000 adrenaline with 1% lidocaine 1:1. In comparing available trainee WALANT records with published UK data, the average volume of WALANT used was 6.6 mls in the current study versus 12.9 mls for similar procedures (wound debridement and skin closure ± local flap, digital nerve repair, fingertip reconstruction, thenar injuries, phalangeal fracture and single digit extensor repair); specifically, for single digit flexor tendon repairs, this was 10 mls versus 16.3 mls.

Conclusions: While the British Society for Surgery of the Hand (BSSH) have developed official guidance for the use of WALANT in the UK, it appears there remains much variation in interpretation and hence, application. Comparison of trainee logbook records of common hand surgery procedures suggests that most can be done with much less WALANT administered than previously reported, with safe and reproducible results.

Level of Evidence: Level IV (Therapeutic)

We report a patient with a severe axial–radial–ulnar (ARU) fracture dislocation of the carpus, involving multiple intermetacarpal dislocations as well as divergent carpometacarpal dislocations involving the index, long, ring and small fingers and peritrapezoid and scaphotrapezial dislocations. She also had a degloving injury involving the dorsal hand. Emergent debridement followed by open reduction and internal fixation of all injuries was performed, followed by soft tissue management. At 6-year follow-up, the patient had adequate active range of motion with the ability to make a full fist and was able to use her wrist and hand for most activities of daily living. Disabilities of the arm, shoulder and hand (DASH) score was 47.5. Michigan hand outcomes questionnaire (MHQ) score was 66.8. Mayo wrist score was 65. Patient-rated wrist evaluation (PRWE) score was 42. Severe ARU fracture dislocations of the carpus can result in adequate functional recovery on long-term follow-up.

Level of Evidence: Level V (Therapeutic)

Recently, recurrent plot (RP) has been used as one of the analysis tools in complex system dynamics. In this paper, we hypothesize that complex features extracted from RP have superiority in discriminating the upper extremity performance in two groups of mulitiple sclerosis (MS) patients without tremor and healthy controls compared to statistical and power spectrum features. We define spiral drawing task for upper extremity and the position signals is recorded from subjects. Then, velocity profiles are extracted and the common statistical and spectral features are exported. To extract complex features from RP, a modified methodological approach based on density distribution is presented and the properties of distribution are calculated as complex features. Finally, the applicability and capabilities of these three groups of features are invested by a Neuro-Fuzzy Classifier. The performance of the Neuro-Fuzzy classifier is reported as sensitivity, specificity and accuracy criteria. The results of the analysis yield out that complex features have the highest performance comparatively. This hypothesis is proven and validated through the experiments and it is shown that the complex features have promising discriminating capabilities. To validate the classifier used, different structures of the neuro-fuzzy classifier are studied in terms of the number of membership functions and the type of fuzzy sets and the most efficient structure is extracted out. Furthermore, the efficiency of the Neuro-fuzzy classifier with its optimum structure and tuned parameters is compared with some other well-known and commonly used classifiers.

Problems with post-stroke shoulder (PSS) are common after stroke. Rehabilitation in this area is complicated and the lack of a framework to guide the scope of physiotherapy practice is recognised. To resolve this issue, this study aims to provide such a suitable framework. The methodology employed by the study was a mixed-method design that included a scoping review of the role of physiotherapy across PSS management, as well as interviews with 15 specialist physiotherapists working in the UK. The scoping review identified 118 papers covering a total of 13 categories. Thematic analysis of interview data enabled these categories to be mapped into a framework with five key domains: prevention, conceptualisation, assessment, management and delivery. Synthesis of the scoping review and interviews were a useful way of mapping the physiotherapy role, and provided the first empirically derived framework that establishes the physiotherapy contribution to the management of PSS. While informing clinical practice and research, the framework may also be helpful to develop practical, and more focused, guidance for physiotherapists, drawn from a complex evidence base for stroke (e.g. across national clinical guidelines).