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Purpose: Axillary lymph node dissection and radiotherapy have been associated with pain, physical symptoms, and decreased functional abilities in the upper extremity. This study aimed to evaluate the potential effects of the proprioceptive neuromuscular facilitation (PNF) technique on muscle strength, pain and functionality in this patient group in comparison with progressive resistance training (PRT)., Methods: The study was conducted with a randomized clinical trial design. Sixty-six women were included in the study and randomly divided into three groups: the PNF group (n = 22), the PRT group (n = 22), and the control group (n = 22). The participants were evaluated at the baseline and after eight weeks of treatment. Outcome measures were determined as pain (the Visual Analog Scale), upper extremity strength (isokinetic dynamometer), functionality (the Disabilities of the Arm, Shoulder and Hand questionnaire), and perception of change (the Global Rating of Change Scale)., Trial Registration: ClinicalTrials.gov identifier: NCT05288036., Results: The results showed statistically significant changes in both treatment groups in terms of shoulder flexors/extensors, abductor/adductors, internal/external rotators strength/power/endurance measurement, pain, and functionality (p < 0.05). Concerning functionality and perception of change, the PNF group had a statistically significantly higher improvement compared to the remaining two groups (p < 0.05)., Conclusion: PNF is an effective technique in increasing upper extremity muscle strength, reducing pain during rest and activity, and improving functionality in patients receiving breast cancer treatment., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest related to the publication of this manuscript., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Upper limb masses are one of the most common presentations in the outpatient setting. However, there is a paucity of information in the literature regarding the epidemiology of upper-extremity masses in the pediatric population. The aim of this study was to determine the differential diagnoses and clinical characteristics in children aged ≤18 years presenting with upper limb masses., Methods: A retrospective review of patients aged ≤18 years managed at our institution over a 5-year period was performed. We obtained information on patient demographics, clinical features, radiological investigations, intraoperative features, and histology. We also evaluated the correlation between the clinical and histopathological diagnoses in patients who underwent surgery., Results: There were 141 upper limb masses in our series. The mean age at presentation was 12 years (SD, 5 years). The most common presenting complaints were asymptomatic swelling, pain, and paresthesia. The majority (128; 91%) of tumors were benign; there were 5 locally aggressive tumors and 6 malignant tumors. The dominant hand was involved in 60 patients. Of 140 patients, 43 (31%) patients had surgery. The procedures included incisional biopsy, excisional biopsy, wide resection, and reconstruction. One patient required a below elbow amputation for an osteosarcoma., Conclusions: Ten percent of cases represented malignant or locally aggressive disease. We have used our observations to develop a clinical algorithm that can assist clinicians in evaluating and managing children and adolescents presenting with upper-extremity masses., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: For more than a year, health systems all over the world have been combating the global coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was first described in the city of Wuhan in China, presenting as an atypical infection of the lower respiratory tract., Methods: COVID-19 is characterized by multisystemic involvement, and mortality is attributed mainly to the respiratory system involvement, which may lead to severe acute respiratory distress syndrome and respiratory failure. Several COVID-19-associated complications are being increasingly reported, including arterial and venous thromboembolic events that may lead to amputation of the affected limbs. So far, a large number of reports have described hypercoagulability crises leading to amputation of the lower limbs. However, a search of the National Library of Medicine (MEDLINE) revealed no cases of urgent upper limb amputation in COVID-19 patients., Results: This article describes a novel case of upper limb ischemia in a COVID-19 patient, with rapid progression to hand necrosis, requiring urgent through-arm amputation of the upper limb., Conclusions: This case emphasizes the need for anticoagulant therapy in COVID-19 patients and to maintain a constant awareness of the possible thromboembolic COVID-19-related sequelae., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

This retrospective study sought to identify a regular pattern of limb bruising which occurs in association with suicidal or accidental hanging. Following exclusion of cases suspicious for homicide, 82 consecutive cases of hanging from a 10-year period were retrospectively reviewed to identify the pattern of traumatic limb injury in each case. Relevant information such as location, toxicology, and type of suspension was also noted. 72% of the reviewed cases had traumatic limb lesions, the majority of which occurred on the posterior upper limb and the anterior lower limb. Although the distribution of limb injury in our study mirrored that found in the literature, the incidence is much higher than in previous studies (7.4-20%). This could either be due to differences in confounding factors such as intoxication and location of hanging or differences in the practice of recording of limb trauma in hanging between centres. Neither type of suspension nor location of hanging were significantly associated with an increased incidence of traumatic limb injury. Positive toxicology was found to increase the likelihood of sustaining limb injury (p = .044084). In conclusion, the presence of this well documented pattern of traumatic limb lesions in cases of hanging should not always raise suspicion of foul play., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2020 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Despite their disabilities, top Paralympic athletes have better motor skills than able-bodied athletes. However, the neural underpinnings of these better motor skills remain unclear. We investigated the reorganization of the primary motor cortex (M1) in a Paralympic athlete with congenital amputation of both arms who holds the world record for the farthest accurate shot in archery (Amputee Archer: AA). We recorded brain activity during contraction of right toe, ankle, knee, and hip joint muscles in the AA and 12 able-bodied control subjects using functional magnetic resonance imaging. The results revealed that M1 activation was more widespread in the AA compared with control subjects during all tasks, and shifted towards the lateral part of the M1 during contraction of toe and knee muscles. We also conducted a motor mapping experiment using navigated transcranial magnetic stimulation. The M1 area receiving stimulation elicited motor-evoked potentials from the toe, lower-leg, and thigh muscles, which were larger in the AA compared with 12 control subjects. Furthermore, the AA's motor maps were shifted towards the lateral side of M1. These results suggest an expansion of lower-limb M1 representation towards the lateral side of M1, including the trunk and upper-limb representations, and an expansion of the area of corticomotor neurons innervating the lower limb muscles in the AA. This unique M1 reorganization could underpin the AA's excellent archery performance in the absence of upper limbs. The current results suggest that Paralympic athletes may exhibit extreme M1 plasticity, which could arise through a combination of rigorous long-term motor training and compensatory M1 reorganization for missing body parts., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The optimal surgical excision margins are uncertain for patients with thick (>2 mm) localised cutaneous melanomas. In our previous report of this multicentre, randomised controlled trial, with a median follow-up of 6·7 years, we showed that a narrow excision margin (2 cm vs 4 cm) did not affect melanoma-specific nor overall survival. Here, we present extended follow-up of this cohort., Methods: In this open-label, multicentre randomised controlled trial, we recruited patients from 53 hospitals in Sweden, Denmark, Estonia, and Norway. We enrolled clinically staged patients aged 75 years or younger diagnosed with localised cutaneous melanoma thicker than 2 mm, and with primary site on the trunk or upper or lower extremities. Patients were randomly allocated (1:1) to treatment either with a 2-cm or a 4-cm excision margin. A physician enrolled the patients after histological confirmation of a cutaneous melanoma thicker than 2 mm. Some patients were enrolled by a physician acting as responsible for clinical care and as a trial investigator (follow-up, data collection, and manuscript writing). In other cases physicians not involved in running the trial enrolled patients. Randomisation was done by telephone call to a randomisation office, by sealed envelope, or by computer generated lists using permuted blocks. Patients were stratified according to geographical region. No part of the trial was masked. The primary outcome in this extended follow-up study was overall survival and the co-primary outcome was melanoma-specific survival. All analyses were done on an intention-to-treat basis. The study is registered with ClinicalTrials.gov, number NCT03638492., Findings: Between Jan 22, 1992, and May 19, 2004, 936 clinically staged patients were recruited and randomly assigned to a 4-cm excision margin (n=465) or a 2-cm excision margin (n=471). At a median overall follow-up of 19·6 years (235 months, IQR 200-260), 621 deaths were reported-304 (49%) in the 2-cm group and 317 (51%) in the 4-cm group (unadjusted HR 0·98, 95% CI 0·83-1·14; p=0·75). 397 deaths were attributed to cutaneous melanoma-192 (48%) in the 2-cm excision margin group and 205 (52%) in the 4-cm excision margin group (unadjusted HR 0·95, 95% CI 0·78-1·16, p=0·61)., Interpretation: A 2-cm excision margin was safe for patients with thick (>2 mm) localised cutaneous melanoma at a follow-up of median 19·6 years. These findings support the use of 2-cm excision margins in current clinical practice., Funding: The Swedish Cancer Society, Stockholm Cancer Society, the Swedish Society for Medical Research, Radiumhemmet Research funds, Stockholm County Council, Wallström funds., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Causes of acute limb ischemia are classically mainly emboli and thrombosis. Nicolau syndrome is a very rare complication of intramuscular injection presumed to be related to the inadvertent intravascular injection. It was first reported after intramuscular injection of bismuth salt, but it can occur as a complication of various other drugs. Acute limb ischemia is one of its severe outcomes but is rarely encountered and reported., Methods: Patients admitted with the final diagnosis of Nicolau syndrome in our institution in 3 years (2016 2017 and 2018) are reviewed in terms of etiology, clinical presentation, management, and outcome., Results: We present here 4 cases of Nicolau syndrome that lead to acute limb ischemia and with the same outcome: limb or fingers loss; there were 2 upper extremities for 2 women secondary to diclofenac and dexamethasone intramuscular administration and 2 lower extremities for 2 men in relation with Benzathine Penicillin intramuscular administration. The medical and surgical management that we attempted did not prevent this severe outcome., Conclusions: Nicolau syndrome should be considered when looking for rare etiologies of acute limb ischemias., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient's existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by postmastectomy upper limb lymphedema. The idea., Materials and Methods: All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire., Results: Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow-up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups (p<0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores (p<0.0001) in all domains at all follow-up appointments in Group A., Conclusions: Patients with postmastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients' quality of life., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The impact of injury on the health and activities of human foragers is of great interest for understanding the adaptability of past populations to their environments. For the Gravettian female of Caviglione 1, a violent blow has been suggested as the origin of the left radial fracture, and abnormal body asymmetry has been observed. Access to high resolution CT-scans of the upper limb allows us to address new etiologic considerations and assess the after-effects of trauma on bone biomechanical properties by focusing on cortical and trabecular bones and conducting a comparative analysis of cross-sectional geometric properties in an Upper Paleolithic context. This originally right-dominant female, who became left-handed, was mainly affected by severe bone modifications on the proximal right humerus due to secondary changes following a traumatic event. The left radial fracture is very well consolidated with thick and homogeneous cortical bone. Etiological considerations point to a Galeazzi fracture for the left forearm occurring during a fall. The bone structure and robusticity of the left arm probably prove the lack of strong and enduring dependency of this female on her group for the usual cultural tasks despite the strongly limited function of the right arm., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: To study the impact of aggressive decongestion in limbs with lymphedema without subcutaneous echo-free space (SEFS) in subcutaneous tissue ultrasonography., Methods: In 13 patients with arm lymphedema (ALE) (13 arms) and 16 patients with leg lymphedema (LLE) (18 legs) without SEFS, an aggressive decongestion was performed as the first phase of complex decongestive therapy. Measurements of circumference and calculation of limb volume were performed before and after the treatment., Results: In ALE, no significant reduction in arm volume (median -63 [range -251 to 176] mL) or edema ratio (-4 [-15 to 12]%) was confirmed. On the other hand, a small but significant reduction in leg volume (-207 [-834 to 131] mL, P < 0.001) and edema ratio (-4 [-14 to 2]%, P < 0.01) was confirmed in LLE., Conclusion: In limbs with lymphedema without SEFS, the impact of aggressive decongestion seemed limited., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Sweet syndrome, or acute febrile neutrophilic dermatosis, is a systemic disease process mainly characterized by hyperpyrexia and skin lesions. A newly described entity, necrotizing Sweet syndrome, is a severe and locally aggressive dermatological condition that clinically and histopathologically resembles a necrotizing soft tissue infection. It is characterized by pathergy, a nonspecific inflammatory response to cutaneous trauma resulting in a propagation of the disease. In contrast to a necrotizing infection, this condition responds to systemic steroids. A high clinical suspicion is required in order to distinguish a necrotizing polymicrobial infection from noninfectious necrotizing Sweet syndrome. We present a case following elective hand surgery., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Proprioceptive deficits are common after stroke and have been associated with poorer recovery. Relatively little is known about the brain regions beyond primary somatosensory cortex that contribute to the percept of proprioception in humans. We examined a large sample (n = 153) of stroke survivors longitudinally to determine which brain regions were associated with persistent post-stroke proprioceptive deficits. A robotic exoskeleton quantified two components of proprioception, position sense and kinesthesia (movement sense), at 2 weeks and again at 6 months post-stroke. A statistical region of interest (sROI) analysis compared the lesion-behaviour relationships of those subjects with cortical and subcortical stroke (n = 136). The impact of damage to brainstem and cerebellum (n = 17) was examined separately. Results indicate that damage to the supramarginal gyrus, the arcuate fasciculus, and Heschl's gyrus are associated with deficits in position sense and kinesthesia at 6 months post-stroke. These results suggest that regions beyond the primary somatosensory cortex contribute to our sense of limb position and movement. This information extends our understanding of proprioceptive processing and may inform personalized interventions such as non-invasive brain stimulation where specific brain regions can be targeted to potentially improve stroke recovery., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

The pathogenesis of neurofibromas is poorly understood outside of neurofibromatosis (NF). The BRAF proto-oncogene has been implicated in malignant peripheral nerve sheath tumors (PNSTs), however its role in neurofibromas has not been described. In this study, we identify a BRAF mutation in a 61-year old non-NF patient with a history of sporadic and recurrent neurofibromas localized to the right upper extremity. Despite repeat resections to establish local control, he developed median nerve neuropathy secondary to a 13×4cm plexiform neurofibroma. Genetic sequencing of the neurofibroma revealed the expression of a novel BRAF L597Q mutation. This study is the first to describe the BRAF L597Q mutation in PNSTs and the first to implicate a BRAF mutation in neurofibroma biology. We hypothesize that BRAF mutations may identify a molecularly-distinct subset of recurrent neurofibromas and may provide potential for targeted therapeutics., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Purple glove syndrome (PGS) is a poorly understood severe adverse drug reaction that is typically associated with intravenous phenytoin administration. Although fosphenytoin is thought to circumvent this risk of PGS, we reveal a rare case of PGS in a patient treated with fosphenytoin therapy., Case Summary: A 71-year-old male with history of epilepsy was admitted for seizures and traumatic brain injury and intravenous fosphenytoin and levetiracetam were initiated. The patient continued to have seizure activity on continuous electroencephalography for which fosphenytoin dosing was increased with subsequent seizure control. Serum phenytoin levels became elevated with a total level reaching as high as 25.8ug/mL. Three days into fosphenytoin therapy he developed PGS in both hands. Causation was assessed with the Naranjo adverse drug reaction algorithm that suggested fosphenytoin was probably the cause of PGS. Ten days after discontinuing the fosphenytoin and administering a 7-day course of methylprednisolone, the purple glove syndrome completely resolved., Conclusion: Early recognition and emergent management of PGS are key for optimal recovery. Although fosphenytoin has a significantly reduced risk of associated PGS compared to phenyotin, increased awareness for fosphenytoin-induce PGS can accelerate intervention and minimize morbidity of this rare yet detrimental adverse reaction., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: Cellulitis is a common skin infection resulting in inflammation that may take weeks to resolve despite appropriate antibiotics. It is unclear whether the adjunctive use of nonsteroidal anti-inflammatory drugs hastens the resolution of inflammation in patients with cellulitis., Methods: We conducted a double-blind, randomized controlled trial comparing ibuprofen 400 mg three times daily for 5 days with identical placebo in adults with uncomplicated cellulitis of the upper or lower limb who were treated with intravenous cefazolin via an outpatient parenteral antibiotic treatment service at one of two Australian hospitals. Participants were assessed twice daily by a study nurse. The primary outcome measure was the proportion of patients with regression of inflammation 48 hours after the first effective dose of parenteral antibiotics (trial registration ANZCTR 12611000515998)., Results: Fifty-one patients were enrolled; 48 had sufficient data available to be included in the modified intention-to-treat analysis. Inflammation had begun to regress at 48 hours in 20 participants (80%) in the ibuprofen group compared to 15 (65%) in the placebo group (absolute risk difference +15%; 95% confidence interval -10 to +40; p >0.05). There was no significant difference in any secondary outcome. Ibuprofen appeared safe, with no patients developing renal impairment or necrotizing fasciitis., Conclusions: This trial demonstrated no significant benefit of adjunctive ibuprofen in adults with uncomplicated cellulitis. The trial was powered to detect a large effect, and hence it is unclear whether the 15% absolute increase in the primary end point in the ibuprofen group was attributable to chance., (Copyright © 2017 European Society of Clinical Microbiology and Infectious Diseases. All rights reserved.)

Background: No previous reports to date have characterized the national profiles of bone sarcoma overall. In the present study, we aimed to describe the nationwide statistics of bone sarcoma in Japan by analyzing data from the Bone and Soft Tissue Tumor (BSTT) Registry in Japan, which is a nationwide organ-specific cancer registry for bone and soft tissue tumor., Methods: We identified 2773 patients with bone sarcomas using the BSTT Registry during 2006-2012. We extracted the data regarding patient demographics, treatment, and prognosis at the last follow-up for each patient., Results: There was a slight male preponderance. The age distribution had 2 peaks overall: one in the second decade and the other in the sixth to seventh decade with the proportion of the elderly patients over 60 years approximately 30%. The most frequent tumor locations were the lower extremity (N = 1342; 48.4%) and the trunk (N = 1038; 37.4%). We also showed the significant association between disease-specific survival and patient's age, histologic grade and subtype, tumor size and location, and limb salvage status based on 1401 patients with bone sarcoma, and demonstrated the worst disease-specific survival in the elderly patients., Conclusions: The present study is the first study to have analyzed data from the BSTT Registry and has provided an overview of the epidemiology, clinical features, treatment, prognosis, and significant factors affecting prognosis of patients with bone sarcoma in Japan based on cases assumed to have received relatively uniform treatment strategies. It is essential to document our data regarding the outcomes of elderly patients so that other countries showing similar population aging trends can learn from our experiences., (Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

The management of upper limb non-unions can be challenging and often with unpredictable outcomes. In this study we present our experience with the use of BMP-7 in the treatment of upper limb non-unions. Between 2004 and 2011 all consecutive patients who were treated with BMP-7 were followed up prospectively until fracture union. Fracture union was assessed with regular radiological and clinical assessment. At the final follow up clinical assessment included the short Disabilities of the Arm, Shoulder and Hand (DASH) score. The minimum follow up was 12 months (12-36). In total 42 patients met the inclusion criteria with a mean age of 47 years. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal forearm, 14 humeri, 6 distal radius and 3 clavicle. 35 patients had atrophic non-union, 11 had previous open fractures, and 10 had bone loss (range 1-3 cm). The mean number of operations performed and the mean time from injury to BMP-7 application was 1.5 and 26 months, respectively. 40 fractures had both clinical and radiological union whereas 2 patients had partial radiological union but a pain free range of motion. BMP-7 was applied in isolation in 1 case and in 41 cases the application was combined with autologous bone grafting. DASH scores were available at final follow up in 23 (55%) patients with a mean of 33 score (range 2-86.4). This study supports the view that the combination of ABG and BMP-7 can be considered as a successful treatment modality for the treatment of recalcitrant upper limb non-unions. Further studies preferably randomised controlled trials are desirable to throw more light into the role of BMP-7 in the treatment of upper limb nonunions., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Unlabelled: Given the frequency and severity of overuse injuries in pediatric athletes and the potential for long-term deleterious effects, it is important for radiologists to have a comprehensive understanding of these injuries and their imaging spectrum. This article addresses chronic overuse injuries involving the upper extremity in the pediatric athlete. Chronic upper extremity overuse injuries in competitive pediatric athletes yield imaging findings that can be subtle, obvious and characteristic, or atypical. Prompt application of the appropriate imaging modalities and their accurate interpretation expedites management, returning the pediatric athlete to the playing field while minimizing long-term adverse outcomes., Summary Statement: Proper modality selection and interpretation in the imaging evaluation of upper extremity overuse injuries in pediatric athletes include an understanding of skeletal development, mechanism of injury, and clinical presentation to provide accurate diagnoses and mitigate long-term adverse sequelae., Learning Objectives: After reading this article and taking the test, the reader will be able to: • Describe the clinical presentation and imaging characteristics of a variety of pediatric overuse injuries in the upper extremity including little league shoulder, rotator cuff tendinosis, gymnast wrist, climber's finger, and myriad pathologies about the elbow. • Explain how the physis plays a crucial role in pediatric overuse injury and how to evaluate physeal injury in a multimodal approach. • Understand the clinical management for certain pediatric overuse injuries, especially those that have potential for long-term and/or permanent disability., (Published by Elsevier Inc.)

Botulinum toxin A is widely used in the clinics to reduce spasticity and improve upper limb function for post-stroke patients. Efficacy and safety of a new botulinum toxin type A, NABOTA (DWP450) in post-stroke upper limb spasticity was evaluated in comparison with Botox (onabotulinum toxin A). A total of 197 patients with post-stroke upper limb spasticity were included in this study and randomly assigned to NABOTA group (n=99) or Botox group (n=98). Wrist flexors with modified Ashworth Scale (MAS) grade 2 or greater, and elbow flexors, thumb flexors and finger flexors with MAS 1 or greater were injected with either drug. The primary outcome was the change of wrist flexor MAS between baseline and 4weeks post-injection. MAS of each injected muscle, Disability Assessment Scale (DAS), and Caregiver Burden Scale were also assessed at baseline and 4, 8, and 12weeks after the injection. Global Assessment Scale (GAS) was evaluated on the last visit at 12weeks. The change of MAS for wrist flexor between baseline and 4weeks post-injection was -1.44±0.72 in the NABOTA group and -1.46±0.77 in the Botox group. The difference of change between both groups was 0.0129 (95% confidence interval -0.2062-0.2319), within the non-inferiority margin of 0.45. Both groups showed significant improvements regarding MAS of all injected muscles, DAS, and Caregiver Burden Scale at all follow-up periods. There were no significant differences in all secondary outcome measures between the two groups. NABOTA demonstrated non-inferior efficacy and safety for improving upper limb spasticity in stroke patients compared to Botox., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Purpose: To determine the outcomes of surgical excision with or without adjuvant treatment in the management of desmoid tumors of the upper extremity., Methods: We retrospectively reviewed 52 patients with a histologically confirmed desmoid tumor in the upper extremity that was managed surgically. All patients presented between 1970 and 2011 and had a minimum 2-year follow-up., Results: There were 25 males and 27 females with an average age of 37 ± 17 years. The most common location was the shoulder (n = 27). The most common symptom was a painful mass (n = 30). Average tumor size was 189 ± 371 cm(3). Negative margins (wide or marginal resection) were achieved in 43 patients. The 5-year disease-free interval was 57%. Patients with recurrence were younger than those without (31 vs 43 y). Postoperative radiotherapy increased the time to recurrence (2.6 vs 1.6 y) but ultimate disease-free interval at 5 years was similar in patients who did and did not receive radiotherapy. Compared with the preoperative evaluation, there was a significant reduction in patients reporting moderate or severe pain postoperatively., Conclusions: Desmoid tumors are locally aggressive fibrous tumors. Recurrence after surgical excision of a desmoid tumor in the upper extremity is common, especially in younger patients. Adjuvant radiation therapy tended to increase time to recurrence but not rate of recurrence., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Health-care costs associated with pressure sores are significant and their financial burden is likely to increase even further. The aim of this study was to analyse the direct medical costs of hospital care for surgical treatment of pressure sores stage III and IV. We performed a retrospective chart study of patients who were surgically treated for stage III and IV pressure sores between 2007 and 2010. Volumes of health-care use were obtained for all patients and direct medical costs were subsequently calculated. In addition, we evaluated the effect of location and number of pressure sores on total costs. A total of 52 cases were identified. Average direct medical costs in hospital were €20,957 for the surgical treatment of pressure sores stage III or IV; average direct medical costs for patients with one pressure sore on an extremity (group 1, n = 5) were €30,286, €10,113 for patients with one pressure sore on the trunk (group 2, n = 32) and €40,882 for patients with multiple pressure sores (group 3, n = 15). The additional costs for patients in group 1 and group 3 compared to group 2 were primarily due to longer hospitalisation. The average direct medical costs for surgical treatment of pressure sores stage III and IV were high. Large differences in costs were related to the location and number of pressure sores. Insight into the distribution of these costs allows identification of high-risk patients and enables the development of specific cost-reducing measures., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

BCRL is the most common morbidity in women with breast cancer. We performed a retrospective analysis of 107 BCRL patients to identify the efficacy of CDP and the predictors of lymphedema severity and response to CDP. The patients received 12 sessions of CDP, the duration of lymphedema was 22.4 months, and 56% of BCRL occurred within 2 years after surgery. Lymphedema severity, baseline and post-CDP percentage of excess volume (PEV), was 27.7% and 14.9%. The baseline PEV was correlated with the duration of lymphedema. The CDP efficacy, percentage reduction of excess volume (PREV), was 50.5%, and was correlated with PEV, duration of lymphedema and age. Baseline lymphedema severity was the most important predictive factor for CDP efficacy. The breast cancer therapy characteristics did not affect PEV or PREV. This study showed the effectiveness of an intensive CDP interventions. The key to predicting successful lymphedema treatment is the baseline PEV., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Amyotrophic lateral sclerosis (ALS) is characterized by pronounced clinical heterogeneity in terms of onset and disease progression. Widespread changes in white matter fibres could be observed by diffusion tensor imaging (DTI), which detects alterations in the degree (diffusivity, ADC) and directedness (fractional anisotropy, FA) of proton movement. The aim of the current study was to determine whether different ALS onset types were reflected in different DTI brain patterns., Methods: Seventeen patients with a diagnosis of ALS (6 bulbar, 11 limb onset) and seventeen age-matched controls received 1.5T DTI, where FA and ADC were analyzed using statistical parametric mapping., Results: In ALS patients, an increased diffusivity in the white matter was found below the precentral gyrus and along the corticospinal tract (CST) right into the internal capsule. The FA was decreased in the posterior limb of internal capsule and in the subcortical white matter in the precentral gyrus. In bulbar onset increased diffusivity was found in the CST, whilst in limb onset, frontal subcortical areas displayed an increased diffusivity., Conclusion: DTI changes can be regarded as prominent features in ALS. Herein we were able to demonstrate discriminating brain DTI patterns due to bulbar or limb onset., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Necrotizing soft tissue infections are rapidly progressive infections with a high rate of mortality. One type of necrotizing soft tissue infection is caused by marine gram-negative bacteria and commonly occurs in immunocompromised hosts. These types of infections are more common in patients with chronic liver disease, possibly because of impaired iron metabolism. We present the case of a rapidly progressive necrotizing soft tissue infection caused by Edwardsiella tarda, a marine gram-negative pathogen common in catfish. Few extraintestinal infections of E tarda have been described previously. Our patient had hepatitis C and was exposed to the bacteria by a puncture injury from a wild catfish. His infection required multiple debridements and ultimately required a transhumeral amputation for local control of the infection., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We analyzed entheseal change in 159 skeletons from Moundville and surrounding settlements using primary fibrocartilaginous attachments of the upper limbs. Risk of entheseal change did not differ bilaterally, suggesting a wide variety of activities were used to exploit a diverse ecosystem. Consistent with predictions, Mississippian (1000-1500 CE) agriculturalists experienced greater risk of entheseal change than did Late Woodland (500-900 CE) hunter-gatherers. Attachments used in arm flexion were most affected, while rotator cuff entheses remained consistent over time. A temporal increase in muscular changes in males in concert with faunal evidence for resurgence of larger game (e.g., deer) is consistent with continued reliance on hunting alongside domestication of maize. Among Mississippians, younger males appear to have been carrying out the most strenuous tasks, contrary to earlier studies that suggested a decline in male activities with domestication. Mound centers consistently experienced the greatest upper body changes, in spite of faunal and botanical data supporting provisioning of elites by outlying sites. Center males, respectively, experienced more than 26 and 12 times greater changes at elbow extensors and brachialis than those from outlying settlements, with a significant decline from young to middle age among adults. Center females experienced increased risk at biceps insertions and common extensors of the humeri - trends that disappeared with age. Overall findings suggest increased upper body demands and shifting sex and age-dependent divisions of labor with maize intensification, but trends across settlements point to significant status-related body size selection in center males, with fewer differences among females., (Copyright © 2012 Elsevier GmbH. All rights reserved.)

Almost always, Hodgkin's lymphoma presents with lymph node involvement. Primary extranodal lymphoma is rare and mostly has a type of non-Hodgkin's lymphoma. We present an unusual presentation of a Hodgkin's lymphoma in a 33-year-old man. There were numerous soft tissue masses localized in the subcutaneous tissue of the left arm along the neurovascular bundle and the ipsilateral axillary region. We found only one Hodgkin's lymphoma case that presented as an upper extremity mass reported in the literature. In cases where a great number of successively lined up soft tissue masses are detected on the extremity, lymphoma takes place among the differential diagnoses., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the phenomenon of vascular ischemic limb necrosis in twin-twin transfusion syndrome (TTTS)., Study Design: This was a multicenter retrospective review of ischemic limb necrosis in patients with TTTS., Results: Twenty cases of fetal ischemic limb necrosis in association with TTTS were identified from 10 fetal medicine centers. The recipient was affected in 19 cases, and the lower limb was affected in 17 cases. The extent of the damage correlated with TTTS severity. Eighty percent of limb defects (16/20) clearly were unrelated to laser treatment (3 cases untreated, 7 cases after amnioreduction, 6 cases present at time of laser). The recipient was relatively polycythemic in 5 of 7 cases in which neonatal or fetal hemoglobin/hematocrit levels were available., Conclusion: Ischemic limb necrosis is a rare complication of TTTS. The lesion is unrelated to therapy and may be the result of polycythemia, hypertension, and vasoconstriction., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Skin cancers represent the most common primary malignancies of the hand. They typically present as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. The most common malignancy is squamous cell carcinoma, followed by basal cell carcinoma and melanoma. The key to successful treatment is early and accurate diagnosis and treatment. Unlike open biopsies, which are indicated for deep soft tissue and bone lesions, biopsies for skin cancer can be performed under local anesthesia in the office setting in the form of shave or punch biopsies. A number of nonsurgical treatment options are available for treatment. However, when surgical excision is indicated, appropriate margin resections are dictated by the grade and stage of the malignancy., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Aim: A lack of consistency in the definition of breast cancer related lymphoedema (BCRL) and of uniform measurement criteria contribute to the wide prevalence range found in current literature. This report aims to describe the long-term prevalence of BCRL and secondly, to compare the long-term prevalence of BCRL when assessed by two objective measures and one subjective measure., Methods: The upper-limbs of 145 post-surgical breast cancer patients were evaluated for the presence of lymphoedema using the water displacement method. Two circumference methods and patient perceived swelling were applied secondarily for comparison. Limb measurements were performed once, more than five years after surgery., Results: The long-term prevalence of BCRL using water displacement was 8%. Prevalence varied when the sum of arm circumference (SOAC), the arm circumference and the self-report methods were used: 16, 31 and 17% [P < 0.001], respectively. Of the women identified with BCRL using the water displacement technique, 82% were detected with the SOAC method, 82% with the arm circumference method and 91% by self-report. Using water displacement as the gold standard the methods with the highest specificities were the SOAC (90%) and self-report method (89%), arm circumference resulted in a low specificity of 73%., Conclusion: The prevalence of BCRL more than five years after surgical treatment differs depending on the measuring method used. Our data underlines the necessity for consensus on the diagnostic criteria for BCRL., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Treatment of giant lymphoedema remains very difficult. The main problem is not only the obtention of early postoperative favorable results but to keep them long-lasting. The available treatment options are numerous and often combined. The indications have to be adapted to the clinical stage of the lesion. Ligasure(®) give us many advantages in the achievement of the surgical resection due to the quality of the lymphostasis that can be obtained and to the very limited thermic lesions caused to tissues. Long lasting postoperative physiotherapy is of first importance. We here describe a case of a giant lymphoedema of the upper limb after axillary lymph node dissection for breast cancer. The first physiotherapy failed, causing a lymphatic decompensation resulting in a lymphoedematous mass of nearly 7kg. The surgical resection with Ligasure(®) associated to drainage and compressive physiotherapy in the long run allows to obtain good results. The late follow-up after 4 years still shows stable results., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: Patients with hereditary spastic paraplegia (HSP) show pathological findings when transcranial magnetic stimulation (TMS) is used to test corticospinal projections to the lower limbs. However, TMS studies on the pathways to the upper limbs revealed inconsistent results. Standard clinical TMS procedures are not well suited for testing axonal integrity, which is thought to be affected in HSP. More appropriate measures can be achieved by testing corticospinal projections with the triple stimulation technique (TST)., Methods: TST was used to test axonal integrity of corticospinal projections to the upper limbs in 15 patients with pure HSP (13 of whom were tested positive for SPG 4) and 15 healthy control subjects., Results: TST measurements revealed normal values for corticospinal transmission in all 15 patients with pure HSP, as well as in all healthy control subjects. No differences between groups could be found., Conclusions: Axonal integrity of projections to the upper limbs is unimpaired in patients with pure HSP. The pathological mechanisms leading to spasticity and motor disability seem to be restricted to those fibres of the corticospinal pathways projecting to the lower limbs., Significance: Abnormal corticospinal function to the upper limbs seems to be incompatible with pure HSP., (Copyright © 2010 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand., (Copyright © 2010. Published by Elsevier Inc.)

Barraquer-Simons syndrome is a rare disorder characterized by a partial lipodystrophy. It is often associated with positive C3 nephritic factor and various glomerular nephropathy. Its association with some autoimmune diseases has also been reported. We report a 30-year-old woman with partial lipodystrophy, lupus erythematosus, hypothyroidism and vitiligo., (Copyright 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Background & Aims: Determine the accuracy of body density (Db) estimated with upper-body skinfold thickness (SFT) measurements compared to air-displacement plethysmography (ADP) and ascertain whether body mass index (BMI) impacts the accuracy of SFT to assess Db., Methods: We estimated Db with SFT and ADP in 131 healthy men and women with normal (N; 18.5-24.9kg/m(2)), overweight (OW; 25-29.9kg/m(2)), and obese (OB; 30-39.9kg/m(2)) BMI., Results: Compared with ADP, SFT overestimated (p<0.05) Db in OW and OB females and in OB males (-0.0047, -0.0164 and -0.0119g/cc, respectively), and underestimated (p<0.05) Db in N females and males (0.0050 and 0.0068g/cc, respectively) but did not differently estimate Db in OW males. The gender by BMI group interaction was not significant. SFT underestimated (p<0.05; 0.0058g/cc) Db in the N and overestimated (p<0.05; 0.0113g/cc) Db in the OB BMI groups. The error in predicting Db did not change significantly over the range of Db within the N (r=0.239, p=0.06) and OB (r=0.160, p=0.934) BMI groups. Limits of agreement were -0.0165 to 0.0284g/cc and -0.0365 to 0.0085g/cc for the N and OB BMI groups, respectively. The error of estimating Db with SFT was correlated with mean Db in the aggregate sample (r=0.495, p<0.0001) and the OW group (r=0.394, p<0.009). The regression-based limits of agreement were +/-0.0226g/cc in the total group and +/-0.0168g/cc in the OW group., Conclusions: Although SFT offer practical advantages, the validity of SFT to estimate Db among individuals with N and OB BMI is adversely affected., (Copyright 2009. Published by Elsevier Ltd.)

Adverse reactions following BCG vaccination are uncommon, with an estimated prevalance of 0.4 per 1000 vaccines [Lotte A, Wasz-Hockert O, Poisson N, et al. Second IUATLD study on complications induced by intradermal BCG vaccination. Bull Int Union Tuber 1988;63:47-59]. Complications include erythema, blistering, abscess formation, regional lymphadenitis and keloid formation. The onset of cutaneous tuberculosis (TB) has also been reported. We describe the case of 12-year-old girl who developed extensive primary ulceration involving most of her left upper arm at the site of a BCG vaccination. A skin graft to the arm failed to take at the periphery and the ulcerated area increased to involve most of the upper lateral arm. Over a period of 18 months, secondary lesions developed on her forehead prompting further investigation of a systemic disease process. Following extensive immunological and microbiological examination, a diagnosis of vaccine-induced granulomatous vasculitis was made and the patient responded to a combination of antituberculous therapy and steroids. Once the disease process was under control, skin grafting of the ulcerated area was successful in achieving wound closure. Non-healing ulceration may be referred to the plastic surgeon and a diagnosis of vasculitis should be considered in difficult cases. A multidisciplinary team approach involving immunologists, dermatologists and plastic surgeons provides the best opportunity for a successful long-term outcome in terms of disease control as well as immediate skin cover.

Background: Tophaceous gout is frequently directly related to the duration and the severity of hyperuricaemia. Conventional surgical debridement of the tophaceous lesions carries the risk of overlying skin necrosis. Life-long urate-lowering drugs have become the mainstay of primary treatment. However, surgical intervention may be necessary when the overlying skin becomes ulcerated and wound infection develops. This has become the impetus for new surgical treatment methods with less potential for morbidity., Methods: From November 2000 to July 2006, 32 patients with chronic tophaceous deposits involving their hands or elbows were treated surgically in our hospital. In this series, a soft tissue shaver device with a mini-incision technique was used to treat upper extremity tophaceous lesions. Multiple 5-mm skin incisions were made to allow direct access to the tophaceous mass. Intra-lesion shaving was done. A tourniquet aided reduction of intraoperative blood loss. Suction and irrigation were performed simultaneously while the shaver system was operating; the chalky deposits of sodium urate were thereby removed efficiently., Results: No major complications were noted among these 32 patients. Using this shaver technique, each tophaceous lesion was removed in less than 15 min. Twenty-nine of these operations (80.6%) were performed for patients at the intercritical gout phase. Two patients suffered a recurrent acute attack of gouty arthritis within 12h after the operation. Symptoms were controlled by oral colchicine as well as nonsteroidal anti-inflammatory drugs (NSAID). Swelling at the operative site was usually evident for the first 10 days postoperatively, therefore posture drainage is advised., Conclusion: The shaver technique provides another option in the surgical treatment of tophaceous lesions. It prevents poor wound healing associated with tendon or joint exposure that often occurs after conventional enucleating procedures. The tophaceous lesions can be treated surgically at the intercritical gout phase. Also, the upper extremity group has a shorter hospitalisation period when compared with our preliminary study involving treatment of tophaceous deposits in the lower extremity. The shaver technique is worthy of consideration in the treatment of upper extremity chronic tophaceous patients.

Objective: The aim of this multicentric study was to multidimensionally evaluate the relationship among somatosensory evoked potentials (SEPs) parameters, patient's perspective and clinical measures of the upper limb impairment in patients with multiple sclerosis (MS)., Methods: We consecutively enrolled 39 MS patients. For median nerve SEPs we acquired the N9, P14, N20 responses and the N9-P14 and P14-N20 interpeak latencies on the dominant side. We also used a validated patient-oriented questionnaire (Disabilities of the Arm, Shoulder and Hand - DASH) and a test of dexterity quantification as the 9-Hole Peg Test (9-HPT)., Results: A significant longer time to complete the 9-HPT (p<0.00006) was observed in patients with abnormal SEPs. Patients with undetectable N20 or P14 responses performed the 9-HPT in a significant longer time than patients with detectable responses (p<0.0006 and p<0.001 respectively). Concerning the perspective of patient (evaluated with the DASH questionnaire) significant differences in patients with undetectable P14 response (p<0.01) were observed., Conclusions: Our data provide further information useful for interpretation of SEPs results, being the median nerve SEPs related to the upper limb performance in MS patients., Significance: These data increase the significance of SEPs both in clinical practice and in experimental studies in MS.

The authors herein describe a case of multifocal peripheral neuropathy with HTLV-I-associated myelopathy (HAM) in a patient with chronic adult T-cell leukemia (ATL). The clinical features included subacute progressive sensory-motor neuropathy in the bilateral upper limbs, and bilateral pyramidal tract involvement with bladder dysfunction. An MRI with (67)gadolinium enhancement revealed enlargement of the affected peripheral nerves. (8)FDG positron emission tomography (PET) disclosed increased uptake in the affected nerves, suggesting neurolymphomatosis or inflammation. Anti-HTLV-I antibody was positive in both the serum and CSF. The HTLV-I proviral load in the peripheral blood mononuclear cells was high. Chemotherapy for ATL resulted in marked improvement of motor functions in the upper limbs. This is the first case of multifocal upper limb neuropathy with HAM in a patient with chronic ATL.

We report a male patient with Hirayama disease aged 13. The disease was insidiously progressive and he had severe disability of the right hand at presentation. He had muscular atrophy in the intrinsic muscles of the right hand and in the distal muscles of the right forearm. The atrophy was pronounced on the ulnar side. Cold paresis was also noticed. There was no sensory disturbance. On Electromyography, neurogenic changes were recorded in several atrophic muscles. Motor and sensory nerve conduction was normal. MR images of the spinal cord were normal when it was performed with a conventional method (i.e., without neck flexion). However, characteristic MR findings were obtained when the patient lay with maximum neck flexion. The posterior wall of the cervical dural canal was shifted anteriorly at the C3-7 vertebral level, which caused cord compression at the lower cervical spinal canal. The epidural space was crescent-shaped and showed high signal intensity on T2-weighted imaging. These clinical features are typical of Hirayama disease. Pediatrician should be aware of this disease and treat it as soon as possible in order to prevent progression of the atrophy.

Aims: To evaluate the generic and condition-specific health-related quality of life (HRQL) of long-term survivors of extremity melanoma treated with isolated limb perfusion (ILP)., Methods: Between 1978 and 2001, 292 patients with melanoma of the limbs underwent ILP in our institution. Of these patients, 59 were alive and disease-free for at least six months prior to study entry. Fifty-one of these 59 patients completed a mailed questionnaire assessing generic HRQL (SF-36), condition-specific HRQL (limb function, cosmetic results, fear of recurrence), and problems regarding work and insurance. An age- and gender-matched, normative sample of the Dutch general population was available for comparison of SF-36 scores., Results: Mean age of patients was 57 years, 90% female, with a median time since ILP of 14 years (range 3-25 years). The SF-36 scores of the patient group were equal to or better than that of the general population, significantly for bodily pain, general health perceptions, and the physical and mental health component scores. Nevertheless, the patients reported a number of specific problems: complaints of limb function were reported by 49-55%, cosmetic problems by 31-38% and fear of local disease recurrence and distant metastases by 77 and 63% of the patients, respectively. Less than 10% of patients reported problems in obtaining a mortgage or life insurance., Conclusions: The HRQL of long-term survivors of melanoma treated with ILP appears comparable to, and sometimes better than that of healthy peers within the general population. Nevertheless, this survivor group reports a number of specific problems that impact on daily life. Although these findings need to be confirmed with larger, prospective studies, they suggest that rehabilitation should focus on improving limb functionality, and addressing chronic fear of disease recurrence.

Cutaneous metastatic breast carcinoma involving the hand is extremely rare. We report a case of a 39-year-old woman with a history of recurrent invasive ductal adenocarcinoma of the breast who had a right modified radical mastectomy, chemotherapy, and radiation therapy before presenting to our institution with extensive cutaneous metastasis to the upper limb including the hand. The presentation, pathogenesis, incidence, prognosis, management, and differential diagnosis of cutaneous metastatic breast carcinoma to the hand and upper limb are discussed.

Pyogenic granuloma is a common, acquired, benign vascular lesion of skin and mucous membranes which may occasionally present intravascularly or subcutaneously. Pyogenic granuloma occur in all age groups and although they may eventually regress, removal of unsightly, bleeding or uncomfortably positioned lesions is usually sought before this takes place. This is a retrospective study of 408 cases of pyogenic granuloma that were analysed by the Stoke Mandeville Histopathology laboratory between 1994 and 2004. This study was carried out to review the sex, age and anatomic distribution of the lesions and to assess the most successful form of treatment on the basis of recurrence risk and other measures such as aesthetic result, acceptability and appropriateness of the procedure with respect to the patient. There was a slight male preponderance especially among children. The exception to this was lesions on mucous membranes, which were more common in women. Head and neck was the most common anatomical location, in particular the cheek and intraoral locations. Fewest recurrences were noted following excision and direct closure although all techniques investigated showed an acceptably low recurrence rate. Whatever technique is used it must yield material for histopathological analysis to ensure the exclusion of differential diagnoses.

Background: In a prospective study, long term upper-limb morbidity, perceived disabilities in activities of daily life (ADL) and quality of life (QOL) were assessed before and 2 years after sentinel lymph node biopsy (SLNB) or axillary lymph node dissections (ALND) for breast cancer., Methods: Two hundred and four patients with stage I/II breast cancer, mean age 55.6 years (SD: 11.6) entered the study and 181 patients (89%) could be evaluated after 2 years. Fifty-seven patients underwent SLNB (31%) and 124 patients underwent an ALND (69%). Assessments included pain, shoulder range of motion, muscle strength, arm volume, perceived shoulder disability in ADL and QOL., Results: Significant (P<0.05) changes between before and 2 years after surgery were found in almost all assessments of shoulder function, ADL and several QOL subscales. Patients in the ALND group showed significant more changes in range of motion (ROM), grip strength, arm volume, ADL and QOL physical- and role functioning, pain and sleeplessness and arm symptoms compared to the SLNB group. Multivariate linear regression analysis showed that ALND could predict decrease of ROM, grip strength, ADL and physical functioning (QOL) and increase of arm volume, pain and arm symptoms score (QOL). Radiation on the axilla predicts an additional decrease in shoulder ROM and increase of arm volume., Conclusion: Two years after surgery for breast cancer, patients show significantly less treatment related upper limb morbidity, perceived disability in ADL and worsening of QOL after SLNB compared with ALND.