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Poster 72: Entrapment of the Ulnar Nerve at the Exit of the Flexor Carpi Ulnaris in a Patient With Bilateral Martin-Gruber Anastomosis: A Case Report
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ACADEMY ANNUAL ASSEMBLY ABSTRACTS
usually affects sensory nerves more than motor nerves. The peripheral neuropathy, which typically does not occur early in the course of SLE, may be due to vasculopathy of the small arteries supplying the affected nerves. Conclusions: The physiatrist should be made aware that a severe peripheral neuropathy may occur early and should be kept in mind as part of the neurologic spectrum in SLE. Key Words: Electromyography; Erythematosus, systemic lupus; Peripheral neuropathies; Rehabilitation. Poster 71 Neuralgic Amyotrophy Affecting Only the Pronator Teres and the Muscles of the Posterior Interosseous Nerve: A Case Report. Kelly Logan, DO (UW Hospitals and Clinics, Madison, Middleton, WI); Bonnie Weigert, MD; Andrew Waclawik, MD; Franz J. Macedo, DO; Eric Kozfkay, DO. Disclosure: K. Logan, None; B. Weigert, None; A. Waclawik, None; F.J. Macedo, None; E. Kozfkay, None. Setting: University hospital, outpatient clinic. Patient: A 45-yearold man with acute onset of left elbow pain and progressive weakness of the left upper extremity causing significant debilitation. Case Description: The patient presented for neuromuscular evaluation after 3 months of progressive weakness of the left arm and hand. Primary complaint was excruciating pain about the left elbow, worse with extension and pronation. Within 48 hours of symptoms, he noticed weakness in his hand and wrist. Pain subsided after 2 weeks, but weakness persisted. There was no trauma, but a positive history of recent viral infection. Laboratory work-up and magnetic resonance imaging (MRI) of the left upper extremity was negative. Physical exam and electromyographic findings were consistent with a posterior interosseous neuropathy, axonal and severe; also neurogenic changes in the left pronator teres were consistent with a neuropathic process affecting the median nerve branch. History and clinical and diagnostic exams were consistent with neurogenic amyotrophy affecting the posterior interosseous nerve as well as the median nerve branch to the pronator teres. The patient started a physical therapy protocol. At 6 months there was clinical improvement in overall strength and function. Follow-up MRI was consistent with denervation edema. Repeat electromyography exhibited evidence of ongoing denervation with reinnervation changes present. Assessment/Results: Physical and clinical findings support a diagnosis of neurogenic amyotrophy affecting the posterior interosseous nerve and the median nerve branch to the pronator teres. Discussion: Neuralgic amytrophy is usually localized to the shoulder region, with broad involvement of the brachial plexus commonly following a viral infection. The signs and symptoms are specific to the distribution of the posterior interosseous nerve as well as the median branch supplying the pronator teres. Conclusions: This case documents neuralgic amyotrophy with specific and limited distribution. Steady improvement was noted and the prognosis is very good. Key Words: Electromyography; Neuralgic amyotrophy; Rehabilitation. Poster 72 Entrapment of the Ulnar Nerve at the Exit of the Flexor Carpi Ulnaris in a Patient With Bilateral Martin-Gruber Anastomosis: A Case Report. Christine N. Smith, MD (University of California, Irvine Medical Ctr and Veterans Administration, Long Beach, CA); Rajasekhar V. Kandala, MD; Raghavaiah V. Kanakamedala, MD. Disclosure: C.N. Smith, None; R.V. Kandala, None; R.V. Kanakamedala, None. Setting: Outpatient clinic. Patient: A 54-year-old woman with paresthesias in left fourth and fifth digits for 6 months. Case Arch Phys Med Rehabil Vol 88, September 2007
Description: The patient reported symptoms after frequent use of hand weights. Physical exam was notable for sensory impairment involving the left fourth and fifth digits and hypothenar region. There was no weakness or atrophy of hand and forearm muscles. Left ulnar sensory nerve conduction study (NCS) was normal. Left ulnar motor NCS revealed marked decrease in amplitude over the exit of the nerve from the flexor carpi ulnaris (FCU). Inching of the ulnar nerve revealed a decline in amplitude and an increase in duration of the motor wave at the exit of the FCU. Needle electromyography was normal in the first dorsal interosseous (FDI), FCU, and flexor digitorum profundus (4th, 5th digits). Bilateral median motor NCS to the FDI revealed motor response of large amplitude with stimulation at the elbow and minimal amplitude with stimulation at the wrist. Assessment/Results: NCS and electromyography were consistent with left ulnar nerve entrapment at the exit from the FCU without evidence of axonal injury in a patient with bilateral Martin-Gruber anastomosis. Relevant waveforms will be presented. Magnetic resonance imaging of the left forearm showed no evidence of focal mass. Ulnar nerve entrapment was likely secondary to repetitive trauma between the heads of the FCU muscle. Discussion: This is the first reported case, to our knowledge, of bilateral Martin-Gruber anastomosis and demyelinating ulnar neuropathy at the exit from the FCU without evidence of axonal injury. Conclusions: Electromyography should be performed in ulnar-innervated muscles to document axonal neuropathy at the exit from the FCU. The presence of Martin-Gruber anastomosis should be considered in patients with evidence of ulnar amplitude decline in the upper forearm. Key Words: Electromyography; Rehabilitation; Ulnar neuropathies. Poster 73 A Case of a Lesion of the Left Lower Trunk of the Brachial Plexus After Lifting Heavy Luggage. Ali I. Khawaja, MD (Nassau University Medical Ctr, East Meadow, NY); Ricardo Cruz, MD; Sarah Sheikh, SPT; Adam Isaacson, MD; Lyn Weiss, MD. Disclosure: A.I. Khawaja, None; R. Cruz, None; S. Sheikh, None; A. Isaacson, None; L. Weiss, None. Setting: Electromyography laboratory and outpatient rehabilitation unit. Patient: A 33-year-old right-hand dominant male gastroenterologist. Case Description: The patient was referred for electromyography and nerve conduction testing due to weakness and numbness of the left hand, which started after the patient lifted heavy luggage. He was unable to perform endoscopic procedures, which involved using his left hand. Assessment/Results: No gross deformity or atrophy of the left upperextremity proximal muscles was noted, while mild atrophy of small muscles of the left hand was noted. Strength in the left hand flexors was 4/5 and in the extensors was 3/5. Muscle strength in the proximal muscle groups was 5/5. Right and left hand grips were 40.5kg (9lb) and 6.8kg (15lb), respectively. Range of motion actively and passively in all joints of left upper extremity was preserved. Sensory deficits in the left hand median, ulnar, and radial distribution were noted. Electrodiagnostic studies revealed severe axonotmetic lesion of the lower trunk. Discussion: Our patient suffered from injury to the lower trunk of the brachial plexus. Partial recovery was seen gradually. The patient underwent outpatient rehabilitation and was eventually successful in resuming his practice by changing his method of performing endoscopy. Conclusions: Electrodiagnostic studies after history and physical examination are helpful diagnostic tools to localize, determine extent of injury, and prognosticate the brachial plexus injuries, and should be considered early. Key Words: Brachial plexus; Electromyography; Rehabilitation.
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
usually affects sensory nerves more than motor nerves. The peripheral neuropathy, which typically does not occur early in the course of SLE, may be due to vasculopathy of the small arteries supplying the affected nerves. Conclusions: The physiatrist should be made aware that a severe peripheral neuropathy may occur early and should be kept in mind as part of the neurologic spectrum in SLE. Key Words: Electromyography; Erythematosus, systemic lupus; Peripheral neuropathies; Rehabilitation. Poster 71 Neuralgic Amyotrophy Affecting Only the Pronator Teres and the Muscles of the Posterior Interosseous Nerve: A Case Report. Kelly Logan, DO (UW Hospitals and Clinics, Madison, Middleton, WI); Bonnie Weigert, MD; Andrew Waclawik, MD; Franz J. Macedo, DO; Eric Kozfkay, DO. Disclosure: K. Logan, None; B. Weigert, None; A. Waclawik, None; F.J. Macedo, None; E. Kozfkay, None. Setting: University hospital, outpatient clinic. Patient: A 45-yearold man with acute onset of left elbow pain and progressive weakness of the left upper extremity causing significant debilitation. Case Description: The patient presented for neuromuscular evaluation after 3 months of progressive weakness of the left arm and hand. Primary complaint was excruciating pain about the left elbow, worse with extension and pronation. Within 48 hours of symptoms, he noticed weakness in his hand and wrist. Pain subsided after 2 weeks, but weakness persisted. There was no trauma, but a positive history of recent viral infection. Laboratory work-up and magnetic resonance imaging (MRI) of the left upper extremity was negative. Physical exam and electromyographic findings were consistent with a posterior interosseous neuropathy, axonal and severe; also neurogenic changes in the left pronator teres were consistent with a neuropathic process affecting the median nerve branch. History and clinical and diagnostic exams were consistent with neurogenic amyotrophy affecting the posterior interosseous nerve as well as the median nerve branch to the pronator teres. The patient started a physical therapy protocol. At 6 months there was clinical improvement in overall strength and function. Follow-up MRI was consistent with denervation edema. Repeat electromyography exhibited evidence of ongoing denervation with reinnervation changes present. Assessment/Results: Physical and clinical findings support a diagnosis of neurogenic amyotrophy affecting the posterior interosseous nerve and the median nerve branch to the pronator teres. Discussion: Neuralgic amytrophy is usually localized to the shoulder region, with broad involvement of the brachial plexus commonly following a viral infection. The signs and symptoms are specific to the distribution of the posterior interosseous nerve as well as the median branch supplying the pronator teres. Conclusions: This case documents neuralgic amyotrophy with specific and limited distribution. Steady improvement was noted and the prognosis is very good. Key Words: Electromyography; Neuralgic amyotrophy; Rehabilitation. Poster 72 Entrapment of the Ulnar Nerve at the Exit of the Flexor Carpi Ulnaris in a Patient With Bilateral Martin-Gruber Anastomosis: A Case Report. Christine N. Smith, MD (University of California, Irvine Medical Ctr and Veterans Administration, Long Beach, CA); Rajasekhar V. Kandala, MD; Raghavaiah V. Kanakamedala, MD. Disclosure: C.N. Smith, None; R.V. Kandala, None; R.V. Kanakamedala, None. Setting: Outpatient clinic. Patient: A 54-year-old woman with paresthesias in left fourth and fifth digits for 6 months. Case Arch Phys Med Rehabil Vol 88, September 2007
Description: The patient reported symptoms after frequent use of hand weights. Physical exam was notable for sensory impairment involving the left fourth and fifth digits and hypothenar region. There was no weakness or atrophy of hand and forearm muscles. Left ulnar sensory nerve conduction study (NCS) was normal. Left ulnar motor NCS revealed marked decrease in amplitude over the exit of the nerve from the flexor carpi ulnaris (FCU). Inching of the ulnar nerve revealed a decline in amplitude and an increase in duration of the motor wave at the exit of the FCU. Needle electromyography was normal in the first dorsal interosseous (FDI), FCU, and flexor digitorum profundus (4th, 5th digits). Bilateral median motor NCS to the FDI revealed motor response of large amplitude with stimulation at the elbow and minimal amplitude with stimulation at the wrist. Assessment/Results: NCS and electromyography were consistent with left ulnar nerve entrapment at the exit from the FCU without evidence of axonal injury in a patient with bilateral Martin-Gruber anastomosis. Relevant waveforms will be presented. Magnetic resonance imaging of the left forearm showed no evidence of focal mass. Ulnar nerve entrapment was likely secondary to repetitive trauma between the heads of the FCU muscle. Discussion: This is the first reported case, to our knowledge, of bilateral Martin-Gruber anastomosis and demyelinating ulnar neuropathy at the exit from the FCU without evidence of axonal injury. Conclusions: Electromyography should be performed in ulnar-innervated muscles to document axonal neuropathy at the exit from the FCU. The presence of Martin-Gruber anastomosis should be considered in patients with evidence of ulnar amplitude decline in the upper forearm. Key Words: Electromyography; Rehabilitation; Ulnar neuropathies. Poster 73 A Case of a Lesion of the Left Lower Trunk of the Brachial Plexus After Lifting Heavy Luggage. Ali I. Khawaja, MD (Nassau University Medical Ctr, East Meadow, NY); Ricardo Cruz, MD; Sarah Sheikh, SPT; Adam Isaacson, MD; Lyn Weiss, MD. Disclosure: A.I. Khawaja, None; R. Cruz, None; S. Sheikh, None; A. Isaacson, None; L. Weiss, None. Setting: Electromyography laboratory and outpatient rehabilitation unit. Patient: A 33-year-old right-hand dominant male gastroenterologist. Case Description: The patient was referred for electromyography and nerve conduction testing due to weakness and numbness of the left hand, which started after the patient lifted heavy luggage. He was unable to perform endoscopic procedures, which involved using his left hand. Assessment/Results: No gross deformity or atrophy of the left upperextremity proximal muscles was noted, while mild atrophy of small muscles of the left hand was noted. Strength in the left hand flexors was 4/5 and in the extensors was 3/5. Muscle strength in the proximal muscle groups was 5/5. Right and left hand grips were 40.5kg (9lb) and 6.8kg (15lb), respectively. Range of motion actively and passively in all joints of left upper extremity was preserved. Sensory deficits in the left hand median, ulnar, and radial distribution were noted. Electrodiagnostic studies revealed severe axonotmetic lesion of the lower trunk. Discussion: Our patient suffered from injury to the lower trunk of the brachial plexus. Partial recovery was seen gradually. The patient underwent outpatient rehabilitation and was eventually successful in resuming his practice by changing his method of performing endoscopy. Conclusions: Electrodiagnostic studies after history and physical examination are helpful diagnostic tools to localize, determine extent of injury, and prognosticate the brachial plexus injuries, and should be considered early. Key Words: Brachial plexus; Electromyography; Rehabilitation.