S207 S290
Poster 235:
Refractory Right Triceps Calcific Tendinopathy
Treated with Ultrasound Guided Needle Barbotage
and Lavage: A Case Report and Review of the
Literature
Philip Chang (New York, NY, USA), Richard G. Chang, MD, MPH,
Jeffrey Okada, MD (The orthopedic c. association, DO)
Disclosures:
Philip Chang: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 35-year-old right-handed male bus
driver presented with a 6-month history of persistent posterior right
elbow pain refractory to Tylenol, NSAIDs, and physical therapy. His
injury started when performing a triceps curl. He developed immedi-
ate pain and heard a popping sound but had no swelling or ecchymosis.
X-rays revealed calcific tendinitis of the right triceps insertion. Ul-
trasound confirmed calcification of the distal triceps and tendinopathy
with changes secondary to a chronic distal insertion tear. His symp-
toms prevented him from upper extremity weight lifting and driving
without discomfort. The procedure was performed with a 19 gauge 1.5
inch needle and 1% lidocaine. Small calcific fragments were noted
upon aspiration. The patient refrained from weight bearing activities
and performed ROM exercises for 1 week. Thereafter, he started
physical therapy, focusing on eccentric strengthening and cryo-
therapy. After 2 weeks he reported 20% relief. Four weeks later, the
patient underwent the same procedure, with the goal of providing
further improved pain relief and function. The procedure was
repeated, but instead an 18 gauge 1.5-inch needle was used. The re-
gion was lavaged with 1% lidocaine and aspiration yielded a sizable
calcified fragment compared to the last visit.
Setting:
Sports and Musculoskeletal Medicine Clinic.
Results:
At 1 week and 1 month follow-up the patient reported 85%
improvement in pain. He could engage in weight lifting activities,
drive, and place his elbow on hard surfaces without pain.
Discussion:
To our knowledge, there is only one other reported case
of triceps calcific tendinopathy successfully treated with ultrasound
guided needle barbotage and lavage.
Conclusions:
Similar to results found in calcific rotator cuff and
lateral/medial extensor tendinosis, US guided needle barbotage,
lavage, and aspiration may potentially provide positive outcomes for
chronic, calcific tendinopathy affecting the triceps tendon, unre-
sponsive to nonsurgical treatment.
Level of Evidence:
Level V
Poster 236:
Sensorimotor Polyneuropathy in a Patient with
Copper Deficiency: A Case Report
Ajaya T. Moturu, MD (Vidant Rehab Ctr/East Carolina Univ/Brod)
Disclosures:
Ajaya Moturu: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 66-year-old woman initially presented
with recurrent falls and right upper and lower extremity weakness and
inability to walk for 24 hours. On exam patient was found to have 2/5
strength in the proximal right lower extremity, 2/5 strength throughout
the right upper extremity and also found to have a right wrist drop.
Patient was admittedwith concern for stroke however work up including
magnetic resonance imaging was negative for any acute abnormality.
Electromyography of the upper extremity showed findings consistent
with sensorimotor polyneuropathy. Patient had a history of gastric
bypass 8 years prior and has been compliant with vitamin therapy since
her surgery. Extensive vitamin workup was done and patient was found
to have severe copper deficiency with a level of 42. The patient was
started on intravenous copper replacement. At time of discharge pa-
tient was able to regain right upper and lower extremity movement.
Setting:
General Inpatient Rehabilitation Center.
Results:
Patient received 5 days of intravenous copper replacement
and was then continued on long term oral copper replacement. With
intensive rehabilitation patient regained complete movement in the
right lower extremity and had significant improvement in the right
upper extremity with some residual right wrist drop.
Discussion:
There have been other case reports showing evidence of
copper deficiency presenting similar to B12 deficiency. The exact mech-
anism for this is not well understood; it is thought that copper deficiency
leads to neuropathy due to its critical involvement in several enzymes
that are critical for nervous system functioning. Enzymes include pepti-
dylglycine alpha-amidating monooxygenase for neuropeptide hormone
processing and ceruloplasmin for brain iron homeostasis.
Conclusions:
Vitamin deficiencies are commonly seen in patients shortly
after gastric bypass and continue to be possible even in compliant pa-
tients post-operatively and can lead to significant neurological dysfunc-
tion which can show improvement with vitamin repletion.
Level of Evidence:
Level V
Poster 237:
Superficial Thrombophlebitis of the Wrist Presenting
as a Ganglion Cyst: A Case Report
Michael Schaefer, MD (Cleveland Clinic Foundation), Ana M. Garcia,
MD, Jose A. Rosa Padilla, MD
Disclosures:
Michael Schaefer, MD: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 46-year-oldwomanwith history of DM type
2, HTN and bilateral carpal tunnel syndrome (CTS) presented with a 3-
monthhistory of a painful, progressively growingmass over the volar aspect
of her dominant right wrist. She denied any inciting event such as trauma
associated. On examination a tender and mobile superficial nodule was
palpated on the volar aspect of the right wrist. There was moderate limi-
tation in the range of motion of thewrist with pain at the end range of wrist
flexion. Neurovascular examwas intact. A ganglion cyst was suspected and
she was referred to our clinic for ultrasound-guided cyst aspiration. Ul-
trasound evaluation was performed prior to the procedure showing a very
small, less than 0.5cm indiameter, hyperechoic and non-compressible area
within a fusiformdilation of a superficial vein. The lesionwas located in the
subcutaneous layer and superficial to the radial artery and correlated with
thepatient’s areaof tenderness. Findingswereconsistentwitha superficial
vein thrombosis. No ganglion cyst was detected.
Setting:
Outpatient Rehabilitation Clinic.
Results:
The lesion persisted despite conservative management.
Discussion:
Ganglion cysts are the most frequent benign tumors in
wrist and hand. The clinical presentation of a ganglion cyst can be
similar to other etiologies such as superficial thrombophlebitis. Other
lesions such as malignancies, abscesses, tendon lacerations, and
foreign body reactions should be considered. Ultrasonography is an
inexpensive and non-invasive method of assessing the soft tissue and
can help differentiate these conditions.
Conclusions:
Performing an ultrasonographic assessment of the wrist
is helpful to assist in the evaluation of soft tissue lesions, especially
before interventional procedures. The information obtained can
significantly influence the appropriate management and treatment.
Superficial vein thrombosis should be considered in the differential
diagnosis for soft tissue masses.
Level of Evidence:
Level V
Poster 238:
Eyrthromelalgia Case Series - Diagnostic and
Treatment Challenges
Neel Chandel, MD (Montefiore Medical Center, Bronx, New York,
United States), Mark A. Thomas, MD
Disclosures:
Neel Chandel, MD: I Have No Relevant Financial Re-
lationships To Disclose
S207
Abstracts / PM R 9 (2017) S131-S290