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Case/Program Description:
Case 1: A 53-year-old woman with pre-
vious left calf DVT 12 years ago presented with disabling burning
pain with paresthesias and allodynia in left medial calf region for 2
years, initially diagnosed as chronic regional pain syndrome (RSD).
The pain was associated with petechial rash in that area. Her
symptoms exacerbate with physical exertion and cold weather. Exam
is notable for a petechial rash from mid-calf to foot, erythema,
extreme sensitivity to palpation and bilateral ankle pitting edema
fluctuating between 1+ and 3+. Skin biopsy showed severe stasis
dermatitis. She had minimal pain relief with pharmacological
treatment with the best response resulting from a combination of
minacipram and pregabalin. Case 2: A 49-year-old woman with a
prior history of bariatric surgery 10 years ago, cervical radiculop-
athy, and depression presented with chronic severe pain in both
hands that began 4 years ago without any initiating event. The pain
is constant and aggravated by physical contact, activity and cold
weather. She is dependent on others for ADL. The initial diagnosis
was chronic RSD with associated Raynaud’s phenomenon. She failed
multiple treatments including physical and occupational therapy,
cognitive-behavioral therapy, dedicated desensitization training,
sympathetic blocks, spinal cord stimulation. Pharmacological treat-
ment had failed including a recent trial of pregabalin. She has been
referred to interventional pain team for consideration of a pulsed
RFA Stellate ganglion block.
Setting:
Outpatient Rehabilitation Clinic.
Results:
The diagnosis of erythromelalgia was made in both cases on
the basis of clinical findings and inconsistent work up relating to RSD.
Discussion:
Erythromelalgia is a rare clinic disease and its clinical
presentation is similar to RSD.
Conclusions:
Physiatrists who encounter chronic pain might consider
this diagnosis in a patient where symptoms, findings and treatment
response related to a diagnosis of RSD are atypical.
Level of Evidence:
Level V
Poster 239:
Atypical Presentation of Dystonia of Right Upper
Extremity Treated with Botulinum Toxin: A Case Report
Kathelynn Aviles (San Juan, San Juan, Puerto Rico), Jose R. Cumba,
MD, Keryl Motta-Valencia, MD
Disclosures:
Kathelynn Aviles: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
This is a 27-year-old patient with history
of right upper extremity trauma with suprascapular and brachial
plexus injury who presented (3 yrs after trauma) with right hand
swelling, discoloration, paresthesia, and flexed 4th and 5th digits. The
patient was initially diagnosed with ulnar nerve pathology and was
scheduled for an ulnar nerve decompression. However, upon evalua-
tion by our service there were no objective findings on EDX, MRI or US
to support an ulnar injury. In addition, the presence of active auto-
nomic symptoms including bluish discoloration, swelling, and changes
in temperature led to explore other etiologies. Bone scan and upper
extremity Doppler ultrasound were done and reported with normal
findings. Final diagnostic impression by exclusion of other diagnosis
was suggestive of right hand dystonia. He was scheduled for a trial of
botulinum toxin type A (Botox) injections. Procedure was performed to
intrinsic and flexor muscles of 4th and 5th digits with electromyog-
raphy assistance.
Setting:
Tertiary care hospital.
Results:
One week after procedure there was a reduction in the
autonomic output, increased coordination for opening hand and while
writing, and a decrement on intrinsic hand tone (hypothenars) at rest
and during activity. Improvement of symptoms were observed on 3-
week follow up and sustained at 2 months follow up.
Discussion:
To our knowledge, this is the first reported case of hand
atypical dystonia presenting as ulnar nerve pathology with marked
autonomic symptoms responsive to botulinum toxin injection.
Conclusions:
In a context of suspected ulnar nerve pathology not
confirmed by objective studies, other etiologies such as dystonia
should be considered. The use of botulinum toxin conveyed diagnostic
and therapeutic advantages to successfully revert symptomatology
such as correction of writing and resolution of autonomic symptoms.
Level of Evidence:
Level V
Poster 240:
Atypical Cause of Shoulder Pain in a Collegiate
Softball Player: A Case Report
Michael J. Slesinski, DO (MI State Univ), Mathew Saffarian, DO
Disclosures:
Michael Slesinski: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 20-year-old female Division I collegiate
softball player. The patient presented with left shoulder pain. No
injury prior to onset of pain. The left shoulder pain started 1 year ago
with “catching” in the left subscapular region, which was worse with
throwing activities and “overuse.” A focused physical exam of the left
shoulder was normal, except there was snapping of the left posterior
shoulder with abduction, which reproduced the pain in the scap-
ulothoracic region. MRI left scapula demonstrated 8 mm circumscribed
T2 hyperintense lesion within the medial aspect of the scapular body
at the level of the posterior fourth rib. Components of the lesion
extend beyond the ventral and dorsal cortical margins. Then, a CT scan
of the left upper extremity showed a 13 mm lucent lesion within the
medial scapular body, mildly expansile, with a thin rim of cortical bone
surrounding the anterior and posterior margins of the lesion. Finally, a
whole body bone scan was performed and was normal. The patient was
referred to an orthopedic oncologist.
Setting:
Outpatient Academic Clinic.
Results:
The patient was diagnosed with left snapping scapula syn-
drome due to a scapular enchondroma. After discussion with an or-
thopedic oncologist, she decided to continue with conservative
management. She continues to play softball with some pain, which is
tolerable. She had two ultrasound-guided scapulothoracic bursa in-
jections over a period of 6 months.
Discussion:
A medial scapular enchondroma is an atypical cause of
snapping scapula syndrome. Enchondromas account for approximately
10% of all benign osseous tumors. The most common locations are
hands, feet, distal femur, proximal humerus, then tibia. Enchon-
dromas are rare in the scapula, pelvis and ribs; enchondromas in these
rare areas should warrant further evaluation for chondrosarcoma.
Conclusions:
Scapular enchondroma is a rare cause of snapping
scapula syndrome. A scapular enchondroma should be evaluated for
chondrosarcoma.
Level of Evidence:
Level V
Poster 241:
Integrating Plastics and PM&R using Electromyography
and Ultrasound after Free Gracilis Transfer to Forearm:
A Case Report
Cole R. Linville, DO, MBA (Univ of TX-UT Houston, Houston, Texas,
United States), Cain R.R. Linville, MD, Faye Chiou-Tan, MD
Disclosures:
Cole Linville: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 26-year-old, previously healthy man
status post motor vehicle accident who sustained a left shoulder
injury. Previous nerve conduction study and electromyography showed
left brachial panplexopathy, proximal to innervation of the serratus
anterior with no motor recruitment. The patient then underwent
exploration and neurolysis of left brachial plexus, harvesting of left
sural nerve and nerve graft/anastomosis of left spinal accessory nerve
to left lateral cord with good shoulder function but no elbow function.
EMG after showed evidence of motor activity in proximal left shoulder
muscles but absent distally. The patient then underwent left free
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Abstracts / PM R 9 (2017) S131-S290