S214 S290
Results:
Differential diagnosis included compression of the radial nerve,
superficial radial nerve, lateral cutaneous nerve of the forearm and
common extensor tendinopathy. Electrodiagnostic evaluations of the
radial sensory and motor nerves as well as the lateral cutaneous nerve of
the forearm were unremarkable bilaterally. Musculoskeletal ultrasound
evaluation identified a well-defined unilobular hypoechoic cyst measuring
approximately 2.05 cm 1.6 cm on the anterolateral aspect of the elbow
joint, causing compression of the identified radial nerve at the elbow prior
to its bifurcation into its deep and superficial branches. Patient underwent
ultrasound-guided cyst aspiration of 2.5 mL of serous fluid with notable
immediate resolution of pressure sensation and sensory symptoms.
Discussion:
This is an atypical case of an elbow cyst causing radial
nerve compression neuropathy presenting with neurologic distribution
other than the typical changes at the radial dorsum of hand, or sig-
nificant wrist extensor weakness. As previously reported in literature,
improvements of symptoms were achieved with ambulatory procedure
such as ultrasound-guided aspiration.
Conclusions:
Anterior elbow cysts may cause radial nerve entrapment
neuropathy and could present with atypical sensory symptomatology;
however, these may be safely treated in ambulatory setting.
Level of Evidence:
Level V
Poster 258:
Limbus Vertebra, A True Cause of Chronic Back Pain?
Yonghoon Lee, MD (Albert Einstein Col of Med, Bronx, NY, United
States), Eathar Saad, MD
Disclosures:
Yonghoon Lee, MD: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 27-year-old man presented with inter-
mittent left sided paralumbar pain over 2 years. The onset of the lower
back pain was unrelated to recent or distant injury. The pain was
reproducible with lumbar flexion, not responsive to NSAID treatment,
and was not associated paresthesia. The initial lumbar x-ray showed an
anterior limbus vertebra at L4 level. Subsequently MRI revealed an
anterior limbus vertebra (ALV) at L4 with bulging discs at L2-L3, L3-L4,
L5-S1, a slight foraminal narrowing at L3-L4, and a spinal canal nar-
rowing at L5-S1 level without spinal cord compression. The patient was
initiated with conservative management including physical therapy.
Setting:
Adult general rehabilitation outpatient clinic.
Results:
The physical therapy only helped with minimal pain relief.
Discussion:
Limbus vertebra is produced by injury to immature vertebral
body leading to a marginal intra-vertebral body herniation of nucleus pul-
posus material around a separated triangular bone segment. Its pathogen-
esis is related to Scheuermann’s disease, which usually coexists. The clinical
significance of ALV has been increasingly debatable. Some studies consid-
ered ALV as an incidental finding. A recent discussion noted ALV was found
mostly in symptomatic patients. Also, the relationship between interver-
tebral disc degeneration (IDD) and ALV were discussed, suggesting ALV as a
predictor for IDD in athletes. The intradiscal pathology could cause a
disturbance in spine biomechanics and increase stress on adjacent struc-
tureswithassociatedpain. However, asystemic reviewonMRI findings of IDD
failed to suggested lower back pain is attributable to underlying pathology.
Conclusions:
The direct clinical role of ALV still remain unclear but its
presence in the setting of lower back pain warrants a CT or MRI study
to evaluate adjacent structures. This case is interesting for the pre-
sentation of chronic back pain with simultaneous radiographic findings
of ALV and IDD, while the true cause of the pain remains debatable.
Level of Evidence:
Level V
Poster 259:
Occult Hip Fracture: A Case Report
Isaac P. Syrop, MD (NY Presby Hosp/Columbia/Cornell, Chappaqua,
NY, United States), George C. Christolias, MD
Disclosures:
Isaac Syrop: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
An 81-year-old man, with a pertinent his-
tory of osteoporosis, presents to an outpatient physiatrist with right hip
pain. His right hip pain began 3 weeks prior with no inciting event. As time
elapsed his pain worsened, associated with a marked decline in function.
Upon presentation, physical examination is pertinent for severe painwith
ROM of the right hip. Manual muscle testing shows 5/5 strength
throughout, except 3/5 in right hip flexion and knee extension, limited by
pain. He is unable to ambulate secondary to pain. Given the patient’s
tremendous functional limitations and lack of home supervision, he is sent
to the emergency department.While in the emergency department, plain
films of the lumbar spine, pelvis, and right hip are performed. Imaging is
only notable for mild osteoarthritis and the patient is admitted to the
hospital for further workup. Physiatry is consulted to assess for an ultra-
sound-guided right hip corticosteroid injection to treat suspected oste-
oarthritis. Upon reassessment by physiatry, osteoarthritis is thought
unlikely as the etiology of acute pain of this severity, and an injection is
deferred. Rather, an MRI of the right hip is recommended.
Setting:
Tertiary care center (outpatient, ED, inpatient).
Results:
MRI Right Hip: Nondisplaced subcapital femoral neck fracture
with moderate bone marrow edema.
Discussion:
When pain and physical exam is out of proportion to im-
aging results, alternative and missed diagnoses should be considered.
Hip radiographs have an estimated sensitivity of 90% to 95%, compared
to the sensitivity of a hip MRI of 100%. A fracture which is not obviously
evident on radiographs is likely to be nondisplaced.
Conclusions:
In patients with continuing clinical suspicion of hip frac-
ture, despite negative radiographic findings, additional imaging should
be considered. The occult hip fracture is one in which the clinical find-
ings are suggestive of a fracture but not confirmed by radiographs.
Level of Evidence:
Level V
Poster 260:
Trifid Median Nerve: A Rare Finding During Ultrasound
Guided Carpal Tunnel Injection
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 75-year-old woman with history of
erosive osteoarthritis and right upper extremity amputation due to
sarcoma was referred to our clinic for ultrasound guided left carpal
tunnel injection. Upon evaluation the patient had chronic left hand
pain and paresthesias involving digits 1-3 and lateral half of 4th finger.
On examination there was atrophy of the thenar eminence, Phalen’s
test and Tinel’s sign were positive along with weakness of the hand
grip, thumb abduction and opposition and sensory deficits in the me-
dian nerve distribution. Electrodiagnostic studies showed severe car-
pal tunnel syndrome (CTS). During ultrasound evaluation of the volar
wrist the median nerve showed three distinct fascicles separated by
hyperechoic septa with a mean cross sectional area of 0.21 cm2 (0.5,
0.5 and 0.11 respectively). Injection of a mixture of lidocaine and
steroid medication was given deep to the radial sided fascicle.
Setting:
Outpatient Rehabilitation Clinic.
Results:
Upon follow up evaluation, the patient reported relief of her
symptoms for around 8 months.
Discussion:
Trifurcation of the median nerve has been rarely described
in the literature with only three cases reported worldwide. It can
contribute to CTS due to its anatomical configuration (higher cross
sectional area, wider configuration of nervefibers or other factors). Nerve
conduction studies may be inaccurate in this condition. Ultrasound is a
cost effective radiological method for the diagnosis of the anatomy var-
iations of the median nerve and should be considered in atypical cases.
Conclusions:
Early identification of this rare anatomic variation may
be important to avoid iatrogenic injuries due to “blind” injections or
surgical procedures.
Level of Evidence:
Level V
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Abstracts / PM R 9 (2017) S131-S290