S215 S290
Poster 261:
Electromyography/Nerve Conduction Studies and
Musculoskeletal Ultrasound in a Patient with Missing
Thumbs in Holt Oram Syndrome: A Case Report
Kelly N. Smith, DO (Baylor Col of Med), Amy T. Cao, MD,
Faye Chiou Tan, MD
Disclosures:
Kelly Smith: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Patient: 44-year-old woman with Holt
Oram Syndrome, the congenital absence of bilateral thumbs including
thenar eminences, presented to rule out bilateral carpal tunnel syn-
drome. Description: Patient with congenital absence of bilateral
thumbs and thenar eminences presented 10-month history of bilateral
hand numbness, weakness, mild edema greater in right hand, positive
nighttime symptoms, and dropping objects. Symptoms present in all
four fingers without alleviating or aggravating factors. Physical exam
was noteworthy for asymmetric length of upper extremities, irregular
muscle contouring of forearms, and widened neck. Patient uses index
fingers for grasping, has decreased active/passive range of motion of
wrists in extension, but has 5/5 strength in bilateral upper extremities,
with negative Phalen’s and positive Tinel’s sign. Xray imaging revealed
congenital absence of the thumb and absence of normal flaring of the
distal radius with fusion of the scaphoid and lunate bilaterally. MRI was
unavailable; US evaluated musculoskeletal aspects and median nerve
size. Patient also had a history of diabetes and hypothyroidism.
Setting:
Outpatient electromyography (EMG) clinic.
Results:
Nerve conduction studies (NCS) demonstrated bilateral me-
dian sensory mononeuropathy at the wrist with no response on the
right and decreased amplitude on the left. A complete electro-
diagnostic evaluation was not possible due to atypical anatomy. No
electrodiagnostic evidence of ulnar mononeuropathy or generalized
peripheral neuropathy was noted. Data were consistent with bilateral
median mononeuropathy at the wrist.
Discussion:
Holt Oram Syndrome affects approximately 1:100,000 live
births. The patient’s clinical presentation and NCS were consistent
with median mononeuropathy at the wrist, despite congenital
anatomic variation of missing bilateral thumbs and thenar eminences.
Conclusions:
This case demonstrates how to diagnose median neu-
ropathy at the wrist without the ability to test median motor recording
from the abductor pollicis brevis muscle in a patient with missing
thumbs due to Holt Oram Syndrome.
Level of Evidence:
Level V
Poster 262:
Delayed Diagnosis of Bilateral Femoral Neck Stress
Reaction in a Young Female U.S. Army Recruit: A Case
Report
Eziamaka C. Okafor, MD (Spaulding Rehab Hosp/Harvard Med Schl),
Cheri Blauwet, MD
Disclosures:
Eziamaka Okafor: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
The patient experienced onset of bilat-
eral anterolateral hip pain, deep and achy in quality, at the conclusion
of U.S. Army basic training. Pain was initially severe however had been
improving. She presented to our clinic 2 months later, reporting pain at
0/10 with ambulation, however 6/10 with running. She had aching at
night and with crossing her legs. She had no dietary restrictions. Her
menstrual cycles were normal, however she reported amenorrhea for
12 weeks throughout basic training.
Setting:
Outpatient sports medicine clinic.
Results:
The patient’s BMI was 20. Lumbar spine and bilateral hip pal-
patory examwerenegative andROMwas both full and painless. Hipspecial
tests including FABER, scour/FADIR, Stinchfields, log roll, and seated
slump tests were negative bilaterally. Bilateral hip radiographs revealed
pincer-type femoroacetabular impingement. Magnetic resonance imaging
was promptly obtained, revealing bilateral grade 3 compression-sided
femoral neck bone stress injuries. The patient was advised to avoidall high
impact exercise, toavoid pain, touse acetaminophen for analgesia, and to
increaseher dietary intake of calciumwith a supplement of VitaminD1000
U daily. Full DEXA/bone health evaluation was deferred to her Army
physicians given her eminent return to duty.
Discussion:
Femoral neck bone stress injuries are relatively rare but
serious orthopedic problem. Although our patient presentedover 2months
after symptom onset andwith unremarkable physical exam, she exhibited
dramatic radiologic changes indicative of persistence of injury given her
delayed diagnosis. In military recruits with risk factors of the female
athlete triad, prompt evaluation with advanced imaging is essential as it
provides superior sensitivity to detect and grade bone stress injury.
Conclusions:
In female military recruits, bone stress injury is a “do
not miss” diagnosis. Severe injuries can persist if not addressed
promptly.
Level of Evidence:
Level V
Poster 263:
Deep Ulnar Motor Neuropathy from Dupuytren Contracture:
A Case Report
Derick Mordus, DO (Walter Reed, North Potomac, MD, United States),
Matthew Miller, MD, Leon Nesti, MD, PhD
Disclosures:
Derick Mordus: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
Described is a 64-year-old right hand
dominant man who presented with 5 months of left hand clumsiness and
inability to open jars with associated loss of muscle mass between the
1st and 2nd digits. His medical history was significant for Dupuytren
contracture of bilateral hands for 12 years, Ramsay Hunt syndrome
associated with chronic left facial palsy, and left scapholunate dissoci-
ation. He reports left wrist pain but denies any hand, elbow, shoulder, or
neck pain. Physical exam was significant hand intrinsic atrophy without
sensory loss. Strength testing of the bilateral upper extremities revealed
5/5 strength except for 4/5 left finger abduction. Tinel at the cubital
tunnel and Guyon canal was negative. Electrodiagnostic evaluation
revealed left deep ulnar motor axonal neuropathy with sparing of the
hypothenar motor and superficial sensory branches. MRI and ultrasound
examination showed no evidence of a structural lesion at Guyon canal or
ulnar nerve enlargement.
Setting:
Tertiary care hospital.
Results:
Patient underwent surgery for ulnar nerve decompression
release of palmar fibromatosis. Three months after surgery, repeat
electrodiagnostic study showed improved compound muscle action
potential and decreased muscle membrane instability to first dorsal
interosseous.
Discussion:
To our knowledge this is the first reported case deep ulnar
motor neuropathy secondary to palmar fibromatosis. It was success-
fully treated with surgery and improvement was confirmed clinically
and electrodiagnostically.
Conclusions:
Palmar fibromatosis (Dupuytren contracture) is a rare
cause of deep ulnar motor neuropathy.
Level of Evidence:
Level V
Poster 264:
Nonoperative Management of a Complete Adductor
Longus Tendon Tear in a Collegiate Football Player: A
Case Report
Brennan Boettcher, DO (Mayo Clinic of Rochester, Rochester, MN,
United States), Elena J. Jelsing, MD
Disclosures:
Brennan Boettcher: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 22-year-old male football player pre-
sented with left groin pain and swelling. He reported a 2-week history of
left groin soreness with sprinting, with an acute increase in the pain and
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Abstracts / PM R 9 (2017) S131-S290