Brennan J. Boettcher

Can a Brief Training Session Prepare Physician Sonographers of Differing Experience to Measure the Ischiofemoral Space? A Reliability Study

The primary aim of this study was to determine the inter‐ and intrarater reliability of ultrasound (US) measurements of the ischiofemoral space (IFS) following a brief training session. A secondary aim was to determine if reliability correlated with sonographer experience.

Poster 264: Nonoperative Management of a Complete Adductor Longus Tendon Tear in a Collegiate Football Player: A Case Report

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 syndrome. 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 median sensory mononeuropathy at the wrist with no response on the right and decreased amplitude on the left. A complete electrodiagnostic 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 neuropathy 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 254: Sacroiliitis Presenting as Hip Pain in an Elite Hockey Player: A Case Report

Disclosures: Katie Fast: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 22-year-old female amateur MMA fighter was scheduled to fight in the 120-pound weight division. Prior to the fight, thorough pre-fight physical examination and questionnaire were performed including a full past medical history (PMH) in which she denoted no significant PMH; her pregnancy test was also negative. The bout was stopped by the referee in the first round due to undefended strikes, with the final blow ending in profuse epistaxis. Setting: Amateur MMA Fight. Results: Immediately after the final blow, the onsite physician entered the ring to evaluate the fighter. She was alert and oriented x3 and appeared to be in no acute distress. An unprecedented amount of bleeding was noted; after 5 minutes of unmitigated bleeding 1:1000 epinephrine swab was applied directly to the nares and eventually the bleeding ceased. The physician questioned her about previous nasal fractures. She denied previous fracture but finally admitted, “I have Von Willy syndrome.” When asked why she had not disclosed this initially, she stated it was genetic and therefore nothing to be done; she also noted her primary-care provider had cleared her to fight. The physician and MMA association enacted a life-time ban on her prohibiting any future participation in their fights again. Discussion: Athletes are motivated patients, but sometimes they are more devoted to their sport than their health. The athlete in this report did not realize the potential consequences of her disease and therefore did not report it. A well-directed blow in a patient with Von Willebrand disease could result in internal or even intracranial bleeding. Event physicians must be diligent in stressing pre-participation physicals and obtaining comprehensive PMH, as the athletes may not fully appreciate the risks involved with their premorbid conditions. Conclusions: Preparticipation history and physicals, though seemingly rudimentary, provide a stop-gap for physicians to prevent serious medical consequences. Level of Evidence: Level V

Poster 312: Rare Cause of Ulnar Neuropathy in an 18-Year-Old Musician: A Case Report

Disclosures: Brennan Boettcher: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 18-year-old right handed female musician presented for evaluation of left hand weakness, first noted 19 months prior while trying to play bar cords on her guitar and subsequently difficulty flattening her hand for a hand scanner in the airport. More recently, she noted hypothenar atrophy in the hand. She had no numbness or other neurologic complaints. She was evaluated elsewhere with electromyography (EMG) which was concerning for a C8 radiculopathy. Cervical spine advanced imaging was normal. Exam revealed left hypothenar atrophy, ulnar clawing, positive Froment’s sign, and severe weakness of the hypothenar and interosseous muscles but no thenar weakness. Sensory exam was normal. Tinel’s in the left forearm was positive, but negative at the ulnar groove and carpal tunnel. Setting: Quaternary care academic center. Results: Nerve conduction studies demonstrated low left ulnar motor amplitude with prominent dispersion and conduction block between the elbow and wrist as well as low amplitude ulnar sensory response. The dorsal ulnar cutaneous and medial antebrachial cutaneous sensory responses were normal. Needle EMG demonstrated chronic neurogenic changes in the ulnar muscles of the hand with sparse fibrillation potentials. Proximal ulnar, medial cord and C8/T1 innervated muscles were normal. Ultrasound of the ulnar nerve demonstrated a focal nerve enlargement in the mid-forearm and loss of fascicular architecture. MRI showed segmental fascicular enlargement, T2 hyperintensity and enhancement of the ulnar nerve with associated muscular denervation changes, suggestive of perineurioma. Discussion: A perineurioma is a rare cause of a peripheral mononeuropathy. Knowledge of this condition and imaging findings are essential for accurate diagnosis. Perineuriomas are slow growing tumors arising from perineural cells demonstrating fusiform fascicular enlargement and intense gadolinium enhancement. Conclusions: Consultation with a peripheral nerve neurosurgeon and peripheral nerve neurologist resulted in a plan for continued observation and repeat imaging with no role for surgery. Level of Evidence: Level V

Neurological Rehabilitation Poster Hall: Case ReportsPoster 291: Severe Sensory Neuropathy vs Sensory Ganglionopathy in a Patient with Sjogren’s Syndrome: A Case Report

Disclosures: Brennan Boettcher: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 42-year-old woman with a 5-year history of Sjogren’s syndrome, chronic steroid use and osteoporosis presented with complaints of numbness and pain in all four limbs and difficulty walking, which had progressed over several years. She had decreased light touch and pinprick sensation to the mid-thighs and elbows bilaterally. Her strength was poor to initial testing, but with visual reinforcement of the tested muscles, strength returned to normal. She was referred for electromyography (EMG) and nerve conduction studies. Antinuclear antibody and anti SS-A/La antibodies were elevated. Setting: Quaternary care academic center. Results: Motor nerve conduction studies and blink reflexes were normal. Sensory nerve conduction studies were non-reactive in the right upper and lower limbs, consistent with a severe sensory peripheral neuropathy vs. sensory ganglionopathy. Needle EMG of the right upper and lower limbs was normal other than short duration, low amplitude motor unit potentials with rapid recruitment in the triceps, perhaps related to steroid use. Rheumatology was consulted, and the patient was ultimately placed on azathioprine as a steroid sparing agent for Sjögren’s syndrome. She was also referred to physical and occupational therapy for fall prevention recommendations, ADL modifications, and adaptive equipment. Discussion: This is a case of a severe sensory neuropathy vs sensory ganglionopathy resulting from Sjogren’s syndrome. Central and peripheral nervous system involvement has been reported in up to 20% of individuals with Sjögren’s syndrome, with sensory ganglionopathy being the most common. Sensory ganglionopathy can be seen with toxic exposure as well as autoimmune, paraneoplastic disorders. The treatment of this condition is not clear, with plasma exchange, IV immunoglobulin, corticosteroids and immunosuppressants reported as possible treatments. Conclusions: Sjogren’s syndrome is usually limited to glandular symptoms but can result in a variety of neuropathic findings, including pure sensory, sensorimotor and small fiber neuropathies. Level of Evidence: Level V

Poster 295 Twice Missed on MRI- Atraumatic Rupture of the Extensor Pollicis Longus Tendon after Casting for Distal Radius Fracture in a Healthy 46 Year Old: A Case Report

Disclosures: R. M. Lazaro: I Have No Relevant Financial Relationships To Disclose. Objective: To determine whether knee varus/valgus during the single-leg step-down (SLSD) and drop-jump (DJ) tests correlates with three-dimensional (3-D) measurements of running gait kinetics and kinematics. Design: Retrospective cross-sectional study. Setting: University-based gait and motion analysis lab. Participants: Previously collected data from 40 adult runners (26 females and 14 males) were analyzed. Interventions: Three-dimensional joint kinematics and kinetics were measured as subjects performed a running trial, SLSD, and DJ. Frontal knee angles during SLSD and DJ were compared to 3-D joint angles, body segment alignment, and ground reaction forces during the midstance phase of running. Main Outcome Measures: Strength and direction of these relationships between frontal knee angles during the SLSD and DJ tests and 3-D variables during midstance running were measured by calculating Pearson product-moment correlation coefficients. Results or Clinical Course: For the correlations between SLSD knee varus/valgus and midstance running for the right knee frontal (RKF), right hip transverse (RHT), left knee frontal (LKF), and left hip transverse (LHT) angles, r values were .749, .683, .737, and .524, respectively (P < .001 for all). In the DJ test, r values for LKF, LHT, and RKF were .556 (P < .001), .507 (P < .001), and .405 (P < .009), respectively. RHT angle did not show a strong correlation between DJ and running as it did between SLSD and running (r 1⁄4 .294, P 1⁄4 .065). Conclusion: Knee varus during the SLSD showed moderate to strong correlations with both knee varus and hip internal rotation during midstance running. Knee varus during the DJ showed weak to moderate correlations with midstance knee varus and hip internal rotation. Both the SLSD and DJ tests may be used to evaluate an athlete’s biomechanics, though the SLSD more accurately reflects biomechanics during running than the DJ does.