Daniel P. Moore

Critical Gastrointestinal Bleeding at an Inpatient Rehabilitation Center: Incidence, Risk Factors, and the Role of Gastrointestinal Prophylaxis

To determine the incidence of critical gastrointestinal bleeding at an inpatient rehabilitation center, the risk factors associated with said bleeding, and the role of gastrointestinal prophylaxis.

Tarsal Tunnel Syndrome Secondary to Suture Material Within the Tibial Artery: A Sonographic Diagnosis

A 58-year-old man presented to a sports medicine clinic with loss of sensation in the heel of his right foot after a repair of an Achilles tendon rupture 6 mos earlier. The tendon fibers were sutured together with number 5 Fiberwire augmented with Vicryl sutures. Postoperative course included standard physical therapy and CAM boot protection of the healing tendon. He denied pain, weakness, or other symptoms. Neurologic examination revealed decreased sensation to light touch and pin prick in a well circumscribed region on the heel of his foot, with normal findings in motor and reflex examination. An ultrasound of the tibial nerve medial to the Achilles tendon and 3 cm posterior to the medial mallelous revealed a suture impinging on the anterior superior aspect of the nerve in short and long axis (Fig. 1). The suture material was within the tibial artery and impinging on the nerve. The tendon was otherwise well healed and intact. Isolated tibial mononeuropathies at the ankle are uncommon entities, with an incidence of tarsal tunnel syndrome varying between 0.58% (Steinitz et al.) and 0.5% (Oh et al.) of patients who present for electrodiagnostic evaluations. Recently, sonography has been advocated to assist in the diagnosis of tarsal tunnel syndrome. Part of the controversy regarding the incidence of these lesions relates to the very complicated anatomy. In this vignette, the authors report an isolated involvement of the calcaneal branch of the tibial nerve. The sonogram reveals a relatively posterior position of the suture material that corresponds to the anatomy of the nerve. This vignette also illustrates howneuromusculoskeletal ultrasound can be useful to quickly, painlessly, and economically diagnose nerve lesions. REFERENCES 1. Steinitz ES, Singh S, Saeed MA: Diagnostic tests help clarify tarsal tunnel mystery. BioMechanics 1999;6:43Y51

Neuromuscular rehabilitation and electrodiagnosis. 5. Myopathy

This self-directed learning module highlights hypotonia, facioscapulohumeral dystrophy, and herbal supplements causing muscle weakness. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section presents advances in the diagnosis of myotubular dystrophy, myoblast transfer, and problems associated with the increased use of herbal supplements.

Topical morphine in a canine model: A pilot study

OBJECTIVE To determine if topical morphine can enter the synovial cavity and the effect of ultrasound on this process. DESIGN A randomized control trial to investigate which body fluids morphine enters after topical application. SETTING A university animal laboratory. SUBJECTS Ten mongrel dogs raised by the Comparative Medicine Department. All animals were certified to be free of disease, all had received standard scheduled immunizations, and none had been used for any other research. INTERVENTION Topical morphine and ultrasound or topical morphine and sham ultrasound was applied to the knees of the dogs. Samples were obtained afterward from synovial fluid, serum, and urine, and were analyzed for the presence of morphine. MAIN OUTCOME MEASURES Blood samples were collected every 60 minutes for 240 minutes, urine samples were collected at 120 minutes and 240 minutes, and synovial joint fluid was collected at 120 minutes and 240 minutes. The process of collection and analysis was the same for dogs treated with topical morphine and ultrasound and those treated with topical morphine and sham ultrasound. Fishers exact test was used to test for an association between the use of ultrasound and the presence of morphine in the synovial fluid, serum, or urine. Two-sample t tests were used to test for group differences in mean body weight. RESULTS All samples (synovial fluid, serum, and urine) were negative at time zero. All of the subsequent serum samples were negative for morphine. Two or three of the dogs in each group of five (ultrasound or sham ultrasound) had positive urine and synovial fluid samples at 120 and 240 minutes. Ultrasound did not affect the results. Body weight of the dogs influenced the results, with lighter animals having a significantly larger percentage (p=.03) of synovial fluid samples positive for morphine. CONCLUSION Ultrasound did not affect the absorption of topical morphine in this canine model. Body weight may have influenced the results. Dogs that tested positive for morphine in synovial fluid had a lower mean body weight than dogs that did not test positive (p=.03).

Poster 314 Amyotrophic Lateral Sclerosis Masquerading as Myelopathy: A Case Report

reduction in right lip inversion and decreased hypertrophy of left facial muscles. Asymmetry was evaluated with patient photographs before and after treatment. Long-term follow up demonstrated sustained functional improvements, requiring re-infiltration at 8 months. Discussion: Aside from the cosmetic and psychological impact, facial palsy may lead to functional problems such as lip biting experienced by this patient. We present the case of an off label use of botulinum toxin injections to reduce the pull from stronger contralateral muscles contributing to functional impairments in a patient with congenital facial palsy. Conclusions: Botulinum toxin type A injections may be useful in reducing functional impairments related to either a congenital or chronic acquired facial palsy, thus contributing to reduced disability. This may be an alternative to more complicated and costly surgical interventions. Level of Evidence: Level V

Poster 260 Atypical Course of an Anomalous Accessory Deep Peroneal Nerve: A Case Report

Participants: Patient with brachial plexopathy of non-dominant upper extremity, patient’s wife, a team of 5 seniors majoring in Mechanical Engineering with 1 member double majoring in fine arts, a nurse specialist in rehabilitation, an occupational therapist with expertise in assistive technology, and a physiatrist. Interventions: Face-to-face encounters supplemented by video conferences. SolidWorks computer program was used to create images of the various iterations. 3D printing was used to fabricate the parts to be assembled. Main Outcome Measures: Patient perception of ease of use. Results or Clinical Course: A novel combination of magnets and interlocking parts were created to make a simple and reliable means for bringing the two ends of the jacket or coat together to bring the zipper ends together. The two-piece system is small enough to carry in a pocket of a jacket or coat. Total expenditures to make the device were less than

Comparison of Two Different Ultrasonographic Parameters for the Diagnosis of Carpal Tunnel Syndrome

1000 dollars and the project was completed within 16 weeks. Conclusion: A one handed system for zipping up a jacket or coat was successfully accomplished by a team of mechanical engineering students. Employing computer aided designs and 3D printing to make prototypes that could be tested and refined, they made a simple and reliable device for a one-armed man to use. Investigations are underway to explore the usefulness of the device for other patients such as stroke survivors and amputees.

Poster 117 Electrophysiological Assessment of the Sural Nerve in Mice Treated with Saline and Cisplatin: A Pilot Study

gained during the Ultrasound course. The overall written examination average was 69% and the average OSCE score was 77%. Discussion: Based on the interest in the voluntary course, this is now part of the regular didactics curriculum. Our first year of this course has served as a template upon which a recurring Ultrasound curriculum has been established at our Residency training program. Conclusions: There is significant interest amongst residents in Ultrasound training. The successful formation of an Ultrasound course demonstrates the possibility of training residents to become competent in this new modality.

Caregiver reports of common symptoms in children following a traumatic brain injury

distal latency with preserved distal amplitude and mild partial sensory conduction block at the wrist. 2. Right median thenar CMAP was reduced in amplitude with initial positive deflection; normal amplitude was restored with stimulation over the ulnar nerve. Median CMAP at lumbrical II was mildly delayed with borderline decreased amplitude. 3. Needle EMG examination of the right APB was normal. Impression: 1. Mild to moderate right median neuropathy at the wrist (carpal tunnel syndrome). 2. Right Riche-Cannieu anastomosis. Discussion: Riche-Cannieu anastomosis is a common neuroanatomical variant involving a deep ulnar motor-to-recurrent median branch anastomosis. The “all ulnar hand“ may initially appear on nerve conduction studies to resemble a severe median neuropathy. This misdiagnosis may lead to unnecessary surgical intervention. Conclusions: Riche-Cannieu anastomosis should be included in the differential when median thenar CMAP is severely reduced in the setting of well-preserved thenar musculature.