Timur Ekiz

Heterotopic Ossification and Peripheral Nerve Entrapment: Ultrasound is a Must-use Imaging Modality

Dear Editor, Heterotopic ossification (HO) —new lamellar bone formation in a place where normally osseous tissue does not exist—is commonly seen around the hip joints ⇓. It is relatively a frequent complication after traumatic brain injury (TBI). HO can present with pain, swelling, local warmth, tenderness, and decrease in range of motion. In addition, nerve or vascular entrapments can develop depending on the location of the ossified tissue ⇓. A 25-year-old man was seen due to stiffness in his right hip and elbow joints, and weakness, numbness, and tingling (in his right thigh and forearm). He had …

Fibrolipomatous Hamartoma of the Median Nerve: Comparison of Magnetic Resonance Imaging and Ultrasound

Fibrolipomatous hamartoma (FLH), also known as lipomatosis, fibrolipomatous nerve enlargement, lipofibroma, fibrofatty overgrowth, fatty infiltration of the nerve, neurolipoma, intraneural lipoma, and perineural lipoma, is designated as nervous lipomatosis by the World Health Organization [1]. FLH is a rare, slow-growing, benign tumor characterized by fibrofatty proliferation that surrounds the nerve bundles and infiltrates the epineurium and perineurium, eventually causing perineural and endoneural fibrosis with normal or atrophic axons. Although its etiology is not clearly known, it is considered to be a congenital tumor by many authors. Most cases are diagnosed in infants and less commonly during childhood or early adulthood [1]. FLH is most commonly seen in the median nerve and rarely in radial, ulnar, and sciatic nerves, nerves of the foot, and cranial nerves [1-3]. Clinically, FLH may be associated with entrapment findings pertaining to the nerve being involved, mostly in the form of carpal tunnel syndrome. Pain, motor, and sensory deficits may be asymptomatic in early cases, and the tumor may be uncovered as a mass only during manual palpation. Although FLH can be seen as a distinct pathology, in approximately two thirds of cases, macrodactyly accompanies the scenario [1]. Figures 1 and 2 show imaging findings of 2 patients with FLH and carpal tunnel syndrome. Case 1 features a 38-year-old woman with a history of carpal tunnel decompression surgery and Case 2 features a 27-year-old man. itation Training and Research Hospital, Ankara, Turkey. Address correspondence to: M.A., Ankara Fizik Tedavi ve Rehabilitasyon Eğitim ve Araştırma Hastanesi Sıhhiye, AnREFERENCES

Magnetic resonance imaging of a fibrous band causing true neurogenic thoracic outlet syndrome.

From the Department of Physical Medicine and Rehabilitation, Ankara Occupational Diseases Hospital (MTY); Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital (TE, MK); Department of Radiology, Primer Magnetic Resonance Imaging Center (MY); and Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School (LÖ), Ankara, Turkey.

Ultrasonographic measurement of the femoral cartilage thickness in patients with occupational lead exposure.

The objective of the present study is to compare distal femoral cartilage thicknesses of patients with occupational lead exposure with those of healthy subjects by using ultrasonography. A total of 48 male workers (a mean age of 34.8±6.8 years and mean body mass index (BMI) of 25.8±3.1 kg/m2) with a likely history of occupational lead exposure and age- and BMI-matched healthy male subjects were enrolled. Demographic and clinical characteristics of the patients, that is, age, weight, height, occupation, estimated duration of lead exposure, and smoking habits were recorded. Femoral cartilage thickness was assessed from the midpoints of right medial condyle (RMC), right lateral condyle (RLC), right intercondylar area (RIA), left medial condyle (LMC), left lateral condyle (LLC), and left intercondylar area (LIA) by using ultrasonography. Although the workers had higher femoral cartilage thickness values at all measurement sites when compared with those of the control subjects, the difference reached statistical significance at RLC (P=0.010), LMC (P=0.001), and LIA (P=0.039). There were no correlations between clinical parameters and cartilage-thickness values of the workers. Subjects with a history of lead exposure had higher femoral cartilage thickness as compared with the healthy subjects. Further studies, including histological evaluations, are awaited to clarify the clinical relevance of this increase in cartilage thickness and to explore the long-term follow-up especially with respect to osteoarthritis development.

Does locomotor training improve pulmonary function in patients with spinal cord injury

Objectives:The aim of this study was to compare the effects of a locomotor training (LT) combined rehabilitation program with a rehabilitation-only program on pulmonary function in spinal cord injury (SCI) patients by investigating spirometric analyses of the patients.Setting:Rehabilitation center in Ankara, Turkey.Methods:Fifty-two patients (40 male, 12 female) with SCI enrolled in the study. The subjects were divided into two groups: the first group (group A) received both LT and a rehabilitation program and the second group (group B) received only the rehabilitation program for 4 weeks. The LT program was prescribed as three 30-min sessions per week. Pulmonary function was evaluated spirometrically in both groups before and after the rehabilitation program.Results:The spirometric values of the SCI patients, including forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow rate and vital capacity (VC) and VC%, increased significantly with LT in the first group (all P<0.05). Maximum voluntary ventilation values increased significantly in both groups (both P<0.05).Conclusion:These findings suggest that LT is effective for improving pulmonary function in SCI patients. We also highlight the useful effects of LT, which are likely the result of erect posture, gait and neuroplastic changes that prevent potential complications in SCI patients.

Sacral Insufficiency Fracture in a Hemiplegic Patient.

A 69-year-old hemiplegic woman was seen due to weakness and hip pain on her right side, and gait difficulty. Medical history revealed hypertension, thrombotic stroke (5 months ago), and pubic ramus fracture. On detailed questioning, she did not declare a fall after stroke. On physical examination, she had extensor spasticity (modified Ashworth Scale 1) and hyperactive deep tendon reflexes in her right lower limb. Brunnstrom’s stages (right side) of upper/lower extremity and hand were 1, 2, and 1, respectively. Hip joint range of motion was painful and limited on the right side. Right side of the sacrum was also painful with palpation. Visual Analog Scale (VAS) pain score was 6, Barthel Index was 10, and Functional Ambulation Classification Scale was 0. Pelvis anteroposterior radiograph and computed tomography (CT) demonstrated symphysis pubis fracture and increased radiolucency (Figure 1). Bone mineral density (BMD) measurements displayed severe osteoporosis; T-scores and BMD values of femur neck and L1-4 vertebra being 3.6 (0.539 g/cm) and 5.3 (0.533 g/cm), respectively. Magnetic resonance imaging (MRI) yielded bone marrow edema and linear sacral insufficiency fracture (SIF) on the right side of the sacrum (Figure 2). Laboratory parameters including complete blood count, erythrocyte sedimentation rate, liver/renal/thyroid function tests, intact parathyroid hormone, prolactin, cortisol, calcium, phosphor, alkaline phosphatase, total protein, and albumin levels were all normal. 25-OH vitamin D level was 7.8 ng/mL (N: 8–60). Following pain control (rest, nonsteroidal anti-inflammatory drug, transcutaneous electrical nerve stimulation), she was early mobilized. As for the osteoporosis treatment, vitamin D was supplemented. Thereafter, intravenous zoledronic acid 100 mL/5 mg/year and oral calcium plus vitamin D 1200 mg-800 IU/day were prescribed. After 2 months of rehabilitation program, Brunnstrom’s stages for the right upper/lower limb and hand were 1, 4, and 1, respectively. Barthel index was 40 and FAC was 2. There was also significant improvement in VAS pain score (2), and she was able to walk with tripod and foot up assistance.

Bilateral quadriceps and triceps tendon rupture in a hemodialysis patient

This paper presented a 58‐year‐old hemodialysis patient who had bilateral quadriceps and triceps tendon rupture, whereby the role of rehabilitation in functional parameters has been highlighted.

Does Vitamin D Affect Muscle Strength and Architecture? An Isokinetic and Ultrasonographic Study

BACKGROUND AND OBJECTIVES The objective of this study was to explore the association between 25- hydroxyvitamin D (25(OH)D) and muscle strength/architecture. METHODS AND STUDY DESIGN Thirty patients (27 women, 3 men) were allocated into Group I (n=15, mean age; 44.4±9.4 years) and Group II (n=15, mean age; 39.0±9.9 years) according to the median of 25(OH)D (<13.7 ng/mL vs >13.7 ng/mL, respectively). Peak torque/body weight of the knee flexor/extensor muscles at 60°/sec and 180°/sec and those of ankle flexor/ extensor muscles at 30°/sec and 90°/sec were evaluated by using a Biodex System 3 Pro Multijoint System isokinetic dynamometer. A 7-12 MHz linear array probe was used to evaluate thickness (MT), pennation angle (PA) and fascicle length (FL) of medial gastrocnemius and vastus lateralis muscles. RESULTS Mean of 25(OH)D was 9.4±2.5 ng/mL and 20.7±8.3 ng/mL in Groups I and II, respectively. Although all isokinetic strength parameters were lower in Group I, significant differences were found in knee flexion at 180°/sec (p=0.007), knee extension at 30°/sec (p=0.038) and 180°/sec (p=0.001), and ankle extension at 30°/sec (p=0.002) and 90°/sec (p=0.007). On the other hand, no significant difference was found between the groups regarding MT, PA and FL values (all p>0.05). CONCLUSION In light of our results, we can argue that 25(OH)D is associated with muscle strength but not with muscle architecture. Further studies concerning the long-term follow-up effects of 25(OH)D treatment on muscle strength are awaited.

Wheelchair appropriateness in patients with spinal cord injury: a Turkish experience

Study design:Descriptive.Objective:To determine the wheelchair appropriateness in patients with spinal cord injury (SCI).Setting:National Rehabilitation Center in Ankara, Turkey.Methods:Twenty-seven (25 male, 2 female) SCI patients were included. Demographic and clinical characteristics of the patients were noted. All wheelchairs were evaluated considering each part (seat length, seat depth, seat height, back height, armrest, headrest, wheels and seat belt) by a physiatrist who had attended the wheelchair-training course. The wheelchair was declared as inappropriate if at least three parts of wheelchair were not appropriate.Results:The mean age of the patients was 32.9±9.3 years and mean duration of wheelchair use was 19.63±23.02 months. Among the patients, 21 (77.8%) were American Spinal Injury Association Impairment Scale (AIS) A, 4 (3.7%) AIS B, 1 (3.7%) AIS C and 1 (3.7%) AIS D. Five (18.5%) wheelchairs were motorized and 22 (81.5%) were manual. Overall, 15 (55.6%) wheelchairs were inappropriate. Seat height, cushion and back height were the most common inappropriate parts.Conclusion:In light of our first and preliminary results, we can argue that 55% of the patients with SCI use inappropriate wheelchairs. In order to achieve better mobility; personally designed wheelchairs should be prescribed by the clinicians.

Severe Bilateral Heterotopic Ossification in a Patient With Multiple Sclerosis.

A 26-year-old woman with a diagnosis of multiple sclerosis (MS) (relapsing remitting form) presented to our clinic (on stretcher) with weakness, hypoesthesia in her lower extremities, and limited knee joint motions. Concerning MS, she had had only two attacks. The first attack was 4 years ago when she had been diagnosed with MS. After the first attack, she had been followed in the intensive care unit for 2 months. She had had the last attack 2 years ago and between the two attacks, the patient had been followed up with medical treatment and a home-based exercise regimen. She has not been able to sit independently after her second attack and unfortunately she did not comply with her MS modifying drugs either. She also did not receive appropriate rehabilitation care. The medical history was otherwise noncontributory. On physical examination, knee joints were found to be fixed in extended position bilaterally. She had a slight increase in muscle tone and minimal resistance at the end of the range of motion on hip flexors and ankle dorsiflexors (Grade 1 spasticity according to Modified Ashworth Scale [Bohannon & Smith, 1987]). Modified Barthel index score was 49 (significantly dependent). Knee joint radiographs showed severe heterotopic ossification (HO) bilaterally (Figure 1). Ultrasonography showed the ossification tissue and its relation with the adjacent soft tissues (Figure 1). As for the laboratory evaluations, erythrocyte sedimentation rate was 38 mm/h (N: 0–30), C-reactive protein was 1.76 mg/dL (N: 0–0.8). Other laboratory investigations including complete blood count, plasma alkaline phosphatase, and renal/liver function tests were