Multidisciplinary Management of Complex Regional Pain Syndrome (CRPS) Type 1 in the Hand and Wrist: A Case Report.

Complex regional pain syndrome (CRPS) is a rare disorder that presents as a highly variable combination of intense regional pain, autonomic and vasomotor disturbances that are uncharacteristic of the inciting trauma or event. We report a 36-year-old male construction worker who presented to the orthopedic department status post crush injury to his hand, with acutely increasing right-hand pain, swelling, skin/hair changes, and dysfunction. Presentation changed over a course of 2-8 weeks, with CRPS becoming the eventual working diagnosis. Initial diagnoses were not made by occupational med, nor the urgent care, and definitive diagnosis was achieved in the orthopedic hand office via a thorough history and physical exam as well as imaging modalities including X-ray, CT, and MRI. A multidisciplinary approach involving aggressive hand therapy, anti-inflammatory agents, high-dose prednisone, Gabapentin, and over-the-counter vitamins and supplements was used in the treatment of this patient. This patient had a unique progression of his condition with respect to his carpus, demonstrating acute reduction of bone density on plain film. Stiffness ensued. This patient's condition was almost "missed" by the masking of the ulnar ossicle variant (os triangulare), and anatomical snuffbox pain on exam, in the face of initially "normal" X-rays. It is important for providers to recognize the clinical signs of complex regional pain syndrome, especially in the acute phase of crush injury, swelling, skin and hair changes, and stiffness, and to treat patients' symptoms with a variety of treatment options due to the marked variability of this condition. The patient has made a favorable recovery with some residual functional deficits, however, the patient stated that his quality of life has been restored despite his current stiffness.

Cervical Spondylotic Myelopathy Presenting as Peripheral Nerve Disease: A Case Report.

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in the elderly population. It is a degenerative disease that classically presents with fine motor dysfunction of the hands and gait instability. These symptoms can easily be masked by old age, complex medical history, and more benign diseases. We describe the case of a 67-year-old male who was referred to orthopedic surgery for bilateral hand numbness and weakness attributed to carpal tunnel syndrome (CTS). The patient had trouble ambulating, rhythmic clonus in his ankles, and a bilateral positive Hoffman sign resulting in a referral to neurosurgery for an emergent spinal cord decompression. To our knowledge, few case reports exist demonstrating how cervical myelopathy can mimic more benign peripheral nerve diseases such as CTS. We describe how difficult early recognition can be, as well as the importance of primary care doctors maintaining a high degree of suspicion for a disease that has nonspecific examination findings and can easily mimic more benign processes.

Achenbach Syndrome: Case Report and Discussion.

Achenbach syndrome is a rare, benign, self-limiting condition characterized by spontaneous, recurrent bruising of the digits without evidence of systemic disease or predisposing factors. We report a middle-aged Caucasian female that presented to the outpatient clinic with spontaneous bruising on the dorsal aspect of her left first metacarpal. Diagnosis of Achenbach syndrome was made through history and physical examination findings, and the patient was discharged with instructions to follow up as needed. It is important for providers to consider Achenbach syndrome to reassure patients and prevent an expensive or invasive workup.

Chronic Exertional Compartment Syndrome of the Hand With Simultaneous Carpal Tunnel Syndrome and Ulnar Nerve Neuropathy: A Clinical Case Report.

Chronic exertional compartment syndrome is a reversible form of compartment syndrome that occurs with exertion and is relieved with rest. Chronic exertional compartment syndrome most commonly occurs in the lower leg and has only rarely been reported in the hand. We report a case of exertional compartment syndrome in the left hand of a 37-year-old male heavy equipment technician with concurrent carpal tunnel syndrome and ulnar neuropathy. Physical examination showed non-exertional numbness and tingling in all five digits while at rest with a reproducible Tinel's test over the carpal tunnel and Guyon's canal. Acute swelling and hand muscle weakness appeared after repetitive pinch and usage of the thenar and intrinsic musculature with acute sensory and motor changes in the ulnar nerve distribution. Elective fasciotomies were performed in the first dorsal interosseous and thenar compartments with concomitant release of the carpal tunnel and ulnar nerve at the wrist. The patient exhibited a full recovery from symptoms with no residual functional deficits. Although rare, patients that perform repetitive hand motions can develop chronic exertional compartment syndrome. To our knowledge, this is the first reported case of chronic exertional compartment syndrome in the hand that occurred with chronic overuse neuropathies and an acute ulnar neuropathy with intrinsic hand muscle weakness at the same time. It is important for providers to conduct a thorough history and physical examination to differentiate multiple hand pathologies that may present simultaneously.

Intraoperative Anaphylaxis in Response to Hemostatic Agents With Protein Derivatives.

Topical hemostatic agents are commonly used in a wide variety of surgical procedures to assist in hemostasis. However, the use of these agents is not without risk as many contain biologically active agents derived from human and animal products that have the potential to cause adverse reactions. This case report covers a 44-year-old man with a history of alpha-gal syndrome who was scheduled for an open reduction and internal fixation of a left distal radius fracture. Alpha-gal syndrome is characterized by an IgE-mediated type 1 hypersensitivity reaction to a mammalian oligosaccharide epitope. Patients with this condition have a history of a past tick bite and subsequent development of an allergic reaction to mammalian protein products, most notably red meat. The patient had concerns about products used during surgery and potential reactions based on his allergy. The intent of this case report is to promote physician awareness of the widespread use of mammalian products in surgical hemostatic agents and potential immunogenic reactions. By increasing awareness of the alpha-gal syndrome, the goal is that medical device companies will actively disclose product components that could potentiate these adverse reactions and continue to develop alternative agents.