Where Is the Ulnar Styloid Process? Identification of the Absolute Location of the Ulnar Styloid Process Based on CT and Verification of Neutral Forearm Rotation on Lateral Radiographs of the Wrist

BACKGROUND: The location of the ulnar styloid process can be confusing because the radius and the hand rotate around the ulna. The purpose of this study was to identify the absolute location of the ulnar styloid process, which is independent of forearm pronation or supination, to use it as a reference for neutral forearm rotation on lateral radiographs of the wrist. METHODS: Computed tomography (CT) images of 23 forearms taken with elbow flexion of 70° to 90° were analyzed. The axial CT images were reconstructed to be perpendicular to the distal ulnar shaft. The absolute location of the ulnar styloid process in this study was defined as the position of the ulnar styloid process on the axial plane of the ulnar head relative to the long axis of the humeral shaft with the elbow set in the position for standard lateral radiographs of the wrist. To identify in which direction the ulnar styloid is located on the axial plane of the ulnar head, the angle between “the line of humeral long axis projected on the axial plane of the ulna” and “the line passing the center of the ulnar head and the center of the ulnar styloid” was measured (ulnar styloid direction angle). To identify how volarly or dorsally the ulnar styloid should appear on the true lateral view of the wrist, the ratio of “the volar-dorsal diameter of the ulnar head” and “the distance between the volar-most aspect of the ulnar head and the center of the ulnar styloid” was calculated (ulnar styloid location ratio). RESULTS: The mean ulnar styloid direction angle was 12° dorsally. The mean ulnar styloid location ratio was 1:0.55. CONCLUSIONS: The ulnar styloid is located at nearly the ulnar-most (the opposite side of the humerus with the elbow flexed) and slightly dorsal aspects of the ulnar head on the axial plane. It should appear almost midway (55% dorsally) from the ulnar head on the standard lateral view of the wrist in neutral forearm rotation. These location references could help clinicians determine whether the forearm is in neutral or rotated position on an axial CT/magnetic resonance imaging scan or a lateral radiograph of the wrist.

Tumor Marker Kinetics as Prognosticators in Patients with Unresectable Gallbladder Adenocarcinoma Undergoing Palliative Chemotherapy

BACKGROUND/AIMS: To determine the prognostic value of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 in gallbladder cancer (GBC) during palliative chemotherapy. METHODS: One hundred and twenty-three patients with pathologically confirmed unresectable GBC were included. Differences in serum CEA and CA 19-9 levels before and after chemotherapy were measured. Receiver operating characteristic curve analysis, Kaplan-Meier analyses of CEA, CA 19-9, and combined changes were performed to assess the optimal cutoff values and survival rates. RESULTS: Patients with decreased tumor markers had significantly better progression-free survival (PFS) and overall survival (OS) than patients with increased tumor markers. The pre- and postchemotherapy CA 19-9 ratio had the highest area-under-the-curve values for predicting 3-month PFS and 1-year OS. In the multivariate analysis, increases in serum CA 19-9 during palliative chemotherapy in patients with unresectable GBC was an independent prognosticator of poor PFS and OS, with hazard ratios of 2.20 (p=0.001) and 1.67 (p=0.020), respectively. Patients with increases >10-fold were considered to have progressive disease, whereas individuals with increases >3-fold were likely to benefit from early imaging follow-up. CONCLUSIONS: CA 19-9 kinetics was a reliable prognosticator of PFS and OS in patients with unresectable GBC who underwent palliative chemotherapy.

Neurologic Deficits after Surgical Enucleation of Schwannoma in the Upper Extremity

PURPOSE: Neurologic deficits after enucleation of schwannoma are not rare. To evaluate the neurologic deficits after surgical enucleation of schwannoma in the upper extremity, we performed a retrospective review of patients with surgically treated schwannoma over a 14-year period at a single institution. METHODS: Between March 2001 and September 2014, 103 patients underwent surgical enucleation for schwannomas; 36 patients of them had lesions in the upper extremity, and 2 out of 36 patients had multiple schwannomas. Each operation was performed by a single surgeon under loupe magnification. The postoperative neurological deficits were graded as major and minor in both immediate postoperatively and at last follow-up. The major deficit was defined as anesthesia or marked hypoesthesia, motor weakness of grade 3 or less and neuropathic pain. Minor deficit was defined as mild symptoms of mild hypoesthesia, paresthesia and motor weakness of grade 4 or more. RESULTS: There were 2 major (2 mixed nerve) and 12 minor (4 motor, 7 sensory, 1 mixed nerve) neurologic deficits after surgery. At the last follow-up, one major mixed neurologic deficit remained as major motor and minor sensory, and other major ones changed to mixed minor. And all minor deficits except 1 sensory deficit were recovered spontaneously. CONCLUSION: Even though high incidence rate of neurologic deficit after enucleation of schwannoma in the upper extremity (38.9%), about three fourths of them were recovered spontaneously. There were 3 permanent neurologic deficits, and one of them was major one. In some cases, surgeon cannot avoid to encounter a neurological deficit. So we recommend more delicate microscopic surgical procedure and preoperative planning and counseling. And surgery is indicated for only symptomatic lesions.

Metronidazole-induced encephalopathy in a patient with Crohn's disease

Metronidazole is a widely used antibiotic for the treatment of anaerobic bacterial infections. Metronidazole-induced encephalopathy (MIEP) is a rare but potentially reversible disease. The mechanism of MIEP remains unclear, and differences in the neurotoxic effects of oral versus intravenous (IV) metronidazole administration have not yet been determined. We report the case of a Crohn's disease (CD) patient who experienced encephalopathy immediately after a single IV dose of metronidazole following long-term exposure to the oral form of the drug. The 64-year-old man with intractable CD experienced a sudden change in mental status, aphasia, and muscle weakness after IV administration of metronidazole. He had previously taken metronidazole orally for 13 years and received intermittent IV metronidazole treatments for CD exacerbation. Brain magnetic resonance imaging (MRI) showed high-intensity signals in the bilateral medial thalamus and the midbrain and pontine tegmentum on fluid-attenuated inversion recovery images. After discontinuation of metronidazole, the high-intensity brain MRI signals resolved and the patient's mental status dramatically improved; however, the patient exhibited mild cognitive dysfunction 2 months after the onset of encephalopathy.

Evaluation of the Foveal Involvement of the Ulnar Styloid Fracture: A Comparison of the Plain Radiography and Three-Dimensional Computed Tomography

PURPOSE: There remains uncertain whether to fix or not an ulnar styloid fracture acommpanied by distal radius fracture. Fixation might be required in cases of the fracture involving a fovea of ulnar head, an attachment site of deep triangular fibrocartilage, which is thought to be important to distal radioulnar joint stability. We analyzed a fovea involvement of an accompanied ulnar styloid fracture in patients with distal radius fracture by simple radiograph and three-dimensional computed tomography (3D CT). METHODS: We retrospectively reviewed 168 patients who underwent surgery with volar locking plate for distal radius fracture in our hospital from January 2005 to March 2015 and evaluated a fovea involvement of ulnar head by simple radiographs and 3D CT respectively, and compared. RESULTS: On simple X-ray, 64 cases (38%) were ulnar styloid fovea fractures; however, 21 cases of these revealed non-fovea fractures by 3D CT. And 7 out of 104 cases determined as non-fovea fracture by simple radiographs were diagnosed as fovea fractures by 3D CT. Sensitivity, specificity and accuracy of evaluation by simple radiograph were 86%, 82% and 83% respectively, when compared with those of 3D CT based evaluation. CONCLUSION: Accuracy of evaluating an accompanied ulnar styloid fovea fracture in patients with distal radius fracture by simple radiograph, when compared with 3D CT, was 83%; therefore, we recommend using the 3D CT based evaluation instead of simple radiograph based one for determination of fovea involvement of ulnar head.

Modified Split Ulnar Gutter Splint for Treatment of Fifth Metacarpal Neck Fractures

PURPOSE: To evaluate radiological results of the modified split ulnar gutter splint for the fifth metacarpal neck fracture. METHODS: Between December 2008 and May 2014, 17 patients (18 cases) with fifth metacarpal neck fractures were managed with our modified split ulnar gutter splint. Radiological outcomes in oblique and lateral radiographs were evaluated. Mean immobilization period was 4.9 weeks (range, 4-7) weeks. Mean follow-up period was 17.1 week (range, 8-80 weeks). RESULTS: All of 18 fractures were completely united. The average of prereduction dorsal angulation, 27degrees in the oblique radiographs and 21degrees in the lateral radiographs, were corrected to 17degrees in the oblique radiographs and 10degrees in the lateral radiographs after closed reduction. At the last follow-up, they were 14degrees and 11degrees respectively. The mean difference of angulation deformity between in postreduction and final follow-up radiograms were 3degrees in the oblique radiographs and 1degrees in the lateral radiographs, which was not significantly different. CONCLUSION: Immobilization using modified split ulnar gutter splint will be a reliable option for the fifth metacarpal neck fractures in selected patients, which will avoid the surgeries.

Simultaneous Esophageal and Gastric Metastases from Lung Cancer

We report of a patient with metastatic adenocarcinoma of the esophagus and stomach from lung cancer. The patient was a 68-year-old man receiving radiotherapy and chemotherapy for stage IV lung cancer, without metastases to the gastrointestinal (GI) tract at the time of the initial diagnosis. During the treatment period, dysphagia and melena newly developed. Upper GI endoscopy revealed geographic erosion at the distal esophagus and multiple volcano-shaped ulcers on the stomach body. Endoscopic biopsy was performed for each lesion. To determine whether the lesions were primary esophageal and gastric cancer masses or metastases from the lung cancer, histopathological testing including immunohistochemical staining was performed, and metastasis from lung cancer was confirmed. The disease progressed despite chemotherapy, and the patient died 5 months after the diagnosis of lung cancer. This is a case report of metastatic adenocarcinoma in the esophagus and stomach, which are very rare sites of spread for lung cancer.

Scaphoid Nonunions Treated with 1, 2-Intercompartment Supraretinacular Artery Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation

PURPOSE: The purpose of this study was to evaluate the clinical results of scaphoid nonunions treated with 1, 2-intercompartment supraretinacular artery (ICSRA) pedicled vascularized bone grafting (VBG) and headless compression screw fixation. METHODS: Since August 1, 2005, 11 scaphoid nonunions with avascular necrosis or bone marrow edema of proximal fragments were managed with 1, 2-ICSRA pedicled VBG combined with headless compression screw fixation. The mean age was 37.1 years (range, 21-66 years). 8 patients had avascular necrosis (AVN) of proximal fragments and 3 patients had bone marrow edema in proximal fragments. Serial radiographic evaluations were performed in every 4-8 weeks for bone union and follow up computed tomography scanning were checked in 8 patients. RESULTS: Bone unions were obtained in all 11 patients at 4.9 months (range, 3-9 months) after operation. At last follow up, the average range of motion was 82.5% and the grip power was 84.1% compared to the contralateral side. The mean New York Orthopaedic Hospital wrist score at last follow up was 83.2 (range, 58.1-93.3). CONCLUSION: Combined 1, 2-ICSRA pedicled VBG and headless compression screw fixation were reliable methods for managements of scaphoid nonunions even with AVN at proximal fragments.

Outcomes of the Sauve-Kapandji Procedure in Patients with Advanced Rheumatoid Arthritis

PURPOSE: We evaluated the clinical and radiographic outcomes of the Sauve-Kapandji procedure for the treatment of advanced rheumatoid arthritis. METHODS: Twenty-severn wrists in twenty-two patients were treated for advanced rheumatoid arthritis with Sauve-Kapandji procedure. Patients were evaluated in terms of wrist pain, bony union, instability of the ulnar proximal stump, ulnar stump pain, range of motion and other complications. Pain was evaluated using a visual analog scale. Radiographic evaluation included calculation of the carpal translation index to assess the extent of ulnar translation of the carpus. RESULTS: The average visual analogue scale score improved from 4+/-1.85 preoperatively to 0.78+/-0.91 at the last follow-up (p=0.003). Bone unions in distal radioulnar joint were obtained in all 22 patients, 27 wrists at mean 10.74 weeks (range, 6-28 weeks) after operation. The supination/pronation range of motion was changed from 55/50 degrees preoperatively to 79/73 degrees at postoperative 6 months follow up (p=0.32). The mean carpal translation index did not change after the operation. CONCLUSION: The Sauve-Kapandji procedure is a reliable methods of relieving pain, preserving range of motion (supination/pronation) and preventing ulnar translation of the carpus in managements of the severely destroyed distal radioulnar joints in rhematoid arthritis.

Evaluation of Neoadjuvant Chemotherapy Effect in Osteosarcoma / 대한골관절종양학회지

PURPOSE: Various diagnostic imaging modalities have been used to evaluate the effect of neoadjuvant chemotherapy for osteosarcoma early and noninvasively. We evaluated the effectiveness of imaging studies of plain radiographs and positron-emission tomography/computed tomography (PET/CT) in predicting neoadjuvant chemotherapy effect for osteosarcoma and tried to establish a general principle in interpretation of PET/CT parameters. MATERIALS AND METHODS: Eighteen patients who underwent two cycles of neoadjuvant chemotherapy and surgical excision for osteosarcoma were enrolled. There were 13 males and 5 females, with a median age of 19 (11-63) years. Fifteen patients of 18 had the American Joint Committe on Cancer (AJCC) stage IIB. They had plain radiographs and PET/CT before and after neoadjuvant chemotherapy. The resected tumor specimens were pathologically examined to determine histological response grade using a conventional mapping method. Statistical analysis was performed to evaluate the correlation between histopathological necrosis rate, and radiographic finding category, post-chemotherapy maximum standardized uptake value (SUVmax), average standardized uptake value and metabolic tumor volume (MTV) as well as reduction rates of them. RESULTS: Eight patients were good responders to neoadjuvant chemotherapy based on histological evaluation. Median SUVmax reduction rate was 73 (23-77) % in good responders and 42 (-32-76) % in poor responders. Median MTV reduction rate was 93.5 (62-99) % in good responders and 46 (-81-100) % in poor responders. While radiographic finding category was not different according to histological response (p=1.0), SUVmax reduction rate was significantly different (p=0.041). Difference in MTV reduction rates approached statistical significance as well (p=0.071). CONCLUSION: While radiographic finding category was not reliable to assess neoadjuvant chemotherapy effect for osteosarcoma, reduction rate of SUVmax was a useful indicator in this study. As parameters of PET/CT can be influenced by various factors of settings, different centers have to make an effort to establish their own standard of judgement with reference of previous studies.

An Atypical Case of Plasmodium vivax Malaria after Initiating Adalimumab Therapy

We report an unusual case of Plasmodium vivax malaria that occurred in a 22-year-old ankylosing spondylitis patient after initiating adalimumab therapy. P. falciparum malaria was initially included as a possible differential diagnosis due to hyperparasitemia and similar features in the peripheral blood smear. The patient was successfully treated with conventional therapy for P. vivax malaria.

Myelopathy Caused by Spinal Dural Arterio-Venous Fistula after First Lumbar Vertebral Body Fracture: A Case Report

Spinal dural arteriovenous fistula is a rare vascular lesion of the spinal cord associated with progressive myelopathy. Symptoms include progressive gait dysfunction, weakness, sensory loss, and bowel and bladder dysfunction. Because these symptoms overlap with other common causes of myelopathy and the disease is rare, spinal dural arteriovenous fistula is often not suspected and the time to diagnosis is long. We report the case of a 60-year-old woman who presented with progressive lower limb weakness and gait disturbance diagnosed as spinal dural arteriovenous fistula involving a fractured L1 vertebral body.

The Intra-articular Shoulder Injection of Botulinum Toxin A on Stroke Patients with Complex Regional Pain Syndrome

OBJECTIVE: To evaluate the short-term clinical effects of intra-articular shoulder injection with botulinum toxin type A (BoNT-A) in acute hemiplegic stroke patients with complex regional pain syndrome type I (CRPS I). METHOD: Fifty patients were assigned at random to receive intra-articular shoulder injection. The treatment groups were divided into two groups: BoNT-A group, 200 IU of BoNT-A and 2 ml of normal saline; triamcinolone acetonide (TA) group, 20 mg of triamcinolone and 2 ml of 2% lidocaine. Uptake ratio of quantitative three phase bone scintigraphy (QTPBS) was calculated by dividing the radioactivity count on the affected side by that on the unaffected side. Shoulder pain was assessed by visual analogue scale (VAS) and neuropathic pain scale (NPS). Range of motion (ROM) of shoulder joint and functional independence measurement (FIM) of upper limb were evaluated. All of them were measured before injection, and 4 weeks after injection. RESULTS: After 4 weeks, the uptake ratio of blood pool phase was significantly decreased in hands of BoNT-A group than TA group. VAS, ROM and upper extremity FIM was similarly improved in both groups. Pain intensity and cold pain of NPS were similarly decreased in both groups. Hot pain and dull pain of NPS decreased more significantly in BoNT-A group than TA group. CONCLUSION: In the short-term, intra-articular BoNT-A shoulder injection maybe has the therapeutic effect on acute CRPS I related stroke. And the uptake ratio of blood pool phase of the hand of QTPBS may be useful to assess the therapeutic effect of CRPS after acute stroke.