"Pronation Compensation Sign" as a New Diagnostic Tool for Carpal Tunnel Syndrome: A Prospective Preliminary Study.

Purpose: Carpal tunnel syndrome (CTS) is commonly encountered in clinical practice. Diagnostic tools that currently exist include painful provocative maneuvers, invasive nerve conduction studies and the use of tests that require physician's direct participation in an era of sanitary crisis and virtual consultations. Therefore, having an easily accessible, reliable and practical tool for diagnosing CTS would be highly beneficial. Herein, we investigated the diagnostic value of the "pronation compensation sign" that we described for diagnosing CTS. Patients and Methods: We included 18 hands with and 18 hands without CTS (age: CTS hands = 52.5 ± 13.8 years, non-CTS hands = 43.2 ± 12.3 years; sex ratio: CTS hands = 12:8, non-CTS hands = 9:9). The presence of the "pronation compensation sign" was evaluated in each included hand. The presence of the "pronation compensation sign" were compared between CTS and non-CTS hands using the chi-squared test. Statistical significance was set at p < 0.05. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated of the "pronation compensation sign" for CTS. Results: All 18 hands with CTS showed a positive "pronation compensation sign", while those without CTS were negative. All 18 hands that were positive for the "pronation compensation sign" were hands with CTS, while those that were negative were hands without CTS. The sensitivity and specificity of the "pronation compensation sign" for diagnosing CTS were both 100%. The PPV and NPV of the "pronation compensation sign" for CTS were both 1.000. The rates of the presence of the "pronation compensation sign" were significantly different between hands with and without CTS (p < 0.001). Conclusion: The "pronation compensation sign" seems a useful tool for diagnosing CTS. We believe that the "pronation compensation sign" will help clinicians diagnose CTS with high diagnostic accuracy.

Lacertus notch as a sign of lacertus syndrome.

OBJECTIVE: Many clinicians are unfamiliar with a diagnosis of lacertus syndrome (LS). We investigated the value of the lacertus notch sign in diagnosing LS. METHODS: We included 56 consecutive patients (112 upper extremities) who had neuropathic pain and neurological symptoms of the hand. The presence of LS and the lacertus notch sign in each upper extremity was assessed. RESULTS: Of the 83 upper extremities with LS, 54 (65.1%) had a lacertus notch sign, whereas 29 (34.9%) did not. Of the 29 upper extremities without LS, 9 (31.0%) and 20 (69.0%) had and did not have a lacertus notch sign, respectively. The rates of lacertus notch presence in upper extremities with and without LS were significantly different. Of the 63 upper extremities with a lacertus notch sign, 54 (85.7%) were diagnosed with LS, whereas 9 (14.3%) were not. Of the 49 upper extremities without a lacertus notch sign, 20 (40.8%) were diagnosed with LS, and 29 (59.2%) were not. We observed significant differences in the rates of LS in upper extremities with and without lacertus notch. CONCLUSIONS: The presence of the lacertus notch sign is useful for diagnosing LS. When patients with neuropathic pain and neurological symptoms present with a lacertus notch sign, clinicians should consider the possibility of LS.

The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb.

OBJECTIVE: The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS: A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS: A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION: A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.

Laparoscopic treatment of Mirizzi syndrome with subtotal cholecystectomy and electrohydraulic lithotripsy: A case report.

Mirizzi syndrome is a rare chronic cholecystitis complication. However, the current consensus on managing this condition remains controversial, especially through laparoscopic surgery. This report describes the feasibility of treating type I Mirizzi syndrome with laparoscopic subtotal cholecystectomy and electrohydraulic lithotripsic gallstone removal. A 53-year-old woman presented with dark urine and right upper quadrant pain for 1 month. On examination, she was jaundiced. Blood tests showed highly elevated liver and biliary enzyme levels. Abdominal ultrasound showed a slightly dilated common bile duct with suspicion of choledocholithiasis. However, endoscopic retrograde cholangiopancreatography showed a narrowed common bile duct extrinsically compressed by a gallstone in the cystic duct, establishing a Mirizzi syndrome diagnosis. Elective laparoscopic cholecystectomy was planned. At operation, the trans-infundibulum approach was used since dissection around the cystic duct was difficult due to severe local inflammation of Calot's triangle. The gallbladder's neck was opened, and the stone was removed by lithotripsy via a flexible choledochoscope. Common bile duct exploration through the cystic duct was normal. The fundus and body of the gallbladder were resected, followed by T-tube drainage and suturing of the gallbladder's neck. The patient's postoperative clinical course was uneventful. Treating Mirizzi syndrome remains a major challenge for hepatobiliary specialists even with open surgery due to high complication rates, including bile duct injuries. Treatment is primarily to clear out the responsible stone and necrotic tissue. Due to advances in endoscopic surgery and equipment, subtotal cholecystectomy with laparoscopic gallstone extraction provides a safe and effective option for patients with Mirizzi syndrome. Laparoscopic subtotal cholecystectomy with electrohydraulic lithotripsy is a feasible and useful approach for treating Mirizzi syndrome that avoids iatrogenic bile duct injury.

Traumatic Macroglossia in a Patient With Rett Syndrome.

Traumatic macroglossia is a rare condition characterized by a sudden edematous swelling of the tongue due to trauma that can progress into upper airway obstruction and asphyxia. We are presenting a case of a 20-year-old female with medical history significant for Rett syndrome who developed severe tongue swelling after multiple attempts of intubation secondary to low Glasgow Coma Scale (GCS) from a high dose of benzodiazepines. Traumatic macroglossia in this case was worsened further by uncontrolled bruxism. Multiple approaches were made to control the situation including placement of bite block, use of paralytics, and steroids. Multiple cases were reported about traumatic macroglossia but our case was unique in the sense that our patient did not respond well to conservative medical therapy and surgical approach was not possible as it was set to be done in a tertiary center; however, transferring the patient was not possible with the COVID-19 pandemic as hospitals were on diversion.

Rectus sheath hematoma following enoxaparin administration.

Low-molecular-weight heparin, including enoxaparin, has efficacy comparable to that of unfractionated heparin and is considered the first-line option for thromboprophylaxis due to a decreased risk profile. This paper presents a rare case of epigastric artery rectus sheath hematoma following enoxaparin injection, resulting in multiorgan failure secondary to hemorrhagic shock. Discussion of this case may assist clinicians in the recognition and treatment of similar cases.

Chronic Eosinophilic Pneumonia in an Airbrush Painter With Poor Response to Systemic Steroids.

Airbrush paints contain low-molecular-weight chemicals that can cause occupational asthma, respiratory sensitization, and hypersensitivity pneumonitis; however, its relationship to chronic eosinophilic pneumonia (CEP) has never been reported. In this article, we are presenting a unique association between CEP and prolonged exposure to acrylic airbrush paints. Unlike the vast majority of CEP patients who exhibit an excellent response to systemic steroids, our patient did not respond to systemic steroids. We believe that his prolonged exposure to airbrush paints and the evolution of organizing pneumonia might have contributed to the unsatisfactory response to systemic steroids, prolonged hypoxia, and the overall worse prognosis. There are no current data that correlate acrylic paints to the development of CEP; our report is the first to introduce a probe to further investigate this association.