Routine 6-weeks outpatient visit in patients treated surgically for upper extremity fractures: Is it truly necessary?

OBJECTIVES: To investigate the usefulness of the routinely planned six-week outpatient visit and x-ray in patients treated surgically for the most common upper extremity fractures including clavicle, proximal humerus, humeral shaft, olecranon, radial shaft and distal radius. METHOD: This was a retrospective cohort study of all patients treated surgically for the most common upper extremity fractures between 2019 and 2022 in a level 1 trauma center. The first outcome of interest was the incidence of abnormalities found on the x-ray made at the 6-week outpatient visit. Abnormalities were defined as all differences between the intra-operative (or direct postoperative) and 6-week x-ray. In case an abnormality was detected, the hospital records were screened to determine its clinical consequence. The clinical consequences were categorized into requiring either additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion (ROM). The second outcome of interest was the incidence of deviations from the local standard post operative treatment and follow-up protocol based on the 6-week outpatient visit as a whole. Deviations were also categorized into either requiring additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion. RESULTS: A total of 267 patients were included. Abnormalities on x-ray at 6 weeks postoperatively were found in only 10 (3.7%) patients of which only 4 (1.5%) had clinical implications (in three patients extra imaging was required and in one patient it was necessary to deviate from standard weightbearing/ROM limitation regime). The clinical/radiological findings during the 6-week outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symptoms suggestive for complications. CONCLUSION: The routine 6-week outpatient visit and x-ray, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered. LEVEL OF EVIDENCE: Level IV; Case Series; Prognosis Study.

Upper Limb Function in People With Upper and Lower Limb Loss 8 Years Postinjury: The Armed Services Trauma Outcome Study (ADVANCE) Cohort Study.

OBJECTIVE: Upper limb (UL) disability in people with UL amputation/s is well reported in the literature, less so for people with lower limb amputation/s. This study aimed to compare UL disability in injured (major trauma) and uninjured UK military personnel, with particular focus on people with upper and lower limb amputation/s. METHODS: A volunteer sample of injured (n = 579) and uninjured (n = 566) UK military personnel who served in a combat role in the Afghanistan war were frequency matched on age, sex, service, rank, regiment, role, and deployment period and recruited to the Armed Services Trauma Rehabilitation Outcome (ADVANCE) longitudinal cohort study. Participants completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, scored from 0 (no disability) to 100 (maximum disability) 8 years postinjury. Mann-Whitney U and Kruskal Wallis tests were used to compared DASH scores between groups. An ordinal model was used to assess the effect of injury and amputation on DASH scores. RESULTS: DASH scores were higher in the group with injuries compared to the group without injuries (3.33 vs 0.00) and higher in people with lower limb loss compared to the group without injuries (0.83 vs 0.00), although this was not statistically significant. In the adjusted ordinal model, the odds of having a higher DASH score was 1.70 (95% CI = 1.18-2.47) times higher for people with lower limb loss compared to the group without injuries. DASH score was not significantly different between people with major and partial UL loss (15.42 vs 12.92). The odds of having a higher DASH score was 8.30 (95% CI = 5.07-13.60) times higher for people with UL loss compared to the uninjured group. CONCLUSION: People with lower limb loss have increased odds of having more UL disability than the uninjured population 8 years postinjury. People with major and partial UL loss have similar UL disability. The ADVANCE study will continue to follow this population for the next 20 years. IMPACT: For the first time, potential for greater upper limb disability has been shown in people with lower limb loss long-term, likely resulting from daily biomechanical compensations such as weight-bearing, balance, and power generation. This population may benefit from prophylactic upper limb rehabilitation, strength, and technique.

Investigation of the effect of task-oriented occupational therapy on daily living activity performance in chronic stroke patients.

Objective: Task-oriented therapy (TOT) is used to increase the effectiveness of upper extremity (UE) in activity daily living (ADL). This study aimed to investigate the effect of TOT on the participation and ADLs of stroke patients. Methods: Between October 2018 and February 2019, 28 chronic stroke patients were included in the study treated in Kocaeli University Hospital, Department of Physical Medicine and Rehabilitation, Turkey. The performance areas and participation status of the patients in which they experienced limitations were evaluated with the Canadian Occupational Performance Scale (COPM), and their level of independence in ADLs was evaluated with the Modified Frenchay Activity Index (mFAI) and Barthel Index (BI). All patients were included in the occupational therapy (OT) program five days a week for three weeks at Kocaeli University Hospital. Three ADLs in which they had difficulties were studied with 28 patients. Each of the activities was designed specifically for the patient. All assessments were repeated after three weeks of treatment. Results: A total of 28 patients, 12 females and 16 males, diagnosed with stroke, were included in the study. A statistically significant increase was found in the COPM performance and satisfaction value compared to the pre-treatment value (p<0.001). A statistically significant difference was found between pre- and post-treatment mFAI and BI values (p<0.001). Conclusions: Adding task-oriented therapy to the rehabilitation programs of stroke patients will contribute to the improvement of ADL.

Effectiveness of virtual reality-supported exercise therapy in improving upper extremity function and activities of daily living among patients after stroke: a systematic review of randomized control trials.

BACKGROUND: This systematic review describes the effectiveness of virtual reality (VR)-supported exercise therapy on upper limb motor function and activities of daily living after stroke. METHODS: Studies published through January 24, 2022, were identified using CINAHL, Cochrane Library, Embase, Medline, and Web of Science. Randomized control trials comparing VR treatment with conventional therapy (CT) for upper extremity rehabilitation after stroke were included. Methodological quality was assessed using the Cochrane risk-of-bias tool. RESULTS: Of 9 included studies, 5 concluded that the VR group outperformed control participants, 1 indicated the superiority of VR-supported exercises alone over CT, and 3 found VR comparable to CT in promoting upper limb motor function. Five studies analyzed independence in daily living, with 4 reporting no significant difference between VR and CT groups. No strong evidence indicated long-term benefits of VR-assisted exercise. All included studies demonstrated low risk of bias concerning random sequence generation, allocation concealment, outcome assessment blinding, incomplete outcome data, and selective reporting bias. However, a high risk of bias was observed regarding participant blinding due to the nature of the intervention. CONCLUSION: Most studies suggested that VR, used alongside CT, can improve motor function following stroke. However, the evidence was insufficient to conclude that VR outperforms conventional approaches.

Influence of Impaired Upper Extremity Motor Function on Static Balance in People with Chronic Stroke.

BACKGROUND: Stroke is a leading cause of disability, especially due to an increased fall risk and postural instability. The objective of this study was to analyze the impact of motor impairment in the hemiparetic UE on static balance in standing, in subject with chronic stroke. METHODS: Seventy adults with chronic stroke, capable of independent standing and walking, participated in this cross-sectional study. The exclusion criteria included vestibular, cerebellar, or posterior cord lesions. The participants were classified based on their UE impairment using the Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA-UE). A posturographic evaluation (mCTSIB) was performed in the standing position to analyze the center of pressure (COP) displacement in the mediolateral (ML) and anteroposterior (AP) axes and its mean speed with eyes open (OE) and closed (EC) on stable and unstable surfaces. RESULTS: A strong and significant correlation (r = -0.53; p < 0.001) was observed between the mediolateral (ML) center of pressure (COP) oscillation and the FMA-UE, which was particularly strong with eyes closed [r(EO) = 0.5; r(EC) = 0.54]. The results of the multiple linear regression analysis indicated that the ML oscillation is influenced significantly by the FMA-Motor, and specifically by the sections on UE, wrist, coordination/speed, and sensation. CONCLUSIONS: The hemiparetic UE motor capacity is strongly related to the ML COP oscillation during standing in individuals with chronic stroke, with a lower motor capacity associated with a greater instability. Understanding these relationships underpins the interventions to improve balance and reduce falls in people who have had a stroke.

Extraskeletal Ewing Sarcoma Disguised as a Vascular Malformation.

Extraskeletal Ewing sarcoma (EES) is a rare entity, accounting for only 3% of lesions encountered in upper extremity. We present two paediatric patients, who were initially diagnosed with a vascular malformation based on clinical assessment and imaging. Final histopathology revealed Ewing sarcoma of soft tissue origin, confirmed by immunohistochemical analysis. Hand surgeons, who are routinely approached for a myriad of hand pathologies, should be wary and consider EES as a differential when treating such lesions. A multidisciplinary approach with an appropriate treatment algorithm can help in a speedy diagnosis, improving the long-term prognosis of the disease. Level of Evidence: Level V (Therapeutic).

Efficacy and Safety of High-Dose TBS on Post-Stroke Upper Extremity Motor Impairment: A Randomized Controlled Trial.

BACKGROUND: Upper extremity (UE) motor function impairment is a major poststroke complication whose recovery remains one of the most challenging tasks in neurological rehabilitation. This study examined the efficacy and safety of the personalized neuroimaging-guided high-dose theta-burst stimulation (TBS) for poststroke UE motor function recovery. METHODS: Patients after stroke with UE motor impairment from a China rehabilitation center were randomly assigned to receive high-dose intermittent TBS (iTBS) to ipsilesional UE sensorimotor network, continuous TBS (cTBS) to contralesional UE sensorimotor network, or sham stimulation, along with conventional therapy for 3 weeks. The primary outcome was the score changes on the Fugl-Meyer assessment-UE from baseline to 1 and 3 weeks. The secondary outcomes included the response rate on Fugl-Meyer assessment-UE scores posttreatment (≥9-point improvement) and score changes in multidimensional scales measuring UE, lower extremity, and activities and participation. RESULTS: From June 2021 to June 2022, 45 participants were randomized and 43 were analyzed. The iTBS and continuous TBS groups showed significantly greater improvement in Fugl-Meyer assessment-UE (mean improvement, iTBS: 10.73 points; continuous TBS: 10.79 points) than the sham group (2.43 points) and exhibited significantly greater response rates on Fugl-Meyer assessment-UE (iTBS, 60.0%; continuous TBS, 64.3%) than the sham group (0.0%). The active groups consistently exhibited superior improvement on the other 2 UE assessments at week 3. However, only the iTBS group showed greater efficacy on 1 lower extremity assessment than the sham group at week 3. Both active groups showed significant improvements in activities and participation assessments. CONCLUSIONS: The study provides evidence for the efficacy and safety of high-dose TBS in facilitating poststroke UE rehabilitation. REGISTRATION: URL: www.chictr.org.cn; Unique identifier: ChiCTR2100047340.

Advancing vascularized composite allotransplantation: essential factors for upper extremity transplant program development.

Vascularized Composite Allotransplantation (VCA) offers a unique option to restore form and function after limb loss or facial trauma that cannot be satisfactorily accomplished through traditional prosthetics or reconstructions. Establishing a successful Upper Extremity Transplantation (UET) program requires strong leadership and a structured surgical team, and extensive interdisciplinary collaboration. We conducted a qualitative study among 12 health care professionals and patients. Informed consent was obtained per protocol, and semi-structured interviews were conducted online and recorded. Participants reported their perceptions of factors that either favored or hindered a successful outcome, including functional status before and after surgery, preparation for transplant, shared decision-making, rehabilitation, and psychosocial support. Thematic analysis revealed that it is essential to establish a team comprising various disciplines well before performing VCA procedures. Defining a common goal and choosing a defined leader is a key factor in procedural success and requires open collaboration beyond what is typical. Primary described categories are interdisciplinary collaboration and skills of the VCA team, building and leading a VCA team, pre-transplant procedures, post-transplant course, and factors to consider when establishing a program. The basic roles of team science play an outsized role in establishing a VCA program. Transplantation medicine involves various overlapping scientific and medical categories requiring health professionals to consciously work together to establish complex vertical and horizontal communication webs between teams to obtain positive outcomes. In addition to medical considerations, patient-specific factors such as transparent communication, therapy plan establishment, plan adherence, and continual follow-up are significant factors to overall success.

Impact of task-oriented training based on acupuncture rehabilitation on upper extremity function and quality of life of patients with early stroke.

BACKGROUND: Eighty percent of stroke patients develop upper limb dysfunction, especially hand dysfunction, which has a very slow recovery, resulting in economic burden to families and society. AIM: To investigate the impact of task-oriented training based on acupuncture therapy on upper extremity function in patients with early stroke. METHODS: Patients with early stroke hemiplegia who visited our hospital between January 2021 and October 2022 were divided into a control group and an observation group, each with 50 cases. The control group underwent head acupuncture plus routine upper limb rehabilitation training (acupuncture therapy). In addition to acupuncture and rehabilitation, the observation group underwent upper limb task-oriented training (30 min). Each group underwent treatment 5 d/wk for 4 wk. Upper extremity function was assessed in both groups using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Wolf Motor Function Rating Scale (WMFT), modified Barthel Index (MBI), and Canadian Occupational Performance Measure (COPM). Quality of life was evaluated using the Short-Form 36-Item Health Survey (SF-36). Clinical efficacy of the interventions was also evaluated. RESULTS: Before intervention, no significant differences were observed in the FMA-UE, MBI, and WMFT scores between the two groups (P > 0.05). After intervention, the FMA-UE, WMFT, MBI, COPM-Functional Mobility and Satisfaction, and SF-36 scores increased in both groups (P < 0.05), with even higher scores in the observation group (P < 0.05). The observation group also obtained a higher total effective rate than the control group (P < 0.05). CONCLUSION: Task-oriented training based on acupuncture rehabilitation significantly enhanced upper extremity mobility, quality of life, and clinical efficacy in patients with early stroke.

Anatomical assessments of injectate spread stratified by the volume of the intertransverse process block at the T2 level.

BACKGROUND: This cadaveric study aimed to analyze injectate spread to target nerves during a single-injection, ultrasound-guided intertransverse process block. METHODS: An ultrasound-guided intertransverse process block with three different injectate volumes was administered to 12 cadavers. Each hemithorax was subjected to computer-generated random allocation of 10, 15, or 20 mL ultrasound-guided, single-injection intertransverse process block at the T2 vertebral level. Latex dye solution was injected into each hemithorax in accordance with the allocated volume. The presence of dye at the nerve root in the sympathetic chain and intercostal nerves at various injection levels was examined via dissection. RESULTS: Injectate spread into the dorsal rami was observed in seven of eight (87.5%), seven of eight (87.5%), and all eight (100%) of the 10, 15, and 20 mL specimens, respectively. In all 20 mL specimens, consistent staining of the dorsal rami, spinal nerve, and dorsal root ganglion was observed. CONCLUSIONS: An injectate volume of 20 mL was required for consistent staining of the dorsal rami, spinal nerve, and dorsal root ganglion in an intertransverse process block. Although an augmented injectate volume was associated with an increased likelihood of target nerve staining, consistent staining of the sympathetic ganglion, rami communicans, and ventral ramus was not observed, even at a volume of 20 mL. The current study presents initial findings suggesting that as opposed to a sympathetic ganglion block, a 20 mL intertransverse process block may act as a feasible substitute for dorsal root ganglion, spinal nerve, and medial branch blocks within a clinical context.

The effect of horse riding simulator on upper extremity skills, trunk control and functionality in cerebral palsy: a randomized controlled trial.

PURPOSE: The aim of this study was to investigate the effect of horse riding simulator on upper extremity skills, trunk control and functionality in cerebral palsy (CP). MATERIALS AND METHODS: This randomized controlled trial included total 32 CP, 16 in horse riding simulator group (HRSG) and 16 in control group (CG). ABILHAND-Kids, Jebsen-Taylor Hand Function Test (JTHFT), Gross Motor Function Measurement-sitting dimension (GMFM-B), Trunk Control Measurement Scale (TCMS), Pediatric Evaluation of Disability Inventory (PEDI) were evaluated before and after procedure. RESULTS: It was observed that there were improvements in both groups for ABILHAND-Kids scores after intervention, but the change in HRSG was significantly higher (p < 0.001). For all parameters of JTHFT (except writing dominant, non-dominant, turning cards-dominant), there was a significant difference between groups in favor of HRSG (p < 0.001-0.002). There was no change in GMFM-B values with intervention for both groups (p > 0.05). There were significant changes in favor of HRSG group in terms TCMS-Total (p = 0.003). There were significant changes in HRSG compared to CG for PEDI (pPEDI-Self-care<0.001, pPEDI-Mobility<0.001, pPEDI-Social function=0.016, respectively). CONCLUSIONS: It has been found that HRS in addition to conventional physiotherapy have positive effects on upper extremity skills, trunk control and functional abilities in daily life in the rehabilitation process of CP.The study protocol is registered on ClinicalTrials.gov (Identifier: NCT05518370).

Horse riding simulator (HRS) in addition to the routine physiotherapy is an effective method to improve upper extremity skills in children with CP.HRS may be an effective method to improve functional abilities of the children with Cerebral Palsy (CP).HRS is suitable for indoor use and has positive therapeutic effects on children with CP.The type and difficulty of the movements can be programmed gradually with HRS.

Incidence of Upper Extremity Neuropathies at a Single Tertiary Care Institution in the United States: Trends in Recent Years, Including the COVID-19 Pandemic.

OBJECTIVE: This study examined trends in upper extremity (UE) neuropathies at a large urban tertiary care center in the Northeastern United States over the past five years, including the period of the COVID-19 pandemic. METHOD: A retrospective medical record review was conducted from 2018 to 2022. We collected data from unique patient records identified using International Classification of Diseases, Tenth Revision (ICD-10) codes for UE neuropathies. We characterized subjects by age, demographics, and duration of symptoms.  Results: This study included 288 pediatric patients and 51,997 adult patients newly diagnosed with UE neuropathy. Most patients were aged 55+; 0.4% of all patients diagnosed with UE neuropathy were children. Across all ages, there was an overall increase in UE neuropathy diagnoses in the past five years, with the most noticeable increases from 2018 to 2019 (+5,761 diagnosed individuals, or +122%) and from 2020 to 2021 (+2,769 diagnosed individuals, or +28.8%). CONCLUSION: Our institution's UE neuropathy diagnoses have increased in the past five years. Of note, there was a significantly increased rate of UE neuropathy diagnoses from 2020 to 2021. This increase coincides with the COVID-19 pandemic, which is leading to a changing environment for many Americans. These societal changes will likely become indelible after the pandemic; safety practices should be enacted to avoid these debilitating neuropathies.

Prospective analysis of glucose metabolism in patients with hand infection.

BACKGROUND: Type-2 diabetes influences the course and severity of hand infections. METHODS: We prospectively examined glucose metabolism in 90 patients with hand infection, distinguishing between normal, prediabetic and diabetic states. HbA1c-levels were evaluated prior to surgery. Patients with normal levels took an oral glucose tolerance test and those diagnosed with prediabetes were retested after the infection subsided. Hospital stay, number of surgical interventions and inflammatory markers were examined per group. RESULTS: Sixty-two patients (68.8%) had abnormal glucose metabolism: 17 (18.9%) with history of diabetes and 11 (12.2%) newly diagnosed. Prediabetes was observed in 34 patients (37.8%). At follow-up, prediabetes and diabetes were diagnosed in 7 cases each, and physiological glucose metabolism was observed in 3 patients. For the 11 patients unable to undergo a second oral glucose tolerance test, detailed phone calls confirmed absence of diabetes. C-reactive protein levels were significantly elevated in diabetic patients compared to those with normal glucose metabolism (p = 0.001) or prediabetes (p = 0.034). Patients with history of diabetes were significantly older than those with normal glucose tolerance (p = 0.001) or prediabetes (p = 0.017). There were no significant intergroup differences in thrombocyte count, length of hospital stay, interval from injury to admission or the number surgical interventions. CONCLUSION: Glucose metabolism should be assessed in patients with hand infections and reassessed after the infection has subsided in prediabetic cases.

Corrigendum: High-definition transcranial direct current stimulation for upper extremity rehabilitation in moderate-to-severe ischemic stroke: a pilot study.

[This corrects the article DOI: 10.3389/fnhum.2023.1286238.].

Upper Extremity Deep Vein Thrombosis in the Setting of Ductal Carcinoma In Situ: A Case Report.

Deep vein thrombosis (DVT) is a type of venous thromboembolism that usually involves a clot formation in the deep veins of the lower extremities. Its formation is linked to Virchow's Triad which factors in venous stasis, endothelial damage, and hypercoagulability. Venous stasis is the primary factor contributing to the development of DVT and it refers to varicosity, external pressure placed on the extremity, or immobilization due to bed rest or long flights. Clinical presentation of DVT depends on the extent and location of the thrombus with common signs including localized swelling, pain, warmth, and edema. The Wells criteria are typically applied to assess the likelihood of thrombus formation alongside D-dimer assay, ultrasound, or CT imaging. As previously mentioned, these mostly occur in the lower extremities. However, upper extremity DVT has been noted and has been linked to inherited issues with coagulation and autoimmune disorders. This report will discuss a case of left-arm DVT in a patient who underwent bilateral mastectomy with sentinel node biopsy for a diagnosis of ductal carcinoma in situ in the left breast.

Conservative Approach to Type III Ulnar Club Hand: Case Report.

Ulnar club hand is a rare condition of the upper limbs, for which treatment depends on the degree of morphological and functional impairment, correlating with the radiographic classification of Dobyns, Wood, and Bayne. The aim of the present study is to report a case of a 6-year-old male patient, followed up for type III ulnar club hand (total ulnar dysplasia). Despite the initial difficulty of manipulating objects and performing everyday tasks, conservative physical therapy treatment provided strength gain and development of functional skills for daily life. We conclude that patients with type III deformity can be properly managed with rehabilitation although they require outpatient follow-up until skeletal maturity is reached, as dynamic deformities and new functional limitations may lead to need for corrective surgeries.

The relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy.

BACKGROUND: Accurate visual information is needed to guide and perform efficient movements in daily life. AIMS: To investigate the relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy (uCP). METHODS AND PROCEDURES: In 49 children with uCP (7-15 y), we investigated the relation between stereoacuity (Titmus Stereo Fly test), visual perception (Test of Visual Perceptual Skills), visuomotor integration (Beery Buktenica Test of Visual-Motor Integration) and functional vision (Flemish cerebral visual impairment questionnaire) with bimanual dexterity (Tyneside Pegboard Test), bimanual coordination (Kinarm exoskeleton robot, Box opening task), and functional hand use (Children's Hand-use Experience Questionnaire; Assisting Hand Assessment) using correlations (rs) and elastic-net regularized regressions (d). OUTCOMES AND RESULTS: Visual perception correlated with bimanual coordination (rs=0.407-0.436) and functional hand use (rs=0.380-0.533). Stereoacuity (rs=-0.404), visual perception (rs=-0.391 to -0.620), and visuomotor integration (rs=-0.377) correlated with bimanual dexterity. Functional vision correlated with functional hand use (rs=-0.441 to -0.458). Visual perception predicted bimanual dexterity (d=0.001-0.315), bimanual coordination (d=0.004-0.176), and functional hand use (d=0.001-0.345), whereas functional vision mainly predicted functional hand use (d=0.001-0.201). CONCLUSIONS AND IMPLICATIONS: Visual functions and functional vision are related to bimanual function in children with uCP highlighting the importance of performing extensive visual assessment to better understand children's difficulties in performing bimanual tasks. WHAT THIS PAPER ADDS: Previous findings showed that up to 62 % of children with unilateral cerebral palsy (uCP) present with visual impairment, which can further compromise their motor performance. However, the relation between visual and motor function has hardly been investigated in this population. This study makes a significant contribution to the literature by comprehensively investigating the multi-level relation between the heterogenous spectrum of visual abilities and bimanual function in children with uCP. We found that mainly decreased visual perception was related to decreased bimanual dexterity, bimanual coordination, and functional hand use while impairments in functional vision were only related to decreased functional hand use. Additionally, elastic-net regression models showed that visual assessments can predict bimanual function in children with uCP, however, effect sizes were only tiny to small. With our study, we demonstrated a relation between visual functions and bimanual function in children with uCP. These findings suggest the relevance of thoroughly examining visual functions in children with uCP to identify the presence of visual impairments that may further compromise their bimanual function.

Acute reversal of respiratory distress after a preoperative single-shot interscalene nerve block.

BACKGROUND: Diaphragmatic paresis is a known complication of the interscalene block used for postoperative analgesia in shoulder surgery. A technique involving the injection of normal saline through the interscalene catheter to alleviate this condition has shown promise. This method, termed the "washing-off" technique, dilutes the local anesthetic around the phrenic nerve, mitigating respiratory symptoms. CASE PRESENTATION: A 65-year-old male patient with multiple comorbidities (American Society of Anesthesiologists physical status classification 4) was scheduled for arteriovenous brachiocephalic fistula creation under regional anesthesia. Following an interscalene block with 32 mL of mepivacaine 1.5%, the patient experienced acute respiratory distress, with SpO2 at 88% despite 6 L O2 via nasal cannula. To avoid intubation, a 20 mL normal saline injection was administered through single-shot interscalene injection under ultrasound guidance. Within 5 min, respiratory distress markedly improved, allowing the patient to converse. Surgery proceeded without complications, maintaining SpO2 at 99% with 6 L O2. Postoperatively, the patient remained stable, with SpO2 at 98% on 2 L O2, and was discharged from the recovery room without additional oxygen requirements. CONCLUSIONS: The "washing-off" technique's mechanism may involve dilutional effects, pH changes or local sodium concentration alterations affecting the phrenic nerve. This case demonstrates its effectiveness in an acute setting, enabling surgery under regional anesthesia without intubation or any additional analgesia. The previously considered placebo effect appears unlikely here.

Point Tenderness for 35 Years: A Rare Presentation of a Glomus Tumor in the Proximal Upper Extremity.

Glomus tumors are rare benign neoplasms that are commonly found on the fingers and distal extremities. Clinically, they are often associated with a symptom triad of moderate pain, cold sensitivity, and point tenderness. These tumors are often not considered during a clinical workup due to their rarity and can be misdiagnosed due to their diverse clinical presentations. Glomus tumors are made up of mesenchymal cells derived from glomus bodies, which are specialized arteriovenous (AV) anastomoses primarily responsible for thermoregulation. Microscopically, they present as intricate nests of endothelial cells surrounding glomus bodies, which can clinically manifest as point tenderness. Glomus tumors are usually benign and are commonly found in locations with a high concentration of glomus bodies such as the fingers. Extradigital tumors are very rare and usually not considered in primary diagnosis. This can lead to patients experiencing years and, in this case, decades of unexplained pain. The diagnostic workup for glomus tumors should include an initial Doppler ultrasound and a definitive diagnosis via immunohistochemistry (IHC). They can be completely cured with surgical excision. Although most glomus tumors are benign and easily treatable, they are often not considered in differential diagnoses when assessing for point tenderness.  This case illustrates an atypical presentation of a glomus tumor that caused 35 years of chronic pain and was incidentally misdiagnosed on imaging, leading to treatment delay by an additional eight months. This exemplifies the necessity of including glomus tumors within the differential diagnosis and diagnostic workup for point tenderness and soft tissue masses of the upper extremity.