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麻痺側の前脛骨筋と中殿筋への機能的電気刺激が脳卒中片麻痺者の歩行に与える即時的な運動学的変化を検討することを目的とした。対象は､左片麻痺を呈し脳梗塞発症後101日が経過した70歳代女性、歩行はT 字杖を使用し､自立していた。麻痺側の前脛骨筋のみに対する電気刺激､前脛骨筋に加え中殿筋にも電気刺激を行う２つの刺激条件下で歩行練習を行い､その前後の歩行を比較した。歩行速度､歩行率､ストライド長は２条件ともに改善したが条件間に明らかな差を認めなかった。一方､前脛骨筋のみの刺激に比べ中殿筋への刺激を追加した条件では、麻痺側初期接地時の上部体幹の矢状面における傾斜が正中位に近くなり、股関節の矢状面における運動範囲が増加した。脳卒中の歩行練習では、前脛骨筋に加え中殿筋に電気刺激を行うことで、麻痺側立脚相の体幹と股関節の運動の改善に寄与する可能性が示唆された。PURPOSE: Stroke can cause impairments in gait kinematics, such as drop foot and lateral trunk fluctuation. Although functional electrical stimulation (FES) to the gluteus medius and tibialis anterior is used during gait training to overcome these impairments, its effects on gait kinematics remain unclear. The purpose of this study was to investigate the kinematic effect of FES to the gluteus medius and tibialis anterior during gait in a post-stroke patient. METHODS: The participant was a female patient in her 70s who had experienced a stroke 101 days previously. She was able to walk without the assistance of a cane. The participant had gait training for periods of 20 minutes at a self-selected velocity under two different FES conditions: stimulation to the tibialis anterior during the swing phase (TA) and stimulation to the gluteus medius and tibialis anterior during the swing and early stance phases (TA+GMed). We compared the change in gait velocity, cadence, and stride length, upper trunk angle in the sagittal and frontal plane at initial contact, and the motion range of angle of the affected hip extension-flexion relative to that before training. RESULTS: Gait velocity, cadence, and stride length showed notable increases post-training, although differences between TA and TA+GMed were not as apparent. Upper trunk angle in the sagittal and frontal plane at initial contact showed greater improvement in the TA+GMed condition than in the TA condition. Motion range of angle of the affected hip extension-flexion at post training examination was 40.49 ± 2.12° and 44.14 ± 1.41° in TA and TA+GMed, respectively. CONCLUSION: The results of this study suggest that FES to the gluteus medius and tibialis anterior during gait produces an improvement in hip and trunk kinematics.

Syphilis is a sexually transmitted infectious disease caused by the bacterium Treponema pallidum and can cause a wide variety of cutaneous manifestations, most commonly, a papulosquamous eruption of the trunk and extremities. Treatment with penicillin is curative. We report a case of a 69-year-old man who presented with recent onset of blurry vision and a non-painful, non-pruritic eruption of pink-to-violaceous dermal nodules on his upper trunk and upper extremities. Biopsies of two separate locations revealed a dense superficial and deep perivascular atypical lymphocytic infiltrate with admixed plasma cells, histiocytes, and eosinophils. Some scattered cells expressed CD30, PD1, BCL-6 and ICOS. TCR-rearrangement showed an identical TCR-gamma clone between both biopsy specimens. The patient was subsequently seen by ophthalmology and diagnosed with acute anterior uveitis. RPR was reactive and CSF studies showed findings consistent with a diagnosis of neurosyphilis. A Treponema pallidum immunostain of the skin biopsies was performed upon re-review, and was diffusely positive for spirochetes at the dermal-epidermal junction and within injured vessels. The patient was treated with penicillin G with near resolution of his skin lesions. This case highlights the unusual ability of syphilis to mimic a T-cell lymphoma with matching clones across two different biopsy sites. This article is protected by copyright. All rights reserved.

Primary cutaneous amyloidoses (PCA) are a group of conditions characterized by deposition of amyloid in previously normal skin, without association with other skin or systemic diseases. We describe a Kazakhstani female with a 30-year history of increasingly spreading hyperpigmented macular as well papular skin lesions on her upper trunk accompanied by pruritus. Moreover, her medical history included intensely rubbing her skin with a cotton towel following bathing and showering. On the basis of the clinical and histopathological findings, the diagnosis of biphasic cutaneous amyloidosis was made. The present unusual case of biphasic cutaneous amyloidosis can be subsumed under mechanically-induced forms of cutaneous amyloidosis. In conclusion, the present case underscores the necessity to explore carefully the patient’s history in order to discover the cause of PCA.

Objectives This study aimed to assess the surgical outcomes of patients with work-related upper extremity musculoskeletal disorders (UE-MSDs) who failed conservative treatment. Material and Methods This was a retrospective study of 17 patients who had work-related UE-MSDs and underwent the following surgeries and follow-up evaluations: decompression, external and internal neurolysis of the upper trunk of the brachial plexus and the long thoracic nerve (LTN), and a partial resection of the anterior and middle scalene muscle. A detailed history of clinical presentation including pain, physical and clinical examinations of the extent of scapular winging (ESW), and upper extremity anatomical postures, such as active forward arm flexion and shoulder abduction, were recorded before and after 3 months of the surgery. Nerve conduction velocity and electromyography examination reports were obtained to assess the sensory or motor loss of the nerve injury before their operation. Results All 17 patients included in this report showed some improvement anatomically in the scapula appearance and functionally in their shoulder movements. More specifically, 9 (53%) patients got a restored to near healthy appearance of the scapula, and 11 (65%) patients recovered a full range of motion, 180° post-surgically. Overall, the mean shoulder flexion and abduction improved to 157±37.5° and 155±40.2° after the surgery from 106±30.2° and 111±34.8°, respectively (p < 0.0001). The ESW score also significantly improved from a mean of 1.5±0.51 to 3.5±0.71 (p < 0.0001). The post-surgical improvements were statistically highly significant (p < 0.0001). Conclusions Decompression and neurolysis of the upper brachial plexus and the LTN, and the partial release of the scalene muscle contracture procedures have fostered improvements in the shoulder anatomical appearance and movements in all 17 patients. Int J Occup Med Environ Health. 2021;34(3):427–35

Madelung disease is a rare, metabolic, malignancy-associated and disfiguring condition of unknown etiology, characterized by potentially debilitating neurological, cardiopulmonary, gastric, musculoskeletal and psycho-social complications. Also known as multiple symmetric lipomatosis (MSL), Benign Lipomatosis (BSL), and Launois-Bensaude syndrome, MSL is characterized by the symmetrical growth of subcutaneous non-encapsulated fat deposits, usually around the neck, but in some cases also around shoulders, the upper trunk, chest and limbs, and hip girdle. These abnormal fat deposits may rapidly grow over a few months or slowly enlarge over several years. Expanding fatty deformations may be disabling, have disfiguring aesthetic consequences, and infiltrate or compress adjacent vital structures. This case illustrates that painful, massive growths may also occur around the knees, re-grow post excision, and present with compressive neurological symptoms necessitating further surgical interventions.

Although recent studies have confirmed that muscles of the upper body are obliquely linked with the muscles of the contralateral lower extremity through posterior oblique sling (POS) system, the upper portion of the POS connected to the lower leg below the hamstring is yet to be determined. In the supine position, the active maximum dorsiflexion (DF) angles of the right and left legs were randomly measured. During passive trunk rotation performed by the therapist, the active maximum DF angles of the right leg (contralateral side) and left leg (ipsilateral side) were measured. In a long sitting position with and without trunk rotation, the active maximum DF angles in both legs were measured. The left upper body was made to rotate rightward in trunk rotation. In the contralateral lower extremity, the DF ROM in the sitting position with trunk rotation was significantly different compared with those in the sitting position without trunk rotation, and in the supine position with trunk rotation. In the comparison between the ipsilateral and contralateral lower extremity, significant differences were found in the DF ROM in the sitting position with trunk rotation. This study indicates that the tensile force generated by trunk rotation is transmitted to the contralateral terminal end by examining changes in DF ROM. Since the upper portion of the POS is connected all the way down to the contralateral calf, the POS must be considered during the clinical treatment of patients with restricted DF mobility.

The aim of this study was to determine the contribution of the upper trunk rotation consisting of roll-pitch-yaw to hand velocity in the forwards-backwards direction during front crawl strokes and to investigate the association of forwards-backwards hand velocity induced by the upper trunk rotation with stroke frequencies. Fifteen skilled swimmers with retro-reflective markers performed front crawl strokes in a swimming pool where a motion capture system was set. Forwards-backwards hand velocity solely induced by the upper trunk rotation was determined during the performance. In the pull and push phases, 28% and 19% of the backward hand velocity was induced by the upper trunk rotation, respectively, while 19% of the forward hand velocity resulted from the upper trunk rotation in the recovery phase. The upper trunk rotation contributed to the forwards-backwards velocity as much as the elbow joint and was the second primary source of backward hand velocity in the pull phase. The forwards-backwards hand velocity created by the upper trunk rotation was associated with the stroke frequencies (r = 0.56, p 0.05). The forwards-backwards hand velocity induced by the upper trunk would influence hand propulsion and stroke frequency so that a swimmer and coach should consider this performance-enhancing variable.

BACKGROUND: Non-neutral postures during computerised device use coupled with increased usage may increase the risk of neck pain. Greater knowledge of postures that individuals with neck pain adopt during computerised device use is warranted. OBJECTIVE: To evaluate neck and upper limb posture while using a tablet, laptop and desktop computer (sitting and standing) in individuals with chronic neck pain. METHODS: Differences in three-dimensional kinematic variables were assessed during four conditions: tablet, laptop, desktop computer (sitting and standing) in 22 individuals with chronic neck pain >3 months. Differences between kinematic variables were determined using one-way repeated measures ANOVA with Bonferroni post-hoc tests. RESULTS: Compared to the desktop (sitting), tablet and laptop use resulted in increased neck flexion (mean difference tablet – 14.42°, 95% CI – 19.88, –8.96, P

Exploration and grafting of the brachial plexus remains the gold standard for post-ganglionic brachial plexus injuries that present within an acceptable time frame from injury. The most common nerves available for grafting include C5 and C6. During the surgical exposure of C5 and C6, the phrenic nerve is anatomically anterior to the cervical spinal nerves, making it vulnerable to injury while performing the dissection and nerve stump to graft coaptation. We describe a novel technique that protects the phrenic nerve from injury during supraclavicular brachial plexus exposure and grafting of C5 or upper trunk ruptures or neuromas in-continuity. A 4-step technique is illustrated: (1) The normal anatomic relationships of the phrenic nerve anterior to C5 is displayed in the face of the traumatic scarring. (2) The C5 spinal nerve stump is then transposed from its anatomic position posterior to the phrenic nerve to an anterior position. (3) The C5 stump is then moved medially for retrograde neurolysis of C5 from its phrenic nerve contribution. The graft coaptation to C5 is performed in this medial position, which minimizes retraction of the phrenic nerve. (4) The normal anatomic relationship of the phrenic nerve and the C5 nerve graft is restored. We have been routinely relocating the C5 spinal nerve stump around the phrenic nerve for the past 10 years. We have experienced no adverse respiratory events. This technique facilitates surgical exposure and prevents iatrogenic injury on the phrenic nerve during nerve reconstruction.

Background The trapezius muscle is often utilized as a muscle or nerve donor for repairing shoulder function in those with brachial plexus birth palsy (BPBP). To evaluate the native role of the trapezius in the affected limb, we demonstrate use of the Motion Browser, a novel visual analytics system to assess an adolescent with BPBP. Method An 18-year-old female with extended upper trunk (C5–6–7) BPBP underwent bilateral upper extremity three-dimensional motion analysis with Motion Browser. Surface electromyography (EMG) from eight muscles in each limb which was recorded during six upper extremity movements, distinguishing between upper trapezius (UT) and lower trapezius (LT). The Motion Browser calculated active range of motion (AROM), compiled the EMG data into measures of muscle activity, and displayed the results in charts. Results All movements, excluding shoulder abduction, had similar AROM in affected and unaffected limbs. In the unaffected limb, LT was more active in proximal movements of shoulder abduction, and shoulder external and internal rotations. In the affected limb, LT was more active in distal movements of forearm pronation and supination; UT was more active in shoulder abduction. Conclusion In this female with BPBP, Motion Browser demonstrated that the native LT in the affected limb contributed to distal movements. Her results suggest that sacrificing her trapezius as a muscle or nerve donor may affect her distal functionality. Clinicians should exercise caution when considering nerve transfers in children with BPBP and consider individualized assessment of functionality before pursuing surgery.

Introduction In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. Patients and methods Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. Results Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. Conclusions The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.

Juvenile xanthogranuloma is a benign histiocytic cell proliferative disorder that occurs in early childhood. The most common presentation occurs within the first 2 years of life with papular or nodular changes to the skin on the head, neck or upper trunk. This case study documents the findings and treatment of a single solitary soft tissue mass in the forefoot of a 17-year-old patient. Unique to this case, the initial diagnosis of tuberous xanthoma was made and, with referral to an outside hospital, changed to a juvenile xanthogranuloma. In addition, unlike most juvenile xanthogranulomas in the literature, there was no superficial dermatological abnormality seen clinically. This change was not a dramatically different diagnosis, but further immunohistochemical staining was necessary for ultimate diagnosis. The soft tissue mass was self-contained to the deeper tissue layers and not the epidermis. The patient was followed for 12 months for possible recurrence and medical workup, without postoperative complications. The purpose of this study was to report on a unique finding and presentation of a xanthogranulomatous soft tissue mass in the forefoot of a pediatric patient.

First described in 1934, eccrine spiradenoma (ES) is a rare, benign adnexal tumour arising from eccrine sweat glands. It commonly presents as a slow-growing nodule on the upper trunk, and head and neck region, mostly in the age bracket of 15-35 years, with no gender preference. While no established guidelines exist for optimal management of malignant ES, some therapies have been studied. The diagnosis of this entity is extremely important as it can harbour a malignant component with disastrous outcomes which may be missed due to its strong resemblance to benign lesions, such as a papilloma. Here, we present the case of a 35-year-old lady who presented with a papilloma-like growth on the upper medial aspect of the thigh which was diagnosed as eccrine spiradenoma upon excision. Keywords: Eccrine Spiradenoma, adnexal tumour, dermal lesion, case report. Continuous...

Becker’s nevus (BN) is an acquired unilateral hyperpigmented hairy macule, whereas morphea is a chronic connective tissue disease of unknown etiology, characterized by skin thickening with increased quantities of collagen in the indurated lesion, usually involving the upper trunk and proximal extremity. The occurrence of both disease in the same anatomical site and individual was not reported previously. We report this rare case in a 17-year-old, Indian girl and was diagnosed after clinical histopathology and dermoscopic correlation. Morphea can be an interesting incidental occurrence within a large plaque of BN.

Objectives Keratosis pilaris (KP) is the condition of the skin with extensive keratin follicular plugging. It may be associated with the erythema. The upper arm extensor area, shoulders, back of neck and thighs, as well as face and the upper trunk are the areas of presentation. Available medications for KP give only symptomatic relief, while some produce serious side effects. There is no proven universal treatment for the disease that can provide complete recovery. Āyuṛveda management of KP is not yet reported. Case presentation A 26-year-old male patient, presented with main complaints started with papular lesions over his right shoulder, chest and upper back along and later with pustular lesions in the past 2 weeks. The condition was associated with redness, mild swelling and itching. The case was diagnosed as Keratosis pilaris based on its presentation, site, and pathogenesis. Also by analyzing the extent of vitiation of doṣas (morbidities), the Vata kapha pitta hara line of treatment was adopted, which was accomplished in two phases i. e. Śodhana Cikitsa and Śamana Cikitsa. Conclusion Both internal and external treatments along with diet restrictions were found effective in arresting the pathogenesis and recovery in a short period. All the symptoms associated with the condition were completely cured with no signs of re-occurrence.

Background Changes in radiation therapy practice and cancer incidence bring into question prior evidence suggesting that radiation therapy predominantly injures the brachial plexus upper trunk, while tumor invasion typically injures the lower trunk. Methods We reviewed electrodiagnostic brachial plexopathy reports in cancer survivors for predominant trunk involvement, injury mechanism (tumor invasion vs radiation), and primary cancer location. Results Fifty-six cases of cancer-associated brachial plexopathy were identified. There was no relationship between injury mechanism and brachial plexus injury level. However, primary cancer location superior/inferior to the clavicle increased the odds of predominantly upper/lower trunk involvement by a factor of 60.0 (95% confidence interval: 7.9, 1401, respectively). Conclusions Cancers superior/inferior to the clavicle increase the likelihood of predominantly upper/lower trunk plexopathy, respectively, regardless plexus injury mechanism. These findings contrast with older work, possibly due to more precise radiation therapy techniques and increased incidence of radiosensitive head and neck cancers.

BACKGROUND Locally advanced malignancies of the upper torso and shoulder girdle (UT-SG) necessitate extensive resection and complex reconstruction. Due to the infrequent nature of these operations, a global reconstructive algorithm has not been defined. METHODS A retrospective review of all patients who received reconstructive surgery following malignant tumor extirpation in the UT-SG from 2008 to 2018 at the University of Texas MD Anderson Cancer Center. Factors predicting the need for flap reconstruction and risk for postoperative complications were evaluated. RESULTS In total, 252 procedures met inclusion criteria. The most common pathology was sarcoma (76%) and 52% were primary tumors. The median defect area was 112 cm2 (range 4-1350 cm2 ). Reconstructive techniques included pedicled flaps (46%), local tissue rearrangement (38%), and free flaps (16%). On univariate analysis, the probability of needing a free flap increased 39% when the defect size increased by 100 cm2 . The strongest independent predictors of requiring a free flap were major vessel exposure (adjusted odds ratio [OR] = 4.92, 95% confidence interval [CI], 1.36-17.84, P = .015) and major peripheral nerve exposure (adjusted OR = 3.2, 95% CI, 1.1-9.2, P = .031). CONCLUSION Despite the aggressive nature of their malignancies, patients requiring an UT-SG resection demonstrate high survival rates and therefore demand a durable reconstruction. Exposed critical structures and defect size were predictive of free tissue transfer.

Guttate psoriasis is a type of psoriasis that presents over the upper trunk and proximal extremities, it is small (0.5 to 1.5 cm in diameter) lesions; it is found frequently in young adults. As per its clinical features we will compare with Kitibha Kushta. The life time prevalence is approximately 2% of individuals with psoriasis. Many treatment modalities have been adopted in medical sciences, but it is having various side effects. So here in this case by using Shodhan, Shaman and Bahirparimarjan chikitsa we successfully treated the case of Kitibha kushtha. It is a single case study, A 22 year male patient approached to Kayachikitsa OPD having complaint of multiple small red lesions over the chest, abdomen, and back region also on both upper limbs and Itching over them since 2 years.The patient was treated with Shodhan and Shaman Chikitsa. Patient got 90% result in chief and associated complaints and during and after the completion of therapy there is improvement in the quality of life of the patient. After Shodhana and Shaman Chikitsa patient got satisfactory relief in symptoms.

Pitch velocity (PV) is important for pitching success, and the pelvis and trunk likely influence pitch performance. The purposes of this study were to examine the differences in pelvis and trunk kinetics and kinematics in professional baseball pitchers who throw at lower versus higher velocities (HVPs) and to examine the relationships among pelvis and trunk kinetics and kinematics and PV during each phase of the pitch delivery. The pitch velocity, pelvis and trunk peak angular velocities, kinetic energies and torques, and elbow and shoulder loads were compared among HVPs (n = 71; PV ≥ 40.2 m/s) and lower velocities pitchers (n = 78; PV P P = .002) and were able to generate greater upper trunk angular velocities (+36.6 m/s,P = .01) compared with lower velocity pitcher. Trunk angular velocity (r = .29) and upper trunk rotation at hand separation (r = .18) and foot contact (r = .17) were weakly related to PV. Therefore, HVPs rotate their upper trunk to a greater degree during the early phases of the pitching motion and subsequently generate greater trunk angular velocities and PV.

We report a 23-year-old woman who presented with generalized scaly erythematous rash predominately on the upper trunk and hemorrhagic stomatitis. The histopathologic and immunopathologic findings were consistent with the diagnosis of paraneoplastic pemphigus. Castleman’s tumor was diagnosed with computed tomography and exploratory laparotomy. A partial clinical improvement was observed after complete tumor removal and intravenous immunoglobulin administration. However, the patient died as a result of septicemia.

麻痺側の前脛骨筋と中殿筋への機能的電気刺激が脳卒中片麻痺者の歩行に与える即時的な運動学的変化を検討することを目的とした。対象は､左片麻痺を呈し脳梗塞発症後101日が経過した70歳代女性、歩行はT 字杖を使用し､自立していた。麻痺側の前脛骨筋のみに対する電気刺激､前脛骨筋に加え中殿筋にも電気刺激を行う２つの刺激条件下で歩行練習を行い､その前後の歩行を比較した。歩行速度､歩行率､ストライド長は２条件ともに改善したが条件間に明らかな差を認めなかった。一方､前脛骨筋のみの刺激に比べ中殿筋への刺激を追加した条件では、麻痺側初期接地時の上部体幹の矢状面における傾斜が正中位に近くなり、股関節の矢状面における運動範囲が増加した。脳卒中の歩行練習では、前脛骨筋に加え中殿筋に電気刺激を行うことで、麻痺側立脚相の体幹と股関節の運動の改善に寄与する可能性が示唆された。PURPOSE: Stroke can cause impairments in gait kinematics, such as drop foot and lateral trunk fluctuation. Although functional electrical stimulation (FES) to the gluteus medius and tibialis anterior is used during gait training to overcome these impairments, its effects on gait kinematics remain unclear. The purpose of this study was to investigate the kinematic effect of FES to the gluteus medius and tibialis anterior during gait in a post-stroke patient. METHODS: The participant was a female patient in her 70s who had experienced a stroke 101 days previously. She was able to walk without the assistance of a cane. The participant had gait training for periods of 20 minutes at a self-selected velocity under two different FES conditions: stimulation to the tibialis anterior during the swing phase (TA) and stimulation to the gluteus medius and tibialis anterior during the swing and early stance phases (TA+GMed). We compared the change in gait velocity, cadence, and stride length, upper trunk angle in the sagittal and frontal plane at initial contact, and the motion range of angle of the affected hip extension-flexion relative to that before training. RESULTS: Gait velocity, cadence, and stride length showed notable increases post-training, although differences between TA and TA+GMed were not as apparent. Upper trunk angle in the sagittal and frontal plane at initial contact showed greater improvement in the TA+GMed condition than in the TA condition. Motion range of angle of the affected hip extension-flexion at post training examination was 40.49 ± 2.12° and 44.14 ± 1.41° in TA and TA+GMed, respectively. CONCLUSION: The results of this study suggest that FES to the gluteus medius and tibialis anterior during gait produces an improvement in hip and trunk kinematics.

Spindle cell lipoma (SCL) is a rare, benign subcutaneous neoplasm that typically occurs on the upper trunk or neck of middle-aged men. The diagnosis of SCL is often straightforward due to its characteristic clinical presentation and classic histologic features of admixed mature adipocytes and CD-34 positive bland spindle cells. However, the diagnosis can be elusive when low-fat and free-fat patterns occur. Due to the lack of lipogenic content and morphologic overlap, this rare tumor is often mistaken for other benign and malignant soft tissue tumors. The authors present the case of a middle-aged man with a fat-free SCL of the temporal scalp. To our knowledge, this is the first reported case in the literature of a fat-free SCL involving the temporal scalp. With careful attention to the clinical context, histologic features, immunohistochemical profile, and cytogenetic abnormalities, the proper diagnosis of SCL without a lipogenic component can be achieved.

Financiado para publicación en acceso aberto: Universidade da Coruña/CISUG [Abstract] Introduction: Phrenic nerve transfer has been shown to achieve good nerve regeneration in brachial plexus avulsion. Acellular nerve allografts (ANAs) showed inferior results to autografts, which is why its use with mesenchymal stem cells (MSCs) is currently being studied. The aim is to study the effect of BM-MSCs associated with ANAs in a rat model of phrenic nerve transfer to the musculocutaneous nerve in a C5-C6 avulsion. Material and methods: 42 Wistar-Lewis rats underwent a C5-C6 lesion in the right forelimb by excising a 3 mm segment from both roots, followed by a phrenic nerve transfer to the musculocutaneous nerve associated with the interposition of a three types of nerve graft (randomly distributed): control (autograft) group (n = 12), ANAs group (n = 12), and ANAs + BM-MSCs group (n = 18) After 12 weeks, amplitude and latency of the NAP and the compound motor action potential (CMAP) were measured. Biceps muscles were studied by histological analysis and nerve grafts by electron microscopy and fluorescence analysis. Results: Statistically significant reductions were found in latency of the CMAP between groups control (2.48 ± 0.47 ms) and experimental (ANAs: 4.38 ± 0.78 ms, ANAs + BM-MSCs: 4.08 ± 0.85 ms) and increases in the amplitude of the CMAP between groups control (0.04388 ± 0.02 V) and ANAs + BM-MSCs (0.02275 ± 0.02 V), as well as in the thickness of the myelin sheath between groups control (0.81 ± 0.07 μm) and experimental (ANAs: 0.72 ± 0.08 μm, ANAs + BM-MSCs: 0.72 ± 0.07 μm) and in the area of the myelin sheath between groups control (13.09 ± 2.67 μm2 ) and ANAs (10.01 ± 2.97 μm2 ) (p < .05). No statistically significant differences have been found between groups ANAs and ANAs + BM-MSCs. Conclusions: This study presents a model for the study of lesions of the upper trunk and validates the autologous graft as the gold standard.

A 55-year-old male presented with an eight-month history of erythematous papules and plaques with demarcated areas of spared skin on his trunk, upper extremities, neck, and face. Grover's disease is a rare, acquired disorder of unknown origin, which is classically characterized by the appearance of erythematous papules on the upper trunk that are usually transient. As in the present case, there are reports of atypical disease, with facial involvement, pityriasis rubra pilaris-like lesions, and a more chronic course.

An 11-year-old boy presented to the emergency department 5 days after playing in the forest. His initial eruption, consistent with allergic contact dermatitis to poison ivy, progressed into target lesions involving his extremities, palms, upper trunk, and face, consistent with an erythema multiforme-like eruption. This report details the case and reviews the literature concerning this atypical and potentially underreported complication of plant-induced allergic contact dermatitis.

Madelung's disease is a rare benign systemic lipomatosis, which often presents in the head, neck and upper trunk regions. The appearance of symmetrical, excessive adipose tissue in the subcutaneous layer is its clinical characteristic. Orbital involvement is unusual with only a few cases reported previously. In this study, we describe the clinical and radiological features of Madelung's disease in the orbits. A 42-year-old man with alcohol addiction presented with chronic bilateral masses of the lower eyelids and proptosis. Computed tomography (CT) scan showed excessive symmetrical non-encapsulated fat deposition in the orbital fat, lower eyelids, salivary glands, subcutaneous tissue along the neck and under the sternocleidomastoid muscles and supraclavicular areas bilaterally. Histopathological study of the orbital masses revealed mature adipose tissue interspersed with thin fibrous septae. He developed recurrent lipomatosis 1 year after surgical excision.

Madelung’s disease is a rare condition characterized by diffuse, multiple, symmetric, nonencapsulated fatty accumulation predominantly in the neck and upper trunk, which can predispose to obstructive sleep apnea. This case report involves a 51-year-old man affected by Madelung’s disease who complained of difficulty breathing and inability to sleep in a supine position. An overnight pulse oximetry was performed, and the result was suggestive of moderate to severe obstructive sleep apnea. After auto-titrating continuous positive airway pressure therapy, the patient was prescribed continuous positive airway pressure therapy at the pressure setting of 13 cm of water. Alcohol cessation was also advised. At the 6-month follow-up visit, a marked improvement in neck cosmetic appearance and alleviation of sleep disturbance–related symptoms were observed. Polysomnography finally confirmed the diagnosis of severe obstructive sleep apnea. This case illustrates that a patient with Madelung’s disease may present with a clinical presentation of obstructive sleep apnea, which should be promptly diagnosed. Continuous positive airway pressure remains the treatment of choice. CITATION: Segsarnviriya C, Chirakalwasan N. A case of Madelung’s disease presenting with obstructive sleep apnea. J Clin Sleep Med. 2020;16(9):1603–1605.

Background In the past, a variety of methods have been explored to determine the center of gravity or gravity line, such as the hanging method or force plate analysis. However, these methods possess limitations related to precise location of center of gravity. The aim of this study was to describe a tissue separation method to precisely calculate the center of gravity in upper trunk. Methods Twenty post-operative patients with thoracolumbar kyphosis were retrospectively studied. Center of gravity models were computed: T1–T5 segment, T6–T10 segment and T1–T10 segment. The tissue separation method was used to calculate the center of gravity in each segment. A new center of gravity was composited from T1–T5 segment and T6–T10 segment by composition formula. Similarity and collinearity between center of gravity models was analyzed to verify the reliability of tissue separation method. Correlation between gravity line and theoretic hip axis was compared on pre- and post-operative radiographs to explore their potential application for surgical plan. Findings Composited center of gravity had significant correlation and high similarity with center of gravity in T1–T10 segment. There was high collinearity between center of gravity points. The post-operative included angle between the gravity line and theoretic hip axis significantly decreased to nearly 0°. Interpretation These findings demonstrate the MIMICS can reliably calculate the center of gravity in the upper trunk by a tissue separation method. The pre-operative included angle between the gravity line and theoretic hip axis was suggested as a parameter to improve surgical design for thoracolumbar kyphosis correction.

Progressive supranuclear palsy (PSP) is characterized by supranuclear gaze palsy, dystonic rigidity of the neck and upper trunk, frequent falls and mild cognitive impairment. Cerebellar ataxia is one of the exclusion criteria given by the National Institute of Neurological Disorders and Stroke and the Society for Progressive Supranuclear Palsy. As a result, pathologically proven PSP patients exhibiting cerebellar ataxia have often been misdiagnosed with spinocerebellar degeneration, specifically multiple system atrophy with predominant cerebellar ataxia (MSA-C). However, more recently, it has been recognized that patients with PSP can present with truncal and limb ataxia as their initial symptom and/or main manifestation. These patients can be classified as having PSP with predominant cerebellar ataxia (PSP-C), a new subtype of PSP. Since the development of this classification, patients with PSP-C have been identified primarily in Asian countries, and it has been noted that this condition is very rare in Western communities. Furthermore, the clinical features of PSP-C have been identified, enabling it to be distinguished from other subtypes of PSP and MSA-C. In this review, we describe the clinical and neuropathological features of PSP-C. The hypothesized pathophysiology of cerebellar ataxia in PSP-C is also discussed.

Eruptive tumor of the follicular infundibulum (TFI) is an extremely rare benign neoplasm that usually presents as asymptomatic multiple hypopigmented macules symmetrically distributed on the head, neck, and upper trunk. Herein, we report a case of eruptive TFI presenting as hypopigmented macules with central and slightly elevated erythematous papules at rarely involved locations of the four extremities, which has not been reported previously. The pathology showed characteristic features that were conclusive of the diagnosis of eruptive TFI. Because hypopigmentation is a common clinical manifestation and malignant transformation is possible with eruptive TFI, correct early diagnosis, and regular follow-ups are recommended.

When people walk on a treadmill, significant differences exist in postural control if compared to walking on the ground. In this paper, a method combining linear and nonlinear analysis is proposed to evaluate the walking postural control ability. In this method, the movements of the upper body and the feet are analyzed separately, because these parts have more capacity to reflect the characteristics of people’s gait. On this basis, the linear and nonlinear indicators of each part are analyzed, and the postural control ability is evaluated. The method is validated by three healthy subjects walking on both the treadmill and the ground. In treadmill walking case, the results show a smaller upper trunk acceleration (UTa) in the anterior-posterior (AP) direction. In the foot movement analysis, there are significant differences in the performance indexes related to the center of pressure (CoP) when people are walking on the treadmill and the ground. When walking on the treadmill, the velocity, acceleration, and jerk of the CoP in the AP direction are smaller than those in the ground walking case. Besides, when people walk on treadmills at uniform speeds, their feet accelerate is less in the vertical direction, and they have shorter stride length (SL) and longer stride time (ST). These results suggest that people have better postural control when walking on a treadmill. This method can be used as a means of assessing people’s behavior when walking on various situations by evaluating their control posture ability.

United States Consumer Product Safety Commission (CPSC) reported a 700% increase in Emergency Department (ED) visits for injuries attributed to unpowered scooter use from January through October 2000. Our objective is to investigate injuries associated with the use of unpowered scooters among adolescents from the age of >9 years to 20 years in the National Electronic Injury Surveillance Study (NEISS) data set from 2007-2017. We analyzed unpowered scooter-related injuries in the NEISS data set using variables: SCOOTER, INJURED, AFTER, OFF, AT and IN; the product code for injuries related to unpowered scooters is 1329, and age ≥9 years and 9 - 19

Although interscalene brachial plexus block (ISB) remains the gold standard for analgesia after shoulder surgery, the inherent risks of ipsilateral phrenic nerve block and hemidiaphragmatic paralysis (HDP) limit its use in patients with preexisting pulmonary compromise. In a previous Daring Discourse (2017), our research team has identified potential diaphragm-sparing alternatives to ISB for patients undergoing shoulder surgery. In recent years, the field has been fertile with research, with the publication of multiple randomized controlled trials investigating supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks. To date, the cumulative evidence (pre-2017 and post-2017) suggests that costoclavicular blocks may provide similar postoperative analgesia to ISB coupled with a 0%-incidence of HDP. However, in light of the small number of patients recruited by the single study investigating costoclavicular blocks, further confirmatory trials are required. Moreover, future investigation should also be undertaken to determine if costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. Anterior suprascapular nerve blocks have been demonstrated to provide surgical anesthesia and similar analgesia to ISB. However, their risk of HDP has not been formally quantified. Of the remaining diaphragm-sparing nerve blocks, supraclavicular blocks (with local anesthetic injection posterolateral to the brachial plexus), upper trunk blocks, and combined infraclavicular-anterior suprascapular blocks merit further investigation, as they have been shown to achieve similar analgesia to ISB, coupled with an HDP incidence

Direct coaptation of contralateral C7 to the upper trunk could avoid the interposition of nerve grafts. We have successfully shortened the gap and graft lengths, and even achieved direct coaptation. However, direct repair can only be performed in some selected cases, and partial procedures still require autografts, which are the gold standard for repairing neurologic defects. As symptoms often occur after autografting, human acellular nerve allografts have been used to avoid concomitant symptoms. This study investigated the quality of shoulder abduction and elbow flexion following direct repair and acellular allografting to evaluate issues requiring attention for brachial plexus injury repair. Fifty-one brachial plexus injury patients in the surgical database were eligible for this retrospective study. Patients were divided into two groups according to different surgical methods. Direct repair was performed in 27 patients, while acellular nerve allografts were used to bridge the gap between the contralateral C7 nerve root and upper trunk in 24 patients. The length of the harvested contralateral C7 nerve root was measured intraoperatively. Deltoid and biceps muscle strength, and degrees of shoulder abduction and elbow flexion were examined according to the British Medical Research Council scoring system; meaningful recovery was defined as M3-M5. Lengths of anterior and posterior divisions of the contralateral C7 in the direct repair group were 7.64 ± 0.69 mm and 7.55 ± 0.69 mm, respectively, and in the acellular nerve allografts group were 6.46 ± 0.58 mm and 6.43 ± 0.59 mm, respectively. After a minimum of 4-year follow-up, meaningful recoveries of deltoid and biceps muscles in the direct repair group were 88.89% and 85.19%, respectively, while they were 70.83% and 66.67% in the acellular nerve allografts group. Time to C5/C6 reinnervation was shorter in the direct repair group compared with the acellular nerve allografts group. Direct repair facilitated the restoration of shoulder abduction and elbow flexion. Thus, if direct coaptation is not possible, use of acellular nerve allografts is a suitable option. This study was approved by the Medical Ethical Committee of the First Affiliated Hospital of Sun Yat-sen University, China (Application ID: [2017] 290) on November 14, 2017.

Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.

We studied 12 patients with Parkinson's disease (PD): 6 with postural instability (Hoehn and Yahr Stage 3) and 6 without (Stage 2 or 2.5), using a quantitative test based on the clinical pull test. Their findings were compared with those for 12 healthy controls. The patients on their usual medications were pulled either forwards or backwards at the level of the shoulders and asked not to take a step in a series of five trials. Acceleration was monitored for the upper trunk, sacrum, and both tibias. EMG was measured in soleus and tibialis anterior (TA) muscles in all and for thigh and truncal muscles in a subgroup. A target of 0.2 g trunk acceleration was used, but smaller perturbations were used in very unstable patients. All the Stage 3 patients lost balance in at least one trial for the posterior perturbations but none for the anterior ones. None of the Stage 2 patients lost balance. There was increased tonic EMG and agonist activity but no difference in EMG onset or initial force production compared to healthy controls. For posterior perturbations, there were two related disorders that separated the PD patients from controls. There was a significantly higher ratio of sacral-to-applied acceleration and both PD groups showed reduced knee acceleration and shortened latency, more so for the Stage 3 group. The increased sacral-to-C7 acceleration ratio was correlated with the tonic level of activation of the hamstrings (HS), quadriceps, and lumbar paraspinal muscles (PS), while the tibial acceleration latency was also correlated with the level of tonic PS activation. We also found that the size of balance responses, 0-200 ms post-perturbation, correlated significantly with the level of tonic activation in nearly all the muscles studied. We confirmed that PD patients show greater instability posteriorly than anteriorly to applied perturbations. Our findings support increasing axial and limb rigidity as the cause of the impaired pull test rather than postural bradykinesia and suggest that tonic truncal and thigh muscle activation may be an important underlying cause.

Purpose: This study examined the effects of sagittal spinopelvic alignment on the clinical parameters, motor symptoms, and respiratory function in patients with mild to moderate Parkinson’s disease (PD). Methods: This study was a prospective assessment of treated patients (n=28, Hoehn and Yahr (H&Y) stage 2-3) in a PD center. Twenty-eight subjects (68.5±5.7 yrs) participated in this study. The clinical and demographic parameters, including age, sex, symptoms duration, treatment duration, and H&Y stage, were collected. Kinematic analysis was conducted in the upright standing posture with a motion capture system. A pulmonary function test (PFT) was performed in the sitting position using a spirometer. The motor symptoms were as sessed on part III of the movement disorder society sponsored version of the unified Parkinson’s disease rating scale (MDS-UPDRS). SPSS 18.0 was used to analyze the collected data. Results: The exceeding 12 degrees group of the lower trunk showed significantly higher on the clinical parameters than the below 12 degrees group. In addition, the exceeding 12 degrees group of the lower trunk showed a significantly lower forced expiratory volume at one second (FEV1) / forced vital capacity (FVC) (%) and 25-75% forced mid-expiratory flow (FEF) (L/s) than in the below group. On the other hand, there was no difference in the upper trunk and the cervical pelvis between the groups. Conclusion: These findings suggest that the sagittal balance in the lower trunk is related to the clinical parameters and respiratory func tion, but not the motor symptoms in patients with mild to moderate PD.

1. Joseph S. Tadros, MD* 2. Yang Yu, MD† 3. Anne W. Lucky, MD†,‡ 1. *University of Cincinnati College of Medicine, Cincinnati, OH 2. †Department of Dermatology, University of Cincinnati Medical Center, Cincinnati, OH 3. ‡Division of General and Community Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH A previously healthy, full-term, 3-month-old girl presents with several annular erythematous patches and plaques on the head, scalp, and upper body. The lesions first appeared at 6 weeks of age and progressively spread to involve the face and upper trunk. Past treatments included the topical antifungal butenafine 1% cream twice daily for 3 weeks without substantial improvement. The rash does not worsen with sun exposure, and there are no pets in the household. The mother notes that the patient’s 2 older siblings both presented with similar eruptions as infants. The patient’s older sister experienced several scaly erythematous lesions on her scalp at 4 months of age that cleared by 6 months after treatment with oral griseofulvin. Her older brother also presented with a similar spot on the abdomen in his first year of life that cleared after butenafine treatment. The family history is notable only for hypothyroidism in the mother and maternal aunt. The initial physical examination revealed several well-defined, 1.5- to 3-cm, annular, erythematous patches and plaques, some of which exhibited peripheral scale. The lesions were found on the scalp, forehead, neck, upper chest, and right arm (Figs 1 and 2). Telangiectasias were noted around the periphery of several lesions. A potassium hydroxide (KOH) examination of the peripheral scale was negative for fungal elements. Electrocardiography and cardiac examination findings were normal. Additional laboratory evaluation identified the diagnosis. …

Clarifying proximal gait adaptations as a strategy to reduce knee joint loading and pain for individuals with knee osteoarthritis (OA) contributes to understanding the pathogenesis of multi-articular OA changes and musculoskeletal pain in other joints. We aimed to determine whether biomechanical alterations in knee OA patients during level walking is increased upper trunk lean in the frontal and sagittal planes, and subsequent alteration in external hip adduction moment (EHAM) and external hip flexion moment (EHFM). A literature search was conducted in PubMed, PEDro, CINAHL, and Cochrane CENTRAL through May 2018. Where possible, data were combined into a meta-analysis; pooled standardized mean differences (SMD) of between knee OA patients and healthy adults were calculated using a random-effect model. In total, 32 articles (2037 participants, mean age, 63.0 years) met inclusion criteria. Individuals with knee OA had significantly increased lateral trunk lean toward the ipsilateral limb (pooled SMD: 1.18; 95% CI: 0.59, 1.77) along with significantly decreased EHAM. These subjects also displayed a non-significantly increased trunk/pelvic flexion angle and EHFM. The GRADE approach judged all measures as “very low.” These results may indicate that biomechanical alterations accompanying knee OA are associated with increased lateral trunk lean and ensuing alterations in EHAM. Biomechanical alterations in the sagittal plane were not evident. Biomechanical adaptations might have negative sequelae, such as secondary hip abductor muscle weakness and low back pain. Thus, investigations of negative sequelae due to proximal gait adaptations are warranted.

Background and Aims There are different scales to assess the degree of difficulty to ventilate and intubate the different patients. unfortunately there is the possibility of having an unanticipated difficult airway scenario. In this case, a 71-year-old female patient with chronic arterial hypertension managed with a diuretic and calcium antagonist; hypothyroidism treated with levothyroxine 100 milligrams a day. His current condition begins with a fall from the stairs with pain in his left shoulder, with deformity and inability to move his upper limb. She has a history of difficult intubation, in her last surgery she required advanced CPR secondary to hypoxia. Therefore, this patient represents a challenge. The objective is to demonstrate the usefulness and advantages offered by this regional technique. Methods An ultrasound-guided block was performed with a 50 mm needle with 20 gauge in the superficial cervical plexus and upper trunk of the brachial plexus in plane, with doses of ropivacaine at 0.25% and lidocaine with epinephrine at 1.75% with a volume of 10 and 5 milliliters, respectively without complications. Results The combined locoregional blockade in this patient was satisfactory, allowing the surgery to be performed with the patient awake, avoiding compromise and manipulation of the airway. Conclusions The anesthetic technique of choice in this type of patient is controversial, but the use of resources and alternatives that can be used is important to reduce the risks and possible complications associated with unwanted events during surgery. It is important to individualize the cases and assess the risk benefit of each anesthetic technique.

Background and Aims Since scapula innervation are very complex, the surgery for scapular fractures usually is done under general anesthesia.1 The aim was to perform successful regional anesthesia management with mild sedation for awake scapular fracture surgery with selective target block combinations. Methods A 77-year-old female patient with a right scapula fracture was scheduled for an open reduction and internal fixation by posterior approach at the beach-chair position. With informed consent, we performed the upper trunk block, a selective supraclavicular, and T3 thoracic paravertebral block. Upper trunk block2 at the point where it bifurcates into the suprascapular nerve/posterior and anterior division was performed with the in-plane technique and 17 mL of Ropivacaine 0.5% in a semi-sitting position in the supraclavicular fossa. (figure 1A). In this case, the supraclavicular nerve, divided into two branches, was blocked separately by 3 mL Ropivacaine 0.5%. (figure 1B) The thoracic paravertebral block at T3 with a total of 20 mL Ropivacaine 0.5% was performed at the sitting position by in the oblique sagittal in-plain technique from lateral to medial. Results The patient was completely awake (Richmond agitation scale 0) during the surgery and no pain in the postoperative care unit. (NRS 0/10). The acetaminophen 1 g orally just once given after almost 5 hours of surgery and she was discharged home 24 hours after the surgery. Conclusions The selective target block combinations might be considered for all structures with complex innervation, such as scapula.

Background Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting. Methods A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation. Results Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268). Conclusion In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery. Level of Evidence Level III; Therapeutic

Background Becker’s nevus syndrome is a syndrome characterized by the presence of a Becker’s nevus with ipsilateral breast hypoplasia or hypoplastic defects of the muscle, skin, or skeleton. The nevus usually consists of a circumscribed, unilateral, irregularly shaped hyperpigmented macule, commonly occurring around the anterior upper trunk, with/without hypertrichosis and/or acneiform lesions. This rare syndrome has not been reported in our locality to the best of our knowledge. Case presentation We report the case of a 15-year-old Igbo female patient who presented to our pediatric endocrinology clinic, University of Nigeria Teaching Hospital, Enugu, with complaints of asymmetry of the breasts and hyperpigmented macules on the side. Based on her symptoms, diagnosis of Becker’s nevus syndrome was made. The diagnosis of Becker’s nevus syndrome is mostly clinical, based on the presence of a Becker’s nevus with ipsilateral breast hypoplasia or hypoplastic defects of the muscle, skin, or skeleton. In our patient, there was a Becker’s nevus with ipsilateral breast hypoplasia. This syndrome, belonging to the class of epidermal nevus syndromes, is very rare, and is usually benign. She was placed on spironolactone tablets 50 mg daily, which have been associated with an improvement in the size of the hypoplastic breast, and her fears were allayed. Conclusion This syndrome has not been reported in our locality to the best of our knowledge and, therefore, has a propensity for misdiagnosis by clinicians because of its rarity. We therefore report this to create awareness among clinicians regarding this condition that is associated with much psychosocial trauma among patients, and that can be easily managed with oral spironolactone.

Background Isolated musculocutaneous nerve injuries are rare, and mostly iatrogenic or traumatic. Case Presentation We present a case of isolated musculocutaneous neurapraxia in an otherwise well young woman following uncomplicated simulated skydiving. Management and Outcome While the injury was quite debilitating, complete neurological recovery occurred within two months without any intervention. Discussion This case illustrates a rare pattern of neurological injury, caused by a recreational activity growing in popularity. The pattern of injury mimics that of an upper trunk brachial plexopathy or C5/6 radiculopathy. Increased awareness of the injury avoids misdiagnosis and affords the opportunity for prevention.

A 2-year-old male child was brought by his mother to outpatient Department of Surgery with chief complains of a swelling in the upper back on left side since birth. Further history suggested, the swelling was small in size since birth with associated mild tenderness and it gradually started increasing in size. On clinical examination, the swelling was pulsatile in nature, soft in consistency with mild reddish discolouration and ulceration of the overlying skin; however, there was no local rise of temperature. The swelling was superficial to the muscle plane and measured approximately 5.5 x 4.7 cm in size. For further investigation, the child was referred to the Department of Radiodiagnosis for ultrasonography. On ultrasound, there were multiple anechoic cystic areas showing increased vascularity on colour Doppler.

Introduction. In patients with delayed presentation between 6 to 12 months, surgical treatment guidelines are not well defined in brachial plexus injury. Still, several authors have agreed that functional outcomes in patients treated within six months from the date of injury have the best results. Nerve transfers are still considered one of the treatment options in the said subset of patients even after six months. In contrast, a primary Steindler flexorplasty, or proximal advancement of the flexor-pronator group, is an ideal technique for elbow flexion with an elapsed time from injury >6 to 9 months. Objective. The purpose of this investigation was to compare the clinical outcome s of nerve transfers versus modified Steindler flexorplasty for the restoration of elbow flexion in upper type brachial plexus injuries (BPI). Methods. A retrospective review of 28 patients who underwent nerve transfers (NT) and 12 patients who underwent modified Steindler flexorplasty (MSF) was done to determine the outcome of treatments. The manual muscle testing using the Medical Research Council scaling system, Visual Analog Scale for pain, active range of motion, and Disabilities of the Arm, Shoulder and Hand form scores were taken as dependent variables. Results. The NT group had a median age of 27.5 years, with 26 men, a median surgical delay of 5.6 months, and a median follow-up of 33 months. Twenty out of 28 patients (71%) had ≥M3 with a median range of 117.6° elbow flexion motion. Median postoperative DASH (n=16) and VAS scores were 29.2 and 3, respectively. For the MSF patients, the median age was 27 years, including ten men, the median surgical delay was 12 months, and the median follow-up was 18.4 months. All the 12 patients had ≥M3, with a median range of motion of 106°. The median postoperative DASH score (n=5) and VAS score were 28.3 and 0, respectively. In the NT group, 73.3% (11/15) achieved ≥M3 elbow flexion if the operation was done in

Herpes zoster is an infection caused by reactivation of varicella-zoster virus presenting as multiple grouped vesicular eruptions in a dermatomal pattern with associated pain. Recurrent herpes zoster is an uncommon event in an immunocompetent host. Here, we report a case of a young male presenting with herpes zoster over the T9 and T10 dermatome with the previous scarring of herpes zoster over the T6 dermatome over the right upper trunk. The patient improved on treatment with oral acyclovir and analgesics. In any patient with recurrenrt hepes zoster, work-up should be done to rule out immunosuppresion.

The cause of neuralgic amyotrophy (NA) is often unknown but is commonly associated with a recent upper respiratory viral tract infection. Since the beginning of the COVID-19 pandemic, there has been a tireless effort to understand the sequelae of the virus. A 46-year-old woman who presented after a COVID-19 hospitalization complicated by hypoxic respiratory failure requiring intubation and mechanical ventilation for 23 days was subsequently found to have lower extremity sensorium changes as well as upper extremity weakness. Left shoulder abduction and extension were both 3/5 in motor strength and left hip flexion strength was 4/5 with diminished sensation to crude touch in the left lateral thigh. Nerve conduction studies and electromyography (NCS/EMG) findings included a mild left median neuropathy at the wrist, and motor unit recruitment pattern consistent with a chronic left upper trunk plexopathy with re-innervation. The case presented describes an extended neuralgic amyotrophy syndrome (ENAS) from an atraumatic mechanism in a previously diagnosed COVID-19 patient. ENAS has at least three immune mediated etiologies postulated 1) direct neuropathogenicity 2) molecular mimicry and 3) direct cytotoxic effects on peripheral nerves. As COVID-19 survivors continue to be seen in outpatient settings, practitioners should remain aware of diffuse neurological complications as sequelae of the virus persist.