Case History #200
Date of Consultation: 6-5-1986
Note: This case includes three follow-up consultations, each with its own set of questions and images. The follow-up sessions are included below.
HISTORY OF PRESENT ILLNESS:
This 17-year-old left-handed white female high school student was referred for evaluation of her left upper limb symptoms. On 4-3-1986, the patient fell while playing soccer and sustained a closed Colles fracture of her left wrist with some impaction. She was placed in a cast, which extended from the mid-arm down to the fingers and held her wrist in flexion. After being placed in the cast, the patient noted numbness, tingling, and pain involving the entire left hand on both the palmar and dorsal surfaces. On 4-7-1986, she was referred to an orthopedic surgeon, who initially attempted to cut and loosen the cast, but finally removed it completely and placed her in a splint. The sensory symptoms and pain continued; so the next day (4-8-86), he performed a carpal tunnel release procedure. After the procedure, her sensory symptoms resolved. She was placed in another cast and was comfortable for the next few weeks. When that cast was removed, she was unable to extend her fingers at the metacarpophalangeal (M-P) joints and her left thumb was weak. Her orthopedist obtained a limited EMG and nerve conduction study (NCS) of the left radial nerve, which showed denervation of the extensor digitorum, extensor carpi ulnaris, and extensor indicis muscles and slowed radial nerve conduction velocity in the forearm. A neurological consultation was obtained at this point.
The patient’s past medical history and family history were unremarkable.
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Intact.
Cranial Nerves: Intact
Motor System: There were no areas of focal muscular atrophy, except for mild left hypothenar eminence atrophy. There were no fasciculations. Muscle tone was normal in all 4 limbs. Muscle power was normal in both lower limbs and in the right upper limb. In the left upper limb, muscle power was normal proximally with 5/5 strength noted in the muscles of the shoulder girdle, shoulder joint, and elbow joint. Normal power (5/5) was noted in the brachioradialis, extensor carpi radialis, and supinator muscles. Wrist and finger flexor muscle groups and forearm pronator muscles were also normal, with the exception of the flexor carpi ulnaris muscle (2/5). Thenar eminence muscles were moderately weak (4/5). Finger abduction, adduction, and hypothenar eminence muscles were markedly weak and rated 1/5. The following muscles were also markedly weak and rated 1-2/5: extensor digitorum, extensor indicis, extensor carpi ulnaris, extensor pollicis longus, and abductor pollicis longus muscles.
Reflexes: Deep tendon reflexes were 2/4 and equal in all 4 limbs. Plantar reflexes were flexor bilaterally.
Sensory System: Sensory examination was normal in both upper and lower limbs, except for slightly decreased appreciation of light touch and pinprick on the palmar aspect of the fourth and fifth fingers and over the hypothenar eminence on the left.
Cerebellar Function: Intact.
Gait and Stance: IntactQuestions
1. Is there evidence of spinal cord involvement in this case and, if so, at what level?
2. Is there evidence of dorsal or ventral root involvement or spinal nerve involvement in this case, and, if so, what is the level(s) of the involvement?
3. Is there evidence of plexus or peripheral nerve involvement in this case, and, if so, how would you differentiate between the two? What evidence is there to support one or the other site of lesion in this case?
4. Indicate the level of the neurologic lesions in this case and the structures involved by the pathologic process.
5. Where is the anatomical location of the pathologic process leading to this patient’s condition?
6. In general, what type of pathological process do you think is involved in this case?
7. What diagnostic procedure(s) would you undertake at this point?
Follow-Up Visit: 12-9-1986
HISTORY:
Since the patient’s deep radial nerve decompression operation on 7-24-86, her left radial nerve function has returned almost to normal. However, she continues to experience signs and symptoms of left ulnar nerve dysfunction. Her left hand is clumsy, and she cannot perform fine, coordinated movements with her hand and fingers. She does not notice any sensory symptoms in the left hand.
Around October 1, 1986, the patient began working as a receptionist at a restaurant, which required her to wear high heel shoes and remain standing for her entire 8 to 10-hour shift. Approximately 1 week later (10-8-86), she went on a long five-hour car trip. During this trip, she noted the onset of numbness and tingling involving the dorsal and plantar surfaces of the first 4 toes of the left foot and a corresponding area of the dorsal and plantar surfaces of the foot, including its medial aspect. These sensory symptoms spared the fifth digit, lateral aspect of the foot, and the heel. She denied any weakness of the left lower limb, ankle, or foot. She also denied any recent injury to the back, left lower limb, or foot. She denied any low back pain.
EXAMINATION:
Neurological examination on this date was normal, except for findings in the left upper and lower limbs. In the left upper limb, median nerve motor and sensory functions were normal, and radial nerve testing revealed only minimal residual weakness in the extensor digiti minimi muscle. However, ulnar nerve function remained markedly impaired and basically unchanged from 6-5-86.
In the left lower limb, motor testing revealed mild weakness (4+/5) of ankle plantar flexion, dorsiflexion, and extension of the big toe. No fasciculations, atrophy, or tone alterations were noted. Deep tendon reflexes in the lower limbs were symmetric, and the plantar reflexes were flexor bilaterally. Sensory testing revealed decreased appreciation of light touch and pinprick on the plantar and dorsal surfaces of the first four digits, corresponding aspects of the plantar and dorsal surfaces of the foot, and the medial aspect of the foot. Tinel signs were absent over the tibial nerve behind the medial malleolus and the common fibular (peroneal) nerve just below the head of the fibula.
1. At this point in time, is there evidence of spinal cord involvement in this case and, if so, at what level?
2. Is there evidence of dorsal or ventral root involvement or spinal nerve involvement in this case, and, if so, what is the level(s) of the involvement?
3. Concerning the patient’s new left lower limb signs and symptoms, is there evidence of plexus or peripheral nerve involvement in this case, and, if so, how would you differentiate between the two? What evidence is there to support one or the other site of lesion in this case?
4. Indicate the level of the neurologic lesions in this case and the structures involved by the pathologic process.
5. Concerning the patient’s new left lower limb signs and symptoms, where is the anatomical location of the pathologic process leading to this patient’s condition?
6. In general, what type of pathological process do you think is involved in this case?
7. What diagnostic procedure(s) would you undertake at this point?
Follow-Up Visit: 4-28-1987
HISTORY:
Since the patient’s last appointment on 12-9-86, her left lower limb signs and symptoms continue to worsen. At rest, her sensory symptoms in the left foot are similar to those that were present in December 1986. However, when she walks or uses the foot for a period of time, the numbness and paresthesias worsen in intensity.
In addition, for the past 3 to 4 weeks, she has noticed increasing weakness and difficulty with walking involving the left foot. She tends to walk with her left foot in an everted position (i.e., pes planus, talipes valgus). She also recently noted an area of exquisite tenderness at the lower border of the left popliteal fossa.
On a positive note, her left ulnar nerve function appears to be slowly improving, and she is able to use her left hand more effectively.
EXAMINATION:
Neurological examination on this date was again normal, except for findings in the left upper and lower limbs. In the left upper limb, median and radial nerve motor and sensory functions were essentially normal. As mentioned, ulnar nerve function continued to be impaired, but improving.
In the left lower limb, motor testing revealed moderate weakness (4/5) of ankle plantar flexion, dorsiflexion, inversion, and extension of the great toe. No fasciculations, atrophy, or tone alterations were noted. Deep tendon reflexes in the lower limbs were symmetric, and the plantar reflexes were flexor bilaterally. Sensory testing revealed decreased appreciation of light touch and pinprick on the plantar and dorsal surfaces of the first four digits, corresponding areas of the plantar and dorsal surfaces of the foot, and the medial aspect of the foot. Exquisite tenderness to palpation and a Tinel sign were present over the tibial nerve in the midline at the lower end of the popliteal fossa. Moderate tenderness to palpation was also present in the lateral aspect of the popliteal fossa, along the medial margin of the tendon of the biceps femoris muscle. When the patient walked, her left foot assumed a flat, everted position, revealing the weakness of the ankle inverters.
A small (3 cm) café au lait spot was noted on the posterior aspect of her left leg.
Questions
1. In view of the above clinical course, is there a change in your working diagnosis concerning the patient’s left lower limb findings?
2. What diagnostic procedure(s) or management options would you undertake at this point?
Follow-Up Visit: 8-17-1987
HISTORY:
Since the patient’s tibial nerve decompression operation on 5-11-87, her left lower limb function has improved and has returned almost to normal. The only time she notices any symptoms is when she tries to run. She continues to notice mild numbness and tingling in the plantar surface of the first 2 or 3 toes and a small area on the sole of the foot. She no longer notes tenderness with palpation of the popliteal fossa.
However, she continues to experience mild to moderate weakness of left ulnar nerve innervated muscles. She does not notice any sensory symptoms in the left hand.
EXAMINATION:
In the left upper limb, her ulnar nerve motor power was somewhat weak (3-4/5), but improving. Median and radial nerve function was normal.
In the left lower limb, mild weakness (4+/5) of ankle dorsiflexion and extension of the great toe persisted, but ankle plantar flexion, inversion, and eversion were normal (5/5). Sensory testing revealed mild hypalgesia involving the plantar surface of the first 2 to 3 toes, but the dorsal surface seemed normal. Of course, she now exhibited diminished perception of pinprick and light touch along the lateral border of the foot due to her sural nerve biopsy.
Questions
1. In view of the above clinical course, is there a change in your working diagnosis concerning the patient’s left lower limb findings?
2. In general, what type of pathological process do you think is involved in this case?
3. The findings in this case most likely represent a known neurologic syndrome. What is the name of this syndrome?
Answers