Multicore myopathy: respiratory failure and paraspinal muscle contractures are important complications

Three ambulant males with multicore myopathy, a rare congenital myopathy, are reported with nocturnal hypoventilation progressing to respiratory failure at the age of 9, 13, and 21 years. Deterioration in these individuals occurred over several months without any precipitating event. Patients had clinical evidence of nocturnal hypoventilation with hypoxaemia and hypercapnia. Forced vital capacity was significantly reduced (20 to 43% of predicted level). These parameters improved on institution of overnight ventilation using a BiPAP pressure support ventilator with face mask or nasal pillows with O2 saturation maintained above 90% overnight and an increase in forced vital capacity by as much as 100% (0.3 to 0.6 litres). This was matched by a symptomatic and functional improvement. Also present in these patients and not previously reported is the association of multicore myopathy with paraspinal contractures which produce a characteristic scoliosis described as a 'side-sliding' spine. This may be improved by spinal bracing or surgery.

[Eosinophilic fasciitis (Shulman syndrome)]

We report on a 35-year-old female with eosinophilic fasciitis (Shulman's syndrome). The characteristic features of this disease are scleroderma-like skin indurations, predominantly on the extremities, with joint contractures and intermittent blood eosinophilia. Histologic findings include fibrosis of muscle fascia and eosinophilic infiltration. Systemic corticosteroid therapy usually results in remission of symptoms. In this case refractory to systemic corticosteroids, we report for the fist time a successful therapy using cyclophosphamide.

Surgical treatment of extraarticular elbow contracture

The problem of the contracted elbow is well-recognized for the circumstances under which it develops and the difficulty of operative and non-operative treatment. Earlier studies report this problem in an unfavorable manner; however, current studies suggest that posttraumatic stiffness of the elbow, particularly when the articular surface is left intact, may be treated reliably. The authors present a specific surgical approach to the elbow that has posttraumatic motion limitation described as extrinsic, that is, primarily attributable to contracture of the capsule and periarticular soft tissues. The limited surgical exposure termed the column procedure allows anterior capsular exposure through an interval in the brachioradialis and extensor carpi radialis longus. Using this procedure the authors report the treatment of 38 elbows (38 patients) with sufficient followup to accurately describe the postoperative course. At a mean of 3.5 years after surgery the total postoperative arc of motion improved from approximately 50 degrees to approximately 90 degrees. There were minimal complications. A static adjustable splint rather than physical therapy is used postoperatively. It is concluded that newer surgical techniques with carefully described programs can be successful in the majority of patients undergoing surgical release for extrinsic contracture of the elbow.

Recognition and treatment of refractory posterior capsular contracture of the shoulder

SUMMARY

Limitation of internal rotation has been reported in conjunction with impingement syndrome of the shoulder. A group of 9 patients was identified who had discrete, painful loss of internal rotation associated with refractory impingement syndrome. The duration of symptoms averaged 18 months (range, 11 to 33 months), and all patients failed a course of physical therapy specifically addressing loss of internal rotation. Six patients reported traction as the mechanism of injury, and 3 developed motion loss and pain following a posterior capsular shift procedure. All patients underwent arthroscopy, and were observed to have a thickened posterior capsule. An arthroscopic release of the posterior capsule improved motion in all patients, with substantial relief of pain. At an average of 19 months follow-up (range, 11 to 35 months), internal rotation in 90 degrees of abduction improved from 10 degrees preoperatively to 47 degrees postoperatively, and there were no complications related to the procedure. We conclude that chronic loss of internal rotation secondary to posterior capsular contracture may be an explanation for refractory pain in some patients with an initial diagnosis of impingement syndrome. This condition appears to be amenable to arthroscopic posterior capsular release.

Treatment of shoulder deformity in acquired spasticity

Cerebrovascular accidents and traumatic brain injury produce most of the deformities seen in patients with spastic imbalance of the shoulder. A general awareness of the global neurologic defect is required to understand appropriate treatment alternatives. Conservative treatment techniques include early initiation of therapy exercises. Muscle or nerve block treatments may prevent severe shoulder contractures. Diagnostic blocks may help differentiate between deformity caused by spasticity and that caused by fixed soft tissue contracture. Operative release procedures are described. These operations, when combined with appropriate postoperative therapy programs, permit correction of contractures caused by unbalanced muscle forces around the shoulder in patients with severe spasticity who do not respond to conservative care.

[Dynamics of thermographic changes in patients with ischemic contracture of the foot]

In 28 patients with the foot ischemic contracture (FIC) the thermographic changes were studied up in reactive-restoration and residual periods. The patients' distribution in the reactive-restoration period according to the level of thermoasymmetry and radiation temperature has significance for the FIC of middle and severe stage prognostication.

Autosomal dominant limb-girdle muscular dystrophy with ankle joint contracture

We herein describe a Japanese family suffering from autosomal dominant limb-girdle muscular dystrophy showing a later onset and a predilection for males. All patients developed a plantar flexion contracture of the ankles when no distal muscular weakness was evident. The serum creatine kinase activity was remarkably elevated to 55 times the normal value. These clinical features suggest a novel phenotype.

Clinical study of the pumping pressure changes in the temporomandibular joint space before and after arthroscopic surgery

When arthroscopy of the temporomandibular joint (TMJ) is performed, we often observe differences in the resistance of hydraulic pressure during intra-articular pumping. It can be speculated that intra-articular adhesion and contracture of the capsule and ligament may cause these differences in resistance. In order to measure the changes in intra-articular hydraulic pressure before and after arthroscopic ablation surgery, seven cases were examined by balloon pumping technique. We concluded that the values of intra-articular hydraulic pressure are implicated in the severity of the internal derangement of TMJ.

Uncommon causes of anterior knee pain: a case report of infrapatellar contracture syndrome

The uncommon causes of anterior knee pain should always be considered in the differential diagnosis of a painful knee when treatment of common origins become ineffective. A case is presented in which the revised diagnosis of infrapatellar contracture syndrome was made after noting delayed progress in the rehabilitation of an active female patient with a presumed anterior horn medial meniscus tear and a contracted patellar tendon. The patient improved after the treatment program was augmented with closed manipulation under arthroscopy and infrapatellar injection of both corticosteroids and a local anesthetic. Infrapatellar contraction syndrome and other uncommon sources of anterior knee pain, including arthrofibrosis, Hoffa's syndrome, tibial collateral ligament bursitis, saphenous nerve palsy, isolated ganglions of the anterior cruciate ligament, slipped capital femoral epiphysis, and knee tumors, are subsequently discussed. Delayed functional advancement in a rehabilitation program requires full reassessment of the patient's diagnosis and treatment plan. Alternative diagnoses of knee pain are not always of common origins. Ample knowledge of uncommon causes of anterior knee pain is necessary to form a full differential diagnosis in patients with challenging presentations.

[Elbow contracture: causes, management]

Early results after conservative or operative treatment of 15 patients (6 females, 9 males) for contracture of the elbow are presented. The correction achieved has been evaluated by Mayo Elbow Performance Index and by range of flexion and extension movement. Immobilization of the injured elbow should be as short as possible, fixed deformity is an indication for surgery. Resulting contracture of the elbow depends not only on injury severity but on the type of treatment also. One case has been discussed.

What is reflex sympathetic dystrophy?

In the literature there is no unanimity with respect to the diagnosis of reflex sympathetic dystrophy (RSD). Frequently, the diagnosis is established on mere clinical grounds. In our opinion, however, bone scintigraphy is of major importance for the diagnosis. Using this examination, true RSD can be clearly differentiated from other conditions which are incorrectly diagnosed and treated as RSD. If the bone scan is not suggestive of RSD, the clinical picture, radiological examination and vascular scan may lead to the correct diagnosis. This may be a pseudodystrophy, in which a hypovascularization is found right from the start, while in true RSD there is initially a hypervascularization. Other conditions which may be confused with RSD are causalgia, neurotic compulsive postures, hysterical conversion, malingering and even self-mutilation. In the spontaneous course of RSD three phases can be distinguished. Stage I is the warm or hypertrophic phase, stage II the cold or atrophic phase. Per definition the third phase corresponds to stabilization or, in rare instances, to healing. By means of the vascular scan the correct stage can be determined, and the results of treatment evaluated. Finally it should be noted that in children the condition is completely different from true RSD, as it concerns a pseudodystrophy or disuse-related dystrophy. This condition may also be seen in adults and adolescents, usually females. The bone scan is always negative. In this way bone scintigraphy constitutes the means to answer the question as to what RSD is and what it is not. An algorithm for the differential diagnosis is presented.

[Malignant hyperthermia and neuroleptic malignant syndrome: report of 4 clinical cases]

Very numerous publication in the literature suggest the probable relationship between three clinical entities: peranesthesic malignant hyperthermia (PMH), exercitional malignant hyperthermia (EMH) and neuroleptic malignant syndrome (NMS). We briefly describe the clinical history and define, as subjects of research, the personal and familial histories of neuromuscular disease of 4 of our patients having presented with neuroleptic malignant syndrome, as recommended by the European group on malignant hyperthermia, the reference contracture test on neuromuscular fibers and anatomic and cytopathological investigations of neuromuscular fibers. We compare the results for our 4 patients having presented with neuroleptic malignant syndrome and their courses. We confirm the necessity of pursuing both case history and laboratory research in order to elucidate the debate on the hypothesis of a common etiopathogenesis for the 3 syndrome entities.

Progressive pseudorheumatoid arthropathy of childhood

Progressive pseudorheumatoid arthropathy of childhood (PPAC) described by Spranger et al is a rare autosomal recessive disorder. An 11 year-old girl was diagnosed as having PPAC at Ege University, Faculty of Medicine, Department of Paediatrics. Her complaints of painful joints, difficulty in walking and joint contractures began at the age of 3 years and she was treated for juvenile rheumatoid arthritis for 8 years. Her symptoms did not respond to nonsteroid anti-inflammatory treatment. During her last hospitalisation period, she was reinvestigated. Radiological examination showed spondyloepiphyseal dysplasia, severe acetabular irregularity and osteoporosis. All the laboratory test results for rheumatoid arthritis were negative. The clinical and radiological findings of the patient are illustrated.

Reconstruction of the elbow: surgeons' perspective

Great progress has been made in surgery of the elbow during the past decade. Better definition of ligamentous anatomy, recognition of previously undescribed instability patterns, and development of ligament reconstruction techniques have helped improve surgery designed to restore stability of the elbow. Surgical release of elbow contractures helps patients with stiffness gain very satisfactory range of motion. New techniques and advances in prostheses have broadened the indications for total elbow arthroplasty, and cases that were previously considered inoperable can now be treated surgically with excellent outcomes. Elbow surgery enters the new millennium having accomplished much, but problems and challenges remain.

Bilateral trigger thumbs in identical twins

Bilateral trigger thumbs in 4-year-old identical male twins are reported. To the authors' best knowledge, this is the first true description of this condition in identical twins. All four thumbs were treated by surgical release of the A1 pulley, with good results. The causes proposed for congenital and acquired trigger thumb are discussed, and it is concluded that the cases described here support a genetic predisposition to the condition.

Flexion contractures associated with a malignant neoplasm: 'A paraneoplastic syndrome?'

A 71-year-old man developed polyarthritis and, subsequently, severe flexion contractures of multiple joints, particularly the joints of the hands. Eighteen months after developing this disease a parailiacal lymph node metastasis of an unknown primary cancer was found. We suggest that this patient's history, dominated by contractures that resembled the 'palmar fasciitis and polyarthritis syndrome', should be considered as a paraneoplastic syndrome.

Prenatal diagnosis of a constitutional interstitial deletion of chromosome 5 (q15q31.1) presenting with features of congenital contractural arachnodactyly

Prenatal diagnosis of a constitutional interstitial deletion of chromosome 5 (q15q31.1) in a 30-year-old woman is reported. At 21 weeks of pregnancy, routine fetal ultrasounds showed the presence of apparently isolated bilateral club feet. Fetal karyotyping documented an interstitial deletion of the long arm of chromosome 5: 46,XX,del(5) (q15q31) in all 50 analyzed metaphases. Because such deletion is associated with severe psychomotor retardation, the pregnancy was terminated. Postmortem karyotyping of skin fibroblasts confirmed the presence of this interstitial de novo deletion in all mitoses. The breakpoints on 5q were analyzed by fluorescent in situ hybridization and were localized at 5q15 and q31.1. This case illustrates the importance of fetal karyotyping in cases of isolated club feet. At autopsy, the fetus presented had minor anomalies and contractures of knee and hip joints. These clinical findings could fit the diagnosis of congenital contractural arachnodactyly (CCA) or Beals syndrome. CCA is caused by a defect in the fibrillin-2 (FBN2) gene. This gene was previously mapped on 5q23-31. Our molecular studies of both parents and the fetus, using an intragenic polymorphic GT repeat, showed that the FBN2 gene was deleted in the fetus and that the de novo interstitial deletion occurred on the paternally inherited chromosome 5. Thus, CCA may be caused by a loss of function of the FBN2 gene. Clinical findings in this fetus and those of other described cases with interstitial 5q deletions are reviewed, and similarities with CCA are stressed.

A new test for estimating iliotibial band contracture

Contracture of the iliotibial band leading to flexion and abduction deformity at the hip is common in residual paralysis after polio. Ober's test has been used to detect this, but it is unreliable and cannot determine the degree of contracture. We describe a new test which quantifies this contracture and can be used for comparative purposes.

Further delineation of a new (Van Den Ende-Gupta) syndrome of blepharophimosis contractural arachnodactyly, and characteristic face

We report on 2 unrelated Indian girls with blepharophimosis, arachnodactyly, digital contractures which improved spontaneously, elbow deformity, beaked nose, everted lips, and large ears, findings similar to those in 2 cases reported previously by Van Den Ende et al. [1992, Am J Med Genet 42:467-469] and Gupta et al. [1995, J Med Genet 32:809-812], thus delineating a new syndrome of contractural arachnodactyly with characteristic facial anomalies.

Contracture of the deltoid muscle: imaging findings in 17 patients

OBJECTIVE

A retrospective review of the MR images and radiographs of 26 shoulders in 17 patients suffering from contracture of the deltoid muscle was used to establish the characteristic imaging findings.

MATERIALS AND METHODS

Deltoid muscle contractures in 26 shoulders in 17 patients encountered over a 4-year period are reported. The history of intramuscular injection and clinical symptoms and signs are detailed. Imaging studies including routine radiographs (24 shoulders), MR images (25 shoulders), and computed arthrotomograms (two shoulders) were reviewed. On MR images, the winging angle of the scapula (angle between the axis of the scapular body and the coronal plane of the chest) and the diameter of the lesion were measured and compared with data derived from 24 age-matched control subjects.

RESULTS

Diagnostic MR features of deltoid muscle contracture include fibrotic cord in the deltoid muscle, especially its middle portion, extending from the superior acromial surface to the deltoid tuberosity, and winging of the scapula (increased winging angle of the scapula). Characteristic radiographic features include abduction contracture, winging of the scapula, lateral down-sloping of the acromial process, and a superior acromial enthesophyte.

CONCLUSION

MR images are sensitive and accurate in the diagnosis of contracture of the deltoid muscles. Characteristic features also allow accurate routine diagnosis on radiographs.

[Acute intermittent porphyria with transient paresis and contracture. Evidence for initial myopathic dysfunction?]

A 70-year old man with acute intermittent porphyria had acute transient bibrachial paresis with moderate contracture of the involved muscles, which showed electrical silence in a conventional electromyographic investigation with surface electrodes placed over the contracted muscle belly (filter: 20 Hz-2 Hz, amplifier 50 microV). Slow finger movements were still possible and showed typical muscle-action potentials. This electroclinical correlation points to myopathic localized dysfunction, perhaps similar to rare case reports with patients having metabolic myopathy of McArdle's type.