Disclosures: Ady M. Correa-Mendoza, MD: No financial relationships or conflicts of interest

Case Description: Case of a young male post-polytrauma, including right shoulder Bankart repair and concomitant ulnar nerve entrapment at the elbow, treated conservatively with good response but 4 years later deteriorated with right forearm dysesthesias along ulnar distribution. Examination was remarkable for hand hypoesthesia, coldness, skin mottling, edema and Benediction hand deformity. Findings interfered with activities of daily living and writing. Follow up electrodiagnostic study lacked interval deteriorations of ulnar nerve entrapment and underlying plexopathy ruled out. Imaging studies were unremarkable for abnormalities of soft tissues, vascular or osseous structures. Exclusion diagnosis of superimposed hand dystonia was made, and corroborated by means of diagnostic and therapeutic OnabotulinumtoxinA infiltration trial.

Setting: Physiatry clinics

Patient: 39-year-old-male with history of polytrauma in 2013. Assessment/

Results: Patient with polytrauma and initial diagnosis of right ulnar neuropathy at the elbow, who presented 4 years later with right hand spasms, autonomic and neuropathic symptoms. After comprehensive workup, the exclusion clinical diagnosis was atypical Writer’s cramp; his hand dystonia was confirmed by diagnostic and therapeutic trial of OnabotulinumtoxinA. He was treated with infiltrations twice in a 2-year period: 10units to flexor digiti minimi brevis, 5units to 4th and 5th lumbricals, and 20units, then 24units to 4th and 5th flexor digitorum superficialis. Patient had marked improvement in autonomic symptoms, spasms and pain, improving his handwriting and dexterity.

Discussion: Our patient presented with atypical hand dystonia with autonomic features. Hand dystonia involves painless sustained muscular contractions and abnormal posturing of muscles. Presence of pain, autonomic symptoms as well as confounding factors such as prior history of trauma and right ulnar neuropathy, could make diagnosis challenging.

Conclusion: A high clinical suspicion, comprehensive examination and electrodiagnostic study aided in appropriate identification of this syndrome and allowed for conservative intervention. OnabotulinumtoxinA infiltration not only resulted in symptom improvement, but helped with clinical differentiation from ulnar neuropathy, preventing a surgical procedure.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2020

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/case-report-atypical-hand-dystonia-after-polytrauma/