A 55-year-old man with uncontrolled diabetes presented with progressive length-dependent weakness, numbness, and paresthesia, leading to profound upper extremity weakness and lower extremity paraplegia in 4 months. A review of systems additionally revealed leg edema, chest wall erythema, and weight loss. Nerve conduction study/electromyography (NCS/EMG) showed axonal length-dependent sensorimotor polyneuropathy. Additional testing revealed a rare etiology. Treatment was started, and the patient's symptoms stabilized. This report discusses the diagnostic approach to rapidly progressive polyneuropathies, emphasizing careful systemic examination, laboratory studies, imaging, and electrophysiologic testing. It also highlights the importance of looking beyond neurologic signs to identify systemic evidence of disease involvement.

Introduction: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity and results from compression of the median nerve within the fibro-osseous carpal tunnel. Anatomical variants such as a bifid median nerve (BMN) and a persistent median artery (PMA) may increase tunnel occupancy and complicate both diagnosis and treatment. High-resolution musculoskeletal ultrasound enables detailed evaluation of these anatomical variations and facilitates image-guided interventions. Ultrasound-guided hydrodissection has emerged as a minimally invasive technique capable of mechanically releasing perineural adhesions and restoring nerve mobility. Alpha-2 macroglobulin (A2M), an autologous plasma protease inhibitor with anti-inflammatory and cytokine-binding properties, has recently been explored as a biologic adjunct in musculoskeletal conditions. Case Presentation: We report the case of a 60-year-old right-handed woman who presented with a one-year history of numbness, paresthesia, and pain within the median nerve distribution of her dominant hand. Ultrasound examination demonstrated a bifid median nerve accompanied by a persistent median artery and perineural edema within the proximal carpal tunnel. The patient underwent three weekly sessions of ultrasound-guided hydrodissection using autologous A2M prepared through the APEX filtration system. The patient reported progressive clinical improvement following treatment. Grip strength increased from 12 kg at baseline to 22 kg at week twelve. Follow-up ultrasound performed ten months after treatment showed restoration of median nerve fascicular architecture and normalization of nerve morphology, findings consistent with interval structural improvement. Discussion: This case highlights the role of ultrasound in the integrated evaluation and management of CTS with anatomical variants, including diagnosis, procedural guidance, and longitudinal assessment. Conclusions: Ultrasound-guided hydrodissection with A2M may represent a feasible minimally invasive approach in selected patients; however, further prospective studies are required to determine its safety and therapeutic efficacy.

Upper extremity deep venous thrombosis (UEDVT) is an uncommon clinical entity in adolescents, most often linked to central venous catheters or hypercoagulable states. Trauma-induced UEDVT is rare and challenging to diagnose due to nonspecific clinical signs that can mimic infection or soft tissue injury. We report an 18-year-old female who developed post-traumatic swelling and tenderness of the right forearm after being beaten by her school teacher. Initial non-contrast CT revealed subcutaneous edema without fracture. Subsequent CT angiography identified right brachial vein thrombosis with prominent collateral veins, confirming venous outflow obstruction. Early diagnosis allowed timely initiation of anticoagulation therapy, preventing complications. This case emphasizes CT angiography's diagnostic value in evaluating post-assault upper limb vascular injuries.

Thoracic outlet syndrome (TOS) is a constellation of symptoms associated with compression of the neurovascular bundle of the brachial plexus or subclavian vessels. TOS can be classified as neurogenic, arterial, or venous depending on the structure that is compressed. Symptoms include arm pain, swelling, fatigue, paresthesia, weakness, and discoloration of the hand. While neurogenic and vascular symptoms are well described, cutaneous manifestations of TOS are less often described. We present the case of a 43- year-old woman with acute right upper extremity (RUE) pain, swelling, and progressive erythema with venous engorgement. Initial workup included Doppler ultrasound, coagulation studies, and D-dimer to rule out deep vein thrombosis (DVT), which were all negative. CT chest with contrast revealed no evidence of a thrombus in the right subclavian vein or dilated collateral veins. Rheumatology suspected superficial thrombophlebitis, suggested warm compresses, and RUE elevation. Dermatology was subsequently consulted and identified a constellation of cutaneous signs, including palmar erythema, prominent superficial venous distension on the RUE, petechiae, and pitting edema. These findings prompted repeat vascular evaluation, and venous duplex ultrasonography confirmed venous TOS (vTOS), for which surgical management was scheduled. This case highlights the diagnostic importance of dermatologic assessment in systemic vascular disorders. Cutaneous changes such as unilateral erythema, venous engorgement, temperature asymmetry, and petechiae may represent early indicators of vTOS, yet are frequently misinterpreted as infectious, rheumatologic, or thrombotic conditions. Incorporating dermatologic clues with vascular examination and targeted imaging may reduce misdiagnosis and expedite definitive management.

ALK-negative anaplastic large cell lymphoma is a well-established hematologic complication of prosthetic breast implantation, but other rare conditions should also be considered. We report a case of a 36-year-old female with bilateral retropectoral breast implants since age 20 who presented with fatigue, lower extremity edema, fevers, and a slowly growing left breast mass. Ultrasound of the left breast revealed a 6 × 6 cm left upper quadrant mass. Surgical excision identified pathologic features consistent with hyaline-vascular unicentric Castleman disease (UCD). This is the first case of breast-implant associated UCD, expanding the differential diagnosis for masses associated with prosthetic breast implantation.

Introduction Hand vascularized composite allotransplantation (VCA) is currently considered a promising reconstructive approach for selected hand amputees. The major limitation of hand VCA is its risk of rejection, which influences the long-term survival of the allograft. The lymphatic system plays a key role in inflammation, antigen presentation, and immune regulation, yet lymphatic regeneration following upper limb VCA is poorly understood. The correlation between donor-recipient lymphatic reconnection and the allograft recovery and rejection is not well understood. This study was designed to describe lymphatic drainage patterns following upper limb transplantation using indocyanine green lymphangiography (ICG-L) and to explore descriptive associations between these patterns and clinical graft status. Materials and methods This single-center, descriptive case series included seven patients who underwent bilateral upper limb transplantation in the tertiary care facility. ICG-L was performed on one transplanted limb per patient at a single, randomly selected follow-up time point. Indocyanine green dye was injected intradermally at the first webspace, fourth webspace, and the ulnar aspect of the wrist on the flexor surface. The lymphatic flow was visualized using near-infrared fluorescence imaging. Lymphatic drainage patterns were assessed within the allograft, across the donor-recipient interface, and in the recipient limb, and were categorized as linear (normal) or non-linear (abnormal) using Yamamoto's classification. Clinical data, including limb edema and biopsy-proven rejection episodes, were collected. All data were analyzed descriptively; no formal statistical correlation was performed. Results ICG-L was performed with timing varied from three months to four years and two months post-transplant. No adverse reactions to indocyanine green were observed. Six patients had no clinical lymphedema, while one patient demonstrated persistent edema associated with chronic rejection. A total of 21 rejection episodes were documented. Limbs demonstrating linear lymphatic flow at the donor-recipient interface accounted for 12 rejection episodes, while limbs with non-linear flow accounted for nine episodes. Lymphatic continuity into the recipient limb was observed in all but one supracondylar-level transplant. Conclusion Lymphatic regeneration occurs following upper limb VCA despite the absence of surgical lymphatic anastomosis. The observed lymphatic patterns may reflect the complex role of lymphatics in edema resolution and alloimmune responses. The findings in this study are exploratory, and they highlight the need for further research on lymphatic reconnection and its potential for improving allograft function and immunotolerance. Limitations include a small sample size and a lack of serial time-bound measurements.

Hand injuries frequently cause significant functional limitations, and patient engagement plays a crucial role in rehabilitation outcomes. Chronotype represents an individual's inherent preference for activity timing and has been linked to variations in physical performance, pain sensitivity, and cognitive abilities; yet its impact within rehabilitation contexts remains insufficiently studied. This study aimed to investigate whether functional performance, pain, edema, and therapist-rated participation during the morning and afternoon rehabilitation sessions differ according to patients' chronotypes following hand injuries. A prospective observational study was conducted with 46 patients (mean age 39.9 ± 17.1 y) undergoing hand rehabilitation. Chronotype was assessed using the Morningness-Eveningness Questionnaire, and each participant attended two rehabilitation sessions on consecutive days - one in the morning (09:00) and one in the afternoon (16:00). Outcome measures included grip strength, the Nine-Hole Peg Test (NHPT), the Visual Analog Scale (VAS) for pain, physiotherapist-rated VAS for participation, metacarpophalangeal (MCP) joint circumferential edema, and QuickDASH scores. Data were analyzed using a three-way mixed-model repeated-measures ANOVA. Chronotype distribution was 41.3% morning-type, 45.7% intermediate-type, and 13.0% evening-type. Morning and intermediate types demonstrated significantly better NHPT performance in the morning sessions (p < 0.05), whereas evening types showed numerically better performance in the afternoon sessions, although this difference did not reach statistical significance. Intermediate and evening types exhibited significantly higher pain VAS scores in the afternoon sessions (p < 0.01). No significant chronotype-related differences were observed in grip strength, edema, or participation scores. This study is among the first to examine the effects of chronotype on hand injury rehabilitation. The findings suggest that scheduling rehabilitation in alignment with a patient's chronotype may enhance functional performance. However, to generalize these findings, studies with larger sample sizes, more homogeneous chronotype distributions, long-term follow-up, and inclusion of cognitive function assessments are needed.