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This syndrome can begin with severe shoulder or arm pain followed by weakness and numbness. Those who suffer from Parsonage–Turner experience acute, sudden-onset pain radiating from the shoulder to the upper arm. Affected muscles become weak and atrophied, and in advanced cases, paralyzed. Occasionally, there will be no pain and just paralysis, and sometimes just pain, not ending in paralysis. MRI may assist in diagnosis. Scapular winging is commonly seen.
Parsonage-Turner involves neuropathy of the suprascapular nerve in 97% of cases, and variably involves the axillary and subscapular nerves. As such, the muscles usually involved are the supraspinatus and infraspinatus, which are both innervated by the suprascapular nerve. Involvement of the deltoid is more variable, as it is innervated by the axillary nerve.
Most patients experience poorly localised pain in the forearm. The pain is sometimes referred into the cubital fossa and elbow pain has been reported as being a primary complaint.
The characteristic impairment of the pincer movement of the thumb and index finger is most striking.
In a pure lesion of the anterior interosseous nerve there may be weakness of the long flexor muscle of the thumb (Flexor pollicis longus), the deep flexor muscles of the index and middle fingers (Flexor digitorum profundus I & II), and the pronator quadratus muscle.
There is little sensory deficit since the anterior interosseous nerve has no cutaneous branch.
Diagnosis is usually suspected by clinical history and confirmed by MRI, in which edema of the teres minor is seen, with variable involvement of the deltoid. The circumflex humeral artery may also be compressed. Before the advent of MRI, compression of this vessel on angiography used to be the mechanism of diagnosis, although this is no longer done as it is an invasive procedure.
Atrophy can occur in cases of chronic nerve impingement. It can be associated with a glenoid labral cyst, with the cyst also reflecting injury of the glenoid labrum.
Differential considerations include similar rotator cuff denervation syndromes such as Parsonage–Turner syndrome, and compression of the suprascapular nerve at the spinoglenoid notch in which the infraspinatus, and to a lesser degree supraspinatus is involved.
Symptoms of HNA may include pain in the back, neck, arms, or shoulders, nerve pulls in the arms or back, muscular atrophy, and weakness.
HNA is an episodic disorder; it is characterized by episodes generally lasting 1–6 weeks. During an episode, the nerves of the brachial plexus are targeted by the body as antigens, and the body's immune system begins to degenerate the nerves of the brachial plexus. The exact order or location of the nerve degeneration cannot be predicted before an episode. Other areas of the nervous system that have been affected are the phrenic nerves and the recurrent laryngeal. As the nerves lose function, the muscles associated with those nerves begin to atrophy. In brachial plexus degeneration, atrophy may occur in the deltoid muscles. In phrenic nerve degeneration, the diaphragm may be affected. In this case, breathing can be impaired due to a lack of muscle control of the diaphragm. If the recurrent larangyl nerve is targeted, the pharynx will begin to atrophy and voice function may be lost.
The skeletal structures of individuals who have this disorder may have pronounced deformities. As reported by several medical doctors, the following features are commonly found in people who suffer from nail–patella syndrome:
Bones and joints
- Patellar involvement is present in approximately 90% of patients; however, patellar aplasia occurs in only 20%.
- In instances in which the patellae are smaller or luxated, the knees may be unstable.
- The elbows may have limited motion (e.g., limited pronation, supination, extension).
- Subluxation of the radial head may occur.
- Arthrodysplasia of the elbows is reported in approximately 90% of patients.
- General hyperextension of the joints can be present.
- Exostoses arising from the posterior aspect of the iliac bones ("iliac horns") are present in as many as 80% of patients; this finding is considered pathognomonic for the syndrome.
- Other reported bone changes include scoliosis, scapular hypoplasia, and the presence of cervical ribs.
Kidney issues may arise such as proteinuria and nephritis. Proteinuria is usually the first sign of renal involvement and either rapidly or years after suffering from asymptomatic proteinuria, renal failure occurs in around 5% of NPS patients. Hypothyroidism, irritable bowel syndrome, attention deficit hyperactivity disorder (ADHD), and thin tooth enamel are associated with NPS, but whether these are related or simply coincidences are unclear.
The most notable features of Wilson-Turner Syndrome are intellectual disability, obesity, hypogonadism, gynecomastia, and distinct facial features. All of the symptoms are chronic. Affected females are known to have less severe signs and symptoms than males. Female carriers of the disorder may have none or mild symptoms.
- Intellectual Disability is the limitation in an individual's mental functioning and skills. Patients of Wilson-Turner Syndrome have mental disability generally ranging from mild to severe, more frequently on the former. This symptom often coincides with delay in speech development and the occurrence of mood swings. Most males were noted to have a quiet and a cheerful disposition. However, individuals who displayed aggression and became easily upset were also seen. Children will display a delay in speech development often combined with excessive drooling and low voice tone. Some of the studied male patients had speech impairment ranging from little or no speech to minor stuttering.
- Obesity is the accumulation of excess fat on the body. Individuals with Wilson-Turner Syndrome are characterized to have truncal obesity, meaning the fat has accumulated in one's middle. Truncal obesity is often related to heart disease, kidney disease, and lowered blood immune system. Truncal obesity in this disorder becomes more apparent around the age of puberty.
- Tapered fingers is when one end of the finger is diminished in thickness, causing the ends of the fingers to appear pointed. This deformity is not debilitating in any particular manner. In addition to tapered fingers, both hands and feet tend to be small. Some males were observed to have pes planus, also known as flat feet.
- Hypogonadism is a condition in which the gonads have a decrease in function. This condition may result from the lack of sex hormone synthesis, such as androgen and estrogen. Hormones produced by the gonads may also decrease. Hypogonadism also influences the onset of other conditions of the Wilson-Turner Syndrome, such as gynecomastia and decreased testes size in males. It can also cause short stature in men and women. In addition to little genital development, pubic and body hair are scant.
- Some of the facial features that are associated with Wilson-Turner Syndrome include small head circumference, high forehead, prominent ears, and nose with a flattened bridge. There have been cases of a moderately high palate. Low muscle tone and subcutaneous swelling in facial tissue has also been noted. Thick eyebrows are also common. However, there has been reported cases where individuals had none of the mentioned facial features, which shows phenotypic abnormalities have possible environmental influences.
- Gynecomastia is a non-cancerous increase in male breast tissue. It is believed that disturbances in the endocrine system leads to an increase in estrogen and androgen hormones lead to the development of gynecomastia. A key feature of gynecomastia is a rubbery or firm glandular subcutaneous chest tissue that is palpated under the areola of the nipple, instead of the soft fatty tissue. There can also be in increase in diameter of the areola asymmetry in the chest tissue. The breast enlargement can occur in one or both side. Similar to truncal obesity, gynecomastia becomes apparent around the age of puberty.
Nail–patella syndrome (NPS) (also known as "HOOD syndrome") is a genetic disorder that results in small, poorly developed nails and kneecaps, but can also affect many other areas of the body, such as the elbows, chest, and hips. The name "nail–patella" can be very misleading because the syndrome often affects many other areas of the body, including even the production of certain proteins. Those affected by NPS may have one or more affected areas of the body, and its severity varies depending on the individual. It is also referred to as iliac horn syndrome, hereditary onychoosteodysplasia (HOOD syndrome), Fong disease or Turner–Kieser syndrome.
Diagnosis of NPS can be made at birth, but is common for it to remain undiagnosed for several generations. While there is no cure available for NPS, treatment is available and recommended.
Wilson-Turner Syndrome (WTS), also known as Mental Retardation X Linked Syndromic 6 (MRXS6), or Mental Retardation X Linked with Gynecomastia and Obesity is a congenital condition characterized by intellectual disability and associated with childhood-onset obesity. It is found to be linked to the X chromosome and caused by a mutation in the HDAC8 gene, which is located on the q arm at locus 13.1. Individuals with Wilson–Turner syndrome have a spectrum of physical characteristics including dysmorphic facial feature, hypogonadism, and short stature. Females generally have milder phenotype than males. The study of X-linked mental retardation began in 1943 when Martin and Bell reported a family exhibiting sex-linked mental retardation. However, this syndrome was not recognized until 1991. Wilson studied 14 males from 3 successive generations that presented hypogonadism, mental retardation, gynecomastia, short stature, among other symptoms. Eventually, this disorder was ruled distinct from a syndrome presented by Prader and Willi (Prader-Willi syndrome) because of its mode of inheritance, gynecomastia, and presence of small hands and feet. However, there are some speculations that this syndrome is in the same spectrum as the Cornelia de Lange syndrome. This disorder affects all demographics equally and is seen in less than one in one million people.
Up to ~85% of people with NS have one of the following heart defects:
- Pulmonary valvular stenosis (50–60%)
- Septal defects: atrial (10–25%) or ventricular (5–20%)
- Hypertrophic cardiomyopathy (12–35%)
Back pain is frequently mentioned as a TMS symptom, but Sarno defines TMS symptoms much more broadly than that:
- "Symptom type:" TMS symptoms include pain, stiffness, weakness, tingling, numbness, muscle contractures, cramps and other negative sensations, according to Sarno.
- "Symptom location:" In addition to the back, Sarno states that TMS symptoms can occur in the neck, knee, arms, wrists, and other parts of the body. Schechter states that the symptoms have a tendency to move to other parts of the body. He considers symptom movement an important indicator that the pain is from TMS.
Cubitus valgus is a medical deformity in which the forearm is angled away from the body to a greater degree than normal when fully extended. A small degree of cubitus valgus (known as the carrying angle) is acceptable and occurs in the general population.
When present at birth, it can be an indication of Turner syndrome or Noonan syndrome. It can also be acquired through fracture or other trauma. The physiological cubitus valgus varies from 3° to 29°. Women usually have a more pronounced Cubitus valgus than men. The deformity can also occur as a complication of fracture of the lateral condyle of the humerus, which may lead to tardy/delayed ulnar nerve palsy.
The opposite condition is cubitus varus ().
Noonan syndrome (NS) is a relatively common autosomal dominant congenital disorder and is named after Jacqueline Noonan, a pediatric cardiologist. It is referred to as the male version of Turner's syndrome; however, the genetic causes of Noonan syndrome and Turner syndrome are distinct and both males and females are affected. The principal features include congenital heart defect (typicall pulmonary valve stenosis with dysplastic pulmonary valve also atrial septal defect and hypertrophic cardiomyopathy), short stature, learning problems, pectus excavatum, impaired blood clotting, and a characteristic configuration of facial features including a webbed neck and a flat nose bridge. NS is a RASopathy, and is one of several disorders that are caused by a disruption of RAS-MAPK signaling pathway.
It is believed that between approximately 1 in 1,000 and 1 in 2,500 children worldwide are born with NS. It is one of the most common genetic syndromes associated with congenital heart disease, similar in frequency to Down syndrome. However, the range and severity of features can vary greatly in patients with NS. Therefore, the syndrome is not always identified at an early age.
Tension myositis syndrome (TMS), also known as tension myoneural syndrome or mindbody syndrome is a name given by John E. Sarno to a condition he describes as characterized by musculoskeletal and nerve symptoms, most notably back pain. Sarno, a Professor of Clinical Rehabilitation Medicine at New York University School of Medicine and Attending Physician at The Rusk Institute of Rehabilitation Medicine at New York University Medical Center, has described TMS in four books, and has stated that the condition may be involved in other pain disorders as well. The treatment protocol for TMS includes education, writing about emotional issues, resumption of a normal lifestyle and, for some patients, support meetings and/or psychotherapy. In 2007, David Schechter (a medical doctor and former student and research assistant of Sarno's) published a peer-reviewed study of TMS treatment showing a 54% success rate for chronic back pain. In terms of statistical significance and success rate, the study outperformed similar studies of other psychological interventions for chronic back pain.
The TMS diagnosis and treatment protocol are not accepted by the mainstream medical community. However, TMS and Sarno's treatment methods have received national attention, including a segment on ABC's "20/20"; an episode of "Larry King Live"; an interview with "Medscape"; and articles in "Newsweek", "The Seattle Times", and "The New York Times". Prominent medical doctors who support TMS treatment include Andrew Weil and Mehmet Oz. Notable patients treated for tension myositis syndrome include Senator Tom Harkin, John Stossel, Howard Stern, and Anne Bancroft.
On babies, webbed neck may look like loose folds of skin on the neck. As the child grows, the skin may stretch out to look like there is little or no neck.
Low-set ears are ears with depressed positioning of the pinna two or more standard deviations below the population average.
It can be associated with conditions such as:
- Down's syndrome
- Turner Syndrome
- Noonan syndrome
- Patau syndrome
- DiGeorge syndrome
- Cri du chat syndrome
- Edwards syndrome
- Fragile X syndrome
It is usually bilateral, but can be unilateral in Goldenhar syndrome.
It is a feature of Turner syndrome (only found in girls) and Noonan syndrome, as well as the rarer Klippel-Feil syndrome, or Diamond-Blackfan Anemia
Of the following common symptoms of Turner syndrome, an individual may have any combination of symptoms and is unlikely to have all symptoms.
- Short stature
- Lymphedema (swelling) of the hands and feet of a newborn
- Broad chest (shield chest) and widely spaced nipples
- Low posterior hairline
- Low-set ears
- Reproductive sterility
- Rudimentary ovaries gonadal streak (underdeveloped gonadal structures that later become fibrotic)
- Amenorrhoea, the absence of a menstrual period
- Increased weight, obesity
- Shortened metacarpal IV
- Small fingernails
- Characteristic facial features
- Webbed neck from cystic hygroma in infancy
- Aortic valve stenosis
- Coarctation of the aorta
- Bicuspid aortic valve (most common cardiac problem)
- Horseshoe kidney
- Visual impairments – sclera, cornea, glaucoma, etc.
- Ear infections and hearing loss
- High waist-to-hip ratio (the hips are not much bigger than the waist)
- Attention deficit hyperactivity disorder (problems with concentration, memory, attention with hyperactivity seen mostly in childhood and adolescence)
- Nonverbal learning disability (problems with maths, social skills, and spatial relations)
Other features may include a small lower jaw (micrognathia), cubitus valgus, soft upturned nails, palmar crease, and drooping eyelids. Less common are pigmented moles, hearing loss, and a high-arch palate (narrow maxilla). Turner syndrome manifests itself differently in each female affected by the condition; therefore, no two individuals share the same features.
While most of the physical findings are harmless, significant medical problems can be associated with the syndrome. Most of these significant conditions are treatable with surgery and medication.
Ullrich congenital muscular dystrophy is a form of congenital muscular dystrophy.It is associated with variants of type VI collagen, it is commonly associated with muscle weakness and respiratory problems, though cardiac issues are not associated with this type of CMD. It is named after Otto Ullrich, who is also known for the Ullrich-Turner syndrome.
Based on the location of the nerve damage, brachial plexus injuries can affect part of or the entire arm. For example, musculocutaneous nerve damage weakens elbow flexors, median nerve damage causes proximal forearm pain, and paralysis of the ulnar nerve causes weak grip and finger numbness. In some cases, these injuries can cause total and irreversible paralysis. In less severe cases, these injuries limit use of these limbs and cause pain.
The cardinal signs of brachial plexus injury then, are weakness in the arm, diminished reflexes, and corresponding sensory deficits.
1. Erb's palsy. "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm".
2. In Klumpke's paralysis, a form of paralysis involving the muscles of the forearm and hand, a characteristic sign is the "clawed hand", due to loss of function of the ulnar nerve and the intrinsic muscles of the hand it supplies.
People with the 47,XYY karyotype have an increased growth velocity from early childhood, with an average final height approximately 7 cm (3") above expected final height. In Edinburgh, Scotland, eight 47,XYY boys born 1967–1972 and identified in a newborn screening programme had an average height of 188.1 cm (6'2") at age 18—their fathers' average height was 174.1 cm (5'8½"), their mothers' average height was 162.8 cm (5'4"). The increased gene dosage of three X/Y chromosome pseudoautosomal region (PAR1) SHOX genes has been postulated as a cause of the increased stature seen in all three sex chromosome trisomies: 47,XXX, 47,XXY, and 47,XYY.
Severe acne was noted in a very few early case reports, but dermatologists specializing in acne now doubt the existence of a relationship with 47,XYY.
Testosterone levels (prenatally) are normal in 47,XYY males. Most 47,XYY males have normal sexual development and have normal fertility.
The presentation of Ullrich congenital muscular dystrophy in an affected individual is as follows:
- Muscle weakness
- Difficulty walking
- Contractures (neck)
- Joint looseness