A rare presentation of bilateral ulnar club hand

A 47-year-old, right-hand dominant man with a history of schizophrenia and learning difficulty presented to his general practitioner with headaches, vomiting and altered level of consciousness. He lives alone in a care home but was fully independent before his admission. He smoked 20 cigarettes a day and was an occasional alcohol drinker. He was referred onto the Accident and Emergency Department where his Glasgow Coma Score was recorded as 7/15. CT scan revealed a significant intraventricular bleed in the posterior fossa. He, thus, underwent a posterior fossa craniotomy with clot evacuation by the neurosurgical team at Queen Square Hospital London. In addition to the intraventricular bleed, he was reported to have fallen on his left hand. Therefore, on his admission to the surgical intensive care unit, radiographs of his upper limbs were obtained (Figures 1 and 2). He was referred to our orthopaedic team for further assessment or intervention. Because of the patient’s decreased level of consciousness, a full clinical examination was not possible. We were, however, able to determine that passive range of motion of all joints of his right upper extremity were within normal limits as were those of the left shoulder, wrist and hand. The left elbow had a passive range of flexion-extension of 80--1701. The radiographs demonstrated a rare case of bilateral ulnar club hand (Figures 3 and 4). Anteroposterior and lateral radiographs of the left arm demonstrated an absent ulna and missing ulnar digits and carpal bones. The right arm radiographs revealed a shortened ulna with radial bowing, missing ulnar digits and, missing carpal bones, but to a lesser extent.