Background and Clinical Significance: Non-palpable migrated contraceptive implants pose significant challenges for removal and are associated with neurovascular complications. Traditional open surgery near nerves is associated with postoperative morbidity. Migrated or deeply embedded implants near critical structures can result in severe complications, such as neuropathy, and their removal typically requires open surgical intervention. Case Presentation: We report a novel, minimally invasive, ultrasound (US)-guided technique for removing a migrated etonogestrel Implanon^® implant that caused ulnar neuropathy. A 38-year-old woman presented with severe neuropathic pain and paresthesia (NPRS 10/10; QuickDASH 55) along her left ulnar nerve following multiple failed removal attempts that induced deep migration. US confirmed the proximity of the implant to the ulnar nerve. Initial US-guided removal exacerbated her symptoms. Hydrodissection (HD) with 50 mL of 5% dextrose in water (D5W) without local anesthetic (LA) was performed to reduce inflammation and achieve separation. The implant migrated proximally during extraction. An additional HD with 50 mL of D5W without LA distally repositioned the implant. Percutaneous stabilization using a 25-gauge needle enabled secure removal. The intact 4 cm implant was extracted under real-time US guidance without open surgery. The patient experienced immediate symptom relief (NPRS 2/10; QuickDASH 4.5 at one month) and full resolution (NPRS 0/10; QuickDASH 0) with no motor deficits at one year. Conclusions: This case represents the first documented percutaneous removal of a nerve-adherent implant using combined US-guided D5W HD and needle stabilization, marking a paradigm shift in the management of such cases. This approach confirms the safety of US-guided foreign body removal using HD for nerve-adjacent implants and demonstrates the efficacy of combining D5W HD with needle stabilization. Surgical morbidity was avoided, while excellent long-term outcomes were achieved.

Background and Clinical Significance: Wartenberg’s syndrome (cheiralgia paresthetica) is classically described as a pure sensory neuropathy of the superficial branch of the radial nerve (SBRN). However, in rare circumstances, dynamic mechanical irritation around the radial styloid may produce an atypical clinical phenotype with concurrent motor impairment, broadening the clinical significance of recognizing motion-related compression mechanisms. Case Presentation: A 35-year-old woman presented with persistent dorsoradial wrist pain and numbness, accompanied by progressive weakness of thumb extension, five years after a conservatively treated nondisplaced scaphoid fracture. Neurological examination demonstrated sensory loss in the SBRN distribution and Medical Research Council (MRC) grade 3/5 strength of the extensor pollicis longus (EPL). Nerve conduction studies revealed a markedly prolonged EPL motor latency (4.5 ms; normal ≤ 2.5 ms) with preserved sensory conduction. High-resolution ultrasound showed focal enlargement of the SBRN (cross-sectional area 0.13 cm²) and, critically, dynamic snapping of the nerve over the radial styloid that reproduced the patient’s symptoms. The patient underwent ten weekly sessions of ultrasound-guided hydrodissection with 5% dextrose. After treatment, the pain Visual Analog Scale improved from 8/10 to 0/10 and EPL strength recovered to MRC 5/5. Follow-up nerve conduction studies demonstrated normalization of EPL motor latency (2.1 ms), and repeat ultrasound confirmed resolution of SBRN enlargement and snapping. Conclusions: This case expands the phenotype of Wartenberg’s syndrome to include mixed sensory–motor involvement associated with dynamic SBRN snapping at the radial styloid. Dynamic ultrasound was pivotal for identifying the motion-dependent mechanism, and ultrasound-guided 5% dextrose hydrodissection achieved complete sensory and motor recovery as a minimally invasive and effective treatment option.

Background: Thoracic outlet syndrome (TOS) is frequently underdiagnosed due to nonspecific symptoms and the absence of definitive radiographic findings. Neurogenic TOS (nTOS), the most common subtype, is typically caused by compression of the brachial plexus within anatomically constrained spaces. While muscular contributors such as the scalene and pectoralis minor muscles have been widely discussed, the role of the subclavius muscle remains underrecognized. Case presentation: A 53-year-old male presented with an 18-month history of progressive right upper limb weakness and medial paresthesia refractory to prior treatments for presumed cervical spondylosis. Electrodiagnostic studies demonstrated persistent proximal motor slowing of the right ulnar nerve. Ultrasonography revealed marked atrophy of the right subclavius muscle compared with the contralateral side. Ultrasound-guided hydrodissection using 30 mL of 5% dextrose in water (D5W) was performed in the infraclavicular region with particular attention to the subclavius muscle and costoclavicular space. Immediate post-procedural assessment showed greater than 70% improvement in paresthesia, with subtle objective motor improvement on bedside examination that was not yet sufficient to change the MRC grade. Following six treatment sessions, complete resolution of symptoms and full motor strength recovery were achieved. Conclusion: In a patient with unexplained proximal neuropathy, ultrasonography identified focal subclavius muscle atrophy as a potential compressive contributor within the costoclavicular space, and ultrasound-guided hydrodissection of the infraclavicular region resulted in rapid and sustained clinical improvement. While the injectate volume (30 mL) likely affected adjacent structures such as the pectoralis minor and surrounding fascial planes, this minimally invasive approach may be a feasible option for selected patients with refractory nTOS. To our knowledge, this is the first reported case of ultrasound-guided hydrodissection of the infraclavicular region with attention to the subclavius muscle for neurogenic thoracic outlet syndrome associated with muscle atrophy. Further studies are warranted to confirm efficacy and to refine patient selection criteria.

Non-palpable migrated contraceptive implants (3-5%) pose significant removal challenges and neurovascular risks. Traditional open surgery near nerves carries postoperative morbidity. We report a novel minimally invasive ultrasound (US)-guided removal of a migrated etonogestrel Implanon® implant causing ulnar neuropathy. A 38-year-old woman presented with severe neuropathic pain and paresthesia (Numeric Pain Rating Scale [NPRS] 10/10; Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH] 55) along her left ulnar nerve after multiple failed removal attempts elsewhere induced deep migration. US confirmed the implant adjacent to the ulnar nerve within the medial arm neurovascular bundle, with direct nerve contact on dynamic imaging. Initial US-guided removal exacerbated symptoms, prompting hydrodissection (HD) using 50 mL dextrose 5% in water (D5W) without local anesthetic (LA) to reduce inflammation and achieve mechanical separation. Despite pain reduction, the slippery implant iatrogenically migrated proximally during extraction, confirmed fluoroscopically and sonographically. Additional HD (50 mL D5W) repositioned the implant distally. Percutaneous stabilization of the proximal tip with a 25-gauge needle then enabled secure grasping and complete extraction through the original incision under real-time US-guidance. The intact 4-cm implant was retrieved without open surgery. Immediate pain reduction (NPRS 2/10) and functional improvement (QuickDASH 4.5 at one month) occurred, with complete symptom resolution (NPRS 0/10; QuickDASH 0) and no motor deficits sustained at one year. This first documented percutaneous removal of a nerve-adherent implant using combined US-guided D5W HD and needle stabilization achieved durable success while avoiding open surgery, signifying a paradigm shift and possibly confirming: (1) safety of US-guided HD for nerve-adjacent implants, (2) efficacy of combined D5W HD and needle stabilization, and (3) elimination of surgical morbidity.

Background: The traditional A1-centric paradigm for trigger finger (TF) management does not fully capture heterogeneous pathology spanning isolated pulley stenosis, tendon degeneration, and impaired tendon–sheath gliding. Methods: A comprehensive literature synthesis (2010–2025) integrating anatomy, biomechanics, and ultrasound-guided interventions was performed to develop a testable, phenotype-driven framework. Results: A continuum model is proposed emphasizing (i) origin-to-insertion assessment of the flexor apparatus, (ii) pragmatic ultrasound phenotyping into pulley-dominant, tendon-dominant, and mixed patterns, and (iii) a stepwise, phenotype-matched management pathway incorporating conservative care, ultrasound-guided injection, selected adjuncts (e.g., hydrodissection, prolotherapy, ESWT) for tendon-dominant or mixed presentations, and percutaneous or open release when an A1 bottleneck is confirmed. Conclusions: This framework is presented as a hypothesis to guide standardized reporting, reliability testing, and phenotype-stratified comparative trials, rather than as a validated clinical guideline. This article proposes a novel, phenotype-driven clinical framework to address this limitation. Contemporary evidence is integrated to construct a model emphasizing (i) a whole-length, origin-to-insertion assessment of the flexor apparatus, (ii) sonographic phenotyping into pulley-dominant, tendon-dominant, and mixed patterns, and (iii) a stepwise treatment algorithm integrating conservative care, ultrasound-guided injections, ultrasound-guided percutaneous release, and selected adjunctive approaches such as hydrodissection (HD), prolotherapy (Prolo), and extracorporeal shockwave therapy (ESWT). While evidence supports individual modalities, the framework’s primary innovation lies in matching interventions to phenotype. This sonographic phenotyping system is presented not as a validated tool, but as a testable hypothesis designed to guide future validation studies. The proposed framework establishes research priorities, including standardized criteria, reliability testing, and comparative effectiveness research for phenotype-stratified management.