S278 S290
Case/Program Description:
A 13-year-old girl was seen 1.5 years
after sustaining a right medial epicondylar fracture upon a gym-
nastic dismount off uneven bars. She was seen by two different
orthopedists prior to PM&R referral made by second orthopedist for
botulinum toxin injection. After initial injury, patient was placed in
24-hour extension splint and started physical therapy but had
persistent right elbow flexion contracture with 30-degree extension
lag along with intermittent right elbow pain and fingers paresthesia
after her gymnastics workout. Botulinum toxin type A (Botox) was
reconstituted with preservative-free 0.9% normal saline to a con-
centration of 50U/ml. A total of 100U Botox were equally divided
between right bicep brachii and brachialis muscles with ultrasound
and EMG guidance. No post-injection complications were noted,
and patient was sent for casting and weekly serial casting by
occupational therapy after Botox injection while continuing phys-
ical therapy.
Setting:
Children Specialized Hospital Outpatient Clinic.
Results:
Over the next few weeks of serial casting, her right
elbow range-of-motion improved from 30-degrees extension lag to
5-degrees extension lag. Patient was also provided an elbow
ratchet brace to wear at nighttime. She returned to clinic nearly
6 months later, continuing twice-a-week physical therapy and
nightly elbow extension splint, with exam revealing10-15 degrees
active extension lag on right elbow, and 10-degrees lag with
brace on.
Discussion:
This is the first reported case, to our knowledge, of
improved elbow flexion contracture following botulinum toxin injec-
tion and serial casting.
Conclusions:
Improvement in post-traumatic elbow flexion contrac-
ture may be possible with botulinum toxin injection followed by serial
casting and bracing.
Level of Evidence:
Level V
Poster 458:
Considerations for Independent Mobility in Craniopagus Twins:
A Case Report
Sonal Oza, MD (Northwestern University/RIC/Ability Lab),
Katharine Tam, MD, Sonia Hyser, BA, Charles E. Sisung, MD
Disclosures:
Sonal Oza, MD: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
12-year-old craniopagus conjoined twins
with history of anuria in Twin A, and spastic hemiplegic cerebral
palsy in Twin B, presented for rehabilitation. Twin B sustained a
traumatic cervical spinal cord injury with resultant left upper ex-
tremity paresis and bilateral lower extremity spasticity. They sit
perpendicular to each other, and recline in a prone and supine po-
sition for Twin A and B. Pre-morbidly, they were ambulatory with
their bodies in an anterior-posterior relation. Twin A was the primary
ambulator. Twin B ambulated with bilateral KAFOs, and relied on
Twin A for support. They used a customized power wheelchair for
mobility, and ambulated when their environment was inaccessible.
Examination of Twin B revealed an internally rotated left lower ex-
tremity, bilateral genu recurvatum, and dorsiflexion weakness. She
was unable to flex her knees to utilize a modified foot platform. She
demonstrated a right lateral lean and left elevated pelvic obliquity
limiting trunk control.
Setting:
Tertiary care rehabilitation hospital.
Results:
Rehabilitation engineers were consulted to aid with device
design. The power wheelchair was modified to provide lateral trunk,
right arm, and bilateral lower extremity support. Novel mobility de-
vices including a collapsible manual wheelchair for universal doorway
clearance, and an assistive device to support single twin ambulation
were designed.
Discussion:
This is the first reported case, to our knowledge, to pre-
sent the rehabilitation challenges of adolescent craniopagus twins.
Craniopagus twinning has an incidence of 0.6 per million births. The
twins shared cranial vasculature and had failed attempted separation
surgery. Twin B’s spastic hemiplegia and spinal cord injury necessi-
tated a mobility device that could access their environment. The
physiatric evaluation informed the engineers’ design of customized
mobility devices.
Conclusions:
This case highlights the role of physiatry in optimizing
mobility devices in environments not accommodated by the ADA.
Continued follow-up is essential to maintain functional independence
and community participation.
Level of Evidence:
Level V
Poster 459:
Ascending Paralysis Following Streptococcal Meningitis
in a Child with Wiskott-Aldrich Syndrome: A Case
Report
Ratnakar Veeramachaneni, MD (Montefiore Medical Center, Bronx, NY,
United States), Yuxi Chen, MD, FAAPMR, Ratnakar Veeramachaneni,
MD, Rahul Thomas, MD, Anna Rozman, DO, MBA
Disclosures:
Ratnakar Veeramachaneni, MD: I Have No Relevant
Financial Relationships To Disclose
Case/Program Description:
A 9-year-old boy with Wiskott-Aldrich
syndrome, a rare X-linked recessive disease characterized by
eczema, thrombocytopenia, immune deficiency, and bloody diar-
rhea, status-post bone marrow transplant and splenectomy, pre-
sented with high fever, neck stiffness and headache. Ascending
paralysis with respiratory failure required intubation on admission.
He was thought to have Guillain-Barre syndrome and treated with
IVIG and steroids. Further investigations confirmed streptococcal
meningitis as patient required prolonged ICU management with tra-
cheostomy and gastric tube.
Setting:
Outpatient Pediatric Rehabilitation Clinic.
Results:
Patient has paraplegia, absent DTR and decreased sensa-
tion to light touch below T7. MRI of thoracic and lumbar spine
showed extensive hyper-intense signals essentially replacing the
cord extending from the T3-T11, likely representing a combination
of a syrinx and loculation. Patient was treated with antibiotics for
meningococcal meningitis and stabilized. He was discharged to
acute inpatient rehabilitation and followed up in a outpatient
rehabilitation clinic where he received PT/OT/ST therapy. Seven
months after paralysis, patient has recovered sensation and
movement in the toes with the sensory level at T9. He also regained
the ability to swallow solid food. He continues to rely on a
wheelchair for mobility, and prognosis for ambulation remains
undetermined.
Discussion:
Previous case series have shown a 4% prevalence of
meningitis among patients with Wiskott-Aldrich syndrome. While
numerous reports exist of tubercular meningitis progressing to syrin-
gomyelia, our patient had streptococcal meningitis leading to syrinx
formation and paraplegia as an additional complication. Imaging and
CSF analysis can direct appropriate management when diagnosis of
ascending paralysis can be a challenge. Early, concentrated, intense
therapy is essential for preserving and regaining function in these
patients.
Conclusions:
Syringomyelia is a possible complication of meningitis
occurring among immune-compromised children with Wiskott-Aldrich
syndrome. Timely, realistic goal-oriented rehabilitation can improve
functional outcomes along with appropriate medical management of
paralysis in these children.
Level of Evidence:
Level V
S278
Abstracts / PM R 9 (2017) S131-S290