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coronary artery disease initially presented for heart transplant
evaluation, who developed a cardiogenic shock shortly requiring intra-
aortic balloon pump support (IABP). IABP placement was complicated
by a left pontine ischemic stroke with right hemiparesis and a retro-
peritoneal hematoma compressing the lumbar plexus involving femoral
and obturator nerves causing lumbar plexopathy adding to the right
lower extremity weakness. The femoral IABP was replaced with
axillary IABP to facilitate physical therapy. Physical therapy was
started gradually 10 days after axillary IABP placement.
Setting:
Tertiary care adult inpatient coronary care unit (CCU).
Results:
The patient was able to tolerate out of bed to chair transfers,
and stand from sitting, and therapeutic exercises. The physical ther-
apy was done in the presence of the CCU nurse and the perfusionist
with no untoward effects. The IABP was eventually weaned off and the
patient was discharged to a subacute rehabilitation facility to optimize
his condition to be eligible for heart transplant.
Discussion:
IABP maximizes coronary artery perfusion and increases
cardiac output by reducing left ventricular afterload, thus increasing
myocardial oxygen supply and decreasing myocardial oxygen demand,
respectively. IABP was traditionally inserted via femoral artery, and
patients were typically on bedrest until removal of the device. Axillary
approach to IABP was developed to facilitate early ambulation which
enables optimization of rehabilitation potential. Axillary IABP was also
found to have increased subsequent heart transplant rate as compared
to the femoral approach.
Conclusions:
The benefits of physical therapy for advanced heart
failure have been understudied. This case was unique that the patient
with IABP with multiple comorbidities in the CCU setting was able to
tolerate a course of physical therapy without untoward effects.
Level of Evidence:
Level V
Poster 178:
Reduction of Residual Limb Pain with Botulinum
Toxin Injection Following Small Finger Amputation:
A Case Report
Eric Chen, MD (Univ of WA Med Ctr), Ileana Howard, MD,
Jeffrey Heckman, DO
Disclosures:
Eric Chen: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A 36-year-old right-hand-dominant male
Veteran with a history of right 5th digit amputation following a trac-
tion injury presented with intractable pain, paresthesia, and fascicu-
lation of the right hypothenar eminence and residual 5th digit, 10
years after initial injury. Symptoms limited the Veteran’s ability to
perform work duties as a computer analyst. Prior treatments with oral
gabapentin, levetiracetam, local lidocaine injections, and desensiti-
zation therapy had been ineffective. A trial of three Onabotulinum
toxin A injections was performed; first, botulinum toxin was recon-
stituted with 0.9% normal saline to a concentration of 100 units per 1.0
cc, and a total of 25 units was administered under EMG guidance to the
hypothenar eminence over a single site. The patient returned to clinic
3 months later, and 33 units of botulinum toxin of the same concen-
tration was injected to the hypothenar eminence over two sites.
Finally, the patient then returned 2 months later, and 75 units of
botulinum toxin of the same concentration was injected to the
hypothenar eminence over two sites.
Setting:
Veterans Affairs Hospital, Rehabilitation Medicine Clinic.
Results:
The patient reported an 80% reduction in pain and fascicu-
lation lasting about 10 weeks after final administration of botulinum
toxin. He denied subjective weakness of the hand and returned to
work as a computer analyst without restrictions.
Discussion:
This case highlights the use of botulinum toxin for the
treatment of residual limb pain following upper extremity amputation
and identifies a specific effective dose to treat such patients. There
have been case reports and small trials of botulinum injection for
residual limb pain after lower extremity amputation. This is the first
reported case of botulinum toxin injection being used to treat residual
limb pain in the upper extremity.
Conclusions:
Botulinum toxin A injection can be a well-tolerated and
efficacious treatment for refractory residual upper limb pain following
traumatic amputation.
Level of Evidence:
Level V
Poster 179:
Functional Outcome 47 Years After Hand Salvage
Surgery Involving Rib Bone Transfer: A Case Report
Kevin F. Barrette (Stanford Univ), Roger R. Klima, MD, Rupali Kumar,
MD
Disclosures:
Kevin Barrette: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient sustained injuries to his right
lower extremity and right upper extremity from a landmine blast. He
underwent an above-the-knee amputation of the right leg and four-
digit amputations of the right hand, sparing only the thumb, with rib
bone transfer to the ulnar aspect of the hand creating a two-digit hand
capable of pincer grasp in 1969. He initially used a prosthesis for the
right lower extremity, but transitioned to crutch use.
Setting:
Veteran’s Hospital Outpatient Clinic.
Results:
47 years after hand salvage therapy, he remains modified
independent for activities of daily living as well as functional mobility
despite the lack of right lower extremity prosthesis. He continues to
ambulate using two crutches, one of which using his two-digit hand. He
has thrived from a functional standpoint pursuing interests such as
weight-lifting where he bimanually bench presses up to 275 lbs,
helping to take care of ill family members, and has even adapted a
guitar which he plays bimanually.
Discussion:
To our knowledge, this is the first case reported 47 years
after surgery, describing functional outcome in a patient who under-
went complex hand salvage surgery using autologous rib bone transfer
to create a two-digit pincer hand. This hand is capable of performing
both fine and gross motor activities, and there have been no subse-
quent reconstructions. There is no comparable prosthesis which could
perform this array of activities. Furthermore, each - less functional -
hand prosthesis would likely last only 3-5 years before requiring
replacement.
Conclusions:
Autologous rib bone transfer may provide reasonable
restoration of function, and be a superior alternative to amputation in
mutilating hand injuries, even when the salvaged hand has only two
digits.
Level of Evidence:
Level V
Poster 180:
Nutritional Supplements Leading to Rhabdomyolysis:
A Case Report
Ryan T. Hudson, MD, MPH (Vidant Rehab Ctr/East Carolina Univ/Brod,
Greenville, North Carolina, United States), Clinton E. Faulk, MD,
FAAPMR
Disclosures:
Ryan Hudson: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 20-year-old man with no significant PMH
presented to OSH with worsening back and buttock pain after taking
several over the counter nutritional supplements. These included a
testosterone pill (Super-T) which he had taken for the first time prior
to the workout. He also had been taking a thermogenic agent (SST-
Performix) intermittently for the past 3 months. On presentation his
CPK was found to be 43,995. Initially there was concern for spinal
compartment syndrome, but MRI of the thoracic spine showed para-
spinal muscle edema and inflammatory changes seen overlying thor-
acolumbar spine, consistent with severe diffuse muscle injury. The MRI
confirmed that there was no spinal canal involvement. He was
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Abstracts / PM R 9 (2017) S131-S290