Summary of Unique Patient postings
Stephen Fletcher
Description
Collection
Title:
Summary of Unique Patient postings
Creator:
Stephen Fletcher
Date:
2/4/2000
Text:
Below is the original posting and the responses to my earlier posting.
Thank you for you suggestions. A final decision has not been made yet on what we are going to do for this patient.
Steve Fletcher, CPO
Shands Hospital at the University of Florida
Hello All.
I have been presented a unique case that I would appreciate any advise you may be able to share.
9 year old child who was involved in some type of trauma approximately 2 years ago. They have been left with an interesting neurologic presentation. The following is on the right side only.
Trace-Zero knee extensors
Trace-Zero hip adductors
Trace- Zero hip flexors
Good hip extensors
Good hip abductors
Normal lower leg musculature.
According to the M.D. the patient and family report that the child does ok when walking at a slow pace, but if they try and ambulate quickly or attempt to run, they have problems.
Physician has already seen patient once and is having them come back in for another evaluation and has asked that I assist in trying to come up with a reccomendation. Again, any insights you would like to share would be greatly appreciated. I will post the responses.
Thank you.
Steve Fletcher, CPO
Shands Hospital at the University of Florida
Responses:
Stephen:
This is in reference to your unique case that you had posted on the
list. Some ?s does the patient use any kind of assertive device like a cane,
crutch, etc. How does he currently ambulating: does he hold this leg in full
extension, does he circumduct etc. Some things to consider. If you need to
hold the knee in extension at foot flat to toe off, then you can consider
using a floor reaction AFO. With his weak hip flexors this might cause some
problems going into swing phase. I have seen a knee orthosis that had knee
extension assist built into it. This again may or may help because of his
weak hip flexors. It is some ting to try. E-mail me back if you want to talk
about this some more.
Steve, just a thought. Your patient may be getting body weight (trunk
weight) anterior of knee center at a slower pace. With a faster pace,
the center of mass falls behind knee center before the hip extensors
have time to compensate. Thus an unstable knee at higher velocities. You
may want to video tape in the saggital plane to verify when the knee
become unstable and collaspes. The week hip flexors inhibit rapid
flexion of the trunk, allowing it to stay behind the knee higher
velocities. Let me know if I am close. Sound good anyway. Good luck.
That is interesting. Sounds like L1-3 polyradiculopathy. I would guess
one of the knee extension assist orthotics that are being tried would be
the best bet. Does he use his hand on his quadriceps when walking??
Hip flexion would also be a mjor problem for running. It would be unique,
but could a reciprocator unit be reversed so that hip extension on the
strong side would give you hip flexion via cable on the weak side??
Dear Stephen,
An interesting case indeed! It sounds like some kind of femoral nerve palsy
from your description. As to your request for assistance for coming up with
recommendations (orthotic I assume), the following points come to mind:
1. as you did not describe the problems the child is having when jogging or
running I had to imagine the possible compensatory mechanisms he/she is
using to ambulate. First I assume that knee stability in stance is ok most
of the time depending on the child's ability to coordinate plantar
flexion-hip extension to lock the knee into extension. If this is not the
case the options are locking the knee up with a KO or assisting knee
stability with offset joints, trick-knee mechanism etc..
2. So with the knee stable the other major problem is right swing leg
acceleration because both the adductors and flexors are affected. This is
the more challenging problem and in my (very limited) experience and I do
not know of any easy solution. The only things that come to mind are some
sort of spring/elastic mechanism to assist hip flexion (bulky and likely not
very effective) or some kind of RGO mechanism around the hip only (also
bulky but has some potential)
That's my shooting from the hip orthotics answer. Hope it helps some
Thank you for you suggestions. A final decision has not been made yet on what we are going to do for this patient.
Steve Fletcher, CPO
Shands Hospital at the University of Florida
Hello All.
I have been presented a unique case that I would appreciate any advise you may be able to share.
9 year old child who was involved in some type of trauma approximately 2 years ago. They have been left with an interesting neurologic presentation. The following is on the right side only.
Trace-Zero knee extensors
Trace-Zero hip adductors
Trace- Zero hip flexors
Good hip extensors
Good hip abductors
Normal lower leg musculature.
According to the M.D. the patient and family report that the child does ok when walking at a slow pace, but if they try and ambulate quickly or attempt to run, they have problems.
Physician has already seen patient once and is having them come back in for another evaluation and has asked that I assist in trying to come up with a reccomendation. Again, any insights you would like to share would be greatly appreciated. I will post the responses.
Thank you.
Steve Fletcher, CPO
Shands Hospital at the University of Florida
Responses:
Stephen:
This is in reference to your unique case that you had posted on the
list. Some ?s does the patient use any kind of assertive device like a cane,
crutch, etc. How does he currently ambulating: does he hold this leg in full
extension, does he circumduct etc. Some things to consider. If you need to
hold the knee in extension at foot flat to toe off, then you can consider
using a floor reaction AFO. With his weak hip flexors this might cause some
problems going into swing phase. I have seen a knee orthosis that had knee
extension assist built into it. This again may or may help because of his
weak hip flexors. It is some ting to try. E-mail me back if you want to talk
about this some more.
Steve, just a thought. Your patient may be getting body weight (trunk
weight) anterior of knee center at a slower pace. With a faster pace,
the center of mass falls behind knee center before the hip extensors
have time to compensate. Thus an unstable knee at higher velocities. You
may want to video tape in the saggital plane to verify when the knee
become unstable and collaspes. The week hip flexors inhibit rapid
flexion of the trunk, allowing it to stay behind the knee higher
velocities. Let me know if I am close. Sound good anyway. Good luck.
That is interesting. Sounds like L1-3 polyradiculopathy. I would guess
one of the knee extension assist orthotics that are being tried would be
the best bet. Does he use his hand on his quadriceps when walking??
Hip flexion would also be a mjor problem for running. It would be unique,
but could a reciprocator unit be reversed so that hip extension on the
strong side would give you hip flexion via cable on the weak side??
Dear Stephen,
An interesting case indeed! It sounds like some kind of femoral nerve palsy
from your description. As to your request for assistance for coming up with
recommendations (orthotic I assume), the following points come to mind:
1. as you did not describe the problems the child is having when jogging or
running I had to imagine the possible compensatory mechanisms he/she is
using to ambulate. First I assume that knee stability in stance is ok most
of the time depending on the child's ability to coordinate plantar
flexion-hip extension to lock the knee into extension. If this is not the
case the options are locking the knee up with a KO or assisting knee
stability with offset joints, trick-knee mechanism etc..
2. So with the knee stable the other major problem is right swing leg
acceleration because both the adductors and flexors are affected. This is
the more challenging problem and in my (very limited) experience and I do
not know of any easy solution. The only things that come to mind are some
sort of spring/elastic mechanism to assist hip flexion (bulky and likely not
very effective) or some kind of RGO mechanism around the hip only (also
bulky but has some potential)
That's my shooting from the hip orthotics answer. Hope it helps some
Citation
Stephen Fletcher, “Summary of Unique Patient postings,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 8, 2024, https://library.drfop.org/items/show/213729.
