Poster 205: Myositis Ossificans Causing Compression Neuropathy of the Ulnar Nerve: A Case Report

Abstracts / PM R 9 (2017) S131-S290 Setting: Outpatient lymphedema-rehabilitation clinic. Results: Patient underwent a thorough evaluation where no clear cause of left upper extremity lymphedema was found. Based on diagnosis of exclusion, the patient was diagnosed with SLE-induced lymphedema and was referred to the rehabilitation clinic for further treatment. The patient was managed with conservative treatment including physical therapy for manual lymphatic drainage, compression and wrapping. Discussion: Damage of the lymphatic drain system resulting in lymphedema is often seen as a consequence of cancer treatment. Resection of axillary lymph nodes as part of the treatment of breast cancer is the most common cause of upper extremity lymphedema. Other causes include infection and trauma of the lymphatic system. Even though pitting edema is often associated to SLE vasculitis and medication side effects, lymphedema is rarely observed. The pathophysiology is not clear, however antibody-related injury is suspected. Conclusions: Lymphedema is a rare complication of SLE and other causes should be ruled out, including malignancy. Once diagnosis is confirmed, a comprehensive functional evaluation should be performed and conservative lymphedema treatment should be in place to avoid further complications. Level of Evidence: Level V Poster 203: Inpatient Rehabilitation for Thoracic Myelopathy Caused By X-Linked Hypophosphatemia, a Form of Congenital Rickets, After Surgical Decompression and Fusion: A Case Report Jennifer Do, DO (University of Arkansas for Med Sciences), Thomas S. Kiser, MD MPH Disclosures: Jennifer Do: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 56-year-old woman with X-linked hypophosphatemia (XLH) underwent more than 30 orthopedic surgeries during her life to address progressive bone deformities and spinal stenosis. In more recent years, she has been managed for chronic back and leg pain from thoracic and lumbar stenosis, sensory changes of the lower extremities, knee pain status post bilateral total knee arthroplasties, and degenerative hip arthritis. She has been fairly independent for most of her life, using a power wheelchair for mobility for the last 12 years and ultilizing hand controls and a van lift to drive. In the past year, however, her functionality greatly declined. Intractable back pain caused her to forgo driving and her ability to transfer was impaired to the point that her husband had to carry her for transfers. She discontinued her favorite pastime, swimming, and lost 120 lbs using a starvation diet to lose weight in an attempt to alleviate the pain that immobilized her. Her orthopedic surgeons ordered thoracic and lumbar CT myelograms to investigate beyond the unimpressive MRI findings. They discovered severe multilevel foraminal stenosis with hardware loosening at T4 and severe bilateral facet arthropathy causing posterior deviation of the spinal cord. They performed posterior decompression of T6-7 and reinstrumentation and fusion of T2-T8. Setting: Acute care hospital, Acute inpatient rehabilitation hospital. Results: The first morning of her admission to acute inpatient rehabilitation, she actually stood to transfer. She ambulated for the first time in 12 years, able to walk 8 feet upon discharge from inpatient rehabilitation and 75 feet by her first orthopedic follow up. Discussion: This is a case of a remarkable functional outcome after surgery and inpatient rehabilitation in a patient with chronic, progressive orthopedic debility. Conclusions: Close multidisciplinary and continuous rehabilitation management in a patient with XLH is imperative for positive patient outcomes. Level of Evidence: Level V

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Poster 204: Creation of Bilateral Above Elbow Functional Prostheses for a Toddler Using Three-Dimensional (3D) Printing Technology: A Case Report Cesar Colasante, MD (State University of New York), (SUNY) Upst, Bronx, NY, United States), Andrew L. Peredo, MD, Yuxi Chen, MD, FAAPMR, Matthew N. Bartels, MD, MPH, FAAPMR Disclosures: Cesar Colasante: I Have No Relevant Financial Relationships To Disclose Case/Program Description: 3D models of the arms of a 3-year-old boy with congenital bilateral standard length above elbow amputation were generated using structured light scanning. These models were used to create bilateral upper arm sockets with friction elbow joints that articulate with a forearm. The forearm was designed with a wrist friction joint articulating with a voluntary-close (VC) prehensile hand as terminal device (TD). The entirety of the device is suspended by an adjusting 8-point harness. The hand is driven by scapular protraction as well as shoulder abduction/adduction depending on the harness adaptation used. Training in the use of the devices was performed by occupational therapist in scheduled biweekly sessions. Setting: Academic Medical Center. Results: Functional 3D printed above elbow prostheses were created and placed on a 3-year-old patient. The patient was able to grasp objects. Discussion: 3D printing can be used to generate custom functional above elbow prosthesis. This method permits scaling and reprinting as needed to compensate for the patient’s growth preventing extended periods of time without the use of the prostheses. Missing milestones in function and control of upper-limb prosthetics during early life is a predictor of non-adherence to prosthetic use as a teenager or adult. Although not insignificant, the cost is significantly lower compared to traditional prosthesis. Conclusions: 3D printing can be used to create above elbow prosthesis in the pediatric population as a bridge to a definitive prosthesis while avoiding extended periods of time without prostheses and missing important milestones in learning the control of the device. The aforementioned could improve patient’s adherence to the use of devices later in life. Level of Evidence: Level V Poster 205: Myositis Ossificans Causing Compression Neuropathy of the Ulnar Nerve: A Case Report Morgan L. Pyne (University of South Florida) Disclosures: Morgan Pyne: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient suffered severe trauma from a car vs. motorcycle collision, resulting in an inferior left iliac bone fracture, left patella fracture, scapular body fracture, multiple displaced rib fractures, T8-T11 transverse process fracture, left brachial plexus injury, along with multiple other injuries. The patient presented to the rehab floor 6 days after the accident with two palpable hematomas, one over the right brachialis and the other over the left quadriceps muscle. A month later, the patient started to develop pain with a decrease in range of motion in his left hip. X-rays revealed extensive heterotopic ossification encapsulating the joint. Around this same time the patient started to develop a right ulnar neuropathy, resulting in “clawing” of his right hand. Electrodiagnostic testing revealed ulnar neuropathy at or above the elbow. X-rays suggested and MRI confirmed myositis ossificans compressing the right ulnar nerve. Setting: Inpatient Rehabilitation Unit. Results: Three months after the initial injury, the Orthopedic Surgery team was asked to evaluate the patient for possible removal of the myositis ossificans. Although typically surgery is withheld for 12 to 18 months after heterotopic ossificans or myositis ossificans is

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discovered, this was a case that could potentially lead to permanent nerve injury. The Orthopedic Surgery team ultimately decided that any surgery, even if just to relocate the ulnar nerve, would result in further trauma that could possibly trigger more heterotopic bone formation. Discussion: This is the first reported case, to our knowledge of myositis ossificans causing an ulnar compression neuropathy. Conclusions: Even if heterotopic bone formation is causing potentially permanent complications, if not life threatening, surgery is often times withheld until the bone has matured, due to the risk of more trauma from surgery resulting in further bone formation. Level of Evidence: Level V Poster 206: A Multi-Disciplinary Approach to Managing Functional Movement Disorders within the Acute Rehab Setting: A Case Report Tasso Papagiannopoulos (Rush University Medical Center Physical, Naperville, IL, USA) Disclosures: Tasso Papagiannopoulos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 37-year-old woman with a history of depression and recently diagnosed functional movement disorder that was refractory to outpatient treatment modalities. The patient reported a steady decline in her functional abilities. Specifically, worsening lower extremity weakness, and antalgic gait pattern with poor truncal balance. She also developed tremors in the right upper extremity causing difficulty with her activities of daily living (ADLs). Her functional decline left her with worsening depression. Setting: Tertiary Care Hospital. Results: She was admitted with plans to focus on correcting her mind-body disconnect. She worked closely with physiatrists and psychiatry while receiving therapy. She was diagnosed with generalized anxiety disorder (GAD). Over the course of her admission, the patient gained insight into how higher levels of stress would correlate with worsening symptoms. Psychiatry initiated escitalopram 10mg daily. By discharge, the patient went from a maximal assistance level for transfers, ambulation, and ADLs, to a minimal assistance/supervision level. Her anxiety also improved. Of note, it was too early to attribute all her success to the use of escitalopram. However, upon follow-up 4 weeks later, as the medication reached therapeutic levels, she had continued improvement in her anxiety and functional status. Discussion: Functional Movement Disorders is a general term for disorders that manifest with abnormal movements (tremor, dystonia, gait disorders) but with no evidence of underlying organic abnormalities. Thus, they are generally described as being due to psychological factors. Due to the poor understanding of the underlying mechanism of disease, there has been a long-standing ambiguity about whether neurology or psychiatry should be managing these patients. As a result, there is little evidence available to guide treatment. Conclusions: This case supports the use of inpatient multi-disciplinary therapy for the management of functional movement disorders when outpatient treatment fails. Further studies are needed to investigate additional therapeutic modalities to manage this debilitating condition. Level of Evidence: Level V Poster 207: Foot Drop and Scapular Stabilizer Weakness in Late Onset FSH Muscular Dystrophy: A Case Report Hugh T. McDermott, MD (Loyola University Department of Orthopedics and Rehabilitation, Naperville, IL, United States) Disclosures: Hugh McDermott: I Have No Relevant Financial Relationships To Disclose

Case/Program Description: A 51-year-old man with fascioscapulohumeral muscular dystrophy presented with a complaint of increasing difficulty sleeping due to pain from worsening upper extremity weakness. He was diagnosed 10 years prior with the presenting symptoms of bilateral foot drop. His foot drop, secondary to profound tibialis anterior weakness, continued to worsen. He is increasingly fatigued throughout the day. Additionally, he had developed paroxysmal atrial flutter secondary to a disorder of mitochondrial respiratory chain complexes. On examination, he had atrophy of bilateral scapular stabilizers, and winging of both scapulae. General upper extremity strength was maintained through compensatory mechanisms. On lower extremity examination, the patient had 2/5 dorsiflexion strength with marked atrophy of bilateral tibialis anterior muscles. Without use of flexible ankle foot orthotics, he demonstrated steppage gait, with compensatory excessive lumbar lordosis and forward riding hips. He was provided with a physical therapy program for increasing flexibility to scapular girdle and lower extremity, as well as proper positioning techniques for energy conservation. His goal is to try and maintain current strength and range of motion or at least postpone some of his disease progression. Setting: Musculoskeletal Clinic. Results: After physical therapy, he increased flexibility and improved ability to avoid activity that irritates upper extremities. Discussion: 90% of people initially present with symptoms during or before their twenties. He was 41. His presenting symptoms were foot drop. While winging was appreciated, his upper extremities were largely spared compared to his lower extremities. Following a literature search, we determined that aerobic exercise improves morbidity, not worsen. Conclusions: Novel case of FSH muscular dystrophy due to the age and original presenting symptoms. One of his complaints is fatigue. The prescription focuses on flexibility and energy conservation techniques to improve daily function. After literature search, we should incorporate an aerobic exercise component to benefit his endurance training and strengthening. Level of Evidence: Level V

Poster 208: Chronic Post-Hypoxic Myoclonus (Lance-Adams Syndrome) After Cardiac Arrest: A Case Report Sameer A. Siddiqui, MD (Detroit Med Ctr/Wayne State University), Zainab A. Naji, MD Disclosures: Sameer Siddiqui: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 64-year-old woman with a past medical history of hypertension and end-stage renal disease on hemodialysis (HD) who was admitted to an acute care hospital following a witnessed cardiac arrest 11 days prior to arrival to inpatient rehabilitation (IPR). Cardiopulmonary resuscitation (CPR) was started in the field and she was successfully resuscitated. Patient was extubated one day after admission and was awake, alert and following commands 2 days later. Once transferred to the regular medical floor, she began complaining of “shaking” of her left upper and lower extremities. She was evaluated by neurology who diagnosed her with Lance-Adams syndrome and started her on levetiracetam (off-label use). This dose was continued in IPR, and was increased once therapists noted that her myoclonus was interfering with her ability to complete therapeutic exercises. The increased dose of levetiracetam seemed to worsen the myoclonus, so it was decreased back to the original dose. Setting: Academic Rehabilitation Hospital. Results: During her 15-day IPR admission, this patient benefited from weighted exercises along with traditional therapy techniques. Between admission and discharge, the mean of the Functional Independence Measure (FIM) scores for eating, grooming, bathing, upper extremity dressing and lower extremity dressing as assessed by occupational therapy improved from 4.6 to 5. On admission, physical therapy assessed the patient’s gait to be 15 feet on a level surface