Management of immature heterotopic ossification (HO) of the hip.

A case of extensive heterotopic ossification involving the left hip in a 16 year old girl who sustained non traumatic spinal paralysis at T4 ASIA scale A. This case demonstrates the practical difficulties facing clinicians involved in the rehabilitation of this paraplegic patient who required intervention before full maturation of her left hip heterotopic ossification (HO). The patient was developing a rapidly progressive fixed scoliosis and severe difficulty in achieving a proper seating posture. In addition there was difficulty with the application of a suitable orthosis to try and limit the progression of scoliosis as a result of the HO. Discussants will comment on heterotopic ossification in general and the course of action in this particular case.

Heterotopic ossification: diagnosis and management, current concepts and controversies.

HO is a pathologic process in which soft tissues undergo ossification. The etiology is unknown. Patients with neurologic deficits develop HO in the proximal joints. An incidence of 20% to 30% is commonly reported; 8% to 10% of these patients develop severe functional limitations. Routine prophylaxis in patients with SCI cannot be justified. Early diagnosis and treatment with EHDP or other anti-inflammatory medications have been shown to result in good functional outcomes. Elevated SAP levels and positive radionuclide scan, in addition to restriction of joint ROM, are indicative of HO formation. Role of other anti-inflammatories, radiation, and early surgical excision without bone maturity in these patients need to be studied further. A small percentage of patients require surgery to improve function. Joint manipulation to produce pseudoarthrosis is not indicated in patients with SCI.

Prevalence and impact of wrist and shoulder pain in patients with spinal cord injury.

Spinal cord injury (SCI) patients experience varying degrees of wrist and shoulder pain. Previous studies indicated that 30 to 64 percent of SCI patients reported chronic shoulder pain. The purpose of this study was to identify the prevalence of chronic wrist and shoulder pain, to determine which activities caused or exacerbated the pain, and assess functional and emotional responses to chronic pain and identify ways in which the pain might be reduced. Eight hundred SCI patients were surveyed by questionnaire with 451 (66 percent) responding. In addition, 30 patients were available for clinical observation and evaluation. Data was evaluated using the Statistical Analysis System and the Cornell Personal Adjustment Scale. Results indicated that wrist and shoulder pain were more prevalent than previously indicated (72.7 percent of respondents reported some degree of chronic pain in one or both of these areas), wheelchair propulsion and transfers caused most pain and also increased the degree of pain. Patient's age, neurologic level and time since injury were not statistically significant in the study and emotional responses did not significantly vary between groups with and without pain. Further, it was noted that among the pain group, various routine therapies were not effective. We conclude that alternative methods for wheelchair propulsion and transfers, which lessen stress and cumulative trauma, need to be developed for SCI patients in order to diminish the incidence of chronic upper limb pain.

Walking after spinal cord injury. Goal or wish?

Less than a third of patients walk again after a spinal cord injury, whereas every one of them wants to try. Residual function, energy expenditure, the extent of orthotic support needed, and patient motivation will determine the outcome. Functional electrical stimulation and other new orthotic designs have not notably increased the number of persons able to walk after a spinal injury. Rehabilitation professionals can use patient education, illustrating relearning to walk with examples of infants' and toddlers' progress, to assist patients in understanding their abilities and limitations. The final decision on ambulation and orthotic prescriptions can be made in stages after a patient adjusts to a wheelchair-independent level.

Non traumatic dislocation of shoulder with rupture of axillary vessel branch in a paraplegic patient: a case report.

Spinal cord injured (SCI) patients utilize the shoulder joints for wheelchair propulsion, for transfers in and out of wheelchairs and for wheelchair "push-ups" for pressure relief, to prevent pressure sores. Accurate incidence of shoulder dislocation in SCI patients is not known. A majority of the dislocations seen are secondary to trauma. A 66-year-old, T10 paraplegic since 1942, developed severe osteoarthritic changes in both shoulders and experienced nontraumatic, recurrent dislocation of his right shoulder with a rupture of the axillary vessel branch. This case is reported here because of its rarity.

Pseudoarthrosis in heterotopic ossification in spinal cord-injured patients.

Heterotopic ossification (HO) of proximal joints is a common complication of spinal cord injury, traumatic brain injury, and burns, and is also seen among an array of other clinical conditions. Of the patients with HO, 3-8% develop ankylosis of the joint involved. Although the etiology of HO is not known, the main goal in its management is to retain the maximum possible functional range of movement in the joint involved. Toward this end, surgical resection of HO with etidronate disodium treatment to mobilize ankylosed joints has been reported, as has forceful joint manipulation in head-injured adults with HO. This paper presents two cases of extensive HO formation around hip and knee joints in patients who developed pseudoarthrosis. Cinradiographic assessment of the joints involved revealed pseudoarthrosis formation at the same axis as the normal anatomical plane of the joint, thus permitting functional range of movement.

Spontaneous dislocation of the radial head in cerebral palsy.

A patient with spastic quadriparetic cerebral palsy and unilateral nontraumatic dislocation of the radial head is presented. The association of radial head dislocation with flexion contracture of the elbow and contracture of the pronators of the forearm is known to occur but is infrequently reported. Early recognition and management of elbow and forearm contractures in cerebral palsy patients is imperative to avoid radial head dislocation, since the outcome of both surgical and rehabilitative management are significantly influenced by its presence. Literature related to this problem and pathokinesiology is discussed.

Spinal cord dysfunction in older patients--rehabilitation outcomes.

Eighty-seven patients discharged from a rehabilitation ward for spinal cord injured persons at Edward Hines Jr. VA Hospital from October 1, 1982 through September 30, 1984 were retrospectively reviewed for rehabilitation outcomes. Forty-three patients (49%) were 50 years of age or older. Of the older patients, 27 (62%) were quadriplegics. Incomplete lesions were more commonly seen in this group. Twenty-six (60%) did not have x-ray evidence of fracture or dislocation. Falls, spinal stenosis and vascular etiologies were commonly noted. Fifty-four (62%) patients were admitted within 60 days of onset of the spinal cord dysfunction. Five patients died during hospitalization, three of whom were more than 60 years of age. Sixty-seven percent of the older patients were discharged to their homes. Transfers, ambulation, self-care, and bladder and bowel continence levels were reviewed. Associated medical conditions and complications were also analyzed. It appears that the overall rehabilitation outcomes in older patients were quite satisfactory when compared to other spinal cord injury patients, but rehabilitation programs and goals must be modified in order to meet their needs. Long-term planning and management are essential.

Resection of heterotopic ossification and Didronel therapy--regaining wheelchair independence in the spinal cord injured patient.

Ankylosis of the joints secondary to heterotopic ossification in the spinal cord injured is not uncommon. Five patients had ankylosis of the hip and knee joints which limited their ability to function in their wheelchairs. They underwent eight resections to improve their functional capabilities. All patients were treated pre- and postoperatively with disodium etidronate (EHDP, DIDRONEL). The average interval from injury to surgery was nine years nine months and the average interval from surgery to follow-up was two years three months. With clearly defined goals, proper patient selection, good pre- and postoperative management and intense rehabilitation combined with Didronel, optimum functional results were achieved.