Cauda Equina Syndrome - Hypotonic No Clonus

Bilateral AFOs. – Orthopedic Surgeon Referral

Cauda equina syndrome with bilateral drop-foot.

This 71-year-old male has no allergies. He is currently taking Xanax and is an insulin-dependent diabetic. He has had many surgeries, spine surgery in December 1999 and June 2000 to relieve pain in his lower limbs. However, his wife reports that this was unsuccessful and they discovered a syrinx at this time. He also had surgery for a broken hip. He has had the 2^nd toe on his left foot amputated. He has had surgery for cataracts and glaucoma. He also has a history of an ulcer on the 2^nd toe of his right foot and on his right heel. He has had no ulcers on his left foot. Today the patient has a small sore on the middle of his right tibia. The patient is a limited household ambulator, uses a walker. Out in the community, however, he does use a wheelchair. He will begin physical therapy after he receives the braces. He has had no previous braces.

The patient's feet present as pronated bilaterally. He is hypotonic with no clonus. Range of motion at his ankles is to 90 degrees with his knees straight. His heels are in valgus and his forefeet are slightly abducted. His right foot is flaccid, and his left foot has a trace of dorsiflexion. His quads are 3+. His skin appears to be somewhat thin. He has some peeling of the skin over his left heels. He has pitting edema in his feet and lower legs. The sensation stops at the top of the left calf and at the middle of the right calf. Traced the patient's legs for conventional AFOs, took impressions for custom inserts, and measured his feet for extra-depth shoes to be attached to the conventional AFOs. I observed the patient's gait with a walker in the office today. He has a very crouched gait and he takes small shuffling steps and drags his toes.

We will order Drew men's doubler shoes for the patient and fabricate custom inserts and bilateral conventional double-upright AFOs with double action ankle joints and an extended stirrup.

KAFO with ShearGuard - Flexion Contracture

The patient is here today to pick up his orthoses that had been adjusted. The left heel counter of the shoe had been cut and the hard aspect of it was removed. We added 3/16 inch Aliplast padding covered with ShearGuard to prevent the patient from rubbing his calcaneus, which would breakdown his scar tissue. He was very satisfied with this. Additionally, the KAFO knee was flexed slightly approximately 3 to 5 degrees to accommodate his flexion contracture. This was also satisfactory. He ambulated in the parallel bars without hands and did very well. He complained of pain in the knee on the lateral aspect of the tibial plateau. When questioned, he described to me that this pain also occurs with physical therapy and range of motion. He is also described some crunching sounds coming from the knee. I suspect that this is meniscus damage from his initial injury and recommended that he discuss this with his physician. Otherwise, he stated that the orthoses are quite comfortable. He will see his physician, and return to see us if any further adjustments are needed.

Loose Rivets - Replace with Copper Rivets

The patient is here today because the rivets have become loose on the graphite reinforcement that we

had placed on the orthoses. To repair it, I will replace these with copper rivets. She will pick this up

tomorrow at approximately 10 am. I will do this at no charge.

Bilateral AFO Wrap-Arounds - Ortho Referral

The patient was in the office today for a routine follow-up on her bilateral AFO-Wrap Arounds. She is doing well and the orthoses are fitting and functioning quite well. I have replaced the straps and pads today at no charge. Of note is a conversation I had with the patient's father today. He stated that they are attempting to stand the patient in a standing frame. She has recently received a new wheelchair, standing frame and varied assistive devices for her home. I briefly discussed with the father the benefits of standing and recommended that he consult with their physician There are different styles of orthoses that may be of benefit to the patient, i.e., a KAFO night splint for extension at the knees, as she has knee and hip flexion contractures. He will consult with physician regarding the orthoses, physical therapy and a game plan to achieve the goal of standing. Otherwise, we will see them in routine follow-up.

Cerebral Palsy - Bilateral Solid Ankle AFO's

Bilateral solid-ankle AFOs. Cerebral palsy. Orthopedic Surgeon Referral

This is a 13-year-old male has no known allergies. He is taking baclofen. He requires maximum assistance when ambulating, and he has not had surgery since his last visit. He receives physical therapy at school, and his previous devices were solid-ankle AFOs with Compcore reinforced at the ankles. The patient brought the braces with him today. He was getting pressure on the right side at the medial malleolus, and on the left at the base of the 5^th metatarsal. These were both heat relieved. He has outgrown the footplate and they are also too short. He can wear them until the new braces are complete. This was explained to the mother.

The casting procedure went well. The patient's heels are in valgus bilaterally and they are not correctable. The right is worse than the left. Range of motion at the ankles is to 90 degrees bilaterally with the knees bent.

Fabricate bilateral solid-ankle AFOs.

Bilateral Equinovarus Contractures

Bilateral free-ankle AFOs with inhibitive footplates. Bilateral equinovarus contractures. Orthopedic Surgeon Referral

This 5-year-old male has no know allergies. He is not taking any medication and is an active community ambulator. He receives physical and occupational therapy. He receives speech therapy at home. He previously had bilateral free-ankle AFOs and did well in them, but has outgrown them.

The patient is a toe walker; however, he is able to come down on his heels when asked to. He slightly pronates bilaterally. Range of motion at the ankles with the knees flexed is +15 degrees, and with the knees straight it is +10 degrees bilaterally. His heels were in a slight amount of valgus but correctable, and his forefeet are slightly abducted but correctable. The casting procedure went well. Mom knows what to expect as far as overall design. NOT footplates will be added. He has mild tone when relaxing or sitting. His tone is more dynamic in nature. When he walks he gets up on his toes.

Bilateral free-ankle AFOs with inhibitive footplates.

Bilateral Equinovarus Contractures

Bilateral free-ankle AFOs with inhibitive footplates. Bilateral equinovarus contractures.

This 5-year-old male has no know allergies. He is not taking any medication and is an active community ambulator. He receives physical and occupational therapy. He receives speech therapy at home. He previously had bilateral free-ankle AFOs and did well in them, but has outgrown them.

The patient is a toe walker; however, he is able to come down on his heels when asked to. He slightly pronates bilaterally. Range of motion at the ankles with the knees flexed is +15 degrees, and with the knees straight it is +10 degrees bilaterally. His heels were in a slight amount of valgus but correctable, and his forefeet are slightly abducted but correctable. The casting procedure went well. Mom knows what to expect as far as overall design. NOT footplates will be added. He has mild tone when relaxing or sitting. His tone is more dynamic in nature. When he walks he gets up on his toes.

Bilateral free-ankle AFOs with inhibitive footplates.