Case of the week: 20-1-2003

from Department Of Pediatric Orthopaedics, Dana Children's Hospital, Tel Aviv Sourasky Medical Center

An very active 5 year old boy with Right Spastic Hemiparesis:

Chief Complaint: Toe walking, knee locking, occassional tripping
Cognitive Ability: No impairment
Visual: Normal
Hearing: Normal
Communication: Normal
Birth Weight: 3.8 kg
Delivery: Normal delivery at 41/40. Diagnosis was made at age of 14 months.
Developmental Milestones: Crawling 0.58, Walking 1.33 years
Functional level: very active - rides a bike without training wheels, plays soccer, swings independently, hikes, etc.

Medical History

Serial Casting for right ankle at age 2 y
Serial Casting for right hamstrings at age of 3 y
Botox injection for right hamstrings at age 3 y 1/2
Botox injection for right hamstrings at age 4 y 10/12 - little effect

Surgery: None
Medication: None

On Going Treatment

PT: once a week
OT: once every 2 weeks
Orthotic Management: Indoor bare feet, Outdoor, right posterior leaf SMO
Functional Ability: Independent walker, Bicycle / Roller-blades

Physical examination
 
Left Right
Hip flex/ext 140 140
Straight Leg Raise 75  55
Thomas Test  10  12
Hip Ab/Adduction  50/0/30 45/0/30
Hip Abduction @ 90º 65 65
Int/Ext Rotation @ 0º 60/0 /20 65/0/25
Int/Ext Rotation @ 90º 55 /0/50 75 /0/40
Duncan Ely Slow/Fast 140/140 130/130
Knee Flexion/Extension 160/0/5 160/0/0
Popliteal Angle 25 70
Dundee Angle Slow/Fast 5/5 0/0
Ankle dorsi/plant @ 0º 25 10
Ankle dorsi/plant @ 90º 40 30
Plantarflexion 40 40
Inversion/Eversion normal normal
Catch On Dorsiflexion - +
Plantarflexor Clonus - -
Confusion Test + +

Anthropometry

Height: 105 cm
Mass: 15 kg
Inter-ASIS distance: 14 cm
 
 
Left
Right
Leg Length (cm) 51 51
Knee Width (cm) 4.8 4.7
Ankle Width (cm) 5.4 5.2
Tibio/Femoral Alignment (º) -10 -8
Tibial Torsion -23 -17
Femoral Anteversion 30 35
Shank Rotation -17 -14
Shank Length 23 23

Movies
 
Sagittal
 right side left side
Frontal front view rear view

Temporal-Spatial Parameters

Right Left Normal
Velocity (m/s) 1.15 1.06 1.08
Cadence (steps/min) 168 160   154
Step Length (cm) 0.41 0.40  0.42
Stride Length (cm) 0.82 0.80  0.84
Stride Time (s) 0.71 0.75    0.77
Step Time (s) 0.33 0.41    0.39
Step Width (m)  0.10 0.13
Single Support (s) 0.30 0.28    0.29
Double Support (s) 0.13 0.15    0.20
Opposite Foot Contact (%) 53.9 45.6    49.7
Opposite Foot Off (%) 11.2 8.89    13.3

3D Biomechanical Analysis

3D Joint Kinematics Joint Kinetics EMG

Points for discussion

The following procedures have been tentatively scheduled:

  1. medial hamstring release (percutaneous)
  2. gastroc release
  3. iliopsoas release
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