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26yr old male
bomb blast injury over his right thigh 9 months back,
had open fracture at distal femur with popliteal nerve injury treated with external fixator.
fractured united well.he has painful foreign body in the plantar aspect of foot.
sensation partially preserved below the knee .


now is is walking with bilateral elbow crutch with now weight bearing walking.

has complete motor loss below knee, no active ankle movements are possible,
hamstring power is 3 (MRC).

my plan to remove the foreign body in foot, exploration of nerve.

any other option for flail ankle.
suresh

 

Re: flail ankle

Hello Suresh,
You always seem to bring some of the most interesting and challenging cases to this website - thank you!
Is there any motor power available at any of the muscle groups of the leg? When you say that sensation is partially preserved below the knee - which cutaneous nerves are patent? Since the patient has impaired posterior thigh muscle power, how does this appear to affect their knee mechanics?
Have you tried an AFO/ ankle splint and if so how stable is the patient when walking with this?
Bob

 

Re: flail ankle

Hello Suresh:
If he sustained injury to the peroneal, anterior and posterior tibial nerves, then the it is likely that motor damage may be permanent or very slow to retain to at least 50%.
After you remove the foreign body, I would recommend an Ankle Foot Orthosis (AFO) with passive/active range of motion therapy of the affected extremity.
Narmo

 

Re: flail ankle

hi bob,

no active muscle in the leg and foot. hamstring is 3.he has decreased sensation in l4,l5 and more in s1. no loss of sensation. he he is not taking weight on that limb because of painful foot. but no progressive improvement for past 3 months.

suresh

 

An AFO supports the forefoot and prevents plantar flexion or "foot drop" during swing. But don't forget, an AFO additionally substitutes for the lack of a plantarflexion moment during stance phase of gait. You see, the plantar flexors must be active during midstance and terminal stance to counter the dorsiflexor moment that is produced by the ground reaction force about the ankle jt. In the presence of weak plantarflexors, the ankle dorsiflexes too rapidly and, because the lower extremity is positioned in a closed chain, the knee flexes.

Midstance knee flexion affects the person's stability. Someone with weak plantar flexors must compensate proximally at the hip, (High-stepping, abducting, circumducting, excessive quad firing, compensatory genurecurvatum, etc.) or must wear an external device (an AFO) that substitutes the force that the plantar flexors ordinarily provide.


An AFO with a dorsiflexion stop can be used to stabilize the knee in extension using GRF control in stance and would also allow knee flexion in swing phase. The degree of correct plantarflexion moment can be dialed in by building the brace in 5-10deg of plantarflexion and adjusting heel height accordingly.

I suppose you could also restrict knee flexion through the use of a KAFO with a locked knee. But the 3PP system which prevents knee flexion in stance phase would also prevent knee flexion in swing phase producing an inefficient walking pattern. The KAFO is a very safe orthosis for sure but, dang, that is one bulky beast of a brace! And Dude still has his Quads, right? Just a 3/5 mmt on the hammy's. The GRF control device (AFO) is more energy efficient but not as safe when compared to the 3PP control orthosis (KAFO) which creates a less energy efficient but safer gait pattern.

Because he's already used to the Lofstrands, your patient might do well with solid ankle AFOs (or a heel-less, anterior cuff style. Then you could include a pressure reducing FO that relieved his forgien body wound site!!) and bilateral rocker sole modifications. If you go this route, the rocker sole mods are the key to controlling the tibia's advencement over the toes through the correct placement of the rocker axis. It will also reduce the plantar pressures that can get pretty high in the FF found with a co-poly full-length footplate.

GLTYand your pT!

Chris