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An 8-year-old female diagnosed with osteogenesis imperfecta (OI) type IV returns to the hospital today for a scheduled admission of spica cast removal. Six weeks ago, she underwent bilateral femoral intramedullary rodding with multiple right corrective femoral osteotomies, and hip spica cast application due to significant progressive anterior bowing of her femurs. The child has typical features of OI with loose joints and short stature. She has had more than 25 fractures over her lifespan, including multiple fractures of bilateral humeri, right ulna, bilateral femurs, and the left tibia. She has mild scoliosis, her right leg is shorter than her left by 2 cm, and she has mild to moderate anterior bowing of her tibias. She wears bilateral lower leg orthoses (left hinged ankle foot orthosis and right UCBL orthosis) for planovalgus feet. The patient has been on bisphosphonate medication since she was 3 years old. This was discontinued 7 months prior to surgery per her metabolic and orthopaedic physicians' recommendations. Prior to surgery, the patient complained of mild bilateral thigh and knee pain, primarily with walking and standing. She had full hip and knee extension and hip and knee flexion to at least 120°. She lacks 20° of elbow extension bilaterally and has mild radial deformities of her wrists. The patient has a rear-wheeled walker and a lightweight manual wheelchair. Over the past 2 years, she has used the walker “off and on” as needed to heal from various fractures and for minimizing lower extremity pain. In the 2 months prior to surgery, she used the walker in the school classroom and in the community. At home, she did not use an assistive device for ambulation; she either walked or knee-walked, depending on pain severity. In general, she uses her wheelchair during healing of fractures and she is independent with propulsion. Prior to surgery, she was also independent with all transfers. The patient has one step to enter her home and she was able to negotiate the step with one handrail and one arm-hold assist. Since surgery, she has been non-weightbearing on bilateral lower extremities and has been using a reclining wheelchair with elevating leg rests for dependent mobility. Her parents have been lifting her for all transfers. Today, the physical therapist is asked to evaluate and treat the patient for initiation of lower extremity weightbearing. She is allowed to bear weight as tolerated, though she must initially use knee immobilizers if weightbearing on land. The radiographs from today show stable healing of bilateral femurs. The patient is seen at bedside with her spica cast already removed and with her mother in the room. She has pressure sores from the cast on her left calcaneus and bilateral anterior knees. The nurse has administered pain medication in anticipation of physical therapy. Although the patient is tearful and states she is scared to start standing, the patient's and mother's short-term goals for this admission are to complete standing transfers with a walker and to sit comfortably in her ...

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