Common Orthopaedic Deformities PDF

# Common Orthopaedic Deformities ## Prof. Dr. Nabil Ghaly Professor of Orthopaedic Surgery Ain Shams University - A deformity is the deviation from the normal appearance of a part of the body. - Common orthopaedic deformities are either congenital or acquired. - Most deformities may require surgic...

# Common Orthopaedic Deformities ## Prof. Dr. Nabil Ghaly Professor of Orthopaedic Surgery Ain Shams University - A deformity is the deviation from the normal appearance of a part of the body. - Common orthopaedic deformities are either congenital or acquired. - Most deformities may require surgical intervention. ## The Knee - **Genu Varum (Bow leg):** - **In infants:** - the most common cause is developmental and physiologic. - The deformity gradually corrects with growth over months, almost correcting completely by the age of 4 years. - No treatment is necessary. - **In children (aged 1.5-2 years):** - Rickets is the commonest cause. - It is associated with its systemic signs, symptoms and laboratory findings. - Treatment is directed to correcting the cause; usually vitamin D deficiency. - In some advanced cases osteoclasis or osteotomy is required. - **In adults:** - Osteoarthritis - Mal-united fracture - Ligamentous injury - Paget's disease are the main causes. - Treatment is also directed at surgical correction of the deformity. - **Genu Valgum (knock knees):** - **Valgus knee up to the age of 4 years:** - Usually developmental or physiological. - Almost always corrects itself by 6-8 years. - If the condition is still progressive at that age, a supracondylar osteotomy of the femur is required. ## The Hip - The normal neck-shaft angle of the proximal femur is 160° at birth, decreasing to 125° at adulthood. - An angle less than 110° is called **coxa vara**. - An angle more than 130° is called **coxa valga**. - They both lead to gait disability and secondary spinal pain and deformity. - Treatment is by corrective subtrochanteric osteotomy. ## The Elbow - The normal carrying angle is 10-15 degrees of valgus, which allows a clearing distance for objects to be carried by hand alongside the trunk while walking. - An angle above that will cause **cubitus valgus**, and below it **cubitus varus**. - These deformities are corrected surgically through a wedge osteotomy at the lower humerus. ## Bone Softening Diseases - The bone is a type of connective tissue formed of cells and matrix. - **Bone cells are mainly 2 types:** - Bone forming cells (osteoblasts). - Bone resorbing cells (osteoclasts). - The bone matrix is called osteoid and is formed of a type of collagen in which calcium salts are deposited. - **Bone softening disease may be caused by:** - 1-Defective formation of osteoid eg. osteogenesis imperfecta. - 2-Defective mineralisation of osteoid e.g. Rickets. - 3-Increased resorption of bone by osteoclasts e.g. hyperparathyroidism. - 4-Decreased formation of bone by osteoblasts e.g. osteoporosis. ## Osteogenesis Imperfecta - It is a generalized mesenchymal disorder characterized by: - 1) Defective osteoid production causing failure of formation of mature bone. The bone formed is fragile resulting in multiple and repeated fractures. - 2) Defective collagen production resulting in ligamentous hyperlaxity of joints and blue sclera. - There are several types of the disease with variable degrees of affection: - 1) Congenital Type: - Still-born or born with multiple fractures. - 2) Infantile type: - They develop manifestations early in infancy by multiple easy fractures. - 3) Tarda type: - some cases develop manifestations in late childhood. - There is no specific treatment of the condition. - **Orthopedic management is directed to:** - Preventing fractures and deformities using plastic supporting devices. - Treating current fractures. - Correcting deformities which may need surgery. ## Rickets - It is a disease of growing bone due to inadequate calcification of bone matrix. - **Causes:** - **Infantile Rickets:** - Due to deficient intake of vitamin D and lack of exposure to sunlight, which is necessary for formation of vitamin D by the skin. - The disease manifests between 6 months and 3 years of age. - The other types of rickets are manifested in an older age. - **Coeliac Rickets:** - Due to deficient absorption of fat and vitamin D caused by hereditary intolerance to gluten. - **Renal rickets:** - Due to disturbed calcium phosphorus metabolism caused by renal dysfunction. - **Clinical Picture:** - The most important bony manifestations are bony deformities causing bow legs (genu varum) or knock knees (genu valgum). - **Characteristic signs of infantile rickets are:** - Boxy-bossy skull - Rickety rosary - Pigeon chest - Harrison Sulcus - Broad metaphysis - Marfan sign - **10 important clinical features in Rickets:** | Feature | Description | |:---|:---| | Delayed closure of fontanelles | | | Frontal bossing | | | Dental hypoplasia | | | Pectus carinatum | | | Swelling in wrist and ankle joints | | | Wide sutures | | | Craniotabes | | | Rachitic rosary | | | Harrison's sulcus | | | Bowing of legs | | - **X-ray:** - shows bone rarefaction (diminished density in x-ray). - The metaphyses become broadened and cupped and show brush border. - With healing the frayed brush border of the metaphysis becomes replaced by a line of calcified bone. - **Treatment:** - **Infantile rickets:** - Good diet rich in Ca, P and Vitamin D and exposure to sunlight as well as administration of vitamin D and calcium. - **Renal rickets:** - Needs administration of high doses of vitamin D in the form of active vitamin D (one alpha) and calcium. - Severe deformities not improving with medical treatment may need surgical correction(osteotomy). ## Hyperparathyroidism - Primary hyperparathyroidism results from increased secretion of parathyroid hormone by parathyroid hyperplasia or tumour. - This causes increased bone resorption by osteoclasts leading to: - 1) Hypercalcemia. - 2) Recurrent renal calculi. - 3) Bone resorption causes cystic changes in bones, bone deformities and pathological fractures. - Surgical treatment is by excision of parathyroid adenoma. ## Osteoporosis - It is diminished bone mass due to diminished bone formation by osteoblasts with aging and after menopause. - **Common sites affected are:** - **Vertebral column:** weakening of vertebrae. Causes vertebral collapse which causes back pain, kyphosis and gives a radiographic appearance of collapsed wedged or biconcave vertebra. - Proximal femur - Proximal humerus - Distal radius causing fracture after minor trauma. - **Diagnosis** is now possible using bone densitometry (DEXA). - **Treatment:** - 1) Adequate diet with good supply of calcium, vitamin D and proteins. - 2) Daily exercises and exposure to sunlight. - 3) Medications including: - Calcium, vitamin D - Calcitonin which increases osteoblastic activity - Bisphosphonates: Oral medications, which inhibit osteoclastic activity - Hormonal Replacement therapy (HRT) used in some cases.