Paediatric Orthopaedics Part 3 PDF

 Blount’s disease Growth disturbance of medial part of proximal tibial physis Acute genu varum with internal rotation Divided into Infantile 11 years  Evaluation Suggestive of pathological bowing Proximal tibial location of bowing Sharply angular d...

 Blount’s disease Growth disturbance of medial part of proximal tibial physis Acute genu varum with internal rotation Divided into Infantile 11 years  Evaluation Suggestive of pathological bowing Proximal tibial location of bowing Sharply angular deformity Asymmetric bowing of legs Progressive deformity Lateral thrust during gait Severe deformity Radiography Standing AP X rays with patellae facing forward Metaphyseal-diaphyseal angle 95% will resolve >16°-> 95% will progress Treatment Nonsurgical Bracing efficacy is controversial Only indicated for pts 2-3 years with mild disease Improvement should occur within 1 year Treatment Surgical Proximal tibial osteotomy Clubfoot Complex, congenital, contractural malalignment of the bones and joints of the foot and ankle Classification: 1. Congenital 2. Neurogenic 3. Syndrome complex 4. Positional  Clubfoot 3,5 per 1000 babies Male: female 2:1 50% bilateral Hereditory Many etiological factors Clubfoot Foot position: “CAVE” Cavus (high arch) Adduction (Midfoot) Varus (hindfoot rotated inwards) Equinus (Foot plantar flexed) Management Goals of treatment Plantigrade, painfree, functional foot Cosmetically acceptable, good mobility, no specialised footwear or orthosis Main treatment method Ponseti serial casting Casts changed at weekly intervals  Management Total number of casts varies from 6 to 10 >90% of feet then require Achilles tenotomy to correct equinus deformity After successful serial casting the child is placed in “boots and bar” splint for 3 months followed by night and nap times until 4 years of age More than 90% success rate Management If more than 10 casts or foot not improving -> conservative treatment has failed Surgery then indicated followed by special shoes (tarso-pronator type shoes) Surgical management: Posteromedial release of the foot Flat feet Physiological flat feet: Flexible flatfoot Normal development (3-5 years old) Generalised laxity Large fat pad medially  Evaluation of Flat Feet Evaluation: Evident arch in toe-standing and heel moves into varus, d/f the big toe (Jack’s test) and NWB Full painless subtalar movement  Flat feet Treatment: Asymptomatic: no treatment Non-surgical: Shoes and orthoses no benefit to arch development, but can relieve pain, UCBL Stretches if tight TA Surgical: Failed conservative treatment Calcaneal neck lengthening with soft tissue balancing (preserves motion and growth)  Flat feet Pathological flat feet: Talipes calcaneovalgus Congenital vertical talus Tarsal coalitions Hypermobile flatfoot with tight TA Neurogenic Accessory navicular bone Cavus feet CONGENITAL FAMILIAL IDIOPATHIC NEUROMUSCULAR DISEASE MUSCLE Muscular dystrophy e.g.., Duchenne NEUROLOGICAL Peripheral nerve Polyneuritis Charcot-Marie-Tooth Ant. Horn cells Polio Myelomeningocele Diastematomyelia Cord tracts Friedereichs’ ataxia Brain Cerebral palsy TRAUMA BURNS IRRADIATION. Cavus feet Always investigate further, especially in unilateral cavus foot. ? + Family history Full neurological examination Spinal X-rays Spinal dysraphism Diastomatomyelia MRI To rule out space occupying lesion  Management Refer to orthopaedic surgeon for investigation and treatment. Surgery Cavus feet Indication varies with the cause, age and severity of the problem. Soft tissue procedures Osteotomies Arthrodesis Important Neurological diseases BRACHIAL PLEXUS INJURIES CEREBRAL PALSY MYELOMENINGOCOELE MUSCLE DYSTROPHY Brachial plexus injury Upper arm involvement = Erb-Duchenne type. Whole arm involvement type. Lower arm involvement type = Klumpke type. Brachial plexus injury UPPER ARM INVOLVEMENT Cephalopelvic disproportion Impaction of the head with traction to the shoulders causes stretching of the plexus. Often upper part of plexus at ERB’S point (C5 and C6 roots) (ERB’S paralysis). Shoulder and elbow affected. Adduction / medial rotation position. Waiters tip arm. Absence of Moro reflex. Brachial plexus injury Diff DX of septic arthritis with pseudo paralysis or fractures (clavicle or humerus) Early diagnosis essential. Document neurological deficit and repeat exam regularly. Ensure mobility of both shoulder and elbow joints: Abduction / external rotation of shoulders 10 X with each nappy change. Most pts have fair prognosis. Bad prognosis if deltoid and biceps function not visible at 3 months. Surgery considered if at 3 months no response: neurolysis or nerve grafts. Brachial plexus injury WHOLE ARM INVOLVEMENT All 3 cords involved Complete flaccid arm Worst prognosis Brachial plexus injury LOWER ARM INVOLVEMENT: Lower 2 cords involved with paralysis of intrinsic muscles of hand. No grip reflex. Intact wrist and finger flexors. Involvement of Cervical sympathetic nerves in 1st dorsal (thoracic) roots → causes ipsilateral Horner syndrome with enophthalmos, myosis and ptosis Can be due to arm presentation with subsequent traction and abduction from trunk. Prognosis:Poor. Prevention of contractures crucial in management.