Chapter 14 Lower Limb Conditions
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Genu Varum and Genu Valgum Genu Varum and Genu Valgum
Common Pediatric Lower Limb Disorders Dr.Kholoud Al-Zain Assistant Professor Consultant, Pediatric Orthopedic Surgeon Nov- 2018 Acknowledgement: Dr.Abdalmonem Alsiddiky Dr.Khalid Bakarman Prof. M. Zamzam Topics to Cover 1. In-toeing 2. Genu (varus & valgus), & proximal tibia vara 3. Club foot 4. L.L deformities in C.P patients 5. Limping & leg length inequality 6. Leg aches 1) Intoeing Intoeing- Evaluation • Detailed history – Onset, who noticed it, progression – Fall a lot – How sits on the ground • Screening examination (head to toe) • Pathology at the level of: – Femoral anteversion – Tibial torsion – Forefoot adduction – Wandering big toe Intoeing- Asses rotational profile Pathology Level Special Test • Femoral anteversion • Hips rotational profile: – Supine – Prone • Tibial torsion • Inter-malleolus axis: – Supine – Prone • Foot thigh axis • Forefoot adduction • Heel bisector line • Wandering big toe Intoeing- Special Test Foot Propagation Angle → normal is (-10°) to (+15°) Intoeing- Femoral Anteversion Hips rotational profile, supine → IR/ER normal = 40-45/45-50° Intoeing- Tibial Torsion Inter-malleolus axis Supine position Sitting position Intoeing- Tibial Torsion Foot Thigh Axis → normal (0°) to (-10°) Intoeing- Forefoot Adduction Heel bisector line → normal along 2 toe Intoeing- Adducted Big Toe Intoeing- Treatment • Establish correct diagnosis • Parents education • Annual clinic F/U → asses degree of deformity • Femoral anti-version → sit cross legged • Tibial torsion → spontaneous improvement • Forefoot adduction → anti-version -
The Foot Angiosomes As Integrated Level of Lower Limb Arterial Perfusion
Research Article iMedPub Journals 2019 www.imedpub.com Journal of Vascular and Endovascular Therapy Vol. 4 No. 1: 7 The Foot Angiosomes as Integrated Level of Alexandrescu VA1* Pottier M1, Lower Limb Arterial Perfusion: Amendments Balthazar S2 and Azdad K3 for Chronic Limb Threatening Ischemia 1Department of Vascular and Thoracic Presentations Surgery, Princess Paola Hospital, Marche- en-Famenne, Belgium 2Department of Anesthesiology, Princess Paola Hospital, Marche-en-Famenne, Belgium Abstract 3Department of Radiology, Princess Paola Introduction: The angiosome concept was initially pioneered by Taylor and Palmer in the Hospital, Marche-en-Famenne, Belgium plastic reconstructive surgery field. The authors described a reproducible model of arterial and venous distribution in humans that follows specific three-dimensional (3D) networks *Corresponding author: Vlad Adrian of tissue. The angiosome model yet represents a specific level among other staged and Alexandrescu graduated levels of harmonious arterial irrigation in the lower extremity. Specific CLTI pathologies enhance characteristic arterial branches affectation, including the angiosomal source arteries. Evaluating main atherosclerotic lesions at peculiar Levels of arterial division [email protected] may afford useful clinical information. Department of Vascular and Thoracic Method: The present study proposes a description of six levels of degressive arterial division Surgery, Princess Paola Hospital, Marche- and collateral distribution in the inferior limb, including the angiosomal stage. Following en-Famenne, Belgium succeeding perioperative 2D angiographic observations over an eight-year period, these levels (I to VI) were analyzed (including the angiosomal Level III) and summarized in attached tables. The medical files of 323 limb-threatening ischemic foot wounds (Rutherford 4-6) in 295 patients (71% men) were retrospectively reviewed. -
OES Site Color Scheme 1
Nuisance Problems You will Grow to Love Thomas V Gocke, MS, ATC, PA-C, DFAAPA President & Founder Orthopaedic Educational Services, Inc. Boone, NC [email protected] www.orthoedu.com Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Faculty Disclosures • Orthopaedic Educational Services, Inc. Financial Intellectual Property No off label product discussions American Academy of Physician Assistants Financial PA Course Director, PA’s Guide to the MSK Galaxy Urgent Care Association of America Financial Intellectual Property Faculty, MSK Workshops Ferring Pharmaceuticals Consultant Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. 2 LEARNING GOALS At the end of this sessions you will be able to: • Recognize nuisance conditions in the Upper Extremity • Recognize nuisance conditions in the Lower Extremity • Recognize common Pediatric Musculoskeletal nuisance problems • Recognize Radiographic changes associates with common MSK nuisance problems • Initiate treatment plans for a variety of MSK nuisance conditions Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Inflammatory Response Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. all rights reserved. Inflammatory Response* When does the Inflammatory response occur: • occurs when injury/infection triggers a non-specific immune response • causes proliferation of leukocytes and increase in blood flow secondary to trauma • increased blood flow brings polymorph-nuclear leukocytes (which facilitate removal of the injured cells/tissues), macrophages, and plasma proteins to injured tissues *Knight KL, Pain and Pain relief during Cryotherapy: Cryotherapy: Theory, Technique and Physiology, 1st edition, Chattanooga Corporation, Chattanooga, TN 1985, p 127-137 Orthopaedic Educational Services, Inc. © 2016 Orthopaedic Educational Services, Inc. -
Neonatal Orthopaedics
NEONATAL ORTHOPAEDICS NEONATAL ORTHOPAEDICS Second Edition N De Mazumder MBBS MS Ex-Professor and Head Department of Orthopaedics Ramakrishna Mission Seva Pratishthan Vivekananda Institute of Medical Sciences Kolkata, West Bengal, India Visiting Surgeon Department of Orthopaedics Chittaranjan Sishu Sadan Kolkata, West Bengal, India Ex-President West Bengal Orthopaedic Association (A Chapter of Indian Orthopaedic Association) Kolkata, West Bengal, India Consultant Orthopaedic Surgeon Park Children’s Centre Kolkata, West Bengal, India Foreword AK Das ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD. New Delhi • London • Philadelphia • Panama (021)66485438 66485457 www.ketabpezeshki.com ® Jaypee Brothers Medical Publishers (P) Ltd. Headquarters Jaypee Brothers Medical Publishers (P) Ltd. 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd. Jaypee-Highlights Medical Publishers Inc. Jaypee Brothers Medical Publishers Ltd. 83, Victoria Street, London City of Knowledge, Bld. 237, Clayton The Bourse SW1H 0HW (UK) Panama City, Panama 111, South Independence Mall East Phone: +44-2031708910 Phone: +507-301-0496 Suite 835, Philadelphia, PA 19106, USA Fax: +02-03-0086180 Fax: +507-301-0499 Phone: +267-519-9789 Email: [email protected] Email: [email protected] Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd. Jaypee Brothers Medical Publishers (P) Ltd. 17/1-B, Babar Road, Block-B, Shaymali Shorakhute, Kathmandu Mohammadpur, Dhaka-1207 Nepal Bangladesh Phone: +00977-9841528578 Mobile: +08801912003485 Email: [email protected] Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. -
Pierre Robin and the Syndrome That Bears His Name PETER RANDALL
Pierre Robin and the Syndrome That Bears His Name PETER RANDALL, M.D. WILTON M. KROGMAN, Ph.D. SOONA JAHINA, B.D.S., M.Sc. Philadelphia, Pennsylvania The Pierre Robin Syndrome refers to a combination of micrognathia (a small jaw) and glossoptosis (literally, a falling downward or back- ward of the tongue) in the newborn infant (Figure 1). These conditions are likely to cause obstruction of the upper airway, and they are fre- quently associated with an incomplete cleft of the palate. Patients with the Pierre Robin Syndrome may present a real emer- gency in the delivery room because of the obstructed upper airway, or the airway problem may not become manifest for several days or weeks (10, 11, 38). There is frequently a feeding problem, as well as problems associated with the cleft of the palate (if one is present) and also an unusual malocclusion (2, 5, 12, 16). In addition, it presents a fascinating anthropological puzzle (22, 23). This paper will review the work of Dr. Robin, consider some possible etiologies of this syndrome, and report on some work on mandibular bone growth in a group of such patients. History Pierre Robin was far from the first person to recognize this syndrome. One account is recorded in 1822 by St. Hilaire. In 1891 Taruffi men- tioned two subclassifications-hypomicrognatus (small jaw) and hypo- agnathus (absent jaw). In 1891, four cases, two of them having cleft palates, were reported by Lanneloague and Monard (12, 14). Shukow- sky in 1902 described a tongue to lip surgical adhesion to overcome the respiratory obstruction (34). -
Basic Biomechanics
Posture analysis • A quick evaluation of structure and function • Doctor views patient from behind (P-A) and from the side (lateral) • References points of patient’s anatomy relative to plumb (a position of balance) 9/3/2013 1 Posture analysis • Lateral View – Knees (anterior, posterior, plumb, genu recurvatum) – Trochanter (anterior, posterior, plumb) – Pelvis (anterior, posterior, neutral pelvic tilt) – Lumbar lordosis (hypo-, hyper-, normal) – Mid-axillary line (anterior, posterior, plumb) – Thoracic kyphosis (hyp-, hyper- normal) – Acromion (anterior, posterior, plumb) – Scapulae (protracted, retracted, normal) – Cervical lordosis (hypo-, hyper-, normal) – External auditory meatus (anterior, posterior, plumb) – Occiput (extended, neutral, flexed) 9/3/2013 2 Posture analysis • Posterior – Anterior View – Feet (pronation, supination, normal) – Achilles tendon (bowed in/out, normal) – Knees (genu valga/vera, normal - internal/external rotation) – Popliteal crease heights (low, high, level) – Trochanter heights (low, high, level) – Iliac crest heights (low on the right/left, normal) – Lumbar scoliosis (right/left, or no signs of) – Thoracic scoliosis (right/left, or no signs of) – Shoulder level (low on the right/left, or normal) – Cervical scoliosis (right/left, or no signs of) – Cervical position (rotation, tilt, neutral) – Mastoid (low on the right/left, or normal) 9/3/2013 3 …..poor postures 9/3/2013 4 Functional Anatomy of the Spine • The vertebral curvatures – Cervical Curve • Anterior convex curve (lordosis) develop in infancy -
Podo Pediatrics Podo Pediatrics
Podo Pediatrics Identifying Biomechanical Pathologies David Lee, D.P.M., D. A.B.P.S. Purpose • Identification of mechanical foot and ankle conditions • Base treatments • Knowing when to refer to a podiatrist Topics • Flatfoot (Pes Plano Valgus) • Equinus • Intoed feet (Cavo-adductor Varus) • Heel pain (Calcaneodynia) • Shin Splints • Various Pedal deformities 1 WHAT IS NORMAL? At birth to ~9 months • Ankle flexible to over 20 deg DF • No “C” shaped foot • No clicking or popping sounds • Babinski sign • Pull up 7-8mo. 9-16 months… • Begin walking • Feet are fat, flat and floppy • Knees are always center or externally rotated, never internal. • Stance is wide and less stable • Stomping gait pattern 2 16-18 months • Able to walk upstairs • Knee never internal • Still wide base and flat and floppy feet • Stomping still 3-7 years • Able toe walk downstairs • Heel-to-toe walk • Watch for – Intoeing – Tripping – Tight ankle joint (equinus) 7 years and up • Arch should be developed • Heel-to-toe walk • Heel is perpendicular to ground • Knees straight ahead 3 Neutral Internal Rotation Early detection is important • Prevent long term adaptation • Joint damage • Adult pathology – Heel pain, bunions, hammertoes, ankle instability, knee pain, shin splints, etc. • Ability to thrive physically and socially 4 THE FLAT FOOT Visual Complaints by the Parent • Tripping or falling • Poor balance- Clumsy • Feet look funny, walks funny • Shoes wearing out quickly Social Complaints by the Parent • Lazy, inactive, “doesn’t like going outside to play or play sports -
ICD-9CM Coding Achilles Bursitis Or Tendinitis 726.71 Adhesive
ICD-9CM CODING OF COMMON CHIROPRACTIC CONDITIONS CONDITION ICD-9CM coding Achilles bursitis or tendinitis 726.71 Adhesive capsulitis of shoulder 726 Anklyosing Spondylitis (spine only) 720 Anterior cruciate ligament (old disruption) 717.83 Bicipital tenosynovitis 726.12 Boutonniere deformity 736.21 Brachial neuritis or radiculitis 723.4 Bunion 727.1 Bursitis of knee 726.6 Calcaneal spur 726.73 Carpal tunnel syndrome 354 Cervical radiculitis 723.4 Cervical spondylosis with myelopathy 721.1 Cervical spondylosis without myelopathy 721 Cervicalgia 723.1 Chondromalacia of patella 717.7 Claw hand (acquired) 736.06 Claw toe (acquired) 735.5 Coccygodynia 724.79 Coxa plana 732.1 Coxa valga (acquired) 736.31 Coxa vara (acquired) 736.32 de Quervain's disease 727.04 Degeneration of cervical intervertebral disc 722.4 Degeneration of thoracic or lumbar intervertebral disc 722.5 Disc Degeneration (Cervical with myelopathy) 722.71 Disc Degeneration (Lumbar with myelopathy) 722.73 Disc Degeneration (Thoracic) 722.51 Disc Degeneration (Cervical) 722.4 Disc Degeneration (Lumbar) 722.52 Disc Degeneration (Thoracic with myelopathy) 722.72 Disc displacement without myelopathy (Thoracic) 722.11 Disc displacement of without myelopathy (Cervical ) 722 Disc displacement without myelopathy (Lumbar) 722.1 Dupuytren's contracture 728.6 Entrapment syndromes 354.0-355.9 Epicondylitis (Lateral) 726.32 Epicondylitis (Medial) 726.31 Flat foot-Pes planus (acquired) 734 Fracture (Lumbar) 805.4 Ganglion of tendon sheath 727.42 Genu recurvatum (acquired) 736.5 Genu valgum -
Muscles Connecting the Upper Limb to the Vertebral Column
Muscles Connecting the Upper Limb to the Vertebral Column 1-Trapezius: O: external occiptal protuberance, superior nuchal line, ligamentum nuchae (along dorsal spine of cervical vertebra ), spines of all thoracic vertebrae and their supraspinous ligament " the extention of ligamentum nuchae ". Ins: (opposite to the Ori. Of Deltoid ) Upper fibers : Post. border lateral third of clavicle. Mid.(lateral fibers): inner surface of acromial process. Lower fibers: upper border of dorsal spine of scapula. N.S: Spinal accessory nerve (motor) and C3 and 4 (sensory) XI(11) cranial nerve (spinal part). *Note that accessory nerve = XI(11) cranial nerve which has 2 parts : cranial / spinal Action : Upper fibers :elevate the scapula. middle fibers: pull scapula medially toward the ribs (retracts). lower fibers: pull medial border of scapula downward . *anterior fibers rotates the scapula. Question 1 : to put your hand over your head what are the responsible muscles?? - Supraspinatus for initiation (0-15) or (0-18) - middle fibers of Deltoid (15 or 18 -90) - Trapezius & serratus anterior :after 90, rotation of scapula. Question 2 : to touch the acromial process of the other side which muscle is responsible , and which nerve will stop the movement of the muscle if we cut it?? -muscle: pectorals major , medial & lateral pectoral nerve. *always choose the easiest movement… 2-Latissimus dorsi : O: Iliac crest, lumbar fascia, spines of lower six thoracic vertebrae (T7-T12), lower three or four ribs, and inferior angle of scapula ,then all fibers make conversion to ins. Ins: Floor of bicipital groove of humerus. N.S: Thoracodorsal nerve (branch of post. Cord of post. -
Analyzing At-Home Prosthesis Use in Unilateral Upper-Limb Amputees To
2017 International Conference on Rehabilitation Robotics (ICORR) QEII Centre, London, UK, July 17-20, 2017. Analyzing At -Home Prosthesis Use in Unilateral Upper -Limb Amputees to Inform Treatment & Device Design Adam J. Spiers, Member, IEEE, Linda Resnik, and Aaron M. Dollar, Senior Member, IEEE Abstract — New upper limb prosthetic devices are continuously being developed by a variety of industrial, academic, and hobbyist groups. Yet, little research has evaluated the long term use of currently available prostheses in daily life activities, beyond laboratory or survey studies. We seek to objectively measure how experienced unilateral upper limb prosthesis-users employ their prosthetic devices and unaffected limb for manipulation during everyday activities. In particular, our goal is to create a method for evaluating all types of amputee manipulation, including non-prehensile actions beyond conventional grasp functions, as well as to examine the relative use of both limbs in unilateral and bilateral cases. This study employs a head-mounted video camera to record participant’s hands and arms as they Figure 1: A video screenshot from the head-mounted camera (for complete unstructured domestic tasks within their own homes. participant P2). A new ‘Unilateral Prosthesis-User Manipulation Taxonomy’ is presented based observations from 10 hours of recorded videos. has been a wide variety of prosthetic TDs (e.g. [4]–[6]). The taxonomy addresses manipulation actions of the intact However, follow-ups of how such devices’ are practically hand, prostheses, bilateral activities, and environmental and specifically used has been limited outside of the feature-use (affordances). Our preliminary results involved laboratory. Further motivation for the need of such tagging 23 minute segments of the full videos from 3 amputee understanding comes from well-known high prevalence rates participants using the taxonomy. -
An Unusual Klebsiella Septic Bursitis Mimicking a Soft Tissue Tumor
Case Report Eur J Gen Med 2013;10(1):47-50 An Unusual Klebsiella Septic Bursitis Mimicking a Soft Tissue Tumor Mehmet Ali Acar1, Nazım Karalezli2, Ali Güleç3 ABSTRACT Because of its subcutaneous location prepatellar bursitis is frequently complicated by an infection. Gram-positive organisms, primarily Staphylococcus aureus account for the majority of cases of septic bursitis. Local cutaneous trauma can lead to direct inoculation of the bursa with normal skin flora in patients with occupations, such as mechanics, carpenters and farmers. A 71-year- old male was admitted to our department with a history of pain and swelling of his right knee over a 20 year period. Physical examination revealed a swollen, suppurative mass with ulceration of the skin and local erythema which mimicked a soft tissue tumor at first sight. Magnetic resonance imaging of the knee revealed a 13*12*10cm well-circumscribed, septated, capsulated, fluid-filled prepatellar bursa without evidence of tendinous or muscular invasion. The mass was excised en bloc, including the bursa and the overlying skin. The defect was closed with a split thickness skin graft. The patient had 100 degrees flexion and full extension after 45 days postoperatively, and he continued to work as a farmer. Key words: Klebsiella, septic bursitis, haemorrhage, mass Yumuşak Doku Tümöre Benzeyen Nadir Klebsiella Septik Bursiti ÖZET ilt altı yerleşiminden dolayı prepatellar bursitlerde enfeksiyon görülmesi sık olur. Gram pozitif mikroorganizmalar, özellikle stafilokokkus aureus en sık etkendir. Tamirciler, halıcılar ve çiftçiler gibi travmaya çok maruz kalan meslek gruplarında direk olarak etken cilt florasından bursaya ulaşabilir. 71 yaşında erkek hasta 20 yılı aşan ağrı ve şişlik nedeni ile kliniğimize başvurdu. -
Non-Cardiac Manifestations of Marfan Syndrome
Keynote Lecture Series Non-cardiac manifestations of Marfan syndrome Anne H. Child Molecular and Clinical Sciences Research Institute, St George’s University of London, Cranmer Terrace, London, UK Correspondence to: Dr. Anne H. Child, MD, FRCP. Reader in Cardiovascular Genetics, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK. Email: [email protected]. Because of the widespread distribution of fibrillin 1 in the body, Marfan syndrome (MFS) affects virtually every system. The expression of this single dominantly inherited gene is variable within a family, and between families. There is some genotype-phenotype correlation which is helpful in guiding long-term prognosis, and management. In general gene mutations have been reported in clusters, with those having mainly ocular manifestations occurring in exons 1 to 15 of this 65-exon gene; those causing cardiac problems often involving cysteine replacement in a calcium binding EGF-like sequence; the most severe mutations occurring in exons 25–32, causing neonatal MFS diagnosed at birth, and severe enough to cause death frequently before the age of 2. Other correlations will certainly be found in future. This condition is progressive, and the manifestations unfold according to age. For example, if the lens is going to dislocate this usually occurs by age 10; scoliosis usually presents itself between the ages of 8 and 15; height should be monitored carefully between the onset of puberty and cessation of growth approximately age 17 or 18. Holistic care should be offered by one doctor who oversees the patient’s welfare. This should be a paediatrician, paediatric cardiologist, or general practitioner in the case of an affected child.