Congenital deformities of lower extremity<br />Foot progression angle<br /><ul><li>Angular diff b/w axis of foot with dire...
Only defines in/out-toeing
Normal= 10-15 degrees external rotation
Mild= -5 to -10; moderate: -10 to -15; severe: > -15</li></ul>Tibial torsion: in-toeing (common): (neither necessary nor h...
Usually resolves spontaneously (medial); lateral may worse w/ tim
Usually from intrauterine crowding
No racial/gender predilection
CT is std for evaluation- views through femoral necks and hips
Normal femoral anteversion goes from 40 degrees at birth to 15 at maturity
Rotation of tibia from 5 to 15
MCC of in-toeing between 18 months and 3 years
Metatarsus adductus: MCC in children under 18 months old (correct w/ casting if severe)
Femoral torsion: MCC older than 3
Must exclude: development hip dysplasia (x-rays to rule out, ortolani and barlow test), genu varus/valgus, mild talipes eq...
Knees point straight ahead
Surgical therapy if deformity greater than 3 std deviations from norm
Osteotomy is surgery of choice (non-weight bearing short leg cast 4-6 weeks, remove hardware and immediate weight bearing)
Medial femoral torsion: avoid “W” sitting</li></ul>Tibial bowing (genu varum): relatively uncommon<br /><ul><li>Wide-based...
Multiple etiologies: some resolve, others complex surgery
Fetal positioning in utero
Vascular abnormalities
Rickets, achondroplasia, metaphyseal dysplasia, traumua, bone infection, excess prenatal fluoride supplementation
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Congenital deformities of lower extremity Foot progression angle ...

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Congenital deformities of lower extremity Foot progression angle ...

  1. 1. Congenital deformities of lower extremity<br />Foot progression angle<br /><ul><li>Angular diff b/w axis of foot with direction walking
  2. 2. Only defines in/out-toeing
  3. 3. Normal= 10-15 degrees external rotation
  4. 4. Mild= -5 to -10; moderate: -10 to -15; severe: > -15</li></ul>Tibial torsion: in-toeing (common): (neither necessary nor helpful to get imaging to dx rotational deformities)<br /><ul><li>Feet turn medially
  5. 5. Usually resolves spontaneously (medial); lateral may worse w/ tim
  6. 6. Usually from intrauterine crowding
  7. 7. No racial/gender predilection
  8. 8. CT is std for evaluation- views through femoral necks and hips
  9. 9. Normal femoral anteversion goes from 40 degrees at birth to 15 at maturity
  10. 10. Rotation of tibia from 5 to 15
  11. 11. MCC of in-toeing between 18 months and 3 years
  12. 12. Metatarsus adductus: MCC in children under 18 months old (correct w/ casting if severe)
  13. 13. Femoral torsion: MCC older than 3
  14. 14. Must exclude: development hip dysplasia (x-rays to rule out, ortolani and barlow test), genu varus/valgus, mild talipes equinovarus (clubfoot)
  15. 15. Knees point straight ahead
  16. 16. Surgical therapy if deformity greater than 3 std deviations from norm
  17. 17. Osteotomy is surgery of choice (non-weight bearing short leg cast 4-6 weeks, remove hardware and immediate weight bearing)
  18. 18. Medial femoral torsion: avoid “W” sitting</li></ul>Tibial bowing (genu varum): relatively uncommon<br /><ul><li>Wide-based gait
  19. 19. Multiple etiologies: some resolve, others complex surgery
  20. 20. Fetal positioning in utero
  21. 21. Vascular abnormalities
  22. 22. Rickets, achondroplasia, metaphyseal dysplasia, traumua, bone infection, excess prenatal fluoride supplementation
  23. 23. Blount disease: African Americans.
  24. 24. Another variation of Blounts: in adolescents and more common in boys
  25. 25. Most likely due to excessive intrauterine forces on bone, altered endochondral bone formation
  26. 26. Plain AP part of initial eval, measure limb lengths
  27. 27. CT for leg length used more (more accurate, less radiation)
  28. 28. LEG LENGTH DIFFERENCES: among the biggest problems (greater than 5cm difficult to treat)
  29. 29. <5cm: shoe lift, osteopathic eval
  30. 30. Large limb discrepancy: surgically corrected: family and child must be educated on outcome/expectations
  31. 31. Can return to sports at 6-12 months post surgery
  32. 32. Follow up x-rays every 6 months until skeletal maturity
  33. 33. Hardware removed after skeletal maturity</li></ul>Genu valgum (knock-knee)<br /><ul><li>Resolution may be spontaneous, but if hereditary (adolescent) or metabolic: surgery
  34. 34. One of MCC of teenage knee pain
  35. 35. Countries w/ malnutrition: rickets, untreated injuries, infectious/rheumatic dz cause more
  36. 36. No racial/ethnic/gender predilections
  37. 37. Marfan syndrome: part of this as well as other syndromes
  38. 38. Stress on lat femur/tibia: inhibits growth at physis
  39. 39. Extra force on epiphysis: inhibitory effect on entire bone: normal lengthening suppressed
  40. 40. Results in tilting of patella, subsequent lateral subluxation
  41. 41. Knee pain, joint laxity- abnormal/awkward gait
  42. 42. AP x-ray std study
  43. 43. Occasionally need to document bone age: AP view of wrist
  44. 44. No CT/MRI
  45. 45. Most imp: recognizing difference in physiologic and pathologic
  46. 46. Under 6 yo: self-limiting and benign
  47. 47. Most important in osteo. Exam: gait observation
  48. 48. Bracing/PT may slow progression, provide temp relief
  49. 49. If requires surgery: staples and new techniques that don’t require hardware
  50. 50. See every 3 months to assess growth, monitor after hardware removal too
  51. 51. Outcome very good: staple minimally invasive w/ fever complications/in-pt time</li></ul>Fibular hemimelia/proximal femoral focal deficiency (PFFD): (rare)<br /><ul><li>Postaxial hypoplasia
  52. 52. Range from min shortening to complete absence
  53. 53. Not hereditary
  54. 54. May be present w/ other birth defects
  55. 55. Blount dz, lat patellar sublux, ankle valgus, absent tarsal bones/toes, femoral hypoplasia
  56. 56. Only known cause: thalidomide
  57. 57. other toxins implicated, but none proven (radiation, ischemia, thermal injury, bacterial/viral infections, chemicals)
  58. 58. Fibular: thought to be from limb bud interference
  59. 59. Fetal period: fibular part dictates growth of prox femur
  60. 60. Anomalies of knee, ankle and foot may be related
  61. 61. No racial/gender/age/ethnic predilections
  62. 62. Imaging: x-rays of extremity, hip films in PFFD
  63. 63. CT/MRI for complex cases involving nervous/vascular system
  64. 64. Treatment
  65. 65. Nonoperative management: only for very mild
  66. 66. Fibular/tibial: shoe lift may be adequate
  67. 67. PFFD: surgery ranging from minor limb lengthening to amputation
  68. 68. Everyone must understand lengthy nature of procedures
  69. 69. Van Ness procedure: where limb lengthening not possible or fails- prosthesis
  70. 70. Require frequent follow-ups
  71. 71. Seated/standing flexion test at each visit b/c have extra stress on abnormal pelvis</li></ul>Tibial hemimelia<br /><ul><li>Many names
  72. 72. From total absence to mild
  73. 73. Leg is short and foot in severe equinovarus</li></ul>Pediatric disorders of thoracic/lumbar spine<br />-On scoliometer: curve less than 5 degrees only needs observation. Info can vary as much as 10 degrees, so eval of any abnormality is warranted.<br />-scoliosis radiographs: Cobb Method- used to calculate curvature in vertebra<br />-curve of 40 degrees: OMT and bracing<br />-curve >50: OMT and surgical eval <br /><ul><li>Harrington rod: to avoid cardio/pulm compromise
  74. 74. VATS (video assisted thoracoscopic surgery): reduces morbidity in spinal surgery. Can also be used for instrumentation implantation w/ much less blood</li></ul>-new device can measure w/o radiation (similar to MRI)<br />-curve <20: can be observed. Many children w/ short leg will improve curve to almost normal w/ regular osteopathic care and shoe lift.<br />**look for underlying pathology: esp pre-teens who may carry heavy backpacks<br />-shoe lift may be indicated for short leg: compliance is issue. Want the heel lift at the calcaneus strike point<br />Thoracic:<br /><ul><li>Sheuermann dz (juvenile kyphosis)
  75. 75. Osteochondrosis of vertebral bodies secondary to ossification centers (abnormal growth in endplate cartilage- decreased collagen/proteoglycan ratio is the cause)
  76. 76. Localized changes in vertebral bodies
  77. 77. Boys>girls
  78. 78. Dx rarely made in children under 10
  79. 79. Pain MC morbidity (in kyphotic region); kyphosis presenting symptom
  80. 80. Typically tall, 13-16, advanced bone age, hx of poor posture, hamstring tight
  81. 81. Radiographic studies most useful
  82. 82. Wedge-shaped vertebral bodies, narrow disk space
  83. 83. Surgery rare, PT/osteopathic tx good
  84. 84. Klippel-feil syndrome
  85. 85. Deformity of cervical spine results from congenital fusion of at least 2 vertebrae
  86. 86. Short neck, limited neck motion, low occipital hairline
  87. 87. Type I: massive fusion of cervical and thoracic spine
  88. 88. Type II: only involves cervical spine, only one or two vertebrae fused
  89. 89. Type III: thoracic and lumbar spine AND involvement to Types I and II present
  90. 90. Plain radiographs for dx: AP/lat of cervical spine
  91. 91. MRI on all persons w/ neurological deficit
  92. 92. Rental US as part of initial eval
  93. 93. ALL affected have audiometric eval
  94. 94. Any high velocity contraindicated!
  95. 95. Surgery carries risk of neurological damage</li></ul>Lumbar:<br /><ul><li>Congenital scoliosis
  96. 96. Caused by anomalous vertebral development in embryo
  97. 97. Congenital malformation of spine caused by:
  98. 98. Malformation: failure of embryological differentiation
  99. 99. Disruption: structural defect from destruction of part that was normal
  100. 100. Deformation: does NOT cause congenital scoliosis
  101. 101. Most severe: unilateral unsegmented bar vertebra w/ contralat hemivertebra at same level
  102. 102. Least severe: caused by a blocked vertebra.
  103. 103. High incidence of other anomalies
  104. 104. Orthotics not effective b/c primary problem is not soft tissue/muscle
  105. 105. Four types of surgery
  106. 106. Convex growth arrest
  107. 107. Posterior fusion
  108. 108. Combined ant/post fusion
  109. 109. Hemivertebra excision
  110. 110. (vertebrectomy most radical: rarely done)
  111. 111. Idiopathic scoliosis: MCC (80%)
  112. 112. Curve presents after birth
  113. 113. 8 times more frequent in females
  114. 114. Possible causes: muscle disorder, elastic fiber system, disorganized skeletal growth, X-linked inheritance
  115. 115. Three subtypes
  116. 116. Infantile
  117. 117. Diagnosed at 3 years or less
  118. 118. MC curve is thoracic
  119. 119. Only type more common in BOYS
  120. 120. Significant spontaneous resolution
  121. 121. Juvenile
  122. 122. Right thoracic curve
  123. 123. Ages 3-12
  124. 124. Considered malignant sub-type
  125. 125. Bracing is primary tx unless angle >50 degrees
  126. 126. Associated w/ neural axis abnormalities: Chiari type I malformations
  127. 127. Adolescent
  128. 128. Most common type overall
  129. 129. Tx driven by magnitude of curve and assoc. sx
  130. 130. Cobb angle used most often (end vertebrae of curve)
  131. 131. Riser-Ferguson angle: more suited to automated eval systems (uses middle vertebrae for the angle
  132. 132. Pulm testing routinely done before and after surgery or if severe curve
  133. 133. MRI/CT in complicated cases
  134. 134. Always evaluate and treat any innominant or sacral base dysfunction before ordering x-rays. Always eval for upslip!
  135. 135. Curve cannot be changed by OMM, but other dysfunction may be making worse
  136. 136. Operative management: now includes minimally invasive ant laparoscopic tx
  137. 137. Pseudoarthritis: common complication
  138. 138. Diskitis
  139. 139. Disk inflam. that may be related to infection: staph aureus
  140. 140. In children, slight male predilection, in adults much more males
  141. 141. In children: age occurrence: 7 years
  142. 142. Second peak at 50 years
  143. 143. Rarely post-op
  144. 144. Children: sudden onset of pain, possibly refusal to walk
  145. 145. Adults: more insidious w/ fever, chills, weight loss
  146. 146. First line tx: antibiotics
  147. 147. OMM contraindicated until improvement or neg cultures
  148. 148. Oral antibiotics NOT effective
  149. 149. Ankylosing spondylitis
  150. 150. More prevelant in north European heritage
  151. 151. Chronic multi-system inflame disorder of SI joints and axial skeleton
  152. 152. Symptoms usually develop in late adolescence
  153. 153. HLA-B27
  154. 154. SI joints most common
  155. 155. Initial event is subchondral granulation tissue that erodes in to the joint
  156. 156. Infections may trigger
  157. 157. Plain radiographs showing involvement of SI joint is requirement
  158. 158. One of following plus sacroiliitis
  159. 159. Limitation of lumbar spinal motion in all three planes
  160. 160. Pain in lumbar or thoracolumbar region
  161. 161. Limitation of chest expansion to one inch or less
  162. 162. Radiographic changes
  163. 163. Avoid HVLA</li></ul>Non-traumatic cervical pain<br />DDX:<br /><ul><li>Somatic dysfunction
  164. 164. Cerfical spondylosis/DJD
  165. 165. Cervical radiculopathy (ribs can cause)
  166. 166. Visceral referred pain (cardiac/GB…)
  167. 167. Mechanical referred pain (TMJ/Shoulder…)
  168. 168. Pathologic fracture
  169. 169. Infection</li></ul>Remember<br /><ul><li>Gross motion head SR in opp: think OA or SCM
  170. 170. Head SR in same: think single SDs
  171. 171. Restriction in flexion: trapezius
  172. 172. Restriction in extension: SCM and strap muscles (connect to hyoid)
  173. 173. Dysphagia: strap muscles and hyoid
  174. 174. Radiation to upper extremities: entrapment
  175. 175. Headache w/ pressure and tight headband sensation: suboccipital and occipitalis muscles and greater/lesser cranial nerves
  176. 176. Any sx: think SD
  177. 177. Dizziness or syncope (esp w/ head turning): compromise of carotids and or vertebral arteries. BE CAREFUL
  178. 178. Respiratory disease: scalene and SCM and C3,4,5 (scalene attach and phrenic nerve)
  179. 179. Radiation to ear or jaw: SCM and stylohyoid</li></ul>Clinical testing<br /><ul><li>AP/lat/oblique
  180. 180. EMG: nerve conduction test
  181. 181. MRI for soft tissue (MS in neck)
  182. 182. Ct for bones
  183. 183. Myelogram if MRI misses disk herniation strongly suspected (long wait to get done, though)</li></ul>Radiculopathy<br /><ul><li>Any pathologic condition of a nerve root: compression, bone spur, etc
  184. 184. Cervical
  185. 185. Sx
  186. 186. Arm pain, clumsiness
  187. 187. Dermatomal paresthesias or hyperesthesia
  188. 188. Etiology
  189. 189. Direct irritation of cervical nerve root</li></ul>Spondylosis<br /><ul><li>Bone
  190. 190. Cervical
  191. 191. Sx
  192. 192. Decreased ROM
  193. 193. Pain, pain with upward gaze or rotation/extension of neck
  194. 194. Etiology
  195. 195. Age-related degeneration
  196. 196. Trauma
  197. 197. Genetics
  198. 198. Progression
  199. 199. Dehydration of intervertebral disc
  200. 200. Thinning of disc space
  201. 201. Buckling/dysfunction of intralaminar ligaments
  202. 202. Possible protrusion of intervertebral disc
  203. 203. Abnormal loading and fxn of joint surface
  204. 204. Compensatory changes
  205. 205. Physical findings
  206. 206. Spams of cervical muscle
  207. 207. Knotty/fibrous texture
  208. 208. Loss of normal lordosis
  209. 209. Somatic dysfunction
  210. 210. Skin feels like leather</li></ul>Degenerative Joint Dz<br /><ul><li>Degenerative/hypertrophic changes in bone/cartilage
  211. 211. Progressive wearing down of opposing joint surfaces w/ consequent distortion of joint position</li></ul>Low back pain<br />Acute: less than 3 months (80-90% recover within 12 weeks regardless of tx)<br />Chronic: more than 3 months<br />14% of new visits to PCP<br /><ul><li>Second most common symptomatic reason for physician office visit
  212. 212. 85% of gen pop will have (60-90% incidence)
  213. 213. Most expensive cause of work related disability</li></ul>**prior hx of low back pain is strongest predictor of a future episode<br />Red flags<br /><ul><li>Major trauma
  214. 214. >50 or <20
  215. 215. Hx of cancer
  216. 216. Cauda equine sx
  217. 217. Saddle anesthesia, bladder dysfunction, neuro sx, muscle weakness
  218. 218. Atherosclerotic dz
  219. 219. Corticosteroids
  220. 220. Hx of osteoporosis
  221. 221. Constitutional sx
  222. 222. Fever, weight loss, chills, recent infection, IV drugs, immune suppression</li></ul>Lumbar vs sacral<br /><ul><li>Single leg raise
  223. 223. Dbl leg raise
  224. 224. Greater motion before pain: SI
  225. 225. Less motion before pain: LS
  226. 226. Goldthwaite’s test
  227. 227. Cephalad palm underneath LS spine and do SLR
  228. 228. Pain before movement: SI</li></ul>Acute lumbar strain<br /><ul><li>Wastebasket diagnosis
  229. 229. Acute injury to soft tissues w/ NO NEUROLOGIC COMPONENT
  230. 230. 85% pts: specific cause not found</li></ul>SI ligaments contain mechanoreceptors<br /><ul><li>Act as strain gauges, even w/ very little motion</li></ul>Iliolumbar ligament sprain<br /><ul><li>Refer pain to ant thigh or groin</li></ul>Facet syndrome<br /><ul><li>Can mimic pars fracture
  231. 231. Focused pain, worse w/ extention
  232. 232. Acute or chronic
  233. 233. Standing and seated kemp’s
  234. 234. Disc early, facet later
  235. 235. Hyperflexion test
  236. 236. Put supine, flexes hips maximally
  237. 237. Will aggravate a disc and relieve a facet problem</li></ul>Lumbar disc herniation<br /><ul><li>Most preceded by bouts of varying degrees and duration of back pain
  238. 238. Pain may eventually radiate to leg, less achy, burning, shooting, stabbing
  239. 239. Three joint complex carries 75% of load (vertebrae and intervertebral disc)
  240. 240. Bulging is normal (over 30% of normal pts have positive MRI!)
  241. 241. Nucleus pulposus has a higher contect of proteoglycans than the disc annulus
  242. 242. L3, 4: radiate to groin or ant thigh
  243. 243. First sacral: pain in post thigh and calf and lateral foot
  244. 244. L5: MOST COMMON: lateral thigh and lower leg pain and dorsum of foot
  245. 245. Surgical indications:
  246. 246. Cauda equine syndrome
  247. 247. Progressive neurologic deficit
  248. 248. Persistent bothersome sciatic pain for 6-12 weeks
  249. 249. Contraindications to surgery
  250. 250. Unrelenting back pain
  251. 251. Incomplete workup
  252. 252. Not provided adequate conservative tx</li></ul>Lumbar discitis<br /><ul><li>Disc infection (after surgery, haematogenous spread)
  253. 253. Increasing, unrelenting low back pain, stiffness, maybe fever
  254. 254. SED rate and C reactive protein off the chart</li></ul>Lumbar spondylolysis and spondylolisthesis<br /><ul><li>Defect in Pars Interarticularis
  255. 255. Know this!
  256. 256. Grade 1 (0-25% slip)
  257. 257. Grade 2 (26-50%)
  258. 258. Grade 3 (51-75%)
  259. 259. Grade 4 (76-100%)
  260. 260. Grade 5 (>100%): surgery!
  261. 261. 82% at L5-S1!!!
  262. 262. Degenerative at L4-5 (more in females)
  263. 263. Most commonly white males
  264. 264. More aggressive in females although get it less often
  265. 265. Acute isthmic
  266. 266. 1st, 2nd decades (most before 15 yo)
  267. 267. Sx at growth spurt
  268. 268. Radicular pain w/ larger slips
  269. 269. Most pts asymptomatic
  270. 270. Degenerative
  271. 271. Insidious onset w/ radiation to post upper thighs
  272. 272. Chronic and progressive
  273. 273. Dysplastic
  274. 274. Presents like isthmic but neurologic compromise more likely
  275. 275. Incomplete fusion of post elements on plain films</li></ul>Pain w/ spine extension is spondolysis until proven otherwise<br />Neurologic exam important!!<br />Causes:<br /><ul><li>Genetic
  276. 276. Familial predisposition
  277. 277. Spina bifida
  278. 278. Dysplastic
  279. 279. Pathologic
  280. 280. Tumor
  281. 281. Bony destructive lesion</li></ul>Workup<br /><ul><li>Lab to rule out pathologic causes
  282. 282. Imaging</li></ul>Do not use HVLA in acute spondy!!<br />Lumbar stenosis<br /><ul><li>Middle-aged and elderly
  283. 283. Neurogenic intermittent claudication: leg fatigue, pain, numbness, weakness
  284. 284. Tx: usually surgical decompression
  285. 285. Lumbar vertebral canal is triangular in shape and narrowest in A-P diameter
  286. 286. Two types: bony encroachment, nonosseous structures</li></ul>Disorders of thoracic spine<br />Test:<br />Pigeon chest: pectus carinatum<br />Barrel chest: increase AP diameter<br />Flail chest: paradoxical movement (emergency!)<br />Rickets: vit D deficiency (beads on chest wall, Harrison groove)<br />Rib notching: neurofibromatosis (also coarctation of aorta)<br />Thoracic kyphosis: most common cause of osteoporosis in elderly<br />Osteoporosis: develop wedging of anterior vertebral body<br />Akylosing spondylitis: poker spine (stiffness), bamboo spine<br />Clavicle: 80% in middle third<br />Costochondritis<br /><ul><li>Dull chest pain
  287. 287. Worse w/ movement and respiration
  288. 288. Tenderness along costochondral joints w/o swelling
  289. 289. Usually benign and self limited
  290. 290. Cause usually unknown: inflame arthritis, IBD..
  291. 291. Tx: rest, nonsteroidal meds
  292. 292. Tietze syndrome: fusiform tender swelling of costal cartilage (upper ribs):rare</li></ul>Pectus carinatum<br /><ul><li>Pigeon chest
  293. 293. Assoc w/ scoliosis and mitral valve prolapsed</li></ul>Pectus excavatum<br /><ul><li>Male
  294. 294. Frequently asymmetric
  295. 295. 1st/2nd ribs and manubrium in normal position
  296. 296. Congenital cardiac deformities common!</li></ul>Poland Syndrome<br /><ul><li>Absence/hypoplasia of unilat pectoralis muscle w/ SYNDACTYLY (fingers grown together)</li></ul>Barrel Chest<br /><ul><li>Increased AP diameter
  297. 297. Expiratory phase inhibited (increased)
  298. 298. Emphysema, senile kyphosis</li></ul>Rib fractures<br />Flail Chest<br /><ul><li>Multiple rib fractures
  299. 299. May be assoc w/ pneumothorax
  300. 300. Med emergency!
  301. 301. Paradoxical movement (breathe in forms neg pressure and wall sucks in)</li></ul>Cicatrix<br /><ul><li>Burns may limit chest excursion
  302. 302. Tx: surgery to release</li></ul>Rickets<br /><ul><li>Vit D deficiency
  303. 303. Lack of mineralized calcium in bones
  304. 304. Rachitic rosary: failure of bones to harden- beads on chest wall
  305. 305. Harrison groove above pot belly</li></ul>Rib notching<br /><ul><li>Due to collateral circulation from cardiac problems such as coarctation of aorta
  306. 306. Neurofibromatosis
  307. 307. Dock’s sign: not the anterior intercostals (it’s the posterior)</li></ul>Cervical ribs<br /><ul><li>Accessory rib (Eve’s) arising from the 7th cervical vertebra transverse process
  308. 308. May be small or can be full
  309. 309. Can cause impingement syndromes and thoracic outlet syndromes</li></ul>Chest wall tumors<br /><ul><li>Usually in ribs
  310. 310. Malignant until proven otherwise
  311. 311. Infectious
  312. 312. Chondrosarcoma most common
  313. 313. Metastatic: breast, thyroid, kidney, lung</li></ul>Thoracic kyphosis<br /><ul><li>MCC osteoporosis
  314. 314. No lateral curvature
  315. 315. Younger: metabolic problem</li></ul>Osteoporosis<br /><ul><li>Fractures frequently in thoracic spine and are MCC
  316. 316. Wedging of ant vertebral body- contributes to kyphosis</li></ul>Arthritis<br />Ankylosing spondylitis<br /><ul><li>Seronegative
  317. 317. Inflammatory changes and new bone at attachment of tendons/ligaments
  318. 318. SI involvement
  319. 319. Poker spine (stiff), bamboo spine
  320. 320. MC complain: pain
  321. 321. Assoc symptoms: anterior uveitis, vascular problems
  322. 322. HLA-B27: Psoriasis, Ankylosing spondylitis, IBD, Reiter’s (PAIR)</li></ul>Clavicle<br /><ul><li>Usually middle third which lacks ligamentous support- rarely needs surgery
  323. 323. Associated lymph nodes important: supra/infraclavicular</li></ul>AC joint dislocation<br /><ul><li>Graded 1-4: complete dislocation requires surgery: grade 4= completely dislocated
  324. 324. May involve tear of coracoclavicular ligament
  325. 325. Pin to repair it</li></ul>Clavicle dysostosis<br /><ul><li>Incomplete ossification of the clavicles- usually assoc w/ other skeletal deformities
  326. 326. Develop abnormalities of shoulders/rib cage</li></ul>Benign Bone Tumors<br />Questions asked in workup of possible tumor<br /><ul><li>Age, duration of complaint, rate of growth, pain (osteochondromas may cause secondary sx), hx of trauma, personal/fam hx of cancer (neuroblastoma prone for bony metastases, retinoblastoma at risk for osteosarcoma), systemic signs</li></ul>Osteochondroma<br /><ul><li>MC benign bone tumors
  327. 327. X-rays show bony outgrowth from cortex
  328. 328. Tend to occur near ends
  329. 329. They are hamartomas (outgrowths of normal bone/cartilage in abnormal locations)
  330. 330. Most often between age 10-20
  331. 331. Multiple osteochondromas tend to run in families: risk to chondrosarcoma may be 30%
  332. 332. Can become malignant!
  333. 333. Tx: excision if near a nerve, causes pain, disturbs growth, transformation to malignant</li></ul>Fibrous dysplasia<br /><ul><li>Anomaly of the bone-forming mesenchyme that manifests as a defect in osteoblastic differentiation and maturation
  334. 334. Virtually any bone can be affected
  335. 335. Nonhereditary
  336. 336. Medullary bone replaced by fibrous tissue- GROUND GLASS appearance
  337. 337. Tx: no specific treatment
  338. 338. Bisphosphonates (IV)
  339. 339. Concomitant calcium and vit D2 (to avoid secondary hyperparathyroidism)
  340. 340. Surgical indications: severe or progressive dz</li></ul>Chondroma (UNCOMMON) <br /><ul><li>Men in 2nd-4th decades
  341. 341. w/in bone marrow cavity
  342. 342. often found when x-rays taken for another reason
  343. 343. tumors- lytic with areas of stippled calcification, viable on bone scan
  344. 344. focal areas of mixoid degeneration: mistaken for chondrosarcoma
  345. 345. conventional radiography primary imaging; CT helps eval of matrix. Biopsy if not sure
  346. 346. Tx: asymptomatic does not need excision or other tx
  347. 347. Follow-up x-rays 6 mo and 1 yr later</li></ul>Non-ossifying fibroma<br /><ul><li>Well circumscribed, solitary fibrous proliferation
  348. 348. Children
  349. 349. Males (may be in as many as 35% of all children)
  350. 350. MC= femur, followed by tibia
  351. 351. Occasionally a larger lesion presents as a pathologic fracture
  352. 352. Serial x-rays show lesion migrating away from epiphyseal plate w/ time
  353. 353. Only definite indication for tx= pathologic fracture</li></ul>Chondroblastoma<br /><ul><li>Codman’s tumor
  354. 354. Originates from cartilage
  355. 355. Must be surgically excised, may reoccur</li></ul>Osteoid osteoma<br /><ul><li>MC benign osteoid-forming tumor
  356. 356. Males
  357. 357. Proximal femur
  358. 358. Tx: NSAIDS because produce lots of prostaglandins
  359. 359. Unique pathogenic nerve supply
  360. 360. Tx: NSAIDS, if growing-surgery, and now RFA (radiofrequency ablation)</li></ul>Benign giant cell tumor (eggshell in picture)<br /><ul><li>Epiphyses and may erode and extend in to soft tissues
  361. 361. Recur!
  362. 362. May metastasize (rare)
  363. 363. Tx: curettage and packing w/ methyl methacrylate</li></ul>Osteoblastoma<br /><ul><li>Solitary benign tumor that produces osteoid and bone
  364. 364. Metaphysic, diaphysis of long bones
  365. 365. Spine: in posterior processes; vertebral bodies are spared: scoliosis, neurological sx
  366. 366. Radio-lucent w/ central density due to ossification
  367. 367. Tx: curettage, intralesional excision or en-bloc excision</li></ul>Enchondroma<br /><ul><li>Benign cartilage tumors (ectopic hyaline in intramedullary bone)
  368. 368. Chondrocytes grow slowly
  369. 369. Unsightly swelling or pathologic fracture of the bone
  370. 370. Hand pain, fracture: calcification
  371. 371. Three types:
  372. 372. ollier dz (age 0-10): multiple lesions
  373. 373. nonhereditary
  374. 374. prognosis is excellent
  375. 375. maffucci dz
  376. 376. nonhereditary
  377. 377. multiple hemangiomas
  378. 378. metachondromatosis
  379. 379. inherited auto. Dom.
  380. 380. Tx: surgery, bone grafting
  381. 381. May just have short stature</li></ul>Chondromyxofibroma<br /><ul><li>Very rare and occurs before age 30
  382. 382. Tx: surgical excision or curettage
  383. 383. Recurrence common</li></ul>Ollier disease<br />May have short stature<br />Malignant lesions five year survival is still 65%<br />In the case presented, what eval would be the LEAST helpful in identifying the boy’s lesions before doing a bx?<br />Blood work w/ CBC <br />In the case presented, what is the most concerning part of the hx?<br />Fx w/o trauma history <br />Choose the correct statement regarding enchondroma <br />Multiple enchondroma have a higher rate of malignancy <br />Concerning the child in this case, multiple enchondromas are :<br />Places him at greater risk for malignancy <br /> <br />What labs should be doing in Ollier dz/<br />No other lab tests necessary <br />Genetic musculoskeletal disorders<br />Mucopolysaccharidoses<br /><ul><li>Inherited (all auto recessive except Hunter: sex-linked)
  384. 384. Result of defective activity of lysosomal enzymes
  385. 385. Cell fxn abnormal due to accumulation of proteins/glycosaminoglycan by products
  386. 386. Degradation products are excreted in urine diagnosis
  387. 387. MPS I (Hurler syndrome ):
  388. 388. Dx at 6-24 months
  389. 389. Corneal clouding, skeletal dysplasia, large tongue, short stature
  390. 390. Death by ten
  391. 391. MPS II (Hunter syndrome): mild and severe forms
  392. 392. Severe: age 2-4- progressive neurologic involvement; death by 10-15
  393. 393. Mild: much slower; normal intelligence; hearing loss, life=60-70 years
  394. 394. MPS III (Sanfilippo syndrome) MOST COMMON
  395. 395. Mental deterioration, lg head, hepatosplenomegaly, course hair, joint stiff
  396. 396. Survival to 2nd or 3rd decade
  397. 397. MPS IV (Morquio syndrome): mild and severe
  398. 398. Orthopedic problems
  399. 399. Tx: no cures
  400. 400. Enzyme laronidase for MPS I
  401. 401. Management of hearing loss
  402. 402. Hydrocelphalus treated w/ shunting when needed</li></ul>Osteogenesis imperfect<br /><ul><li>Genetic condition caused by qualitative/quantitative defects in type I collagen
  403. 403. Fragile, brittle bones
  404. 404. Type I collagen
  405. 405. Bone, organ capsules, fascia, cornea, sclera, tendons, meninges, dermis
  406. 406. Type I
  407. 407. A: dentinogenesis imperfect absent
  408. 408. B: dentinogenesis imperfect PRESENT
  409. 409. Blue sclera, in utero fractures, hearing loss, easy bruising, short
  410. 410. Autosomal dominant
  411. 411. Type II
  412. 412. Most do not survive first year of life, stillborn, etc…
  413. 413. No hearing loss, small nose, all have in utero fractures
  414. 414. Beaded ribs
  415. 415. Autosomal dominant
  416. 416. Type III
  417. 417. Fairly normal life span if survive infancy/early childhood
  418. 418. Dentinogenesis imperfect
  419. 419. No hearing loss, variable sclera
  420. 420. 50% w/ fractures in utero
  421. 421. Pulmonary hypertension
  422. 422. Triangular face and frontal bossing, limb shortening
  423. 423. Autosomal dominant
  424. 424. Type IV
  425. 425. A: dentinogenesis imperfect absent
  426. 426. B: PRESENT; normal sclera/hearing, angulation of long bones
  427. 427. Autosomal dominant
  428. 428. Lab studies are normal!
  429. 429. Collagen syn analysis and prenatal chorionic villus sampling can be done
  430. 430. Tx: no medical therapy exists</li></ul>Limping child<br />Developmental dysplasia of hip<br /><ul><li>Proximal femur and acetabulum
  431. 431. Hips dislocated or easily dislocatable
  432. 432. Risk: female, first pregnancy, clubfoot, breech, multiple gestation
  433. 433. L more common than R
  434. 434. Two types: typical and teratologic
  435. 435. Unequal thigh creases
  436. 436. Tests: barlow and ortolani maneuver
  437. 437. Galeazzi/Allis sign: shortened thigh
  438. 438. Anything abnormal on phys exam: GET US OR HIP X-RAYS
  439. 439. US preferred evaluation modality (coronal and transverse planes)
  440. 440. Hilgenreiner/Perkins/Shenton: line measurements to evaluate femoral head/acetabulum relationship
  441. 441. Using triple diapers no longer done!
  442. 442. Use the Pavlik harness (keep in flexion and abduction)</li></ul>Slipped capital femoral epiphysis<br /><ul><li>Salter-Harris type I fracture through prox femoral physis, due to stress around the hip
  443. 443. Almost exclusively during pubertal growth spurt
  444. 444. Modality of choice: AP films of pelvis and lateral frog-leg views
  445. 445. OMM ALWAYS contraindicated!!
  446. 446. No hip joint manipulation until incisions are healed</li></ul>Legg-Calve-Perthes<br /><ul><li>Avascular necrosis of prox femoral head from compromised blood supply
  447. 447. Usually children ages 4-10
  448. 448. New bone may appear NORMAL on x-ray
  449. 449. Short stature and delayed bone age commonly assoc
  450. 450. Most common presentation: painless limp
  451. 451. Tx: Scottish rite or Atlanta brace</li></ul>Transient synovitis<br /><ul><li>Arthralgia from non-specific inflammation in hip synovium
  452. 452. Male between 3-10
  453. 453. Present w/ onset of pain when walking
  454. 454. High fever rare, but some children may have mildly elevated temp
  455. 455. Usully recent history of URI
  456. 456. NOT assoc. w/ skin erythema over affected area
  457. 457. Leg roll test most sensitive
  458. 458. Want to examine knee, eval for bacterial joint infection if fever/high ESR
  459. 459. Tx: heat and gentle ROM
  460. 460. Any manipulation of hip contraindicated until dx confirmed
  461. 461. Most resolve spontaneously

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