Talipes equinovarus (congenital club foot)
Unknown; usually referred to as idiopathic club foot
Isolated lesions may be result of a neurologic d/o that is not immediately evident at the
time of birth
Most widely accepted pathogenesis:
Arrested or anomalous development of this particular part of the embryo in the
first trimester of pregnancy.
Inward rotation of the foot fails to occur at the 7th month of pregnancy.
Occurs about once in every 1000 live births
Twice as common in boys as in girls
Slightly over half of the patients the disorder is bilateral
In Unilateral cases right and left sides are affected with equal frequency
Occasionally there is talipes equinivarus on one side with metatarsus varus or talipes
calcaneovalgus on the other.
Achilles Tendon shortened
Ant. And post. Tibial tendons cx in proportion to the degree of varus deformity
Degenerative changes in fibers of certain ms. And anomalous insertion of tendons in the
At birth ligaments and joint capsules on the med. Side of the foot are cx.
Consistent deformity neck of talus shortened & dev. Med.
Most striking abnormality talocalcaneonavicular jt.
Navicular bone displaced med. Around the head of the talus.
Forepart of the foot follows the med. Displaced navicular
Subtalar surfaces tilted into varus & equinus & med. Rot.
Calcaneous slightly shortened & widened
As the child grows talus wedge shape with its post. Surface apposed to the tibia,
calcaneous points downward and rot. Med.
Structural changes may be found in all other bones but in lesser degree
Heel is drawn up, the entire foot below the talus is inverted, and the ant. Half of the foot
Med. Border of the foot is concave, lat. Border is covex
(+) transverse crease across the sole @ the level of the mediotarsal joint
If not corrected before the infant starts to walk suffers a serious handicap because of
inability to WB N°
Ms. Easily fatigued & (+) atrophy
Pain is developed only by Adult Pt. (arthritic changes)
Seen frequently in association with paralytic changes in the lower ex, in myelodysplasia,
CP & poliomyelitis
Range of severity and rigidity extends from a relatively flexible talipes equinvarus
responds to non-operative Rx; tight resistant clubfoot requires surgical correction.
Foot Cx med. & post. Tse. That make it resistant to gentle manual correction without
surgical release of the contracted soft tse POOR prognosis
Must start as the clubfoot is recognized
Correcting thoroughly all elements of the deformity, maintaining the correction until N°
ms balance developed; cont. until an over correction has been reached.
Goal of every Rx: Position of DF & Ev of the foot & Abd of the forefoot.
Functional result will be good if the final position can be obtained without the trauma of
forceful manipulation & without radical surgery interference with bone growth and by
stiffness of the joints of the foot.
Rx starts: first week or two after birth should consist of gently manipulating the foot to
improved position holding the position by adhesive strapping or light plaster cast
Key to success is reduction of the talonavicular joint by gently stretching the med.
Border of the foot by longitudinal traction on the forefoot with a force directing the
navicular around the front of the head of talus; an everting and downward pull is exerted
on the tiny heel to roll the calcaneous lat. From its inverted position beneath the talus.
When the full correction is achieved foot must be held in corrected position in a cast for
3-4 mo.; cast are changed 3-4 weeks, after child is fitted with clubfoot shoes attached to
denis browne splint Worn day and night except during ex. And bathing. If infant is
ready to walk splints may be worn only at night & clubfoot shoes for day use.
Simplest and most frequently used operation is lengthening of Achilles tendon to lessen
the equinus deformity; may be done early @ the age of 2/3 mo.
The correction of clubfoot in a child more than 10years old or in an adult requires
operation on the tarsal bones.
Congenital Abnormalities of fingers and toes
Syndactyly (webbed fingers/toes)
A common anomaly occurs twice as often in boys as in girls & more often in the hand
than in the foot.
Ulnar side is more affected, & thumb is seldom involved.
Union between affected digits may consist only of skin and connective tissue simple
syndactyly; if union includes bone complex
Separation of involved fingers dividing soft tissues/bony structures; done bet. 18 mo
& 5 yrs., earlier when hand function is impaired.
Overdevelpment of one or more fingers/toes
Rx: amputation but occasionaly a plastic operation to effect a reduction in size is preferable
Supernumery digits; common & frequently inherited anomalies
Often Bilateral; may be compined with syndactyly
Amputation of the extra finger/ toe is indicated.
General Affectations of bones
Causative agent is unkown
Active stages blood flow to bone greatly ↑ high output cardiac failure
Gross skeletal changes developing thickening and bowing of the shafts of the long
bones (tibia and femur) & generalized thickening of the cranium
Often affect only a single bone
Bones lose their ability to withstand N° stresses & ↑ degree of curvature
Spine (frequently involved) partial collapse of one or more of the vertebral bodies
Later stage: bones matrix is laid down calcifies thick, hard osseous structure
o Clinical picture
Affects man more frequently than women and occasionally it occurs in families
40-60y.o when symptoms begin, may develop the ff:
Severe intractable pain
May complain of fatigue and aching in legs
h/a & backache
legs are becoming bowed, that the back is stooped or the head is becoming larger
moderately advanced stage: head appears massive an too large for the body; face
is relatively small, head may droop forward, long dorsal kyphosis; chest is barrel
shaped & lumbar spine flexed, legs are bowed outward & forward
no mental changes
may develop deafness and tinnitus and an impairment of vision
Required no treatment
If with significant symptoms drugs: Calcitonin. Bisphosphonates & mithramycin
↓bone pain & control the activity of the dse.
Bracing for long bones and spine
Cardiovascular complication MC cause of death
Length of life is good
Pathologic Fx is the MC complication (femur)
Ankylosing spondylitis (Strumpell –Marie Arthritis)
o Characterized by ossification of the ligaments of the spine and by involvement of the hips &
o Sacroiliac joints are affected early
o Cause is unkown
o 10x < men
o Begins @ ages of 20-30 y.o
Progressive ossification capsular & intervertebral ligaments fusing lower and later the
entire spine into a single mass.
Vertebral bodies seemed to be osteoporotic
(+) irregular spur formation & lipping of the vertebrae
Onset: maybe assoc. with acute pain
Stiffness without pain may be the first symptom
Malaise and fatigability accompanied with wgt loss
Pain first appears @ hip, buttocks or lumbosacral region
LBP while pt. is recumbent in early morning hours
Pain & tenderness @ sacroiliac region when pelvic wings are pressed together /when hips
are stressed in extremes of rot.
↓spinal mobility & diminished chest expansion
Associated with other conditions: Plantar fasciitis, tendinitis of Achilles tendon, heel
Pain lessens as the stiffness ↑
There is no involvement of the smaller joints
Rest & well- balanced diet
Control of pain
o Regular dose of Aspirin
o Saliciylates and other NSAIDs
o Rare: steroid therapy
Local non-surgical measures
Bed rest (firm mattress/bed board should be use & rest without a pillow)
Hyperextension ex. Should be done & position of extension should be maintained
Wearing 3-point brace to prevent kyphosis
Osteotomy of the spine
Joint replacement painful ankylosis of the hip
MC benign tumors of bone
They are hamartomas rather than true tumors
First Dx with persons ages 10 – 25 y.o. & typically situated near the ends of long bones
Swelling / lump is only pt’s complain
Discomfort to adjacent bones
MC location: near the adjacent ends of the femur & tibia / upper end of the humerus; flat bones,
scapula MC involved
Operation is not always necessary
Any large osteochondroma in location that is prone to trauma must be removed
Postpubertal enlargement and pain suggest malignant change.
Osteogenic sarcoma (Osteosarcoma)
MC malignant primary bone tumor
Typically develops in the metaphysis of a long bone in late childhood or early adult life (bet. 10
& 20 y.o.)
Aggressive tumor rapid growth, early pulmonary metastases,
No definite cause
MC sites Upper tibia, lower femur, & upper humerus
Hallmark: Osteoid matrix produced by the tumor cells
MC in children & young adults
Occasionally occurs In later adult years, but usually 2° to a pre-existing lesions such as
Dull, constant, aching pain first symptom
Hard bony enlargement that is slightly tender and typically located above/below the knee
or near the sho.
Rapidly growing tumors distention of the superficial veins and ↑ of skin temp.
Treatment and prognosis
Classical methods of amputation or disarticulation well above the lesion
o Any break in the continuity of the bone.
A fx where there is a communication bet. The bone and outside
Complicated by infection. Osteomyelitis, delayed union & even nonunion
Close Fx – there is no such communication
Pathologic Fx- occurs in bones weakened by pre-existing dse such as tumor, cysts,
osteomyelitis or osteoporosis.
Stress Fx – result of bone fatigue from repeated unaccostumed loading & inadequate
o Described as;
Transverse – caused by simple angulatory forces
Oblique – unstable
Spiral- result from torsion ; unstable
Comminuted - the bone is broken into 3/more fragments; unstable
o FX Rx 3 basic objectives:
Reduction / replacement of the bone fragments to as near anatomic position as possible.
Maintenance of reduction until healing is sufficient to & tendonsprevent displacement
External fixation (cast/splint)
o Skin traction
o Skeletal traction
o Transfixion screw
o Bone plate
o Intramedullary rod or nail
Preservation and restoration of function of ms. Joints
Fx in children
Greenstick Fx - An incomplete Fx in which the angulating force bends the cortex on the
compression side and breaks it on the distraction side
Torus Fx- Frequently seen in the distal fourth of the radius, where mild angulation casues
buckling or buldging of the cortex on the compression side.
Fx heal by physiologic process similar to the repair of wounds of soft tissues, conditioned
by factors such as:
Rigidity of bone
Tendency of the Fx fragments to displace
o Spiral fx heals more rapidly than transverse fx.
Length of time required for newly formed bone to restore strong union of
o Humerus & FA – 3 mo
o Femur & tibia – 4-6 mo.
3 late bony complications of Fx
Delayed union – fx healing is abnormally slow
o (+) if tibia close fx does not become clinically firm in 20 weeks, humerus
in 10 weeks 7 femur in 20 weeks
Causes of delay
Inadequate/ interrupted immobilization
Severe local traumatization
Impairment of bone circulation
Loss of bone substance
Distraction or separation of fragmentd
Early, accurate and gentle reduction and immobilization
Maintenance of function
Abstention from repeated trauma
Sound judgement and technique in the us of Internal Fixation
Non-union – healing stops short of firm union
o NO Fx should be considerd ununited until @ least 6 mo. After the date of
Extensive tissue damage
Impairment of bone blood supply
Acceptance of the defect
Use of simple brace
Autogenous bone – taken from the patient
Homogenous bone – taken from other person
Malunion- healing takes place in unsatisfactory alignments
o May be a result of congenital limb deficiencies or may be acquired
o Indications/ common reason
Thermal, chemical or electrical injury
o Types of surgical amputation
Disarticulation – amputation preforemed through a joint
Open amputation – surface of the wound is left unclosed
Closed amputation – a final or definitive amputation stump
Minor amputations amputations through th or distal to the metacarpus or the metatarsus
Major amputations – all amputations proximal to the metacarpal or metatarsal bones.
o amputation levels
o Scoliosis is a lateral deviation of the vertebral column.
o MC found in the thoracic region and may be caused by muscular or vertebral defects.
o Scoliosis is a deformity rather than a disease, and its causes are many often, scoliosis is
compensatory and may be caused by a short leg or hip disease.
o Classification and Etiology
Non-structural Scoliosis (Functional)
Not accompanied by rotational or asymmetric changes in the individual
structures of the spine.
The curve is not fixed, in that in the bending in the opposite direction is not
restricted, and the patient can actively and completely correct the deformity by
It may result from poor posture or leg length discrepancies and usually poses no
major therapeutic problem.
It may also be caused by nerve root irritation such as sciatic scoliosis seen in
acute lumbar disk herniation.
Functional scoliosis can become structural if untreated.
A fixed curvature of the spine associated with vertebral rotation and asymmetry
of the ligamentous supporting structures.
It can be caused by deformity of the vertebral bodies and may be:
o Congenital – defect in embryologic development of the vertebrae or ribs
(e.g., wedge vertebrae, fused ribs or vertebrae, hemivertebrae)
o Musculoskeletal (e.g., osteoporosis, spinal tuberculosis, rheumatoid
o Neuromuscular – associated with a great variety of paralytic disorders
that causeasymmetric paralysis of the trunk muscles. (e.g., cerebral palsy,
polio, myelomeningocele, muscular dystrophy)
o Idiopathic (MC) – Scoliosis with unknown pathogenesis
All the structures of the concave side are compressed or shortened; those in the convex
side may remain normal or become lengthened.
The apical vertebrae, situated at the middle of the curve, shows the greatest curve, shows
the greatest change, being wedge shaped and most rotated.
The vertebrae above and below it undergo similar but less pronounced changes. It always
turns toward the convex side of the curve, and spinous process toward the concavity.
The IVD are compressed on the opposite side as a result of the pressure; nucleus
pulposus migrates toward the convex side.
The anterior longitudinal ligament is thickened on the concave side and thinned on the
o Age of onset: from birth onward
infantile (0 to 3 years)
juvenile (ages 3 to 10)
adolescent (age 10 until bone maturity at between 18 and 20 years of age)
adult (after skeletal maturation)
o Clinical manifestations
Curvatures of < 20 degrees rarely cause significant problems.
Back most prominent features:
Asymmetric flank folds
Prominence of the scapula and shoulder
Severe untreated scoliosis (> 60 degrees) may produce
reduced lung capacity
degenerative spinal arthritis
The adult with scoliosis back pain d/t:
degenerative disk disease
Curves are designated as right or left depending on the convexity
Two primary curvatures may exist
rib hump (gibbus)
tests and Measures
Diagnosis by clinical examination:
Plumb line test
Leg length discrepancy
neurologic examination to rule out an underlying neurologic disorder
Observation and monitoring
Charleston Bending brace
Surgeries for curvatures greater than 45 degrees have been recommended.
adult with scoliosis:
conservative nonoperative course of physical therapy
smoking (or tobacco-use) cessation
and nerve root blocks
epidural steroid injections before surgery is considered
Postural curvatures resolve as the primary problem is treated.
Structural curvatures are not eliminated but rather increase during periods of rapid
If the curvature is <40 degrees at skeletal maturity, the risk of progression is small.
In curvatures >50 degrees, the spine is biomechanically unstable, and the curvature will
likely continue to progress at a rate of 1 degree/yr throughout life.
Poor seating can contribute to this progression.
In severe kyphoscoliosis, pain and comfortable positioning can complicate care, and
pulmonary compromise can lead to death.
AFFECTATIONS OF THE HIP
Coxa vara and coxa valga
o Coxa vara
Abnormality of the upper end of the femur, consisting of a decrease in the neck-shaft
angle (angle of inclination) shortening of the limb Limits abduction of the hips.
May be congenital or acquired (MC)
o Coxa valga
Increase of the neck – shaft angle N° in infants before WB, persist in children who
are unable to stand because of chronic disability & seen as a secondary deformity in
congenital dislocation of the hip.
AFFECTATIONS OF THE KNEE
Cruciate ligaments injuries
o ALC tear (MC)- hyper / force pushing the femur backward on the tibia
o PCL tear – force applied to the front of the tibia push the tibia backward on the femur.
o MCL tear – a valgus / abduction force sometimes associated with rotation or hyper /
o LCL tear – a varus / Adduction force
o LL< common than ML
o Clinical picture
Usually accompanied by hemarthrosis
@ time of injury pt. will often note a definite “pop”
ACL associated with abnormal forward movement of the tibia on the femur; (+)
PCL Abnormal forward or backward displacement of tibia on femur; (+) posterior
MCL pain & swelling, tenderness on med. Side which may be localized just above or
below the joint line; (+) valgus stress test; <5mm min., 5-10 mm mod., >10mm severe
LCL swelling 7 tenderness on lat. Side; (+) Varus stress test
o Classification of ligamentous injury
Mild/grade I – (-) instability & tear is only partial/interstitial
Mod./ grade II – mild instability, secondary supporting structures are intact
Severe/grade III – complete rupture of the ligaments and gross instability of the joint.
Short period of immobilization in soft splint
Early movement of the knee (pain and swelling subsides)
Immobilization in plaster cast for 6-8 weeks
Exercises for the quads & hamstrings
Ex. Involving Terminal ext. of knee should be avoided in ACL injuries
Require surgical repair
Close Rx with cast immobilization
Brace that allow limited ROM
Patellar tendinitis (Jumper’s knee)
o A common affectation of athletes
o Characterized by pain & tenderness over the patellar tendon & pain on forceful / of the knee
Rest & restriction of forceful knee /
Use of splints/cast
Surgical debridement (rare)
AFFECTATIONS OF ANKLE AND FOOT
o Common overuse condition characterized by pain & tenderness Longitudinal arch d/t
excessive & unaccustomed standing & walking.
o Clinical Picture
Acute foot strain
Manifested by pain & tenderness longitudinal arch antalgic gait
Chronic foot strain
Complains of fatigue & aching in the feet
Discomfort longitudinal arch calves
Symptoms is worst @ the end of the day, by evening feet may feel tight and swollen
M.I. finding localized tenderness under the NAVICULAR bone @ the apex of long.
Local Rx Hot soaks/contrast baths = relieve discomfort
felt / sponge rubber arch pad
shoe with a long counter & firm shank will give inc. support
Thomas heel give support to navicular bone
o Lat. Angulation of the great toe @ its MTP joint.
o Etiology & Pathology
Med. Deviation of the 1st metatarsal is accompanied by lat. Deviation of the great toe
Ant part of foot is widened & metatarsal arch depressed
Cx of FHL &EHL is associated with a lat. Displacement of extensor tendons
Rx & prognosis
Mild cases properly fitting shoes & repeated overcorrection by stretching
If accompanied by diabling pain surgery removal of exostosis & bursa
Silver operation EHL tendon is sectioned/ lengthened
Keller/ Schanz operation resection of the proximal half of the first phalanx (for severe
Arthodesis of MTP joints
Osteotomy of Proximal or distal portions of 1st metatarsals / proximal phalanx
Splint/cast/soft cushion pad placed bet. 1st & 2nd toe
Warm soaks & corrective foot ex.
o Medial angulation of the great toe @ the MTP joint
o May be congenital in origin
o Casuse: Trauma, infection, ms. Imbalance, paralysis of Add Hallucis & bunion operation
Mild cases corrected by surgically relaeasing Cx structures on the med. Side of the toe
& placating the lat. Part of the joint capsule
Severe osteotomy of the metatarsal head & use of sectioned EHB in a tenodesis to
maintain the corrected alignment.
AFFECTATION OF NECK & SHOULDER
o A deformity of the neck rotation & flexion
o 1 SCM is shortened tilting of the head towards the affected side & rot. Of chin to the opposite
side; shoulder of affected side is elevated
o Congenital torticollis (muscular torticollis)
Seen with relative frequency after difficult deliveries, with breech presentation &
o Clinical picture:
facial asymmetry develop within the first 3 months (affected: on the side which the head
Proper Rx = complete cure
Incomplete surgical correction recurrence
Corrected before 3 / 4 y.o. facial asymmetry msy completely disappear
Passive stretching of the neck in overcorrected position
Proper positioning of the head during sleep
If old enough active exercises to strtch the short SCM
Section of SCM
Maintenance of overcorrection of the deformity plaster cast, brace/ traction
Program of ex. For securing ms. Balance to maintain the correction permanently
Operation MC used open resection of 1 cm segmentof SCM near its origin
from sternum & clavicle; platysma miss also included
After operation: corrective ex for 6 mo.
Accompanied by pain & stiffness as well as bizarre deformities of the neck
Acute traumatic/inflammatory caused by cervical injuries, atlantoaxial rotary
subluxation or inflammation of the ms/lymph nodes
Chronic infectious/ neoplastic caused by osteomyelitis, tuberculosis, or tumors
of the spine.spinal cord
Arthritic caused by RA, ankylosing spondylitis or OA
Cicatricial Cx of scar tse after burn
Paralytic assymetric flaccid/spastic paralysis of neck ms.
Hysterical Psychogenic inability of the pt. to control neck ms.
Spasmodic CNS/ cervical root lesion & manifested by involuntary rhythmic
Contraction of the neck ms.
Is that of its 1° cause
Helps treating the symptoms
o Hot application
o Gentle massage
o Horizontal/vertical neck traction
o Cervical orthoses
AFFECTATIONS OF THE SHOULDER
Adhesive Capsulitis (frozen shoulder)
o A chronic affectation characterized by pain and LOM (sho) that becomes worse over a period of
o Frequently seen in pt.’s over 40y/o
o Women> men
o A.k.a. Periarthritis, obliterative bursitis & diffuse rotator cuff tendinitis
Changes in jt. Capsule Edema, Fibrosis, round cell infiltration (indicating low-grade
Synovial recesses adherent LOM
Periarticular tse lose elasticity, become shortened & fibrotic fixing the head in the
(+) ms. Atrophy
Cx CHL & subscapularis tendon prevent ER of humerus
Articular surface uninvolved
o Clinical picture
May have an insidious onset
Frequently follows supraspinatus tendinitis, subacromial bursitis & tenosynovitis of the
long head of biceps
May result from AC arthritis . play a part in shoulder-hand syndrome Arm is kept in
(+) pain ExAbEr
Night time pain loss of sleep emotionally upset
↓ Active & passive mobility in SH joint restriction: ExAb
Gravity free ex. Within painless arcs of motion
Analgesic & anti-inflammatory drugs
Antigravity ex. (later part) e.g. finger ladder
Procaine blocks of the suprascapular nn. relieve pain temporarily
Late stage: Acromioplasty or resection of the acromioclavicular jt.
AFFECTATIONS OF THE ELBOW
o Common in children bet. 2-5 y/o
o Locking of FA in pronation / neutral rot. When a segment of annular ligament is pilled over the
edge of the radial head
o A.k.a nursemaid’s elbow
o MOI: sudden direct pull on the elevated limb with the elbow / and FA pronated
o Clinical Picture
Child refuses to use the arm & the elbow is held slightly flexed
All N° ROM except supination
Attempts to supinate causes pain & a sensation of mechanical blocking
Brief manipulation without anesthesia elbow flex to a right angle FA supinated
quickly while pressure is everted to the radial head. a click is felt, if not carried out
AFFECTAIONS OF THE WRIST AND HAND
Rupture of the central extensor slip
o Rupture: near the insertion into the base of the mid phalanx flexion deformity of the PIP jt.
o A.k.a boutonniere (buttonhole)
o Rx: suturing the central slip if possible, repositioning the lat. Bands & releasing them distally
Avulsion of the Flexor Profundus Tendon
o MOI: d/t forced / of firmly flexed fingers
o MC in young athletes, usually involved the ring finger
o (+) loss of active flexion of the distal joint & tenderness & swelling on the volar aspect of the
o Rx: surgical reattachment of the avulsed tendon
Mallet Finger (baseball/dropped finger)
o MOI: sudden forcible flexion of the distal phalanx may cause an avulsion of the extensor tendon
@ its insertion
o Common: athletes
o (+) inability to / actively the distal phalanx
o (+) swelling and tenderness
o Rx: DIP is held constantly in hyper / for 6 weeks done with a plaster splint/ small metal/plastic
o Late cases: suture of the tendon/ bone fragment to the phalanx = unsatisfactory
o Disability : very slight
o A slow progressive Cx of the palmar fascia
Men > women
Between ages 55 -75 y/o
When it occurs in women younger group
Changes involves:Ring finger, Little finger or both
Usually Bilat. ; when unilat. right MC
Chronic inflammation of the palmar fascia progressive fibrosis Cx of Palamar
Advance cases: skin is involved
(+) small nodular painless thickening in the palmar fascia overlying a flexor tendon in the
region of MCP jt. often associated with dimpling of the skin.
Thickened longitudinal band is formed flexion Cx of finger ↑
MCP & adjacent IP joints become flexed
DIP jt. remains N°
Earliest cases frequent passive stretching
Post-op:/ splint + ex.
Active and passive motion must begin as the healing of the skin permits