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Author(s): Clifford Craig, M.D., 2009License: Unless otherwise noted, this material is made available under the terms ofth...
Citation Key                          for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Ada...
COMMON        MUSCULOSKELETAL           PROBLEMS          C. CRAIG   M2 - MUSCULOSKELETALFall 2008
ANGULAR and TORSIONAL   DEFORMITIES of the  LOWER EXTREMITIES
TERMSValgus - deviation away from midlineVarus - deviation toward midlineTorsion (rotation) Internal ExternalVersion (rota...
EXAMINATIONRelaxedSupine/sitting/walkingEach individual jointBeware any asymmetry
IN - TOEINGMetatarsus adductus Newborn – 18 months Limited to forefoot 80 % improve spontaneously Casting Surgery - rare
Allison Gilmore, MD, ET AL
IN - TOEINGInternal tibial torsion  6 – 18 months  85 % improve spontaneously  Defined by transmalleolar axis    Infant +5...
!        !        ! "#$%&!(!)*+$,!-./+0!.&#1&2!        !        !         !
FEMORAL ANTEVERSION3 – 9 yearsNot hip problemImproves spontaneously until age 12
The Internet Journal of Biological Anthropology 2009 : Volume 3 Number 1
Source Undetermined
Source Undetermined
DIFFERENTIAL DIAGNOSISEquinovarus (clubfoot)Neurologic problems Cerebral palsy Myelodysplasia
Source Undetermined
Source Undetermined
Source Undetermined
Source Undetermined
OUT-TOEINGCalcaneovalgus foot Usually improves spontaneouslyExternal tibial torsion Uncommon – neurologic problems   Myelo...
Source Undetermined
Source Undetermined
OUT - TOEINGExternal rotation contractures hips Seen in newborn Improve spontaneously first year
!                 !                 !       3.$4+0%!(!0&4*.0!       5-6!-&+0%!.&#1&2!                 !                 ! ...
BOWLEGS / KNOCK KNEES
EVALUATIONClinical Knee joint laxity Range of motion Location of angulation – femur/joint/tibia Assess alignment – AP/late...
EVALUATIONRadiographic Long films – standing   Neutral alignment
Source Undetermined
EVALUATIONLaboratory Renal function studies – BUN/creatinine Calcium/Phosphorus/Alk.phos.
BOWLEGS (GENU VARUM)
Differential diagnosisPhysiologic (most common)Blount s DiseaseRicketsSkeletal dysplasia
PHYSIOLOGIC BOWLEGSNormal in infants (15 degrees)Neutral by 18-24 monthsX-rays normal except for bowing
Dr. C. Robert DushackSource Undetermined
Source Undetermined
INFANTILE BLOUNT S         DISEASEGrowth retardation proximal tibial epiphysis Medial / posteriorAbnormal weightbearing st...
IMAGINGMedial beaking initial signProgressive depression medial tibial plateau  Langenskiold stages I-V
Source Undetermined
Source Undetermined
GENU VALGUMDevelopmental most commonDifferential diagnosis Metabolic bone disease    Renal osteodystrophy Trauma – proxima...
Source Undetermined
DEVELOPMENTAL HIP        DYSPLASIAEtiology  Multifactorial  Not always congenital or dislocated   continuum of dysplasia
DDH - ETIOLOGYMechanical factors First born (small space) Breech presentation (60%) Left hip (60%) Torticollis (20%) Metat...
DDH – ETIOLOGYPhysiologic factors Female (6:1)   Hormones – estrogen Environment   Cradle boards
HIP AT RISKMajor Abnormal clinical exam Breech presentation First born female Family history DDH
HIP AT RISKMinor Limitation of abduction Sacral dimple Foot deformity Torticollis Scoliosis
NEWBORN TO TWO          MONTHSOrtolani and Barlow tests most reliable X-rays unreliable (false neg. 50%) Ultrasound – non-...
Source Undetermined
DDH - EXAMInfant relaxed/supineStabilize pelvisFlex hip 90 degreesAdduct past midline / gentle outward pressureGentle abdu...
!                      !                      !            78&-9:!(!33;!&<$#!                 .&#1&2!                     ...
!          !          !78&-9:!(!33;!&<$#!     .&#1&2!          !          !           !
NEWBORN TO SIX MONTHSOrtolani positive – reducible Reduce femoral head Maintain abducted and flexed   100 degrees flexion/...
PAVLIK HARNESSMaintains flexed/abducted posture Free motion within limited range   Safe zone of Ramsey Flexion above 90 de...
Source Undetermined
TWO MONTHS TO TWO         YEARSRadiographic findings Shenton s line broken Proximal/lateral migration femoral head False a...
Source Undetermined
DDH EXAMEVERY WELL BABY EXAMINATION
IDIOPATHIC SCOLIOSISIncidence - 22/1000  4/22 require treatmentSorting  Discovery – school screening  Initial exam – famil...
SCOLIOSIS     ETIOLOGY - GENETIC80% Positive family historyVariable expressionHigh degree penetranceEqual sex distribution
SCOLIOSIS   CLINICAL EVALUATIONA-P alignment Curve types   Right thoracic/left lumbar most common   Double major/thoracolu...
!        !        !78&-9:!(!/9,+/+/! &<$#!.&#1&2!        !        !         !
!         !         ! 78&-9:!(!/9,+/+/!1&.-&*.$&!!.&#1&2!         !         !          !
Source Undetermined
SCOLIOSIS   CLINICAL EVALUATIONSagittal alignment Thoracic lordosis Kyphosis Lumbar lordosis
Source Undetermined
Source Undetermined
SCOLIOSISRADIOLOGIC EVALUATIONStanding PA and lateral films (initial)  Entire spineCobb measurement methodMinimize follow ...
Radiology at the University of Washington           Zorkun at Wikidoc.org
Xray2000
Source Undetermined
SCOLIOSIS                  BEWAREPainful scoliosis/neurologic findingsProgressive curve in malesUnusual pattern (left thor...
SUMMARYMost angular deformities resolve with growthExam best screen for DDH in newborn Caution hip at riskMajority of scol...
Additional Source Information                           for more information see: http://open.umich.edu/wiki/CitationPolic...
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12.08.08: Common Musculoskeletal Problems

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Transcript of "12.08.08: Common Musculoskeletal Problems"

  1. 1. Author(s): Clifford Craig, M.D., 2009License: Unless otherwise noted, this material is made available under the terms ofthe Creative Commons Attribution–Noncommercial–Share Alike 3.0 License:http://creativecommons.org/licenses/by-nc-sa/3.0/We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use,share, and adapt it. The citation key on the following slide provides information about how you may share and adapt thismaterial.Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions,corrections, or clarification regarding the use of content.For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or areplacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to yourphysician if you have questions about your medical condition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicyUse + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. COMMON MUSCULOSKELETAL PROBLEMS C. CRAIG M2 - MUSCULOSKELETALFall 2008
  4. 4. ANGULAR and TORSIONAL DEFORMITIES of the LOWER EXTREMITIES
  5. 5. TERMSValgus - deviation away from midlineVarus - deviation toward midlineTorsion (rotation) Internal ExternalVersion (rotation) Anteversion/retroversion
  6. 6. EXAMINATIONRelaxedSupine/sitting/walkingEach individual jointBeware any asymmetry
  7. 7. IN - TOEINGMetatarsus adductus Newborn – 18 months Limited to forefoot 80 % improve spontaneously Casting Surgery - rare
  8. 8. Allison Gilmore, MD, ET AL
  9. 9. IN - TOEINGInternal tibial torsion 6 – 18 months 85 % improve spontaneously Defined by transmalleolar axis Infant +5 /adult + 22 degrees
  10. 10. ! ! ! "#$%&!(!)*+$,!-./+0!.&#1&2! ! ! !
  11. 11. FEMORAL ANTEVERSION3 – 9 yearsNot hip problemImproves spontaneously until age 12
  12. 12. The Internet Journal of Biological Anthropology 2009 : Volume 3 Number 1
  13. 13. Source Undetermined
  14. 14. Source Undetermined
  15. 15. DIFFERENTIAL DIAGNOSISEquinovarus (clubfoot)Neurologic problems Cerebral palsy Myelodysplasia
  16. 16. Source Undetermined
  17. 17. Source Undetermined
  18. 18. Source Undetermined
  19. 19. Source Undetermined
  20. 20. OUT-TOEINGCalcaneovalgus foot Usually improves spontaneouslyExternal tibial torsion Uncommon – neurologic problems Myelodysplasia Cerebral palsy
  21. 21. Source Undetermined
  22. 22. Source Undetermined
  23. 23. OUT - TOEINGExternal rotation contractures hips Seen in newborn Improve spontaneously first year
  24. 24. ! ! ! 3.$4+0%!(!0&4*.0! 5-6!-&+0%!.&#1&2! ! ! !Please see: http://www.cssd.us/body.cfm?id=1218
  25. 25. BOWLEGS / KNOCK KNEES
  26. 26. EVALUATIONClinical Knee joint laxity Range of motion Location of angulation – femur/joint/tibia Assess alignment – AP/lateral/rotation
  27. 27. EVALUATIONRadiographic Long films – standing Neutral alignment
  28. 28. Source Undetermined
  29. 29. EVALUATIONLaboratory Renal function studies – BUN/creatinine Calcium/Phosphorus/Alk.phos.
  30. 30. BOWLEGS (GENU VARUM)
  31. 31. Differential diagnosisPhysiologic (most common)Blount s DiseaseRicketsSkeletal dysplasia
  32. 32. PHYSIOLOGIC BOWLEGSNormal in infants (15 degrees)Neutral by 18-24 monthsX-rays normal except for bowing
  33. 33. Dr. C. Robert DushackSource Undetermined
  34. 34. Source Undetermined
  35. 35. INFANTILE BLOUNT S DISEASEGrowth retardation proximal tibial epiphysis Medial / posteriorAbnormal weightbearing stresses Early walkers ObesityRacialBilateral 75 %
  36. 36. IMAGINGMedial beaking initial signProgressive depression medial tibial plateau Langenskiold stages I-V
  37. 37. Source Undetermined
  38. 38. Source Undetermined
  39. 39. GENU VALGUMDevelopmental most commonDifferential diagnosis Metabolic bone disease Renal osteodystrophy Trauma – proximal tibial fx. Tumor – fibrous dysplasia
  40. 40. Source Undetermined
  41. 41. DEVELOPMENTAL HIP DYSPLASIAEtiology Multifactorial Not always congenital or dislocated continuum of dysplasia
  42. 42. DDH - ETIOLOGYMechanical factors First born (small space) Breech presentation (60%) Left hip (60%) Torticollis (20%) Metatarsus adductus/calcaneovalgus
  43. 43. DDH – ETIOLOGYPhysiologic factors Female (6:1) Hormones – estrogen Environment Cradle boards
  44. 44. HIP AT RISKMajor Abnormal clinical exam Breech presentation First born female Family history DDH
  45. 45. HIP AT RISKMinor Limitation of abduction Sacral dimple Foot deformity Torticollis Scoliosis
  46. 46. NEWBORN TO TWO MONTHSOrtolani and Barlow tests most reliable X-rays unreliable (false neg. 50%) Ultrasound – non-invasive Age limited Operator dependent May be too sensitive (immaturity) Helpful for brace follow up
  47. 47. Source Undetermined
  48. 48. DDH - EXAMInfant relaxed/supineStabilize pelvisFlex hip 90 degreesAdduct past midline / gentle outward pressureGentle abduction – lift toward socketFeel dislocation/relocationNot just abduction test
  49. 49. ! ! ! 78&-9:!(!33;!&<$#! .&#1&2! ! ! !Refer to: http://static.howstuffworks.com/gif/hip-dysplasia-screening.jpg
  50. 50. ! ! !78&-9:!(!33;!&<$#! .&#1&2! ! ! !
  51. 51. NEWBORN TO SIX MONTHSOrtolani positive – reducible Reduce femoral head Maintain abducted and flexed 100 degrees flexion/60 degrees abduction Document reduction (x-ray/ultrasound)
  52. 52. PAVLIK HARNESSMaintains flexed/abducted posture Free motion within limited range Safe zone of Ramsey Flexion above 90 degrees Avoid excessive abduction Avascular necrosis
  53. 53. Source Undetermined
  54. 54. TWO MONTHS TO TWO YEARSRadiographic findings Shenton s line broken Proximal/lateral migration femoral head False acetabulum (acetabular dysplasia)
  55. 55. Source Undetermined
  56. 56. DDH EXAMEVERY WELL BABY EXAMINATION
  57. 57. IDIOPATHIC SCOLIOSISIncidence - 22/1000 4/22 require treatmentSorting Discovery – school screening Initial exam – family MD/pediatrician Disposition - orthopaedist
  58. 58. SCOLIOSIS ETIOLOGY - GENETIC80% Positive family historyVariable expressionHigh degree penetranceEqual sex distribution
  59. 59. SCOLIOSIS CLINICAL EVALUATIONA-P alignment Curve types Right thoracic/left lumbar most common Double major/thoracolumbar Trunk alignment Rib hump (forward bending test)
  60. 60. ! ! !78&-9:!(!/9,+/+/! &<$#!.&#1&2! ! ! !
  61. 61. ! ! ! 78&-9:!(!/9,+/+/!1&.-&*.$&!!.&#1&2! ! ! !
  62. 62. Source Undetermined
  63. 63. SCOLIOSIS CLINICAL EVALUATIONSagittal alignment Thoracic lordosis Kyphosis Lumbar lordosis
  64. 64. Source Undetermined
  65. 65. Source Undetermined
  66. 66. SCOLIOSISRADIOLOGIC EVALUATIONStanding PA and lateral films (initial) Entire spineCobb measurement methodMinimize follow up filmsRisser grading – skeletal maturity
  67. 67. Radiology at the University of Washington Zorkun at Wikidoc.org
  68. 68. Xray2000
  69. 69. Source Undetermined
  70. 70. SCOLIOSIS BEWAREPainful scoliosis/neurologic findingsProgressive curve in malesUnusual pattern (left thoracic)Rapid progression (> 1 degree/month)INTRADURAL ABNORMALITY Tumor/syrinx/ruptured disc
  71. 71. SUMMARYMost angular deformities resolve with growthExam best screen for DDH in newborn Caution hip at riskMajority of scoliosis non-progressiveBeware unusual scoliosis
  72. 72. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicySlide 8: Allison Gilmore, MD, ET AL, http://www.consultantlive.com/display/article/10162/33387Slide 12: The Internet Journal of Biological Anthropology 2009 : Volume 3 Number 1, http://www.ispub.com/journal/the_internet_journal_of_biological_anthropology/volume_3_number_1_63/article_printable/femoral-anteversion- comparison-by-two-methods.htmlSlide 13: Source UndeterminedSlide 14: Source UndeterminedSlide 16: Source UndeterminedSlide 17: Source UndeterminedSlide 18: Source UndeterminedSlide 19: Source UndeterminedSlide 21: Source UndeterminedSlide 22: Source UndeterminedSlide 28: Source UndeterminedSlide 33: Dr. C. Robert Dushack, http://www.pffcpc.com/flatfoot.shtml; Source UndeterminedSlide 34: Source UndeterminedSlide 37: Source UndeterminedSlide 38: Source UndeterminedSlide 40: Source UndeterminedSlide 47: Source UndeterminedSlide 49: Refer to http://static.howstuffworks.com/gif/hip-dysplasia-screening.jpgSlide 53: Source UndeterminedSlide 55: Source UndeterminedSlide 62: Source UndeterminedSlide 64: Source UndeterminedSlide 65: Source UndeterminedSlide 67: Zorkun at Wikidoc.org, http://www.wikidoc.org/index.php/Image:Scoliosis_cobb.gifSlide 68: Xray2000, http://www.e-radiography.net/radpath/r/risser-sign.htm#TOPSlide 69: Source Undetermined
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