Deformities of human body pps


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Deformities of human body pps

  1. 1. By: Aamir Rauf Memon1st Year DPT Student 1
  2. 2. INTRODUCTION―Deformity is the malformation of any component of the body‖. The malformation my be the result of bony distortion or alteration in the topography of soft tissues. The deformity could lead to an impairment or even functional loss along with cosmetic disfigurement. 2
  3. 3. TYPES OF DEFORMITYThere are two types of deformity:1. Congenital.2. Acquired. 3
  4. 4. Congenital Deformity Incorrect position in the uterus, abnormal development due to a combination of genetic and acquired factors are the principal causes of congenital deformity. The congenital deformity may or may not be hereditary. 4
  5. 5. Acquired Deformity The acquired deformity is that which was not present at birth, and has developed after birth. It can be produced as a result of following causes:1. Bone disease2. Joint diseases3. Muscular causes: They are of following types: 5
  6. 6. Acquired Deformities cont….a)Muscle Paralysisb)Muscle spasticityc)Muscular diseased)Shortening of musculo-tendinous complex4. Trauma5. Postural causes6. Nerve lesions 6
  7. 7. Classification of the Degree of Deformity A deformity is classified into the following three grades:1. First degree: The deformity is mild and can be corrected by passive stretching.2. Second degree: Shortening in the soft tissues prevents full passive correction of the deformity. Attempted passive correction results in pain. Slight degree of bony changes may be present.3. Third degree: The deformity is rigid and can‘t be corrected by passive manoeuvres. It may be associated with bony changes. 7
  8. 8. Congenital DeformitiesShoulder Joint 1.Sprangel’s shoulder: Also called ―high scapula‖. It is characterized by an abnormally raised scapula, on one or both sides. The eliology is unknown. The scapular muscles are poorly developed and may be represented by fibrous bands. It may be accompanied by scoliosis(thoracic curve) with convexity on the involved side. The movement of scapula is markedly limited due to fibrous bands or a bony bar resulting in the limitation of shoulder abduction and elevation. 8
  9. 9. Elbow Joint 1.Congenital Dislocation: This may be anterior or posterior and is usually bilateral. The patient may notice the lump, which is easily palpable and can be felt to move when the forearm is rotated. X- rays show that the dislocated radial head is dome- shaped(due to abnormal modeling). Function is usually surprisingly good and pain is unusual. Surgery is therefore rarely required; however, if the lump limits elbow flexion it can be excised. 9
  10. 10. 2. Congenital Synostosis: Congenital deficiencies of the forearm bones are occasionally associated with fusion of the humerus to the radius or ulna. This disabling condition is fortunately very rare. A more useful angle can be achieved by osteotomy. Proximal radio-ulnar synostosis causes loss of rotation, but elbow flexion is retained and the inconvenience is often only moderate. 10
  11. 11. 3. Dislocation of the Radial Head: Rare (familial) and often associated with other abnormalities. Associated with congenital below elbow amputation (hemimelia),arthrogryposis, Ehlers-Danlos syndrome. May be anterior or posterior and is usually bilateral The patients usually notice a lump which moves on rotation of the forearm X-Rays show the dislocated radial head is dome shaped. Treatment: If the lump limits elbow flexion it can be excised Congenital subluxation of the radial head is usually lateral and commonly associated with a wide variety of bone dysplasias 11
  12. 12. Wrist Joint1. Carpal fusions: Coalition of one or more carpal bones is one of the commonest congenital wrist abnormalities; it is usually inherited or an autosomal dominant trait and may be bilateral. Often it is associated with other abnormalities. It seldom causes problem and no treatment is necessary. 12
  13. 13. 2. Transverse Absence: The commonestsite of transverse absence in the upper limb is atthe junction of the middle and the upper onethird of the forearm. A static prosthesis is fittedat 6 months. If facilities are available, it isreplaced at 18 months by a split hook operated bya cord from the outer shoulder, and at about 3years by a myoelectric prosthesis. 13
  14. 14. 3. Radial Longitudinal Deficiency(Radial Club Hand): The infant is born with the wrist in marked radial deviation- hence the name ―club hand‖. Bilateral deformity is more common than unilateral. There is absence of the whole or part of the radius; often the thumb,scaphoid and trapezium fail to develop normally. It usually occurs as an isolated abnormality but is occasionally associated with other conditions such as thrombocytopaenia and absent radius(TAR),Fanconi anaemia, atrial septal defect(Holt-Oram syndrome) or the VATER syndrome(Vertebral defects, anal atresia , Tracheal-Esophageal fistula, renal and Radial dysplasia). Treatment in the neonate consists of gentle manipulation and splintage. 14
  15. 15. 4. Ulnar Longitudinal Deficiency: In thisrare deformity ulnar deviation is present at birth andis due to partial or complete absence of ulna; inaddition the ulnar rays of the hand may be missing.As the child grows the radial head may dislocate.Treatment consists of stretching and splintageduring the first few months. 15
  16. 16. 5. Distal Ulnar Dysplasia: In older children withhereditary multiple exostoses there is often disproportionateshortening of the ulna ; its distal end becomes carrot-shaped and theradius is bowed. The same deformity is sometimes seen indyschondroplasia, and occasionally without any obvious bonedisease.Treatment is seldom necessary. If deformity is marked, ulnarlengthening with or without osteotomy of the radius) may beadvisable. 16
  17. 17. 6.Madelung’s Deformity: In this deformity thelower radius curves forwards, carrying with it the carpus and the hand butleaving the lower ulna sticking out as a lump on the back of the wrist. It maybe congenital or post-traumatic. The congenital disorder may appear as anisolated entity or as part of a generalized dysplasia; although theabnormality is present at birth, the deformity is rarely seen before the age of10 years, after which it increases until growth is complete. Function isusually excellent.Treatment: If deformity is severe the lower end of the ulna may beexcised(Darrach‘s procedure), this is sometimes combined with osteotomy ofthe radius. 17
  18. 18. 7. Arthrogryposis Multiplex Congenita: Multiple, non-progressive joint contractures are noted at birth. The cause is unknown; there is an underlying neuropathy or myopathy. The limbs appear atrophic, with waxy skin lacking normal joint creases. The elbows are extended, the wrists flexed and ulnar deviated, the thumb adducted and clasped, and the fingers flexed.Treatment is difficult. Serial splintage is started soon after birth; however, correction is often inadequate. 18
  19. 19. Congenital VariationsThe hand and foot are much the commonest sites ofcongenital variations in the musculoskeletal system;the incidence is at least one in 1000 live births. Thecause may be an inherited genetic defect, achromosome disorder or an embryonal insult due toviral infection, nuclear radiation or harmful drugadministration during the first 2 months ofpregnancy.The clinical disorders are conventionally divided into7 groups. 19
  20. 20. TYPE EXAMPLEFailure of formation Transverse absence Longitudinal absence- radial (radial club hand) Longitudinal absence-ulnar (ulnar club hand) Longitudinal absence-central (typical cleft hand)Failure of differentiation Syndactyly Symphalangism Camptodactyly Flexed Thumb ArthrogrypoisDuplication Thumb duplicationOvergrowth MacrodactylyUndergrowth Thumb hypoplasiaConstriction ring syndrome Simple ringsGeneralized skeletal abnormalities Marfan‘s, Turner‘s, Down‘s etc. 20
  21. 21. Failure of FormationThe upper limb can fail to develop eithertransversely or longitudinally.Transverse Failure: It may occur at anylevel, the commonest being the proximal third of thefore arm. Absence of parts of thefingers(symbrachydactyly) can be managed by non-vascularized bone transfer or microvascular transferof a toe, or by simply fitting a prosthesis. 21
  22. 22. Longitudinal Failure: The deficiency can be radial, ulnar or central.1. Radial longitudinal deficiency(Radial club hand): There is partial or complete absence of the thumb and/or radius; the typical deformity is one of marked radial deviation of the wrist and hand. In some cases the humerus is fused with ulna.2. Ulnar longitudinal deficiency(Ulnar club hand): This is much rarer than radial club hand. Digits are absent from the ulnar side of the hand and the remaining digits are often syndactylized. The elbow is frequently unstable or stiff. The condition is associated with skeletal defects such as fibular hemimelia rather than the visceral defects which frequently accompany a radial longitudinal deficiency. treatment includes syndactyly release, excision of soft tissue tether(anlage) and stabilization of the elbow. 22
  23. 23. 3. Central longitudinal deficiency(Cleft hand): This is usually present as a familiar disorder. Typically, the second, third and fourth rays are affected. The condition is bilateral and the feet are often involved. The appearance ranges from a simple cleft, with only the middle ray missing, to absence of all three central rays(unkindly described as a ‗lobster claw‘). 23
  24. 24. Failure of differentiation1. Syndactyly(congenital webbing): It is the mostcommon congenital variation in the hand. It may be simple(skinonly) or complex(skin and bone). With acrosyndactyly, only the tipsare joined.2. Camptodactyly: It is a flexion deformity of the proximalinterphalangeal joint(usually of the little finger). It is hereditary andoften bilateral, but deformity is rarely obvious before the age of 10years. A normal distal interphalangeal joint distinguishes it from aboutonniere deformity. 24
  25. 25. 3. Kirner’s deformity: It is not congenital but is mentioned here as it could otherwise be mistaken for camptodactyly or clinodactyly. Presenting in adolescence, the distal phalanx(yet again the little finger) becomes swollen and curved. Treatment is with splintage and occasionally osteotomy. 4. Hereditary symphalangism: It describes cognitive stiffness of the proximal interphalangeal joint. The whole finger is small, shiny and stiff. Motion can not be restored with surgery. 25
  26. 26. 5. Arthrogryposis: It is a condition in which there is severemuscle weakness caused by an intrinsic abnormality of themotor nerves and muscle. The joint are stiff and contracted.The overlying skin is smooth, without flexion creases. Theremay be a single abnormality, such as pronated forearm, flexedwrist and clasped thumb, or the whole limb may be involved.Treatment includes splintage, tendon transfers and arthidesis.6. Congenital clasped thumb: It is due to weak or absentextensor tendons(and contractures of the MCP and CMC jointsin severe cases). Simple extensor tendon weakness mayrespond to splintage in extension for a few months; if this fails;an extensor tendon transfer is needed.The condition must be distinguished from a ‘congenital’trigger thumb, which is due to stenosing tenovaginitis of theflexor pollicis longus. 26
  27. 27. Duplication1.Polydactyly(extra digits): It is nearly ascommon as syndactyly. An extra little finger isusually inherited and other variations may bepresent. By contrast, an extra thumb is usuallysporadic. An extra central digit, the rarest of theduplication, is often associated with syndactyly anddisorganization of the skeleton.Extra skin tags can be simply excised. 27
  28. 28. Overgrowth1.Macrodactyly: It has a neurogenic cause. The giant finger isstiff and unsightly, but attempts at operative reduction are fraughtwith complications. The finger can not be made normal; severalattempts may be made to reduce the size, each leaving the fingerincreasingly stiff and scarred. 28
  29. 29. UndergrowthThe thumb is most commonly affected, the defect ranging from a slightly small digit to complete aplasia. The most severe forms need a pollicization to provide a post to oppose against the fingers; less severer forms may need a web space release, stabilization of the MCP joint, correction of abnormal tendons and a muscle transfer to provide opposition. 29
  30. 30. Constriction BandsThese may occur in any part of the limb. The consequences range from complete amputation to an obvious circumferential constriction with a viable distal part. The latter is treated by multiple Z-pasties. 30
  31. 31. Generalized Skeletal AbnormalitiesGeneralized skeletal disorders often involve the hand,e.g. Marfan‘s syndrome(‗spider hand‘),achondroplasia(‗trident hand‘) and Down‘ssyndrome(short little finger, often curved). 31
  32. 32. Neck Region1.Torticollis(wry neck): This is description ratherthan a diagnosis. The chin is twisted upwards towards oneside. There are many causes. The condition may be eithercongenital or acquired. Infantile(congenital) torticollis: This condition iscommon. The sternomastoid muscle on one side is fibrous and fails toelongate as the child grows; consequently, progressive deformitydevelops. The cause is unknown; the muscle may have sufferedischaemia from a distorted position in utero(the association withbreech presentation and hip dysplasia is supporting evidence), or itmay have been injured at birth.A history of difficult labour or breech birth is common. Deformitydoes not become apparent until the child is 1-2 years old. The head istilted on one side, so that the ear approaches shoulder; thesternomastoid on that side may feel tight and hard. There may also beasymmetrical development of the face(plagiocephaly). These featuresbecome increasingly obvious as the child grows. 32
  33. 33. Secondary Torticollis: Childhood torticollis may be secondary to congenital bone anomalies, atlantoaxial rotatory displacement, infection(lymphadentitis, retropharyngeal abscess, tonsillitis, discitis, tuberculosis), trauma, juvenile rheumatoid arthritis, posterior fossa tumours, dystonia(benign paroxysmal torticollis) or ocular dysfunction. Atlantoaxial Rotatory Displacement: The aetiology of this condition is unclear, but it is thought to be due to muscle spasm resulting from inflammation of the atlantoaxial region. There may be a history of trauma of upper RTI. The child presents with a painful wry neck. 33
  34. 34. Vertebral Anomalies: There are many anomalies andmost are very rare. Three are described here:1. Klippel-Feil syndrome(cervical-vertebralsynostosis):This developmental disorder represents a failure of segmentation of thecervical somites; it is often associated with abnormalities in the genito-urinary, nervous or cardiovascular system. Some children have a hearingimpediment.Children with synostosis have a characteristic appearance: the neck is shortor non-existent and there may be webbing; the hairline is low; and neckmovements are limited. About one in three children with Klippel-Feilsyndrome also has Sprengel‘s deformity of the scapula. Scoliosis is present inabout 60% and rib anomalies in about 30%. Hand deformities such assyndactyly, thumb hypoplasia and extra digits are also present. X-rays revealfusion of two or more cervical vertebrae. 34
  35. 35. 2. Basilar Impression: In this condition the floor of the skull is indented by the upper cervical spine. The odontoid can impinge upon the brain stem. The cause is either a primary bone abnormality(associated with other bone defects such as odontoid abnormalities, Morquio syndrome and Klippel-Feil syndrome) or secondary to softening of the bones(osteomalacia, rickets rheumatoid arthritis, neurofibromatosis etc). The patients may present-often in the second or third decade-with symptoms of raised intracranial pressure(because the aqueduct of Sylvius becomes blocked), weakness and paraesthesia of the limbs(because of direct compression or ischaemia of the cord). Treatment involves surgical decompression and stabilization. 35
  36. 36. 3. Odontoid Anomalies: The odontoid may be absent or hypoplastic, or there may be a separate ossicle(the os odontoideum). The anomaly should be suspected(and looked for even if the child does not complain) in skeletal dysplasias which involve the spine. This is especially important in patients undergoing operation; the atlantoaxial joint may subluxate under anaesthesia. In the majority of cases the anomaly is discovered by chance in a routine cervical spine X-rays following trauma. Open-mouth radiographs show the abnormality; lateral flexion/extension views may show instability of the C1-C2 articulation. 36
  37. 37. 4.Bifid rib: A bifid rib or bifurcated rib orsternum bifidum is a congenital deformity occurring inabout 1.2% of the population. Bifid ribs occur in up to 8.4% ofSamoans (McKinley & OLoughlin, p. 214). The sternal end ofthe rib is cleaved into two. It is usually unilateral.Bifid ribs are usually asymptomatic, and are often discoveredincidentally by chest x-ray. Effects of this neuroskeletalanomaly can include respiratory difficulties, neurologicaldifficulties, limitations, and limited energy from the stress ofneeding to compensate for the neurophysiological difficulties 37
  38. 38. 5.Cervical rib: A cervical rib is asupernumerary (or extra) rib which arises from theseventh cervical vertebra. It is a congenitalabnormality located above the normal first rib. Acervical rib is present in only about 1 in 500 (0.2%)of people; in even rarer cases, an individual mayhave two cervical ribs. 38
  39. 39. Back RegionSpinal Deformities: Variations andabnormalities of segmentation are common. Themost serious type of congenital defect is spina bifida.‗Spinal deformity‘(as opposed to deformities ofindividual vertebrae) affects the entire shape of theback and manifests as abnormal curvature, in eitherthe coronal plane(scoliosis) or the sagittalplane(hyperkyphosis and hyperlordosis). 39
  40. 40. 1.Spina Bifida:(Latin: "split spine") is a developmental birth defect caused bythe incomplete closure of the embryonic neural tube. Some vertebrae overlying the spinalcord are not fully formed and remain unfused and open. If the opening is largeenough, this allows a portion of the spinal cord to stick out through the opening in thebones. There may or may not be a fluid filled sac surrounding the spinal cord. Otherneural tube defects include anencephaly, a condition in which the portion of the neuraltube which will become the cerebrum does not close, and enecphalocele, which resultswhen other parts of the brain remain unfused.Spina bifida malformations fall into four categories: spina bifida occulta, spina bifidacystica (myelomeningocele), meningocele and lipomeningocele. The most commonlocation of the malformations is the lumbar and sacral areas . Myelomeningocele is themost significant form and it is this that leads to disability in most affected individuals.The terms spina bifida and myelomeningocele are usually used interchangeably.Spina bifida can be surgically closed after birth, but this does not restore normal functionto the affected part of the spinal cord. Intrauterine surgery for spina bifida has also beenperformed and the safety and efficacy of this procedure is currently being investigated.The incidence of spina bifida can be decreased by up to 75% when daily folic acidsupplements are taken prior to conception. 40
  41. 41. 2. Scoliosis: (from Greek: skoliosis meaning "crooked condition," from skolios, "crooked"). Scoliosis is an apparent lateral(sideways) curvature of the spine. ‗Apparent‘ because, although lateral curvature does occur, the commonest form of scoliosis is actually a triplanar deformity with lateral, anteroposterior and rotational components[Dickson et al, 1984). Two broad types of deformity are defined: postural and structural. a. Postural Scoliosis: In postural scoliosis the deformity is secondary or compensatory to some condition outside the spine, such as a short leg, or pelvic tilt due to the contracture of the hip; when the patient sits(thereby cancelling leg asymmetry) the curves disappear. Local muscle spasm associated with a prolapsed lumber disc may cause a skew back; although sometimes called ―sciatic scoliosis‖ this, too, is a spurious deformity. 41
  42. 42. Scoliosis cont….b. Structural or Fixed Scoliosis: In structural scoliosis there is non-correctible deformity of the affected spinal segment, an essential component of which is vertebral rotation. The spinous processes swing round towards the concavity of the curve and the transverse processes on the convexity rotate posteriorly; in the thoracic region the ribs on the convex side stand out prominently, producing the rib hump which is a characteristic part of the overall deformity. Dickson et al (1984) pointed out this is really a lordoscoliosis associated with rotational buckling of the spine. Most cases have no obvious cause(idiopathic scoliosis); other varieties are congenital or osteopathic(due to bony anomalies), neuropathic, myopathic(associated with some muscle dystrophies) and a miscellaneous group of connective-tissue disorders. 42
  43. 43. Scoliosis Images: 43
  44. 44. Scoliosis cont…Idiopathic scoliosis: This group constitutes about 80% ofall cases of scoliosis. The deformity is often familial, and thepopulation incidence of serious curves(over 30° and thereforeneeding treatment) is three per 1000; trivial curves are verymuch more common. The age at onset has been used to definethree groups: adolescence, juvenile and infantile. A simplerdivision is early onset(before puberty) and late onset(afterpuberty) scoliosis. 44
  45. 45. Scoliosis cont…Adolescent Idiopathic Scoliosis:(Presenting at aged 10 years or over)This, the commonest type, occurs mostly(99%) in girls. Primary thoracic curvesare usually convex to the right, lumber curves to the left;intermediate(thoracolumber) and combined(double primary) curves also occur.Progression is inevitable; indeed, most curves under 20° either remainspontaneously or remain unchanged. However, once a curve starts to progress, itsusually goes on doing so throughout the remaining growth period(and, to a muchlesser degree, beyond that). Reliable predictors of progression are (1) a very youngage, (2) marked curvature and (3) and incomplete Risser sign at presentation(Lonstein and Carlson, 1984). 45
  46. 46. Scoliosis cont… Juvenile Idiopathic Scoliosis:(presenting at age 4-9 years) This is uncommon. The characteristics of this group are similar to those of adolescent group, but the prognosis is worse and surgical correction may be necessary before puberty. However, if the child is very young, a brace may hold the curve stationary until he or she is about 10 years old, when fusion is more likely to succeed. 46
  47. 47. Scoliosis cont…Infantile Idiopathic Scoliosis:(presenting age 3 years and under)This variety is becoming uncommon, perhaps because most babies now a days are allowed to sleep prone. Boys predominate and most curves are thoracic with convexity to the left. Although 90% of the infantile curves resolve spontaneously, progressive curves can become very severe; those in which the rib-vertebra angle at the apex of the curve differs on the two sides by more than 20° are likely to deteriorate (Mehta, 1972). And because this also influences the development of the lungs, there is a high incidence of cardiopulmonary dysfunction.If the deformity continues to deteriorate, surgical correction may be required. 47
  48. 48. 3. Kyphosis: (Greek - kyphos, a hump), also called hunchback,is a common condition of a curvature of the upper (thoracic) spine.Rather confusingly, the term ‗kyphosis‘ is used to describe both thenormal(the gentle rounding of the thoracic spine) and theabnormal(excessive thoracic curvature or straightening out of thecervical or lumbar lordotic curves). Excessive thoracic curvature mightbe better described as ‗hyperkyphosis‘. Kyphos, or gibbus, is a sharpposterior angulation due to localized collapse or wedging of one or morevertebrae. This may be the result of the congenital defect, afracture(sometimes pathological) or spinal tuberculosis.Two broad types of deformity are defined: postural andstructural. 48
  49. 49. Kyphosis cont…a. Postural kyphosis: It is usually associated with otherpostural defects such as flat feet. It is voluntarily correctable. Iftreatment I needed, this consists of posture training and exercises.Compensatory kyphosis is secondary to some other deformity; usuallyincreased lumbosacral lordosis. This deformity too, is correctable. 49
  50. 50. Kyphosis cont…b. Structural Kyphosis: It is fixed and is associated withchanges in the shape of the vertebrae. In children this may be dueto congenital vertebral defects; it is also seen in skeletal dysplasiasuch as achondroplasia and in osteogenesis imperfecta. Olderchildren may develop severe deformity secondary to tuberculousspondylitis.In adolescence the commonest cause is Scheuermann‘disease.In adults kyphosis could be due to an old childhooddisorder, tuberculous spondylitis, ankylosing spondylitis or spinaltrauma.In elderly people, osteoporosis may result in vertebralcompression and an increase in a previously mild, asymptomaticdeformity. 50
  51. 51. Kyphosis cont…c. Congenital Kyphosis: Vertebral anomalies leading to kyphosismay be due to failure of formation(type I), failure ofsegmentation(type II) or a combination of these.Type I (failure of formation) is the commonest(and the worst). If theanterior part of the vertebral body fails to develop, progressivekyphosis and posterior displacement of the hemivertebra may lead tocord compression. In children under 6 years with curves of less than40° , posterior spinal fusion alone may prevent further progression.Older children or more severe curves may need combined anterior andposterior fusion; and those with neurological complications willrequire cord depression as well as fusion.Type II (failure of segmentation) usually takes the form of an anteriorintervertebral bar; as the posterior elements continue to grow, thatsegment of the spine gradually becomes kyphotic. The risk ofneurological compression is much less, but if the curve is progressive aposterior fusion will be needed. 51
  52. 52. Kyphosis cont…d. Adolescent Kyphosis (Scheuermann’s Disease):Scheuermann, in 1920, described a condition which he called Juvenile dorsalkyphosis, distinguishing it from the more common postural(correctable) kyphosis.The characteristic feature was a fixed round-back deformity associated with wedgingof several thoracic vertebrae. The term ‗vertebral osteochondritis‘ was adoptedbecause the primary defect appeared to be in the ossification of the epiphyseal ringwhich define the peripheral rims on the upper and lower surfaces of each vertebralbody. The true nature of the disorder is still unknown; the cartilaginous end-platesmay be weaker than normal (perhaps due to a collagen defect) and are thendamaged by pressure of the adjacent intervertebral discs during strenuous activity. 52
  53. 53. Kyphosis cont…e. Osteoporotic Kiphosis(Elderly Kiphosis):Postmenopausal osteoporosis may result in one or morecompression fractures of the thoracic spine. Patients areusually in their 60s or 70s and may complain of pain.Kyphosis is seldom marked. Often the main complaint is oflumbosacral pain, which results from the compensatorylumbar lordosis in an ageing, osteoarthritic spine.Senile osteoporosis affects both men and women. Patientsare usually over 75 years of age, often incapacitated bysome other illness, and lacking exercise. They complain ofback pain, and spinal deformity may be marked. It isimportant to exclude other conditions such as metastaticdisease or myelomatosis. 53
  54. 54. Hip Joint 1.Developmental Dysplasia of the Hip: This condition was formerly known as ―congenital dislocation of the hip (CDH)‖, and now called ―developmental dysplasia of the hip (DDH)‖, comprises a spectrum of disorders: acetabular dysplasia without displacement; instability (subluxation or dislocation); and teratological forms of malarticulation. Whether the instability comes first and then affects acetabular development because of imperfect seating of the femoral head, or is a result of a primary acetabular dysplasia, is still unknown for sure. Both mechanisms might be important.The reported incidence of neonatal hip instability is 5-20 per 1000 live births; however, most of these hips stabilize spontaneously, and on re- examination 3 weeks after birth the incidence of instability in only 1 or 2 per 1000 infants. Girls are much more commonly affected than boys, the ratio being about 7:1. The left hip is more often affected than the right; in 1 in 5 cases the condition is bilateral. 54
  55. 55. Hip Joint cont…2. Acetbular Dysplasia and Subluxation:Acetabular dysplasia may be genetically determined or mayfollow incomplete reduction of a congenital dislocation, damageto the lateral acetabular epiphysis or maldevelopment of thefemoral head (either congenital or, for example, after Parthes‘disease). The socket is unusually shallow, the roof is sloping andthere is deficient coverage of the femoral head superolaterallyand anteriorly; in some cases the hip subluxates. Faulty loadtransmission in the lateral part of the joint may lead tosecondary osteoarthritis. 55
  56. 56. Hip Joint cont…3. Congenital Coxa vara: This is a rare developmental disorderof infancy and early childhood and may be associated with DevelopmentalDysplasia of the Hip(DDH). It is due to a defect of endochondral ossificationin the medial part of the femoral neck. There is marked decrease in the anglebetween the neck and the shaft of the femur (90° or less) along withsubluxation of the head and the distortion of the neck(bending backwards),the greater trochanter is raised. Adductor muscle group weakens and tends toshort and contracted. When the child starts to crawl or stand, the femoralneck bends or develops a stress fracture, and with continued weight bearing itcollapses increasingly into varus and retroversion. Sometimes there isshortening or bowing of the femoral shaft. The condition is bilateral and isabout one-third of cases. 56
  57. 57. Hip Joint cont…4. Congenital Short Femur: The proximal femur isusually short and rudimentary resulting in marked shorteningof the leg. The limb length disparity gives rise to difficulty instanding and walking, besides putting extra strain on thenormal limb.Treatment: It depends on the degree of the limb lengthdisparity. Compensatory shoe raise is the accepted method ofmanagement. Surgery can be performed either on the affectedlimb or the normal limb. 57
  58. 58. Hip Joint cont… 5.Congenital Limb Reduction: Thalilomide was the most celebrated limb reducing insult(teratogen) in humans which also produced a range of otherdeformities depending on developmental time andconcentration of the drug exposure.Agents - Many substances have been found capable ofproducing limb reduction defects in experimental animalsbut few have been related to humans.Mechanisms - Limb reduction defects may also beindirect, for example with loss of blood supply to part of thelimb or to defects in innervation at the spinal or cerebrallevel. Also there are a number of as yet undefinedmechanisms involved.Limb reduction defects may be apical (congenitalamputation) or pre- or post-axial (absence of radius andlateral digits; ulnar and medial digits). 58
  59. 59. Hip Joint cont…6. Proximal Femoral Focal Deficiency(PFFD):This is a rare non-genetic(possibly teratogenic) anomaly in which part of all theproximal femur is missing. The most useful classification is that of Aitken. Intype A there appears to be a gap in the femoral neck or subtrochantericregion, which is infact a segment of unossified cartilage. This does eventuallyossify, but by then the proximal femur has developed a varus deformity andshortening. In type B the ‗gap‘ persists, the femoral head and acetabulum aredysplastic and there is significant shortening. In type C the femoral head ismissing and the acetabulum is undeveloped. In type D there is agenesis of theentire proximal femur and acetabulum. Both hips may be affected and in halfthe cases there are also distal anomalies. 59
  60. 60. Leg Region1. Congenital absence of the fibula(fibular hemimelia):Congenital absence of the fibula, also known as fibular hemimelia, encompasses aspectrum of anomalies involving abnormal growth and development of the fibula. Itis the most common long bone deficiency, followed by aplasia of the radius.According to Coventry and Johnson, the condition was first described in 1698.Manifestations of this condition range from mild degrees of limb shortening to itsmost severe form, which includes complete absence of the fibula with accompanyingdefects in the femur, tibia, and foot. The severity of foot abnormalities appears tocorrelate with the severity of the fibular deficiency.Only a few reports of prenatally diagnosed fibular hemimelia have been published,and to our knowledge there are no prior reports of isolated fibular hemimeliadiagnosed antenatally on the basis of sonography. We report a case of the antenatalsonographic diagnosis of complete bilateral fibular hemimelia without the presenceof other congenital anomalies. 60
  61. 61. 2. Congenital absence of the tibia(tibial hemimelia): Tibial hemimelia is a rare anomaly characterized by deficiency of the tibia with relatively intact fibula. Jones et al. (1978) classified the anomaly into 4 types according to radiologic criteria. It may present as an isolated anomaly or be associated with a variety of skeletal and extraskeletal malformations. Tibial hemimelia may also constitute a part of a more complicated malformation complex or syndrome, such as the Gollop-Wolfgang complex and triphalangeal thumb-polysyndactyly syndrome (Matsuyama et al., 2003). Emami-Ahari and Mahloudji (1974) described bilateral absence of the tibia in 3 children, 2 males and 1 female, of phenotypically normal but related parents. No other anomalies were present and intelligence was normal. Jones et al. (1978) reported affected brother and sister. McKay et al. (1984) reported affected sisters. McKay et al. (1984) reviewed syndromes of congenital defects in which tibial hemimelia is a feature. Richieri-Costa et al. (1987) reported on 37 patients belonging to different families who had the tibial hemimelia/split-hand/split-foot syndrome. Quoting others, they suggested that the maximum risk to the offspring of an affected person married to an unaffected person is 8.6% and the maximum risk to a sib of an isolated patient is 12.5%. They suggested that there are 4 well-established and 2 other possible autosomal dominant tibial hemimelia syndromes in addition to 2 types with autosomal recessive inheritance. Richieri-Costa (1987) reported a Brazilian child, born to consanguineous but healthy parents, who had cleft lip/palate in addition to tibial hemimelia. Stevens and Moore (1999) described a girl with Langer-Giedion syndrome (LGS), a contiguous gene syndrome caused by deletion in the 8q24.1 region. The patient also showed bilateral tibial hemimelia and unilateral absence of the ulna. Turleau et al. (1982) had described an 8-year-old boy with LGS and bilateral tibial hemimelia. Although no genes involving limb development in the human had been identified in the 8q24.1 region, 2 mouse syndromes with limb abnormalities mapped to the homologous region of 9A1-A4: luxoid (absent toes, radial and tibial hemimelia, preaxial polydactyly, bent tail, and oligospermia) and aft (abnormal feet and tail). Stevens and Moore (1999) suggested that a gene involved in limb development is contiguous with the gene(s) for LGS and that deletion of this gene causes tibial hemimelia. 61
  62. 62. 3.Congenital Pseudarthrosis of Tibia:Congenital pseudoarthrosis of the tibia, which has been known to be one of thediseases of the orthopaedic surgery, the treatment of which is the most difficult,since it was first described by Hatzoecher 1708, is an ossification defect, which islocalized at the junction the middie third and lower third of the tibial shaft. Itmay be associated with fibrous dysplasia or neurofibromatosis. In order not tocause any errors as regards to therapy, one should identify congenital tibialangulatlons adequately, which should especiaily be carefully evaluated indiferential diagnosis. A great variety of procedures have been suggested in itstreatment. But, with the establishment of the effects of electromagnetic currentsand the advances realized in microsurgery and the application of freevoscularized bone grafts have increased the chance of curability of this disease,the treatment of which in extremely difficult. Attempts have been made topresent congenital pseudoarthrosis of the tibia and its angulations treated bysurgery as well as treatment methods applied and results obtained. It is rare, occurring equally in girls and boys; disease is almost always unilateral;acute fractures occur during first 2 yrs of life, usually shortly after birth. It isassociated with anterolateral bowing and neurofibromatosis; neurofibromatosisis present in approx 40-50% of patients with pseudarthrosis, while about 10% ofpatients with neurofibromatosis will have pseudarthrosis of tibia; dysplastic typeis characterized by narrowing, sclerosis, and obliteration of the medullary canal. 62
  63. 63. 4.Blounts disease(Blount-Barber disease):(nonrachitic bowlegs in children)Blounts Disease is one which affects the bone development of toddlers and older children. Most often,it starts as bow-leggedness which does not improve in a child between two and four years of age.Seeking appropriate treatment in a timely matter can help your child develop normally.Bow-leggedness in toddlers is particularly common most especially in those who walk at an early ageand those who are slightly overweight for their age and height. But legs that are bowed and which donot correct by age two are cause for concern and investigation to see if Blounts Disease is apossibility.What happens with Blounts Disease is that as the child grows and the legs are bowed, some childrenhave the tendency, for unknown reasons, to develop bones which continue to bow. It is a viciouscircle. The bow-leggedness causes further bow-leggedness which perpetuates the problem.So as the legs continue to grow abnormally the child is forced to walk with knees that bulge outwardand continue to get worse. What often accompanies this is a condition called internal tibial torsion.What this is, is toes which turn inward below the knee. The toes point obviously inward and somechildren even have a tendency to fall down more often with this infliction. When bow-leggedness andtibial torsion occur together it is a red flag g that it is probably Blounts Disease. Radiographic Appearance: Physiologic bowing typically show flaring and bowing of tibia andfemur in a symmetric fashion and is normal in children < 2 years of age (maximal at about 18 mo);physiologic genu valgum, or knock knees, develops next, with maximal deformity occurring at 3years of age; gradual correction to ultimate alignment of slight genu valgum occurs by 9 years of agein the great majority of patients. 63
  64. 64. Foot Region 1. Congenital Talipes Equinovarus(CTEV): (Idiopathic Club Foot) The term ‗talipes‘ is derived from talus(Latin=ankle bone) and pes (Latin=foot). The elements of this congenital deformity are: Adduction and Inversion of the Forefoot. Inversion of the heel (hind foot) Cavus and equinus with clawing of the toes. The abnormality is relatively common, the incidence ranging from 1-2 per thousand births; boys are affected twice as often as girls and the condition is bilateral in one- third of the cases. The exact cause is unknown; it could be a genetic defect or a form of arrested development. Its occurrence in neurological disorders and neural tube defects(e.g. myelomeningocele and spinal dysraphism) points to a neuromuscular disorder. 64
  65. 65. 2. Telipes Calcaneo-valgus: It is a commondeformity which presents in the newborn as an acutelydorsiflexed foot. There is a deep crease (or severalwrinkles) on the front of the ankle, and the calcaneumjust out posteriorly. It is usually bilateral. There is anassociation with hip dysplasia, especially if it presents onone side only. This is a postural deformity, probably dueto abnormal intrauterine positioning, and it oftencorrects spontaneously in the neonatal period. 65
  66. 66. 3. Metatarsus Addutus ( Metatarsus varus): Here the foot is adducted at the TMT joint but the foot is plantigrade. It varies from a slightly curved forefoot to something resembling a mild club foot. The majority (99%) either improve spontaneously or can be managed non-operatively using serial corrective casts followed by straight-last shoes. Variations of the Dilwyn Evans procedure(which aims to balance the lengths of the medial and lateral columns of the foot), often in combination with basal metatarsal osteotomies, are suitable for the small percentage of children who require surgical treatment. 66
  67. 67. 4.Congenital Convex Pes Valgus(Congenital FlatFoot):(Congenital Vertical Talus)This rare condition is seen in infants, usually affecting both feet.Superficially it resembles other types of valgus foot, but the deformity ismore severe; the medial arch is not only flat , it is the most prominentpart of the sole, producing the appearance of a ‗rocker-bottom‘ foot. Thehind foot is equinus and valgus and the talus points almost verticallytowards the sole; the forefoot is abducted,pronated and dorsiflexed, withsubluxation of the talonavicular joint. Passive correction is impossible;by the time child is seen, the tendons and ligaments on the dorsolateralside of the foot are usually shortened. 67
  68. 68. 5. High-Arched Feet(Pes Cavus): In pes cavus thearch is higher than the normal, and often there is also clawing of thetoes. The close resemblance to deformities seen in the neurologicaldisorders where the intrinsic muscles are weak or paralyzed suggeststhat all types of pes cavus are due to some type of muscle imbalance.There are rare congenital causes such as arthrogryposis, but in themajority of cases pes cavus results from an acquired neuromusculardisorder. Hereditary motor and sensory neuropathies and spinalcord abnormalities(tethered cord syndrome, diastematomyelia) arethe commonest, but poliomyelitis is the most commonest causeworldwide. Occasionally the deformity follows trauma-burns or acompartment syndrome resulting in Volkmann‘s contracture of thesole. 68
  69. 69. Acquired DeformitiesShoulder Joint 1. Winged scapula: Winged scapula (scapula alata) is a condition in which the medial border (the side nearest the spine) of a persons scapula is abnormally positioned outward and backward. The resulting appearance of the upper back is said to be wing-like because the inferior angle of the shoulder blade protrudes backward rather than lying mostly flat like in people without the condition.CausesAlthough there are many causes of the condition, the most common is when theserratus anterior muscle are weakened (for various reasons) or when they areweakened and/or paralyzed by impingement of the long thoracic nerve. TreatmentSurgery is sometimes used to treat the condition.Symptoms can also be alleviated through rehabilitation by using differentstrengthening and endurance exercises. Stretching is used with some precautionsunder supervision of a Certified Athletic Trainer or licensed PT. 69
  70. 70. 2. Adhesive capsulitis of shoulder: Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, and grows together with abnormal bands of tissue, called adhesions, greatly restricting motion and causing chronic pain. Adhesive capsulitis is a painful and disabling condition that often causes great frustration for patients and caregivers due to slow recovery. Movement of the shoulder is severely restricted. Pain is usually constant, worse at night, when the weather is colder, and along with the restricted movement can make even small tasks impossible. Certain movements can cause sudden onset of tremendous pain and cramping that can last several minutes. This condition, for which an exact cause is unknown, can last from five months to three years or more and is thought in some cases to be caused by injury or trauma to the area. It is believed that it may have an autoimmune component, with the body attacking healthy tissue in the shoulder. The condition may also cause chronic inflammation. Adhesions grow between the joints and tissue, greatly restricting motion and causing a number of painful complications. There is also a lack of fluid in the joint, further restricting movement. 70
  71. 71. 3. Rotator cuff tear: Rotator cuff tears are tears of one, or more, of the four tendons of the rotator cuff muscles. A rotator cuff injury can include any type of irritation or damage to your rotator cuff muscles or tendons. Rotator cuff tears are among the most common conditions affecting the shoulder. The tendons of the rotator cuff, not the muscles, are most commonly torn. Of the four tendons, the supraspinatus is most frequently torn; the tear usually occurs at its point of insertion onto the humeral head at the greater tuberosity. 71
  72. 72. 4. Subacromial bursitis: Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the suprasinatus tendon (one of the four tendons of the rotator cuff) from the overlying coraco-acromial ligament, acromion, coracoid ( the acromial arch) and from the deep surface of the deltoid muscle . The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work. Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. According to the American Academy of Orthopedic Surgeons (AAOS) visits to orthopedic specialists for shoulder pain has been rising since 1998 and in 2005 over 13 million patients sought medical care for shoulder pain, of which only 34% were related to injury. Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune inflammatory conditions (rheumatoid arthritis), crystal deposition (Gout or Pseudo gout), calcific loose bodies (rheumatoid arthritis) and infection. More commonly, subacromial bursitis arises as a result of complex factors, thought to cause shoulder impingement symptoms. These factors are broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury (Bigliani and Levine, Journal Bone Joint Surgery 1997). 72
  73. 73. Elbow Joint 1. Cubitus valgus: Cubitus valgus is a medical deformity in which the elbows are turned in. A small degree of cubitus valgus (known as the carrying angle) is acceptable and occurs in the general population. When present at birth, it can be an indication of Noonan syndrome or Turner syndrome. It can also be acquired through fracture or other trauma.The physiological cubitus valgus varies from 3° to 29°. Women usually have a more pronounced Cubitus valgus than men. The commonest cause is a malunion of a supra-condylar fracture and the deformity is obvious only when the elbow is extended The hand brushes against the side during normal walking Deformity can be corrected by a wedge osteotomy of the distal humerus. 73
  74. 74. 2. Cubitus varus(‘Gun-stock’ deformity) : Cubitus varus (varus means a deformity of a limb in which part of it is deviated towards the midline of the body) is a common deformity in which the extended forearm is deviated towards midline of the body . Cubitus varus is often referred to as Gunstock deformity, due to the crooked nature of the healing. The commonest cause is a malunion or non-union of a number of the lateral condyle of the humerus. The medial epicondyle becomes prominent on the medial side of the joint and there is a tendency for the development of a delayed ulnar nerve palsy (weakness of the hand and tingling of the ulnar fingers) The deformity itself may need no treatment but the delayed ulnar nerve palsy may require ulnar nerve transposition 74
  75. 75. 3.Subluxation of Radial Head: This iscommonly associated with bony dysplasias inwhich the ulna is disproportionately shortened(e.g. hereditary multiple exostosis). It causes littledisability, but if it becomes troublesome the radialhead can be excised after all growth has ceased. 75
  76. 76. 4.Unreduced Dislocation of the head of Radius:Dislocation of the radial head occurs most frequently in men who are subject to high-force injury. In children, the radial head is much more commonly subluxed thandislocated.Isolated radial head dislocations are rare; only 20 cases have been reported in 30years. Radial head dislocations are usually complicated by complete elbowdislocations or fractures, as in the Monteggia complex.Monteggia described the combination of radial head dislocation and proximal ulnarfracture in 1814. More than a century later, Bado further classified the Monteggiainjury into 4 types based on the angulation of the fracture and direction of dislocation(see Table). The Bado classification is useful descriptively but not prognostically.Radial head dislocation is often associated with significant trauma (eg, motor vehicleaccidents, pedestrian–motor vehicle accidents, significant falls). 76
  77. 77. 5.Pulled Elbow: Nursemaids elbow or Babysitters elbow is a dislocation of the elbow joint caused by a sudden pull on the extended pronated arm, such as by an adult tugging on an uncooperative child. The technical term for the injury is radial head subluxation. A pulled elbow, also known as nursemaids elbow or a partially dislocated elbow joint, commonly occurs to toddlers and preschoolers(under 6 years of age). Nursemaids elbow happens when kids are picked up or swung around by their hands. The ligament of the elbow may stretch and slip out of place causing severe pain. 77
  78. 78. Wrist Joint1.Proximal Humeral Physeal Injuries: most of theseinjuries are either Salter I or II fractures; fractures separations of proximalhumeral epiphysis occur most often between ages of 11 and 15 years; 80% oflongitudinal growth of humerus occurs in proximal physis;large percentage ofgrowth allows significant remodeling following injuries of proximal humeralphysis;associated injuries:brachial plexus injuries: look for decrease sensation to pain.classification: type I epiphyseal injury: in newborns, fractures are usually Salter Harris type Iinjuries; type II epiphyseal fractures: in older children, they are most always Salter Harristype II; type III, IV, and V fractures: rare because of greater mobility of theglenohumeral joint;diff dx of proximal humeral injuries:tumor of proximal humeruslittle league shoulderclavicle fracturesnormal varient (accentuated w/ humerus externally rotated) 78
  79. 79. 2. Wrist drop: Wrist drop, also known as radial nerve palsy, orSaturday night palsy, is a condition where a person can not extend their wristand it hangs flaccidly. To demonstrate wrist drop, hold your arm out in front ofyou with your forearm parallel to the floor. With the back of your hand facing theceiling (i.e. pronated), let your hand hang limply so that your fingers pointdownward. A person with wrist drop would be unable to move from this positionto one in which the fingers are pointing up towards the ceiling.Symptoms of wrist drop include wrist weakness, resulting in the inability to raisethe hand at the wrist. Additional symptoms may include wrist pain, wristtenderness, or wrist swelling, wrist deformity, hand numbness (unilateral), andhand weakness (unilateral).Initial management includes splinting of the wrist for support along withoccupational or physical therapy. In some cases surgical removal of bone spurs orother anatomical defects that may be impinging on the nerve might be warranted. 79
  80. 80. Wrist drop: Wrist drop, also known as radial nerve palsy, or Saturday nightpalsy, is a condition where a person can not extend their wrist and it hangs flaccidly. Todemonstrate wrist drop, hold your arm out in front of you with your forearm parallel to thefloor. With the back of your hand facing the ceiling (i.e. pronated), let your hand hanglimply so that your fingers point downward. A person with wrist drop would be unable tomove from this position to one in which the fingers are pointing up towards the ceiling.Causes: Stab wounds to the chest at or below the clavicle may result in wristdrop. The radial nerve is the terminal branch of the posterior cord of the brachialplexus. A stab wound may damage the posterior cord and result in neurologicaldeficits including an inability to abduct the shoulder beyond 15 degrees, aninability to extend the forearm, reduced ability to supinate the hand, reducedability to abduct the thumb and sensory loss to the posterior surface of the armand hand.The radial nerve can be damaged if the humerus (the bone of the arm) is broken,because it runs through the radial groove on the lateral border of this bone.Wrist drop is also associated with lead poisoning because of the effect of lead onthe radial nerve.Persistent injury to the nerve is also a common cause through either repetitivemotion or by applying pressure externally along the route of the radial nerve as inthe prolonged use of crutches or extended leaning on the elbows. 80
  81. 81. Hand 1.Boutonniere deformity: Boutonniere deformity is a deformed position of the finger, in which the joint nearest the knuckle (PIP) is permanently bent toward the palm while the furthest joint (DIP) is bent back away (PIP hyperflexion with DIP hyperextension). It is commonly caused by injury or by an inflammatory conditions like rheumatoid arthritis. Stages Mild extension lag, passively correctable Moderate extension lag, passively correctable Mild flexion contracture Advanced flexion contracture 81
  82. 82. Boutonnière Deformity cont…(Buttonhole Deformity) :Boutonnière deformity (buttonhole deformity) is a deformity inwhich the middle finger joint is bent in a fixed position inward(toward the palm) and the outermost finger joint is bent excessivelyoutward (away from the palm).This disorder most often results from rheumatoid arthritis but canalso occur from injury (such as deep cuts, joint dislocation, orfractures) or osteoarthritis . People with rheumatoid arthritis candevelop the disorder because they have long-standing inflammationof the middle joint of a finger. If the deformity is caused by an injury,the injury usually occurs at the base of a tendon (called the middlephalanx extensor tendon). As a result, the middle joint (called theproximal interphalangeal joint) becomes ―buttonholed‖ between theouter bands of the tendon that runs to the end of the finger. Thedeformity can, but need not, interfere with hand function. The doctormakes the diagnosis by examining the finger. 82
  83. 83. 2.Dupuytren’s Contracture: Dupuytrenscontracture (also known as "Morbus Dupuytren," "Dupuytrens disease," or"Palmar fibromatosis", and sometimes misspelled as Dupuytrens constricture) is afixed flexion contracture of the hand where the fingers bend towards the palm andcannot be fully extended (straightened). It is named after Baron GuillaumeDupuytren, the surgeon who described an operation to correct the affliction.Dupuytrens contracture is caused by underlying contractures of the palmar fascia.The ring finger and little finger are the fingers most commonly affected. The middlefinger may be affected in advanced cases, but the index finger and the thumb arenearly always spared. Dupuytrens contracture progresses slowly and is usuallypainless. In patients with this condition, the tissues under the skin on the palm of thehand thicken and shorten so that the tendons connected to the fingers cannot movefreely. The palmar aponeurosis becomes hyperplastic and undergoes contracture.Incidence increases after the age of 40; at this age men are affected more often thanwomen. After the age of 80 the distribution is about even. 83
  84. 84. 3.Volkmanns Ischaemic Contracture: Volkmannscontracture, also known as Volkmanns ischaemic contracture, isa permanent flexion contracture of the hand at the wrist, resulting in aclaw-like deformity of the hand and fingers.Volkmanns contracture is a deformity of the hand, fingers, and wrist caused byinjury to the muscles of the forearm.Volkmanns contracture occurs when there is a lack of blood flow (ischemia) to theforearm. This usually occurs when there is increased pressure due to swelling, a conditioncalled compartment syndrome.Trauma to the arm, including a crush injury or fracture, can lead to swelling thatcompresses blood vessels and can decrease blood flow to the arm. A prolonged decrease inblood flow will injure the nerves and muscles, causing them to shorten and become stiff(scarred).When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if itwere normally contracted, but because it is stiff the joint remains bent and cannotstraighten. This condition is called a contracture.In Volkmanns contracture, the muscles of the forearm are severely injured, resulting incontracture deformities of the fingers, hand, and wrist. 84
  85. 85. 4.Mallet finger: In medicine, mallet finger, alsobaseball finger, dropped finger and (more generally) extensortendon injury, is an injury of the extensor digitorum tendon of thefingers at the distal interphalangeal joint(DIP). It results fromhyperflexion of the extensor digitorum tendon, and usually occurswhen a ball (such as a softball, basketball, or volleyball), while beingcaught, hits an outstretched finger and jams it.Management options include putting the finger in a Mallet splint for6 to 8 weeks or extension block k-wire for 4 weeks. This allows thetendon to reattach, if the finger is bent during these weeks thehealing process must start all over again. 85
  86. 86. Mallet Finger cont… Mallet finger is a deformity in which the fingertip is curled in andcannot straighten itself.This deformity usually results from injury, which either damages thetendon or tears the tendon from the bone. It can affect one or morefingers. A doctor can make the diagnosis by examining the finger. An x-ray is usually taken to be sure that there is no fracture. The usualtreatment is placing a splint on the finger with the finger straightened.The tendon may take 6 to 10 weeks to heal. Mallet finger rarelyrequires surgery, unless a large fragment of bone has broken off or thejoint is partially dislocated. Mallet finger has also been referred to asdrop, hammer, or baseball finger (although baseball accounts for onlya small percentage of such injuries). 86
  87. 87. 5.Swan-Neck Deformity: Swan-neck deformity is a bending in (flexion) of the base of the finger, astraightening out (extension) of the middle joint, and a bending in (flexion) of theoutermost joint.The most common cause is rheumatoid arthritis. Other causes include untreatedmallet finger, looseness (laxity) of the fibrous plate inside the hand at the base ofthe fingers or of the finger ligaments, muscle spasm affecting the hands, andmisalignment in the healing of a fracture of the middle bone of the finger.Normal bending of the finger may become impossible. The deformity cantherefore result in considerable disability.True swan-neck deformity does not affect the thumb, which has one less jointthan the other fingers. However, in a variant of swan-neck deformity, calledduck-bill deformity, the top joint of the thumb is severely over straightened witha bending in of the joint at the base of the thumb to form a 90° angle. If duck-billdeformity and swan-neck deformity of one or more fingers occur together, theability to pinch can be seriously reduced. 87
  88. 88. 6.Trigger Finger:In trigger finger (flexor digital tenosynovitis), a finger becomes locked in a bentposition. The finger locks when one of the tendons that flex the finger becomesinflamed and swollen. Normally, the tendon moves smoothly in and out of itssurrounding sheath as the finger straightens and bends. In trigger finger, theinflamed tendon can move out of the sheath as the finger bends. However, whenthe tendon is very swollen, it cannot easily move back in as the fingerstraightens, and therefore the finger locks.Trigger finger can result from repetitive use of the hands (as may occur fromusing heavy gardening shears) or from inflammation (as occurs in rheumatoidarthritis). To straighten the finger, a person must force the swollen area into thesheath—causing a popping sensation similar to that felt when pulling a trigger.Splinting, moist heat, and nonsteroidal anti-inflammatory drugs (NSAIDs) canhelp in mild cases. Sometimes a corticosteroid and a local anesthetic are injectedinto the tendon sheath. Surgery is commonly needed to treat chronic triggerfinger. 88
  89. 89. 7.Erosive (Inflammatory) Osteoarthritis:Erosive (inflammatory) osteoarthritis is a form ofosteoarthritis that, in the hand, causes swelling, pain,and sometimes formation of cysts on the finger joints(particularly the outermost ones).Osteoarthritis of the hand is apparent byenlargement of bones over the outermost joints ofthe fingers (Heberdens nodes) and overgrowth ofbones over the middle joints of the fingers(Bouchards nodules). With erosive osteoarthritis,there is also swelling of surrounding tissues. Thejoints between the fingers and hand and the wristsare usually not affected. The involved joints canbecome misaligned. 89
  90. 90. 8.Intrinsic Plus Hand: results from intrinsic stiffness(contracture).specific causes: They may be truama,posttraumatic intrinsiccontractures may occur after severe injuries to hand that haveresulted in considerable edema or hematoma; ischemia, rheumatoidarthritis, Stills disease, mycobacterium leprae,CNSlesions, Parkinsons disease, cerebral palsy. Treatment: corrected with therapy, or if that fails, sometimes byintrinsic release/transfer (Little - distal) or (Zancolli - proximal), latedeformity, distal intrinsic release of those oblique fibers contributingto lateral bands, preserving more proximal transverse contribution ofinterosseous aponeurotic expansion. 90
  91. 91. 9.Intrinsic Minus and Claw Hand: claw hand deformity ismanifested by flattening of the transverse metacarpal arch andlongitudinal arches, with hyperextension of MCP joints and flexion ofthe PIP and DIP joints; deformity is produced by imbalance of theintrinsic & extrinsics; intrinsic muscles must be markedly weakened orparalyzed to produce claw deformity; long extensor muscleshyperextend the MCP joint, & long flexor muscles flex the PIP and DIPjoints; weakness of the long flexors (as in high palsy) actually decreasesclaw fingers; PIP joint loses the ability to extend thru the lateral bandsand must rely on the central slip; due to the anatomy of the saggitalband, MP joint hyperextension blocks the the central slip fromextending the PIP; hence, main force of contracted extensor mechanismis focused on saggital band, leading to further MCP hyperextension;tenodesis effect of extending the fingers with wrist flexion is lost;smooth flexion pattern is lost: normally, MP flexion initiates fingerflexion, and all joint achieve full flexion nearly simultaneously; distaljoint flexion is completed prior to initiation of MP joint flexion;hence, the fingers immediately come into contact with the palm withflexion;causes: combined low median and ulnar nerve lesions (may result insignificant decreases in grip strength); brachial plexus injuries; spinalcord injuries; Charcot-Marie-Tooth-Disease; 91
  92. 92. Hip Joint1.Coxa valga:It is a deformity of the hip where the angle formedbetween the head and neck of the femur and its shaftis increased, usually above 135 degrees. It is caused bya slipped epiphysis of the femoral head. 92
  93. 93. 2.Coxa vara:Coxa vara is a deformity of the hip,whereby the angle between the ball and the shaft of the femur is reduced toless than 120 degrees which is 160° at birth and 125° in adults. This results inthe leg being shortened, and therefore a limp occurs. It is commonly causedby injury, such as a fracture. It can also occur when the bone tissue in theneck of the femur is softer than normal, meaning it bends under the weightof the body. This may either be congenital, also known as Mau-NilsonneSyndrome, or the result of a bone disorder. The most common cause of coxavara is either congenital or developmental. Other common causes includemetabolic bone diseases (e.g. Pagets disease of bone), post Perthesdeformity, osteomyelitis, and post traumatic (due to improper healing of afracture between the greater and lesser trochanter). Shepherds Crookdeformity is a severe form of coxa vara where the proximal femur is severelydeformed with a reduction in the neck shaft angle beyond 90 degrees. It ismost commonly a sequellae of osteogenesis imperfecta, Pagets disease,osteomyelitis, tumour and tumour-like conditions (e.g. fibrous dysplasia). Treatment: Treatment depends on the cause of the condition. Most casesdo not require any treatment. If treatment is required, it is usually a valgusosteotomy of the femur fixed by an angled blade plate device or even adynamic hip screw. 93
  94. 94. 3.Protrusio acetabuli(Otto pelvis): Protrusio acetabuli is an uncommon defect of the acetabulum. The acetabulum is the socket that receives the femoral head to make the hip joint. The hip bone of the pelvic bone/girdle is composed of three bones, the ilium, the ischium and the pubis. The socket is too deep and may protrude into the pelvis. ClassificationProtrusio acetabuli is divided into two types, primary and secondary. Primary protrusio acetabuliCharacterized by progressive protrusio in middle aged women. May be associated with OA. May be familial Secondary protrusio acetabuliCauses include: may be present bilaterally in Pagets disease, Marfan syndrome, RA, AS, & osteomalacia; Femoral head prosthesis, Cup arthroplasty,Septic arthritis, Central fracture dislocation, Total hip replacement surgery TreatmentJoint replacement surgery is indicated for severe pain or substantial joint restriction. Prominent trabeculae. * Normal sacro-iliac joints and symphysis pubis. 94
  95. 95. 4. Femoral Anteversion(in-toe gait): Femoralanteversion in children is usually congenital, meaning that the child is born withthis condition. Up to ten percent of children are born with femur anteversion,and girls are twice as likely as boys to be affected. This condition does notincrease the child‘s risk of developing conditions such as arthritis, or any othermuscle or bone diseases.The exact cause of anteversion of the femur is unknown. It is thought to relate tothe position of the child within the uterus, as certain positions may cause the hipmuscles and femur bones to become abnormally situated. The condition mayalso be partially genetically inherited, as there is a tendency for the pigeon-toedgait and appearance to run in families.At birth, femur bones are normally anteverted approximately 40 degrees. Byadolescence, this has reduced to between 10 and 15 degrees. In a child withfemoral anteversion, the femurs are anteverted by more than 40 degrees, and insome cases, more than 50. When the anteversion is between 40 and 50 degrees,treatment is often not required, because the anteversion will have reducedsignificantly by the time the child enters adolescence. 95
  96. 96. 5.Unequal leg length: Unequal leg length or leg length inequality (LLI) refers to a medical condition where the legs are of different lengths. One form is "leg length alignment asymmetry" (LLAA) which is a condition in physiology where one leg (the short leg, or unloaded leg) is unequal in length while in a supine or prone position (i.e., lying down). LLAA can be either anatomical in nature (short bones due to growth or an accident) or neuromuscular (hypertonicity in the musculature of the pelvis or leg). The most common treatment for discrepancies in leg length is the use of a simple heel lift, which can be placed within the shoe. Although prone "functional leg length" is a widely used chiropractic tool in their Activator technique, it is not a recognized anthropometric technique, since legs are usually of unequal length, and measurements in the prone position are not entirely valid estimates of standing X-ray differences. Measurements in the standing position are far more reliable. Another confounding factor is that simply moving the two legs held together and leaning them imperceptibly to one side or the other produces different results 96
  97. 97. Chest1.Pectus excavatum: Pectus excavatum (a Latin term meaning hollowed chest) is the most common congenital deformity of the anterior wall of the chest , in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest. It can either be present at birth or not develop until puberty. Pectus excavatum is sometimes considered to be cosmetic; however, depending on the severity, it can impair cardiac and respiratory function and cause pain in the chest and back. People with the abnormality may experience negative psychosocial effects, and avoid activities that expose the chest. Pectus excavatum is sometimes referred to as cobblers chest, sunken chest, funnel chest or simply a dent in the chest. 97
  98. 98. 2.Pectus carinatum: Pectus carinatum, (L carīnātus, carīn(a) keel), also called pigeon chest, is a deformity of the chest characterized by aprotrusion of the sternum and ribs. It is the opposite of pectus excavatum.Causes: Pectus carinatum is an overgrowth of cartilage causing the sternum to protrudeforward. It occurs in 3 different ways. The least common way is post surgically after openheart surgery. Sometimes the sternum does not heal flat and there is a protrusion of thesternum. The second most common is from birth. It is evident in new borns are a roundedchest and as they reach 2 or 3 years old the sternum begins to grow outwardly even more.The most common occurrence for pectus carinatum seems to be in the 11-14 year oldpubertal male undergoing a growth spurt. Some parents report that their childs pectusseemingly popped up overnight.It may occur as a solitary congenital abnormality or in association with other geneticdisorders or syndromes : Marfan syndrome, Morquio syndrome, Noonansyndrome, Trisomy 18, Trisomy 21, homocystinuria, osteogenesis imperfecta, multiplelentigines syndrome, and Sly syndrome. In about 25% of cases of pectus carinatum, the patient has a family member with thecondition. 98
  99. 99. Neck 1.Acquired Scoliosis: Scoliosis is an abnormal curvature of the spine to one side. In those who have the condition, the spine bends either to the left or to the right. The bend can occur at any point along the spine, from the top to the bottom. The curvature can also vary from a slight to severe. However, the chest area (thoracic scoliosis) and the lower part of the back (lumbar scoliosis) are the most common regions to be affected. Scoliosis affects 3-4 children out of every 1,000. In 90% of cases of scoliosis, treatment is not required because the condition corrects itself as the child grows. Most of the remaining 10% of cases can be successfully treated by using a back brace to prevent further curvature. Three out of every 1,000 children with scoliosis will need surgical treatment. Scoliosis can develop at any time during childhood and adolescence. It is more common in girls than boys, most commonly occurring at the start of adolescence. In approximately 80% of scoliosis cases, the causes are unknown (idiopathic). Scoliosis is normally not a serious condition, but treatment is essential. Left untreated, the curve of the spine can worsen, and cause damage to the spine, chest, pelvis, heart and lungs. In approximately 80% of cases, the cause of scoliosis is unknown (idiopathic). However, it is thought that idiopathic scoliosis runs in families, and researchers have recently discovered a gene that may make people more susceptible to idiopathic scoliosis. 99
  100. 100. 2.Acquired torticollis: Torticollis, or wry neck, is a condition in which the head is tilted toward one side (cervical Lateral flexion), and the chin is elevated and turned toward the opposite side (cervical extension). Acquired torticollis occurs because of another problem and usually presents in previously normal children and adults. Trauma to the neck can cause atlantoaxial rotatory subluxation, in which the two vertebrae closest to the skull slide with respect to each other, tearing stabilizing ligaments; this condition is treated with traction to reduce the subluxation, followed by bracing or casting until the ligamentous injury heals. Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically. Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridement in intractable cases. Ear infections and surgical removal of the adenoids can cause an entity known as Grisels syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge must either be broken through manipulation of the neck, or surgically resected. The use of certain drugs, such as antipsychotics, can cause torticollis. There are many other rare causes of torticollis. 100
  101. 101. Knee Joint1.Genu varum: Genu varum (also called bow-leggedness or bandiness), is a deformity marked by medial angulation of the leg in relation to the thigh, an outward bowing of the legs, giving the appearance of a bow. It is also known as bandy-leg, bowleg, bow-leg, and tibia vara. Usually there is an outward curvature of both femur and tibia. "Genu varum" is distinguished from Blounts disease because it involves both the femur and the tibia, while Blounts disease affects only the tibia with no femur involvement.CausesIf a child is sickly, either with rickets or suffering from any ailment that prevents the due ossification of the bones, or is improperly fed, the bowed condition may remain persistent. Thus the chief cause of this deformity is rickets. Skeletal problems, infection, and tumors can also affect the growth of the leg, sometimes giving rise to a one-sided bow-leggedness. The remaining causes are occupational, especially among jockeys, and from physical trauma, the condition being very likely to supervene after accidents involving the condyles of the femur.Adults with rickets are thought to be bowlegged due to horse back riding. 101
  102. 102. 2.Genu valgum: Genu valgum, commonly called"knock-knees", is a condition where the knees angle in and touch oneanother when the legs are straightened. Females have a wider pelvisthan men and a relatively shorter length of the thigh bone, and as aresult, have a greater static genu valgum than men. Individuals withsevere valgus deformities are typically unable to touch their feet togetherwhile simultaneously straightening the legs. The term originates fromthe Latin genu, "knee", and valgus, "bent inward". For a discussion ofthe etymology of valgus, see the entry under varus.Mild genu valgum can be seen in children from ages 2 to 5, and is oftencorrected naturally as children grow. However, the condition maycontinue or worsen with age, particularly when it is the result of adisease, such as rickets or obesity. Idiopathic is the term used todescribe genu valgum that is congenital or has no known cause. 102
  103. 103. 3.Genu Recurvatum: Etymology: L, genu, knee, recurvare, tobend back: A deformity in which the lower leg is hyperextended at the kneejoint. Also called back knee.Genu recurvatum denotes hyperextension of the tibiofemoral joint. It can besubdivided into constitutional physiological and acquired pathologicalvariants. Constitutional genu recurvatum is generally bilateral, symmetric, <15°, and asymptomatic. Acquired genu recurvatum usually is unilateral, >15°, and often symptomatic. Acquired genu recurvatum is known to havemultiple causative factors including physealtrauma, osteomyelitis, poliomyelitis, tibial wire traction, and soft-tissuetrauma. To emphasize the pathoanatomical changes responsible for genurecurvatum, Moroni et al qualified the deformity into three subtypes:bony, soft tissue, and combined bony and soft tissue. Signs and symptoms ofpathological genu recurvatum include weakness, pain, and instability. Thedegree of deformity differed between them, but deformities began at the sameage in both (17 years) and progressed over a short period. 103
  104. 104. Foot1.Flat feet: Flat feet (also called pes planusor fallen arches) is an informal reference to amedical condition in which the arch of the footcollapses, with the entire sole of the foot coming intocomplete or near-complete contact with the ground. Insome individuals (an estimated 20–30% of the generalpopulation) the arch simply never develops in one foot(unilaterally) or both feet (bilaterally). 104
  105. 105. Flat feet in children: The appearance of flat feet is normal and common in infants, partly due to "baby fat" which masks the developing arch and partly because the arch has not yet fully developed. The human arch develops in infancy and early childhood as part of normal muscle, tendon, ligament and bone growth. Training of the feet, especially by foot gymnastics and going barefoot on varying terrain, can facilitate the formation of arches during childhood, with a developed arch occurring for most by the age of four to six years. Flat arches in children usually become proper arches and high arches while the child progresses through adolescence and into adulthood. Because young children are unlikely to suspect or identify flat feet on their own, it is a good idea for parents or other adult caregivers to check on this themselves. Besides visual inspection, parents should notice whether a child begins to walk oddly, for example on the outer edges of the feet, or to limp, during long walks, and to ask the child whether he or she feels foot pain or fatigue during such walks. Flat feet of a child are usually expected to develop into high or proper arches, as shown by feet of the mother. Children who complain about calf muscle pains or any other pains around the foot area, may be developing or have flat feet. Pain or discomfort may also develop in the knee joints. A recent randomized controlled trial found no evidence for the treatment of flat feet in children either for expensive prescribed orthoses (shoe inserts) or less expensive over-the-counter orthoses. 105
  106. 106. Flat feet in adults: Flat feet can also develop as an adult ("adult acquired flatfoot") due to injury, illness, unusual or prolonged stress to the foot, faulty biomechanics, or as part of the normal aging process. Flat feet can also occur in pregnant women as a result of temporary changes, due to increased elastin (elasticity) during pregnancy. However, if developed by adulthood, flat feet generally remain flat permanently. Flatfoot in a 55 years old female with ankle and knee arthritis. If a youth or adult appears flatfooted while standing in a full weight bearing position, but an arch appears when the person dorsiflexes (stands on heel or pulls the toes back with the rest of the foot flat on the floor), this condition is called flexible flatfoot. This is not a true collapsed arch, as the medial longitudinal arch is still present and the Windlass mechanism still operates; this presentation is actually due to excessive pronation of the foot (rolling inwards), although the term flat foot is still applicable as it is a somewhat generic term. Muscular training of the feet, while generally helpful, will usually not result in increased arch height in adults, because the muscles in the human foot are so short that exercise will generally not make much difference, regardless of the variety or amount of exercise. However, as long as the foot is still growing, it may be possible that a lasting arch can be created. 106
  107. 107. 2.Foot drop: Foot drop is a deficit in turning the ankle andtoes upward, known as dorsiflexion. Therefore, the foot will hang inferiorly.The deep fibular/peroneal nerve innervates the anterior compartment of theleg. Damage to this nerve will lead to the inability for the leg to dorsiflex thefoot, therefore causing foot drop. Conditions leading to foot drop may beneurologic, muscular or anatomic in origin, often with significant overlap.The result is an abnormal gait.FeaturesFoot drop is characterized by steppage gait. When the person with foot dropwalks, the foot slaps down onto the floor. To accommodate the toe drop, thepatient may use a characteristic tiptoe walk on the opposite leg, raising thethigh excessively, as if walking upstairs, while letting the toe drop. 107
  108. 108. 3.Hammer toe: A hammer toe is a deformity of theproximal interphalangeal joint of the second, third, or fourth toe causing it to bepermanently bent, resembling a hammer. Mallet toe is a similar condition affectingthe upper joint. CausesHammer toe most frequently results from wearing poorly-fit shoes that can force thetoe into a bent position, such as excessively high heels or shoes that are too short ornarrow for the foot. Having the toes bent for long periods of time can cause themuscles in them to shorten, resulting in the hammer toe deformity. This is often foundin conjunction with bunions or other foot problems. It can also be caused bymuscle, nerve, or joint damage resulting from conditions such asosteoarthritis, rheumatoid arthritis, stroke, Charcot-Marie-Tooth disease or diabetes. TreatmentIn many cases, conservative treatment consisting of physical therapy and new shoeswith soft, spacious toe boxes is enough to resolve the condition, while in more severeor longstanding cases orthopedic surgery may be necessary to correct the deformity. 108
  109. 109. 4.Hallux rigidus: Hallux rigidus is a condition restricting dorsiflexion of the hallux ("big toe"). Symptoms Pain in the big toe when walking, standing, running or even during rest Inflammation around the toe Cure During the early stages, one can place the foot in warm water for few minutes which may relieve the pain and ointment can be applied after drying the foot completely Taking enough rest Removing the dead skin with pumice stone Foot massage releaves pain 109
  110. 110. 5.Hallux varus: Hallux varus is a deformityof the great toe joint where the hallux is deviatedmedially (towards the midline of the body) awayfrom the first metatarsal bone. The hallux usuallymoves in the transverse plane. 110
  111. 111. 6.Bunion(hellux velgus): A bunion is a structural deformity of the bones and the joint between the foot and big toe, and may be painful. A bunion is an enlargement of bone or tissue around the joint at the base of the big toe (metatarsophalangeal joint).The big toe may turn in toward the second toe (angulation), and the tissues surrounding the joint may be swollen and tender. Today the term usually is used to refer to the pathological bump on the side of the great toe joint. The bump is the swollen bursal sac and/or an osseous (bony) deformity that has grown on the mesophalangeal joint (where the first metatarsal bone and hallux meet). Symptoms The symptoms of bunions include irritated skin around the bunion, pain when walking, joint redness and pain, and possible shift of the big toe toward the other toes. Treatment Bunions may be treated conservatively with changes in shoe gear, different orthotics (accommodative padding and shielding), rest, ice, and medications. These sorts of treatments address symptoms more than they correct the actual deformity. Surgery, by a podiatrist or an orthopeadist, may be necessary if discomfort is severe enough or when . correction of the deformity is desired 111
  112. 112. Bunion cont….Hallux Valgus (Bunion Deformity): The big toe ofthe foot is called the hallux. If the big toe starts to deviate inward inthe direction of the baby toe the condition is called hallux valgus. Asthe big toe drifts over into valgus, a bump starts to develop on theinside of the big toe over the metatarsal bone. This bone prominenceon the inner edge for the metatarsal is referred to as a bunion. 112