Orthopedic + erb palsy

1. OBSTETRICAL BRACHIAL PLEXUS
PALSY

2. Definition
• A flaccid paralysis of an upper extremity due to
traumatic stretching of the brachial plexus (spinal root
C5-T1) received at birth.
• incidence 0.19 - 2.5 / 1000

3. Risk factors
• high birth weight >4kg (Gestational DM, post date gestation)
• low APGAR score at 1min, 5min, 10min
• Breach fetal position(feet or bottom first)
• Mother age >35 years
• cephalopelvic disproportion
• increased duration of 2nd stage of labour
• direct compression of fetal neck during delivery by forceps

4. Classification
• Duchenne-Erb’s palsy (injury to C5, C6)
• Klumpke’s palsy (injury to C8, T1)
• Total brachial plexus palsy (C5-T1)
• Erbs type > Total > Klumpke

5. Erb’s Palsy
• Muscles paralysed
• Deltoid - Supraspinatus - Infraspinatus - Rhomboids - Teres minor -
Biceps - Brachialis - Extensor carpi radialis and brevis
• Clinical Presentation
• Shoulder internaly rotated
• Elbow extended
• forearm pronated
• hand and finger functions preserved

6. Klumpke’s palsy
• injury to C8-T1
• muscles paralysed
• Flexors of wrist - Flexors of fingers - intinsic muscles of hand
• if sympathetic trunk is involved results in ipsilateral horner syndrome
• drooping of eyelid
• less sweating
• decreased pupil size and sinked eyes

7. Total brachial plexus injury
• The entire arm is flail and the hand fisted.
• Vasomotor impairment gives the limb a pale or marbled appearance
and sensation is diminished.
• Horner’s sign

9. Physiotherapy
1.initial rest
2.passive ROM
3.Positioning
4.Stretching
5.Exercise
6.Sensory stimulation
7.Educating parents
8.electorstimulation for weak muscles
9.splinting

10. Physiotherapy – early intervention
• 1. initial rest period of 7-10 days
• to allow for reduction of hemorrhage and edema around truamatized
nerve.
• the involved limb positioned across the abdomen
• avoid lying on effected arm

11. Physiotherapy – early intervention
• 2. Passive movement
• a full range of passive movement of the hand, wrist, forearm and
elbow can begin immediately.
• Movement of the shoulder should preferably be started after 7-10
days.
• 3. Positioning
• maintaining lateral rotation, abduction and elevation of the shoulder
flexion of eblow, forearm supination.

12. Physiotherapy – early intervention
• 4. Muscles stretches
• 5. Exercise
• hand to mouth
• weight shifting in prone and quadruped
• creeping
• reaching toys at variety of angles
• restraining uninvolved arm to encourage involved arem
• 6. for sensory different textures and temperatures in han,
blindfolding
• 7. Educating parents to keep full ROM, tactile stimulus.

13. Prognosis
• Complete or close to complete recovery if biceps and deltoid activity
is present by the end of the first month and normal contraction by
the end of the second month.
• Poorer results will be found in those infants who have neither deltoid
nor biceps contraction by the third month.
• if there is no recovery in biceps by 3 months of age to consider
surgery. Nerve grafting may be carried out and postoperative
recovery will begin by 6–10 months and continue for 2 years in upper
nerve root lesions for 3–4 years in complete lesions

19. splint for erb’s palsy, airplane splint
• keeps the shoulder in 90 degree abduction
• shoulder external rotation
• elbow 90 degree flexion
• elbow cock up splint
• hand resting splint

20. normal foot

21. The ankle and foot
• The foot and ankle make up a complex anatomical structure
consisting of 26 irregularly shaped bones, 30 synovial joints, more
than 100 ligaments, and 30 muscles acting on the segments. All of
these joints must interact harmoniously and in combination to
achieve a smooth motion.

24. Ankle joint (talocrural joint)
• It is a uniaxial hinge joint formed by
• The tibia and fibula (tibiofibular joint);
• The tibia and talus (tibiotalar joint).
• movement is dorsiflexion and plantar flexion

25. SUBTALAR JOINT
• subtalar, or talocalcaneal, joint, which consists of the articulation
between the talus and the calcaneus.
• The talus and the calcaneus are the largest of the weightbearing
bones in the foot and form the hindfoot.
• movement in subtalar joint is inversion and eversion
• if it involves the forefoot the inversion acompany pronation and
eversion acompany supination

26. Foot deformities

27. Naming
• Equinus ( ankle plantar flexion)
• calcaneus (ankle dorsi flexion)
• varus (ankle inversion)
• valgus (ankle eversion)
• cavus ( the arch is high)
• planus (the arch is low)
• talipes (club foot, or foot deformity)
• pes (foot deformity)

28. talipes valgus, talipes varus
talipes equinus, talipes
calcaneus

29. talipes equinovarus

30. talipes equinovalgus

31. calcaneovalgus, calcaneovarus

32. talipes cavus, talipes planus

33. Flat Foot

34. Physiological flat foot
• Physiological flat feet are very common, flexible, benign and a normal
variant.
• Flexible flat foot can be divided into two types: developmental and
static.

36. Physiological flat foot
• Parents are often concerned that as their child starts to walk the feet
appear to roll over.
• Developmental flat foot is apparent when the child starts to walk and
disappears spontaneously at around the age of 3–5 years.
• Asking the child to stand on tiptoe or using the great-toe extension
test will demonstrate restoration of the medial arch to anxious
parents.

37. Physiological flat foot
• Static flat feet are associated with generalized laxity and often other
family members have flat feet.
• Flexible flat feet require no treatment.
• Advice regarding choice of shoe wear may be needed (high-top
trainers, integral medial arch support, shock absorbence soles) and
only occasionally is orthotic support indicated.

38. Pathological flat foot
• Pathological flat foot shows some degree of stiffness, such as loss of
subtalar movement or tightness of the Achilles tendon (less than 10°
dorsiflexion).

39. Pathological flat foot
• Talipes calcaneovalgus
• will resolve spontaneously but demonstration of passive stretches
into plantarflexion and inversion, to be carried out regularly with
nappy changes, may be helpful in supporting the parents

41. Pathological flat foot
• Congenital vertical talus
• A severe foot deformity in which the head of the talus can be felt in
the sole of the foot. Viewed from the side, the foot will have a rocker-
bottom appearance with fixed equinus of the hindfoot and calcaneus
and valgus of the forefoot.
• Surgical management is necessary to realign the talus.
• Physiotherapy cab help through serial splintage, passive stretches.

43. Pathological flat foot
• Tarsal coalitions,
• peroneal spastic flat foot, can be unilateral or bilateral.
• The usual initial presentation is after a simple twist or sprain of the
foot or ankle in a child over the age of 10 years. An abnormal fibrous
band, present from birth, between the bones begins to ossify at
around this age, causing stiffness and pain.
• Surgical resection of the bar can be successful in relieving symptoms.
• Physiotherapy may be needed to restore range of movement and re-
educate gait after the postoperative plaster has been removed

45. Club foot

46. • Congenital talipes equinovarus (CTEV), commonly known as club foot,
is a common deformity in which the foot is pointing downwards and
inwards.
• There are four types of club foot
• 1. Positional – this is a normal foot, which was held in an abnormal
position in utero. The bony anatomy of the foot is normal and the
foot will usually correct spontaneously or with appropriate passive
stretches

47. • 2. Teratogenic – this is club foot associated with neurological
conditions such as spina bifida or sacral agenesis
• 3. Syndromic – syndromic club foot is associated with conditions such
as arthrogryposis, Freeman–Sheldon syndrome and congenital
myopathy
• Congenital – there is abnormal bony anatomy which is not associated
with a neuromuscular cause or syndrome.

49. • The aim of club foot management should be to
1. Correct the foot position carefully, without injuring the soft
cartilaginous structures of the foot,
2. retain mobility.
3. The foot should be plantargrade, have a normal load-bearing area
and fit into normal shoes.
4. Some form of serial splintage

50. • 5. surgical release of the Achilles tendon, full-leg plasters are applied
immediately with dorsiflexion of 20° and everted to at least 50°.
• Approximately 3 weeks later the plaster is removed and boots
attached to a bar, keeping the feet in 70° eversion and 20°
dorsiflexion, are applied.
• Ponseti recommends that these are worn full-time for the first 3
months, apart from when bathing, and then at nighttime until the
child is 4 years of age

52. Metatarsus Adductus

53. Metatarsus adductus
• a medial deviation (adduction) of the forefoot, the lateral border of
the foot is convex and the base of the 5th metatarsal bone has
icreased prominence
• the medial aspect is concave, there might be a slight separation
between the great toe and 2nd toe
• can be bilateral or unilateral
• more common in the first child

55. • type 1 the forefoot flexible and corrects past neutral passively and
activly
• type 2 the forefoot partial flexible and correct past neutral passivlely
and to neutral actively
• type 3 the forefoot is rigid and cannot correct to neutral even with
passive stretching

56. Management
• type 1 and type 2 need only observation, it may correct by itself by
the age of 3
• in not corrected may need corrective shoe or orthosis
• type 3 managed by serial casting befor 8 months of age (short leg
cast)
• the cast changed in 2 weeks intervals until complete correction
• usually correct in 6 to 8 weeks
• after 6 years of age if not corrected it may need surgery

57. • skewfoot has the same clinical appearance as metatarsus adductus
but with hindfoot eversion (valgus) and more rigidity, the achilles
tendon may be contracted
• skewfoot may result from metatarsus varus (adduction and
supination), with ambulation the forefoot supination resolves but the
hindfoot valgus created, this is developmental deformity

59. management
• serial casting correct forefoot to neutral position and hindfoot into a
varus position (pronation)
• long le casting required
• surgical intervention may be required if serial casting fails to correct

60. calcaneovalgus foot
• excessive dorsiflexion that allows dorsum to come into contact with
the anterior aspect of lower leg, the forefoot is abducted
• plantar flexion usually remains normal
• usually unilateral deformity

62. management
• the problem usually resolve when the child begins to walk
• passive movement
• no casting required

63. associated Foot Orthosis

64. Shoes anatomy

65. • shoes throat
• blucher: open throat more room
• balmoral: less open space to
acomodate orthsis

66. shoe modification
• rocker sole To reduce pain of arthritis
• This design limits the motion of the ankle and
midfoot because the foot rolls faster off the
heel, also beneficial for patients with diabetes
that need to redistribute their plantar
pressure during gait

68. • Heel flare: Increases stability of the shoe and
gently forces the foot away from the modified
side.

69. • T ankle strap
• for alignment of ankle varus and valgus

70. • thomas heel: a heel one half inch longer and
an eighth to a sixth of an inch higher on the
inside;
• used to bring the heel of the foot into varus
and to prevent depression in the region of the
head of the talus.
• for pes planovalgus, kocked knee, flat foot

71. • thomas heel and reverse thomas heel

72. • CTEV shoes
• for club foot

73. • heel wedges
• for valgus or valus heel

74. • medial arch support
• for flat foot

75. • metatarsal pad
• reduce pressure on the ball of your foot and
keeps toes properly positioned

76. • excavated heel cushion
• for calcaneal spur

77. • the presence of calluses indicates areas of
friction in loose shoes
• the presence of corns indicates areas of
friction in bony prominance because of tight
shoes

78. UCBL orthosis
• stablize subtalar and
tarsal joints
• realigns the
calcaneus improving
the angle of pull of
the acilles tendon

79. supramalleolar afo
• redistributes plantar pressures of spastic
equinovarus from the anterior foot to the heel

80. Dynamic afo
• stabilize ankle foot
• allow dorsiflexion
• restrict plantar flexion

81. TORTICOLLIS

82. • is a descriptive term of abnormal posture in which the head and neck
are held in side flexion towards the affected side, with rotation of the
head to the opposite side.

83. Etiology
• Muscular: contracture of the sternomastoid muscle on one side,
noted in the early months of life.
• Trauma: fractures of the upper humerus, clavical, C1–2 subluxation
• Congenital: abnormal formation of the cervical spine resulting in bony
deformity
• Infection: viral infections causing inflammation of the cervical glands,
retropharyngeal abscesses
• Occular problems: squint, visual field defects

84. • Neurological: such as dystonia, posterior fossa tumours, Sandifer’s
syndrome
• Pain: bone tumours such as osteoid osteoma, Ewing’s sarcoma
• Idiopathic: no obvious organic cause.

85. Congenial muscular torticollis
• CMT may not be noticed initially but at around the age 4 months or
so, the parent may notice a lump in the muscle (sternomastoid
tumour), level with the angle of the jaw, which is apparent when the
baby cries.
• Tightness of the sternocleidomastoid muscle may not be
accompanied by a tumour.

86. Physiotherapy
1.Massage to relax the spastic muscle
2.Passive movement slowly to relax the muscle
3.Stretches for the affected muscle
4.maintenance of correction using sandbag
5.active correction- attract child attention
6.cervical collar
7.thermal therapy to relax the muscle (with caution)
8.educating parents

87. Physiotherapy
• Passive stretches to the neck carried out by two people, one to
stabilize the shoulder girdle whilst the other stretches the neck by
exerting traction using the baby’s head.
• use positioning to improve the head position and muscle length, as
well as encouraging active movement to address the muscle
imbalance

88. • Strengthening the overstretched muscles on the other side of the
neck can be achieved through the use of postural reactions as the
baby gains head control, such as the neck-righting reflex.
• Surgical release may be necessary if there is restriction of movement
by more than 20° by the age of 1 year.

90. Developmental Dysplasia of the
Hip DDH

91. • The shallow acetabulum, less rounded femoral head, and increased
femoral anteversion in infants at birth result in a very unstable hip.
• In the postnatal period (6 weeks) , the depth of the acetabulum
increases relative to diameter, producing a more stable ball-and-
socket joint.
• The most significant acetabular growth occurs during the first 18
months, and minimal acetabular growth occurs after 3 years of age

92. • Any interference with the normal growth and development of the hip
joint may result in DDH.
• DDH in a newborn can be classified as subluxatable, dislocatable,
subluxed, or dislocated.

93. Assessment (first 2 months)
• The Ortolani maneuver. From a flexed and adduced position, the hip
is abducted; the examiner feels a clunk as the femoral head moves
into the socket. The examiner’s other hand stabilizes the infant’s
pelvis.
• The Barlow test. The examiner holds the infant’s hip in flexion and
slight abduction. The infant’s hip is adduced while applying pressure
in a posterior direction. Dislocation of the femoral head with pressure
indicates an unstable hip.

95. After 2 months
• asymmetry of thigh or gluteal folds,
• limitation of hip abduction ROM
• asymmetric hip abduction ROM,
• apparent unequal femoral lengths, referred to as Galeazzi sign.

96. Walking with DDH
• Children with unilateral DDH exhibit a positive
Trendelenburg sign,
• Children with bilateral DDH walk with a
waddle
• When DDH is suspected from your
assessment, the infant is referred for an
ultrasound or radiography

97. Management
• The aim of treatment is to return the femoral head to its normal
relationship within the acetabulum and to maintain this relationship
until the abnormal changes reverse

98. • NEWBORN TO 6 MONTHS
• The goal of treatment is to maintain the
femoral head within the acetabulum.
• An orthosis, typically the Pavlik harness, is
used to maintain the infant’s hips in a flexed
and abducted position
• The Pavlik harness is worn 23 to 24 hours a
day until the hip is stable

99. • SIX TO 12 MONTHS
• After 6 months of age, it may become
more difficult to relocate the femoral head
in the acetabulum.
• Traction for a period of time may be
attempted to relocate the hip and then
institute wearing of the Pavlik harness.
• If the child moves or walk abduction
orthosis is used

100. • AFTER 12 MONTHS
• Rarely will the child’s hip be able to be relocated without surgical
intervention.