miscellaneous regional diseases

1. Torticollis (wry neck)
This is the deformity of the neck where head and
neck are turned and twisted to one side.

2. Torticollis
 It may be permanent, temporary or spasmodic.
Spasmodic torticollis is the commonest. Most
often, torticollis is secondary to pain and reflex
muscle spasm and recovers once the
inflammatory process subsides. Congenital
torticollis, a common cause of permanent
torticollis, is of orthopaedic interest.

3. Causes of
torticollis
 Congenital sternocleidomastoid tumour
 Infection tonsilitis
atlantoaxial infections
labyrinthis
 Reflex spasm acute disc prolapse(cervical)
 Neurogenic spasmodic condition
paralytic condition
 Ocular compensation for squint
 Others rheumatoid arthritis
spasmodic torticollis

4. Congenital
torticollis
(infantile
torticollis,
sterno-
mastoid
tumour)
 The sterno-mastoid muscle on one side of the
neck is fibrosed and fails to elongate as the
child grows, and thus results in a progressive
deformity.The causes of fibrosis is not known,
but it is possibly a result of ischaemic necrosis
of the sterno-mastoid muscle at birth. Evidence
in favour of this theory is the presence of lump
in the sterno-mastoid muscle in the first few
weeks of life, probably a swollen ischaemic
muscle.This is termed sterno-mastoid tumour.
The lump disappears spontaneously within a
few months, leaving a fibrosed muscle.
Torticollis occurs more commonly in children
with breech presentation.

5. Diagnosis
 The child usually presents at 3-4 yrs of age,
often as late as puberty.The head is tilted to
one side so that the chin faces to the opposite
side.The sterno-mastoid is prominent on the
side the head tilts, and becomes more
prominent on trying to passively correct the
head tilt. In cases presenting in the first week of
life, a lump may be felt in the sterno-mastoid
muscle. Fascial asymmetry develops in cases
who present later in life. Radiological
examination is normal, and is carried out to rule
out an underlying bone defect such as scoliosis.

6. Treatment
 In a child presenting with sterno-mastoid
tumour, progress to torticollis can be prevented
by passive stretching and splinting.The same
may also be sufficient for mild deformities in
younger children. For severe deformities,
especially in older children, release of the
contracted sterno-mastoid muscle is required.
It is usually released from its lower attachment,
but sometimes both attachments need to be
released. Following surgery, the neck is
maintained in the corrected position in a
callot’s cast.

7. Cervical rib
 This is an additional rib which arises from the
7th cervical vertebra. It is usually attached to
the first rib close to the insertion of the
scalenus ant muscle, and is present in less than
0.5 percent of the population. It may be a
complete rib, but more often it is present
posteriorly for a short distance only; the ant
part being just a fibrous band.The cervical rib is
usually unilateral and is more common on the
right side.

8. Clinical
features
 In 90% of cases, there are no symptoms; an extra rib is detected
on an X-ray made for some other purpose. In others, it produces
symptoms after the age of 30 yrs., probably because with
declining youth the shoulders sag, increasing the angulation of the
neurovascular structures of the upper limb as they come out of the
neck. It is more often symptomatic in females. A patient may
present with following symptoms:
a) Neurological symptom
b) Vascular symptom
c) Local symptom

9. Neurological
symptoms
 Tingling and numbness along the distribution of the lowest part of
brachial plexus (T1 dermatome), along the medial border of the
forearm and hand, is the commonest complaint.There may be
weakness and wasting of hand muscles and clumsiness in the use
of the hand.

10. Vascular
symptoms
 These are uncommon. Compression of the subclavian artery may
result in an aneurysm distal to constriction.This is a potential
source of tiny emboli to the hand and may cause gangrege of the
finger tips.There may be a history of pain in the upper limb on
using the arm or elevating the hand (claudication).

11. Local
symptoms
 Occasionally, the patient presents with a tender supraclavicular
lump (the ant. end of the cervical rib) which, on palpation, is bony
hard and fixed.

12. Radiological
examination
 X-ray examination may show a well-formed rib articulating
posteriorly with transverse process of C7 vertebra. It is attached
anteriorly to the middle of the 1st rib. More often there is no fully
developed cervical rib but merely an enlargement of the
transverse process of the 7th cervical vertebra.

13. X-ray of the neck, AP view, showing a cervical rib

14. Differential
diagnosis
 A patient with cervical rib is to be differentiated from those
presenting with pain radiating down the upper limb due to other
causes. Some of these causes are:

15. Carpal tunnel
syndrome
 The symptoms are in the median nerve distribution. Nocturnal
pain is characteristic.

16. Cervical spine
lesions
 In cases with cervical disc prolapse and spondylosis, pain radiates
to outer side of the arm and forearm. Associated limitation of neck
movt. and characterstic X-ray appearance may help in diagnosis.

17. Spinal cord
lesions
 Syringomyelia or other spinal cord lesions may cause wasting of
the hand, but other neurological features help in reaching a
diagnosis.

18. Ulnar neuritis  Ulnar neuritis may mimic this lesion but can be differentiated on
clinical examination or by electrodiagnostic studies.

19. Treatment
 Conservative treatment is usually rewarding. It consists of
‘shrugging the shoulder’ exercises to build up the muscles, and
avoidance of carrying heavy objects like shopping bag, bucket full
of water, suitcase etc. occasionally, surgical excision of the 1st rib
may be required to relieve compression on the neurovascular
bundle of the upper limb.

20. Observation
hip (Transient
synovitis)
 This is a non-specific synovitis of the hip seen in children 4-8 yrs.
Of age. It results in a painful stiffness of the hip which subsides
after 2-3 weeks of rest and analgesics.X-ray examination and the
ESR are normal. It is termed ‘observation hip’ because it must be
‘observed’ and differentiated from the following conditions:

21. Early infective
arthritis
 Some cases of early tuberculosis or septic arthritis may have
features similar to observation hip.A high ESR, systemic
symptoms, and persistent signs may necessitate a biopsy;
especially in countries where tuberculosis is common.

22. Chronic
synovitis
 A mono-articular rheumatoid arthritis may resemble an
observation hip.

23. Perthes
disease
 In its early stages, before X-ray findings appear, perthes disease
may resemble a transient synovitis, but further follow up shows
characterstic X-ray changes of the former.

24. Treatment  It consists of bed rest and analgesics. Recovery occurs within a few
weeks.

25. Coxa vara  Coxa vara is a term used to describe a reduced angle between the
neck and shaft of the femur. It may be congenital or acquired.

26. Infantile coxa
vara
 This is coxa vara resulting from some unknown growth anomaly at
the upper femoral epiphysis. It is noticed as a painless limp in a
child who has just started walking. In severe cases, shortening of
the leg may be obvious. On examination, abduction and int
rotation of the hip are limited and the leg is short. X-rays will show
a reduction in neck-shaft angle.

27. X-ray of the pelvis, AP view, showing coxa vara of the hip
(note reduction of neck-shaft angle of the femur)

28. The epiphyseal plate may be too vertical.There may be a separate triangle of bone in the inf.
Portion of the metaphysis, called fairbank’s triangle.Treatment is by a subtrochanteric corrective
anatomy.
Coxa vara – fairbank’s triangle

29. Slipped capital
femoral
epiphysis
 In this condition, the upper femoral epiphysis may get displaced at
the growth plate, usually postero-medially, resulting in coxa vara.
The slip occurs gradually in majority of cases, but in some it occurs
suddenly.

30. Causes
 Aetiology is not known but it is thought to be a result of trauma in
the presence of some not yet understood underlying abnormality.
It occurs more commonly in unduly fat and sexually
underdeveloped; or tall, thin sexually normal children.

31. CLINICAL
FEATURES
 Following are the salient clinical features:
 AGE: it occurs at puberty(12-14yrs)
 It is commoner in boys.
 SIDE : its occurs on both sides in 30% of cases.
 There is a definite history of trauma in some cases.
 It is commoner in patients with endocrine abnormalities.

32. PRESENTING
SYMPTOMS
 Pain in the groin, often radiating to the thigh and knee is the
common complaint.Often in the initial stages, the symptoms are
considered due to a sprain and are disregarded.They soon
disappear only to recur. Limp occurs early and is more constant.

33. EXAMINATIO
N
 The leg is found to be externally rotated and 1-2cm short.
Limitation of hip moments is characteristic – there is limited
abduction and internal rotation, with a corresponding increase in
adduction and external rotation.When the hip is flexed, the knee
goes towards the ipsilateral axilla. Muscle bulk may be reduced.
Trendelenburg’s sign may be positive.

34. Clinical examination in slipped capital femoral epiphysis.The knee
points towards axilla.

35. Radiological
features
 X-ray changes are best seen on a lateral view of the hip.The
following signs may be present:
OnAP view: the growth plate is displaced towards the
metaphyseal side. A line drawn along the sup. Surface of the neck
remains superior to the head unlike in a normal hip where it passes
bisecting the head – trethowan’s sign.
On lateral view: the head is angulated on the neck.This can be
detected early.

36. Trethowan’s sign

37. Treatment
 It is based on the following considerations:
a) Treatment of an acute slip: this is by closed reduction and
pinning, as for a fracture of the neck of femur.
b) Treatment of the gradual slip: this depends upon severity of the
slip present. If it is less than 1/3 the diameter of the femoral
neck, the epiphysis is fixed internally in situ. If the slip is more
than 1/3, a corrective osteotomy is performed at the inter-
trochanteric region.
c) Treatment of the unaffected side: in unilateral cases: since the
incidence of bilateral involvement is 30%, prophylactic pinning
of the unaffected side in a case with unilateral slip is justified.