BRASHEAR MS BOOSTERS
CHAPTER 2: Congenital Deformities
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Congenital Hip Dislocation
Considered as a spectrum of hip deficiencies
Congenital hip dysplasia – dislocatable hip of the newborn
Acetabular dysplasia – changes in hip socket that are demonstrable on radiographs after age of 3 to 4 months.
Congenital subluxation – hip that is neither completely dislocated nor concentrically seated in acetabulum
Epidemiology:

True dislocation -- Rarely present at birth

Incidence of CHD is generally to be in range of 1-2 per 1000 births

5 times Girls > Boys

Northern Italy and in Japan = greatest prevalence

Uncommon in black and Chinese

Higher incidence in infants with ligamentous laxity or other congenital anomalies

Common in breech deliveries and primapara

Unilateral > Bilateral

More common on Left side
Etiology:

Exact cause is unknown

But believed to be result from:
1. Genetic Influences
a. Chromosome anomalies
2. Intrauterine environmental influences
a. Heavy irradiation
b. Thalidomide
c. Folic acid antagonist aminopterin
d. Rubella
e. Toxoplasmosis
f. Androgenic hormones
3. Combined genetic and environmental influences


The frequency in firstborn children may be related to tight maternal structures in primaparas
Infants wrapped in swaddling clothes keeping the hips adducted and extended. (More common practice in Italy, India and Japan)
Pathology:
Pathologic changes varies with age
At birth:
 Abnormally lax hip capsule
 Elongated Ligamentum teres
 Increased anterversion
 Normal or nearly normal acetabulum and femur
 Cartilaginous acetabular roof obliquity
Pathologic changes when aging d/t weight bearing and growth
 Acetabulum becomes shallow and its roof sloping
 Femoral head displaced upward and backward on ilium and becomes flattened
 Increased anterversion and valgus of femoral neck
 Elongated, thick and fibrous capsule
 Adductor muscles becomes shortened and contracted
With continued weight bearing:
 Shallow acetabulum may develop on wing of ilium
 Pelvis is underdeveloped on affected side
 Postural deviation: Forward tilting of pelvis and increased lumbar lordosis in unilateral dislocation
Clinical Features:

Neonatal period

Infant

2-6 yeards

Older
Neonatal Period

Birth to 1 month of age

1 of 100 births

Careful examination within the first 24 hours

Special Test:

(+) Barlow Test for relocation

+ O tola i’s Test fo Dislo atio

(+) Abduction test for unilateral dysplasia
o **if positive, thigh on the dysplastic side cannot be abducted so far as the thigh on the side with a N hip.
o Noted deepening of proximal fold in the affected side

Asymmetry of thigh folds
Infancy
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Neonatal period to 2 years old
Painless and no obvious deformity
Test for hip dislocation should be noted
Tight legs when applying diapers
(+) short leg discrepancy
+ Galeazzi’s Sig
(+) Telescoping or Piston Mobility
o **if e te ded thigh is fi st push to a d the i fa t’s head a d the pulled distall , the g eate t o
proximally and distally in the buttock
LOM of hip abduction
(+)/(- Ba lo ’s a d O tola i’s Test
Slight delay in walking
(+) Abductor lurching gait
o ** caused by shortened, impaired gluteus med muscle
(+) Trendelenburg Test
In bilateral dislocation:
o Each step of patient, it lurches toward the weight-bearing side due to instability of the hips.
o Perineum is wide, buttocks are wide, transverse gluteal fold are altered
(+) waddling gait
Increased lumbar lordosis
Protrusion of abdomen
Pelvis tilted downward
a
e felt to
o e
Roentgenographic Pictures
Three classic signs of CHD:
1. Delayed growth of the ossification center of the capital epiphysis
2. Upward and outward displacement of the femoral head
3. Increased obliquity of the acetabular roof
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The acetabular index or slop of the acetabulum is increased
This is the angle made between a horizontal line through the triradiate cartilages (Hilgen ei e ’s Li e a d a o li ue li e d a f o
the medial to the outer edge of its roof.
o **angle greater than 30deg in early infancy is abN
A e ti al li e f o the oute edge of the a eta ulu , pe pe di ula to a d ossi g the Hilge ei e ’s Li e, esta lishes four quadrants
Pe ki ’s Li e .
N femoral head lies in the inferior medial quadrant
Displaced (abN) head lies superior lateral quadrant
CE Angle decreaed
She to ’s Li e dis upted
Age of 2-6 years

By this age, hip no longer slips in and out of the acetabulum

(- O tola i’s/Ba lo ’s Test

Gait is now well established

In unilateral cases, limp is quite obvious

(+) Trendelenburg sign

(+) waddling gait

(+)/(-) hip adductor contracture

(+) LOM on hip abduction, Flexion and extension

(+) telescoping sign (in complete dislocation only)

Shortening, telescoping and thigh fold asymmetry are absent
Roentgenographic pictures


Acetabular roof is dysplastic and slanting
She to ’s li e is ildl dis upted
Over 6 years of age

Rare to have diagnosed by the age of 6

Similar findings to earlier groups

But contractures are more severe and limp disability grows further more

Subluxated hip

(+) trendelenburg test

LOM on hip abduction, Flexion, extension
Complications

Osteonecrosis of the head
o Follow loss of blood supply from constriction of the capsular vessels by excessive compression or tension in extreme positions
of the hip, from excessive pressure on the capital epiphysis after manipulation

Acetabular dysplasia
o Hip pain on activity

Hip OA
o
Common complication when the combination of functional stresses and joint incongruities over the years
Treatment
Neonatal period

Mild splinting that prevents adduction or extension of hip

Pavlik harness, von rosen splin or Frejka pillow is quite satisfactory

It must be under observation
Infancy
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Frejka pillows, pavlik harness and other non-rigid splinting = splints continued for 4 to 6 months
GPS to increased ROM (primarily to increase abduction)
With any form of splinting or cast, avoid placing hip in strained or forced position
Especially abduction in more than 60deg for precautions of osteonecrosis
Manual traction until the hip can be gently and gradually pulled down to the level of acetabulum
o May be applied in 90 def of flexion but not more than 60 deg of abduction.
Age 2 to 6 years

Forceful attempts at closed reduction are ill advised
o It can injure the blood supply to the capital epiphysis

Manual traction

Tenotomy of adductor muscles

Osteotomy site by derotating the femur

Cast immobilization is necessary until the bone healed and hip become stable
Over 6 years of age

Goals:
o Concentric reduction of the femoral head in the acetabulum and adequate coverage of the head so that subluxation will not
recur
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Untreated subluxation may progress to painful degenerative arthritis in later years

It may need more than one surgical procedure:

If femoral neck valgus and anterversion are factors = VARUS DEROTATION OSTEOTOMY of PROX. FEMUR

Acetabular coverage of femoral head improvement = SALTER’s INNOMINATE OSTEOTOMY

For older child = CHIARI PELVIC OSTEOTOMY

For surgical deepening of acetabulum = COLONNA CAPSULAR ARTHOPLASTY for (6-8 y/o)

For adults, THR
Congenital Knee Dislocation
1.
2.
Hyperextesnsion of the Knee (congenital recurvatum) [more common than true dislocation]
Complete anterior displacement of tibial condyles of femur [more severe type]
Causes:
1. Abnormal position of knee in utero
Prognosis:
1. Simple hyperextension – can be corrected
2. Severe type of hyperextension – LOM of knee will persists
Clinical Picture:
- Quads contracture
- anterior joint capsule contracture
- absent/little patella
- wrinkling of skin over patella
- valgus/varus deformity of knee
- lateral instability
- may assoc. c tetraplegia
Tx:
-gentle manipulation of joint
- casts in increasing flexion form
- after reduction, knee should be kept in flexed position by posterior splint
- traction followed by surgical release
Congenital Talipes
4 cardinal positions
1. Varus – inversion
2. Valgus – Eversion
3. Calcaneus –DF
4. Equinus – PF
Most Common Combination = equinovarus
TALIPES EQUINOVARUS
(congenital Clubfoot)
- etiology: unknown
- present at birth or may be assoc. c other diseases
- twice common in boys than girls
- CLINICAL PICTURE
- medial toe touch
- shortened Achilles tendon
- anterior and posterior tibial tendons are contacted
- MOST STRIKING ABNORMALITY JOINT AFFECTED: TALOCALCANEONAVICULAR JOINT
- navicular bone displaced medially around head of talus
- forefoot follows medially
- subtalar tilted into varus and equinus and IR
- calcaneus shortened
- MOST COMMON CLINICAL PICTURE:
- Heel is drawn, entire foot below talus inverted anterior half of foot adducted
- XRAY
- anteroposterior view of N: line drawn through the long axes of these two bone diverge 20-30 deg
- in Clubfoot: the calcaneus is inverted beneath the talus, and these lines approaches paralleled – KITE’s ANGLE
- long axis of calcaneus: 20-30 deg
- CLUBFOOT seen frequently c paralytic changes in LE
- MYELODYSPLASIA
- CEREBRAL PALSY
- POLIOMYELITIS
-FIRST SIGN of PERONEAL TYPE OF MUSCULAR ATROPHY? = EQUINOVARUS
- MOST SEVERE FORM: if associated with arthrogrypsia
Tx:
Correction of Clubfoot:
1. Abduction
2. Eversion
3. DF
Surgical Casting sequence
1. Adduction
2. Subtalar Inversion
3. Ankle PF
-Denis Browne Splint
- MOST/SIMPLEST FREQUENTLY USED SURGICAL PROCEDURE: ACHILLES LENGTHENING
TALIPES CALCANEOVALGUS
- eversion of the foot, increased DF of the ankle and apparent lengthening of Achilles Tendon
-can be easily corrected by stretching
- MOST NOTICEABLE IMMEDIATELY AFTER BIRTH
Tx:
Mild – No treatment
Moderate – Gentle Stretching
Severe – Light corrective cast for several weeks
-DENIS BROWNE SPLINT
METASTARSUS VARUS (METATARSUS ADDUCTUS)
- quite common
- more frequently than talipes equinovarus
- caused by combination of genetics and environmental factors
- adduction of forefoot at TMT joint
- (+)/(-) supination
- described as 1/3 of clubfoot
st
nd
- WIDENING BET. 1 and 2 toes – METATARSUS PRIMUS ADDUCTUS
- One of the most common cause of Pigeon toes
Tx:
Mild – stretching into forefoot abduction while holding the hindfoot inverted
- five/six times a day
Moderate – BOOTE CAST; surgical tx
CONGENITAL VERTICAL TALUS
(Congenital Convex Pes Valgus)
-uncommon; birth
-severe form of flatfoot
-excessive PF of talus
- (+) calcaneus equines
- (+) navicular bone dislocated
- (+) prominent talus
- (+) rocker bottom deformity
Tx:
Infant: alignment of foot c PF; talus by a series of cast
Early Surgical Tx:
- to reduce talovnavicular joint and correct the hindfoot equines
- if not corrected, foot may be painful and disabling
CONGENITAL CLUBHAND
Congenital Absence of Radius
- uncommon congenital malformation usually associated with complete or partial absence of radius
- boys > girls
- bilateral > unilateral; R > L [unilateral]
- marked radial deviation of hand; shortening of FA
- THUMB RAY – underdeveloped/absent radial carpal bones – Navicular
- Ulna is almpost always bowed; concavity directed toward the radial side
- hands are small
- shoulder girdle underdeveloped
- absent radial nerve, artery,l muscles of the thumb
- MEDIAN NERVE – takes over the sensory function of RADIAL NERVE
- elbow abnormal [LOM]
Tx:
-Passive Stretching
- Corrective cast: Kirschner Wire
Congenital Absence of Ulna
-Rare
- analogous anomaly
- absence of ulna, greater instability of elbow
Tx: Selective Surgical Procedures
CONGENITAL DEFECTS OF INDIVIDUAL BONES
1.
2.
3.
4.
5.
6.
Humerus , Radias and Ulna
- uncommon; rare
Sacrum and Coccyx
- rare
- paresis of lumbar spine; motor and sensory paralysis
- atrophy and contracture
Femur
- underdeveloped/ partial absence of femur especially UPPER THIRD or PROXIMAL FEMORAL FOCAL DEFICIENCY
Tibia
- rare
-hip ER and Adducted
- knee flexed [upper fibula displaced laterally]
- fibula is bowed
- TX: amputation above the knee
Fibula
- MOST COMMON CONGENITAL ABSENCE THAN ANY OTHER LONG BONES
- bowed anteriorly, foot short
- TX: o e tio of ti ial o i g, osteoto of ti ia, s e’s a putatio
Patella
- ossification center in upper and lateral segment fails to fuse with the remainder of bone
- BIPARTITE PATELLA
- bilateral > unilateral
- underdevelopment of quads tendon with congenital dislocation of knee
- often to be seen in uncommon inherited disorders known as ONYCHO- OSTEODYSPLASIA or NAIL-PATELLA syndrome [hypoplasitc/
(-) patella]
CONGENITAL RADIOULNAR SYNOSTOSIS
- Infrequent congenital anomaly
- occurs as rule at proximal end of radius and ulna
-bilateral
- fibrous union between bones in lower third of FA
- head of radius dislocation
- absent elbow joint
- elbow extension LOM
TX: resection of radius
- bone between radius and ulna
-proximal osteotomy
CONGENITAL CONTRACTURES
Camptodactyly
-flexion contracture of finger
Syndactyly
- webbed fingers
Macrodactyly
- overdevelopment of more fingers or toes
Tx:
General manipulation
Retention Splints
Active Exercises
CONGENITAL CONTRICTING BANDS AND INTRAUTERINE AMPUTATIONS
- more common in fingers and toes
- obstructs circulation of distal tissues leading to gangrene and intrauterine amputation
- result from prenatal environment produces either a focal mesenchymal defect or rupture of amnion
ASSYMETRIC DEVELOPMENT
(Congenital Hemihyperthrophy)
-unknown etiology
- INCREASED BLOOD SUPPLY TO ONE SIDE OF BODY [Von-Recklin Ha se ’s Disease] resulti g fro
circulatory system
- (+) neurofibromatosis
- (+) unilateral elephantiasis
Tx: cosmetics; operative procedure: EPIPHYSIODEIS
develop e tal ab or ality of
ARTHROGRYPHOSIS MULTIPLEX CONGENITA
- incomplete congenital fibrous ankylosis of many or all joints of limbs
- symmetrical
- joint capsules thickened and contracted
- decreased muscle bulk
TRIAD:
- shoulder IR and flexion contracture
- elbow and knees fusiform appearance
- absence of biceps
-hip flexed and ER
- (+) dislocation or (-) patella
- (+) clubfoot
- (+) polydactyl / syndactyly
- (+) brachialis
Tx:
-cast and manipulation
-surgical release of soft tissues
CLEIDOCRANIAL DYSOSTOSIS
- (-) clavicle
- autosomal dominant trait
- delayed ossification of fontanels
- no treatment
CONGENITAL HIGH SCAPULA
o ge ital ele atio of s apula; SPRENGEL’s DEFORMITY
- elevated 1-4 inch above its normal position
- inferior angle is rotated medially
- affected scapula is small, decreased length, increased width
- cervical muscles shortened
- extends from spinous process, lamina, transverse process of vertebras – osseous bridge
- (+) omovertebral bone
- (+) torticollis
- GH rotation is affected
Tx: postural taping and exercises of SH muscles
CONGENITAL SYNOSTOSIS OF CERVICAL SPINE
(KLIPPEL-FEIL SYNDROME)
- Fusion of all/only lower vertebrae
- posterior portion of laminal arches is not developed (spina bifida)
- shortness of neck may unnoticeable, or obvious
- (+) congenital torticollis
- trapz stretch winglike from mastoid process = PTERYGIUM COLLI/ WEB NECK
Tx: NO treatment; surgery
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BRASHEAR MS BOOSTERS
CHAPTER 3: General Affectations of the Bone
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Functional Adaptations of the bone:
WOLFF’S LAW
- every change in the form and the function of bone or in their function alone, is followed by certain definite changes in their internal
architecture and equally definite changes in their external conformation in accordance with mathematical laws
I. AFFECTATIONS WITH GENETIC ABNORMALITIES
ACHONDROPLASIA
- autosomal dominant trait
- disproportion between lengths of trunk and limbs become evident
- adult height = 4 feet
- brachiocephalic skull
- AP diameter less than N
- facial expression, high and broad forehead, flattered nose with depressed bridge and prominent lower jaw is typical
- MAIN EN TRIDENT
- hands are short and broad with pudgy fingers of almost equal length, tend to spread in radial manner with a gap between the
rd
th
3 and 4 fingers
- mentally developmental impaired
- NO TREATMENT
OTHER FORMS OF SHORT LIMB DWARFISM
a. PSEUDOANCHONDROPLASIA
- same manifestation but not present at birth
- face and cranium are N
b. METAPHYSEAL CHONDROPLASIA
- metaphyseal dysostosis
- metaphyseal changes seen in rickets
- autosomal inheritance
c. CHONDROECTODERMAL DYSPLASIA
- Ellis Van Creveld Syndrome
- Short limb dwarfism
- autosomal recessive
- characterized by polydactyly, dysplastic fingers, and distal shortening of FA and legs
d. CHONDRODYSPLASIA PUNCTATA
- Stippled Epiphysis
- irregular stippled calcification of epiphysis
- proximal bones = most affected
- mongoloid faces
e. DIASTROPHIC DWARFISM
- characterized by short limb, multiple joint contractures, external ear deformities
- + hit hhiker’s thu
- kyphoscoliotic posture
- clubfoot deformities
MULTIPLE EXOSTOSES
- diaphyseal aclasis
- presence of osteocartilages masses that protrude from the metaphyseal portion of long bones
- shortening og ulna and curbature of radius and dislocation of radial head
- SHORT STATURE, LEG DISCREPANCIES
- Tx: removal is not feasible
OSTEOSCLEROSIS
- increase bone density
a. OSTEOPETROSIS
- ALBERS – SCHENBERG DISEASE
- marble bones
- increase bone density wide spread including pelvis, vertebrae, skull and limbs
- in severe form, hydrocephalus, blindness, enlargement of spleen, liver, osteomyelitis of mandible, malnutrition
- (+) transverse pathologic fracture
- In X-RAY:
- metaphyses of long bones are splayed because of failure of N remodeling
- celery like appearance with dense longitudinal striatus
b.
c.
- PYKNODYSOSTOSIS
- may be confused with osteopetrosis
- characterized by sclerotic bones, persistence of cranial sutures, dental anomalies and short distal phalanges
- autosomal recessive disorder with bone fragility
OSTEOPATHIA STRIATA
- form of osteosclerosis in which COARSE LONGITUDINAL STRIATIONS are seen in cancellous bone
OSTEOPOIKILOSIS
- Spotted bones
- small, scattered condensation
- thickened trabeculae in cancellous bone
- MOST COMMON INVOLVED = METAPHYSEAL AND EPIPHYSEAL REGION
- autosomal dominant trait
PROGRESSIVE DIAPHYSEAL DYSPLASIA
- ENGELMANN’s DISEASE
- rare, autosomal dominant
- symmetric expansion and sclerosis of diaphyses of bone
MOST COMMON IN CHILDREN [M=F]
- autosomal dominant trait
- bone proliferates by B endosteal and periosteal growth producing a thickened, fusiform center without trabeculae pattern and
narrowed medullary cavity
- increase density of skull
- (+) leg pain, increased fatigability and muscle weakness
- Tx: NO TREATMENT
PROGRESSIVE MYOSITIS OSSIFICANS
- Fibrodysplasia Ossificans Progressive
- not a disease of skeleton its anchored stage
OSTEOGENESIS IMPERFECTA
- Fragilitas Ossium
TRIAD:
- brittle bones
- blue sclera
- bingi (deafness)
- occurrence of fracture due to extremity fragility of bones
- CLINICAL PICTURE:
-wedgewood sclera (blue) d/t decreased opacity permitting pigmentation of the choroids to show through
- hypermobility of joints, thinning of the skin progressive deafness
-SABER SHIN – anterior bowing of tibia
- TYPE I
- blue sclera
- early onset deafness
- hypermobility and bruising
- TYPE II
- MOST SEVERE c NEONATAL Fx
- early death
- fx may occur from simple birth handling
- TYPE III
- PROGRESSIVE ENTITY c BIZARRE SKELETAL DEFORMITY
- scoliosis
- blue sclera
- but color fades c age
- extreme disability and small stature
MARFAN’s SYNDROME
- ARACHNODACTYLY DOLICHOSTENOMELIA
- autosomal dominant
- hereditary disorder with impaired collagen synthesis and characterized by tall stature c excessing long thin extremities compared to
trunk
- SCOLIOSIS; acetabular protrusion
- STEINBERG SKIN [yung thumb nasa labas]
- WALKER MURDOCH SIGN [yung thumb nasa labas]
- SPIDER FINGERS
- ECTOPIA LENTIS – subluxed/ dislocated lenses
- DISSECTING ANEURYSM – dilatation; abdominal aorta
- MOST COMMON COMPLICATION – heart abnormality
- Striated muscles are underdeveloped with hypermobility of joint
SPONDYLOEPIPHYSEAL DYSPLESIA
- rare disorder of bone that results in dwarfism, skeletal abnormalities in spine (spondyle) and ends of bone (epiphyses) that are
congenital and occasionally problems with vision and hearing
GAUCHER’s DISEASE
- most common lysosomal stage disease
- hereditary of GLUCOCEREBROSIDASE
- which accumulates and may collect in spleen, liver, kidneys, lungs, brain and bone marrow
- FIRST SYMPTOM – SPLENOMEGALY (liver – lungs – brain – bone marrow)
- ERLEN MEYER FLASK APPEARANCE
NIEMANN-PICK DISEASE
- genetic disease which are classified in subgroup of lipid disorder
- deficiency in SPHINGOMYELINASE which accumulates in the cerebellum that leads to gait ataxia, dysarthria, dysphagia (Spleen –
Liver – Brain)
TYPES
MPS I-H
MUCOPOLYSACCHARIDOSES
NAMES
HURLER’s
MPS I-S
SCHEIE
MPS II
HUNTER’S
MPS III
SANFILLIPO
MPS IV
MORQUIO
CHARACTERISTICS
- most common and most severe
- onset during infancy; death before 10
years
- dwarfing apparent at 2 yrs. With
progressive disability
- presence of large cells – HURLER/
GARGOYLE CELLS
- Grostesque Fascie, MR, Deafness,
Corneal Clouding
- ilder for of Hurler’s
- juvenile onset of stiff joints with
development of clavicle, hands, and
deformed feet
-X linked recessive
- (-) corneal clouding
- death by 15 years
- severe form: Dwarfing and mental
retardation
- defect of ENZYME SUFOIDURONIDINE
SULPATASE
- characterized by CNS deterioration
- juvenile onset; death by adolescence or
rd
3 decade
- mental involvement with speech
deterioration, mild somatic involvement
and urinary excretion of HEPARIN sulfate
- (-) corneal clouding
- defective enzyme: SULFOGLUCOSAMINE SULFASE
-severe skeletal disorder, little
neurologic abnormality and urinary
excretion of KERATAN SULFATE
- N Intelligence
st
- skeletal manifestations in 1 year; (+)
odontoid hypoplasia
rd
th
- death by 3 or 4 decade d/t
cardiac/respiratory disease
MPS VI
MAROTEAUXLAMY
MPS VII
SLY
- resembles MPSI because of prominent
skeletal disease
- N intelligence
- short stature
- urinary excretion of DERMATAN
SULFATE
- presents with hydrocephalus
II. AFFECTATIONS ASSOCIATED WITH DIETARY OR METABOLIC ABNORMALITIES
Vitamin A
-Specific effect on the osteoblasts, osteoclasts and epiphyseal chondroblasts of growing bone
-Affects the pattern of bone growth
CHRONIC HYPERVITAMINOSIS A
- caused by excessive administration of Vitamin A
- produces elevation of periosteum followed by subperiosteal calcification
- usually accompanied with pain in the extremities, irritability
- children between ages 1-3
- Ulna and metatarsals are MOST FREQUENTLY INVOLVED
- Serum Vitamin A level is greatly elevated
- a e o fused to s urv a d Caffe ’s Disease
Vitamin C
- regulating the formation of intracellular substance such as osteoid, collagen and ground substance
- needed for the conversion of proline to hydroxyproline – an important step in synthesis of collagen
- Deficiency of vitamin C interferes with osteoblastic activity, resulting in diminished formation of bone matrix
- IMPORTANT CLINICAL MANIFESTATION: Hemorrhage – results from defective capillary walls
SCURVY
- acquired constitutional disease caused by deficient dietary intake of Vitamin C, or ascorbic acid
- occurs most frequently in the infantile [6-18 months] form and rarely is seen in adults
- Bony changes are characterized by OSTEOPOROSIS, DEPRESSED OSTEOBLASTIC ACTIVITY
- Zone of Provisional calcification of the epiphyseal cartilage is widened
- It appears in X ray as a dense line – SCORBUTIC LINE – parallel to growth plate
- irritable, feeds poorly, and experiences extreme pain [when the joints are moved or pressured]
- subperiosteal hemorrhages – palpable thickening of the bone
- ADULT SCURVY
- poor wound healing
- gum hemorrhages
- petechiae rather than the skeletal changes found in infants
-Tx:
- administration of ascorbic acid
Vitamin D
- principal physiologic action of vitamin D regulation of the calcium and phosphorus in the blood
- increasing absorption from the intestine. It promotes the deposition of calcium and phosphorous in the osteoid matrix or protein
framework of bone
RICKETS
- constitutional disease of infancy and childhood caused by lack of vitamin D and evidenced by bone deformities, which may be
striking in degree and widespread in distributio
- FIRST SYMPTOM: Lethargy and weakness
- in infants, hypocalcemia may be associated with convulsions and tetany
- in severe rickets, pale skin and flabby subcutaneous tissue and poorly developed musculature
- NOTICEABLE RAPIDLY GROWING EPIPHYSES:
- knee and wrist
- thorax (RACHITIC ROSARY) – [ aused e large e t of the osto ho dral ju tio s or HARRISON’s GROOVE
- Abdomen is prominent
- skull is large
- because of its imperfect calcification, may be soft and exhibit a delicate crepitation on palpation, -- CRANIOTABES
- noticeable delay in closure of fontanels,
- delay in development of teeth
- delay of acquisition of ability to stand
- Bow leg, knock-knee, coxa vara and scoliosis
-Tx:
- intake of Vitamin D, bracing and prevention of deformity
OSTEOMALACIA
(Adult Rickets)
- refers to an excess of unmineralized bone matrix
- also used to designate a specific group of nutritional disease of adult bone corresponding closely to infantile rickets in pathogenesis
- the commonest contemporary cause of osteomalacia is GASTROINTESTINAL MALABSORPTION
- all characterized by steatorrhhea, include a number of gastric, intestinal, hepatic and pancreatic disease
- patient may complain of shooting pains referred on pelvis, hip and back
- + Looser’s )o es or Pseudofra tures o ur ost ofte i the ri, s pu i o e, pro i al fe ur, a d a illar order of the scapula)
VITAMIN D-DEPENDENT RICKETS
- active rickets associated with hypercalcemia, excessive phospahautria, aminoaciduria and increased serum parathyroid hormone
levels
HYPOPHOSPHATASIA
- severe familial form of rickets inherited as an autosomal recessvive trait characterized by extremely low level of alkaline
phosphatase
RENAL OSTEODYSTROPHY
- renal dwarfism
- disturbances in the metabolism of vitamin D, calcium and phosphorus caused directly or indirectly by the renal failure
- the bones may be dwarfed, softened and deformed
III. AFFECTIONS ASSOCIATED WITH ENDOCRINE ABNORMALITIES
HYPOPITUATARY DWARFISM
- d/t decreased growth hormone
HYPERPITUITARY – causes in increase in growth hormones
- pituitary gigantism
- Acromegaly
CRETINISM
- decreased thyroid hormones; occurs in children that causes mental and physical retardation
HYPERPARATHYROIDISM
- cause increase in function of osteoclasts
III. AFFECTIONS OF UNKNOWN ETIOLOGY
INFANTILE CORTICAL HYPEROSTOSIS CAFFEY’s DISEASE
- self limited inflammatory disorder (6-9 months) of infants that causes triad of bony changes, soft tissue swelling and inatability
- biopsy show inflammation of periosteum
HISTOPLASMOSIS
- ave’s disease, darli g’s disease, ohio disease
- caused by fungus HISTOPLASMA CAPSULATUM primarily affect the lungs
- 3 affectations
1. Eosinophilic Granuloma – increased macrophages
2. Hand Schuller disease – Exopthalmos, lytic bony changes and diabetes insipidus
3. Letter – Siwe Disease – spleen, liver and lymph nodes are enlarged
ECHODROMATOSIS OLLIER’s DISEASE, DYSCHONDROPLASIA
- cartilage cyst in bone marrow
- form of osteochondroplasia characterized by proliferation of enchondroma
(+) leg length discrepancies
- MAFFUCI SYNDROME
- echondromatosis with hemiangioma
FIBROUS DYSPLASIA
- monostatic
- polystatic
- ALBIGHT’s SYNDROME
- girls
- café au lait pigmentations
- ground glass appearance
- shepherd’d rook defor it
MELOHEORSTOSIS
- flowing or linear, longitudinal hyperostosis of limb bones
- osteoclerotic streaks and ridges along one side of long bone
- leg length discrepancies are common
- inconstant aching pain or stiffness of affected joints
HYPERTROPHIC OSTEOARTHROPATHY
- pulmonary osteoarthropathy of Marie
- clubbing of the fingers, painful swelling and periosteal new bone deposition in the extremities
- thickening ridges and increased convexity and bend down over the ends of the phalanges – HIPPOCRATIC FINGERS
BRASHEAR MS BOOSTERS
CHAPTER 4: Infections of the Bones
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Pyogenic Infections
- gain access thru
Bloodstream
Ext. inoculation
Extension from adjacent soft tissue
HEMATOGENOUS
OSTEOMYELITIS
- infection of the bone
- most common in childhood; boys > girls
- involves metaphyseal ends of long bones
- adult: result of surgery
Etiology:
- 80% - S. Aureus
- pts c sickle cell anemia – gram negative bacilli
- children with S. Aureus, Haemophilus influenza, S. Pneumonia, group B Streptocaccus
-Trauma
Pathology:
- children – gain entrance thru nutrient artery
- osteomyelitis of upper femoral metaphysic may lead very quickly to septic arthritis of the hip
Earliest Roenthgraphic Change:
- MOTTLED RAREFRACTION OF METAPHYSIS
-visible 10-12 days after infection
SEQUESTRUM – isolated segment of dead bone, usually surrounded by pus
INVOLCRUM – enveloping, immature, periosteal bone
CLOACAE – openings in the involcrum
Clinical Picture:
- Acute: malaise, aching, Increased Body temperature
Pain on affected side,
- (+) muscle spasm  joint usually in flexion
- affected LE -> refuses weight bearing
CHRONIC GRANULOMATOUS DISEASE OF CHILDHOOD
- repeated infections of many organs systems
- involves small bones of hands and feet
- roentgraphic picture: tuberculosis dactylitis
- inherited deficiency in ability of neutrophils to kill engulfed bacteria
- bone scan using polyphosphonate
Treatment:
- methicillin or oxacillin  penicillin-resistant
- penicillin G
- cephalospuvin  if allergic to penicillin
- intravenous for 2-4 wks followed by oral antibiotics
Chronic Stage Treatments:
Sequestrectomy -> indicated if patient is in good general condition, necrotic bone is well separated and adequate involcrum is formed
Saucerization -> removal of all scar tissue, infected granulation tissue, sequestra, sclerotic bone and overhanging bone edges
BRODIE’S ABSCESS
- localized form of chronic hematogenous osteomyelitis due to recognized or unrecognized bacterimia that have preceded the clinical
appearance of the abscess for years
- most common at LOWER END OF TIBIA
- most common in older children and young adult
- local pain worst at night, increased heat and tenderness
- Roentnogram: area of decreased density surrounded by sclerotic bone
Treatment:
- operation and antibiotics
EXOGENOUS OSTEOMYELITIS
(from open wounds)
- most common cause of Osteomyelitis
- open fracture, GSW, surgery, puncture
Pathology:
- tends to remain confirmed to one part of the bone
- healing of fracture with osteomyelitis is delayed or prevented
- localized
Clinical Picture:
- apparent at 36-48 hrs
- increase pain and tightness; swelling; tenderness, malaise, increase body temperature
- wound becomes red and tissues tenses
Treatment:
- early drainage and antibiotics
- sequestrectomy, saucerization and removal of foreign materials are needed when deep infections persists
- may lead to squamous carcinoma if drainage continous for several years with chronic irritation of epithelium
- amputation
OSTEITIS PUBIS
- painful, usually non-supporative affectation of pubic symphysis after prostatic operation (M) or pelvic surgery (F)
Clinical Picture:
- pain over one side of symphysis and pubic tenderness after 2-8 weeks of surgery
- pain worse on coughing, defecation and urination
- patient tends to lie on one patients with flexed hips or severe adductor muscle spasm
- spontaneous surgery
ROENTGRAM: symphysis become irregular and pubic bodies and rami become osteoporotic
Treatment:
- rest, medication, HMP or cold packs
- short, B hip spica cast may give relief at acute phase
DISKITIS (IVD Inflammation in children)
- benign
- common in children <6 y/o
- lumbar disk
- refusal to walk, sit, back pain and irritability
- paravertebral spasm, LOM in back, localized spinal tenderness
- low grade fever and increased sedimentation rate
- increased WBC count
ROENTGRAM: narrowing of disc space is evident after 2 weeks
- irregularity in vertebral end plates after 4 weeks
Treatment:
- bed rest, immobilization in a cast extending from sternum to both knees for 2-3 months
- antibiotics  if (+) fever
INFECTIOUS ARTHRITIS (PYOGENIC, SUPPURATIVE, OR SEPTIC)
- due to activity of pus forming bacteria in the synovial joint
- needs prompt recognition and vigorous treatment
- more common in infants and children
- M>F
- HIP and KNEE – most common
Etilogy:
- trauma, steroids
-most common: S. Aureus
- Haemophilus Influenzae: occurs in very young children
Pathology:
- synovial men becomes hyperemic, edematous, and infiltrated with inflammation cells
- destruction of articular cartilages takes place
- cartilage erosion
Clinical Picture:
- usually monoarticular; increased in local heat; usually becomes flexed due to spasm; pain on movement
- infection may spread to neighboring structures giving rise to brawny induration and thickening of periarticular tissues
Treatment:
- IV Antibiotics
- aspiration of the joint
- splints or traction to decrease pain and rest
PYOGENIC ARTHRITIS OF THE HIP IN INFANTS
- blood borne
- puncture of femoral artery or vein
Diagnosis:
- localm acute inflammation signs of swellin, tenderness and pain on motion
Treatment:
- surgical drainage; rest in spica cast with hip in extension slight IR and moderate abduction
GONOCOCCAL ARTHRITIS
-due to inadequately treated acute gonorrheal urethritis
- more common in women
nd
rd
- common in 2 and 3 decade of life
- most common infections arthritis in this age group
Clinical Picture:
- joint involvement appears 2-3 weeks after onset of urethral/vaginal discontinence
- poly or monoarticular
- transient skin rash
- most common: KNEE>ANKLE
- redness, increased heat, swelling, muscle spasm, fever and severe leukocytosis
Diagnosis:
- identification of organisms in the urethral or vaginal d/c
- gonococci often found in the joint fluid after 10 days
Treatmetnt:
- penicillin
- elevation, heat, support in a functional position
SALMONELLA OSTEOMYELITIS AND ARTHRITIS
-high in patients with sickle cell anemia
- severe bones may be involved with local pain, tenderness and roentgraphic changes, enteric fever
- hro i lo alized osteo yelitis rese li g rodie’s a s ess ay ake joi ts its appeara e after a y years
BRUCELLA OSTEOMYELITIS AND ARTHRITIS
- uncommon
- direct contact with cattle or swine or drinking unpasteurized milk
- fever, fatigue, aches, pains without local infection foci
- osteomyelitis, arthritis, bursitis
MOST COMMON BURSA: PREPATELLAR
- MOST COMMON JOINT: HIP OR KNEE
- lumbar affectation may lead to ankylosis
- Tetracycline drugs and streptomycin
TUBERCULOSIS OF BONES AND JOINTS
- due to mycobacterium tuberculosis
- cmmon in children due to drinking of contaminated milk
- primarily a disease of adults
- MOST FREQUENT: SPINE > HIP > KNEE
- may travel in the bloodstream or lymphatic system from lungs
- destruction with little tendency toward formation of new bone
-formation of TUBERCLES
- o tai s epithelioid ells a d o e or ore La gha ’s gia t ells
Clinical Picture:
- weight loss and generalized weakness
- history of active TB or exposure, chronic cough or hemoptysis
- monoarticular
- pain on motion, spasm, LOM, painless, kyphosis, boggy swellin in superior joints
- ROENTGRAM:
- complete lack of bone regeneration
- Treatment:
- anti-TB drug therapy
- immobilization
TUBERCULOSIS OF SPINE
- most common among other sites
- POTT’s DISEASE
- begins at cancellous bone; uncommonly may start in the posterior arch
- produces kyphosis and ankylosis
- produces abscess that appear fusiform in roentgrams
- paraplegia may result becase abscesses may compress the SC, sensory changes are usually less profound than motor changes
SYPHILIS OF BONE AND JOINTS
- early infancy: osteochondritis is a characteristic manifestation of congenital syphilis
- symmetrical, ends of long bones
- occasionally the epiphysis separates from the shaft resulting to distortion
- Pseudoparalysis = infant appears to be partially paralyzed
- PERIOSITIS – produces hard, dense enlargement of the convex side of shaft of long bone
- SABER SHIN – tibia involved
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- CLUTTON’s JOINT – painless, B serous synovitis of the knee that persists for years without disability subsiding at the 20 year
- ADULTS
- periositis, osteomyelitis, arthritis, and
GUMMA  necrotizing, ischemic, proliferative lesion characteristic of late syphllis
- skull and long bones may be involved
- syphilitic involvement of NS in the form of tabes dorsalis may result in charcot joints
FUNGUS INFECTIONS OF BONES AND JOINTS
- uncommon and rare
- hematogenous or direct extension
- lesions  infections granulomas and ostelytic
ACTINOMYCOSIS
-jaw
- due to dental; extractions
- sulfur granules  purulent exudates containing mycotic colonies
BLASTOMYCOSIS
- pulmonary
- may cause hematogenous inflammation
- causes chronic destructive osteomyelitis of vertebrae, ribs and skull
- may mimic Pott’s Disease
COCCIDIDIDOMYCOSIS
- pulmonary infection followed by a systemic disease
- grave prognosis
CRYPTOCOCCOSIS
- pulmonary disease that involves the CNS as diffuse meningitis
SPOROTRICHOSIS
- disease of gardeners and farmers, since the fungus is a saphophyte of plants and trees
- starts as a thorn prick
- hematogenous
Treatment:
- chemotherapy and exicision of infected tissue
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A project in Medical Foundation 1
Reference: Handbook of Orthopaedic
Surgery, 10th edition
John Christopher Examen, BSPT4
REGION: NECK
CONDITION: Congenital Torticollis (Wryneck/Muscular Torticollis)
DESCRIPTION: a deformity of the neck in which sternocleidomastoid is
shortened.
ETIOLOGY:
1. Abnormal Position of the head in utero during birth
2. Fibroma of prenatal origin in this muscle
3. Rupture of SCM muscle during birth with hematoma and scar
formation.
PATHOPHYSIOLOGY:
1. Regression of the mass takes place slowly in 3 to 6 mos. Incomplete
regression may be followed by the development of permanent
contracture.
DIAGNOSIS:
(-) X-ray
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. Girls > Boys
2. Characteristic Flattening and Shortening of the face on the side to
which the head is tilted.
3. Facial Asymmetry begins within first 3 months.
4. Chin is rotated away from the side of the shortened muscle and the
head is displaced and tilted toward the side of shortening.
5. Rotation and lateral bending of the neck is restricted.
6. Eyestrain
7. Chin is elevated in midline
TREATMENT:
1. Overcorrection of the shortened SCM.
2. Passive stretching of the neck into the overcorrected position
3. Active stretching to stretch the short SCM muscle
4. Surgical Measures (section of the SCM muscle)
5. Maintenance of overcorrection of deformity (plaster, cast)
6. Exercises for muscle balance to maintain correctionpermanently
REGION: NECK
CONDITION: Acquired Torticollis
DESCRIPTION: shortened SCM muscle due to affection of diverse nature
ETIOLOGY and PATHOPHYSIOLOGY:
1. Acute traumatic or Inflammatory
- caused by cervical injuries, atlanto axial rotary subluxation, or
inflammations of the muscles or cervical lymph nodes.
2. Chronic Infectious or Neoplastic
-caused by osteomyelitis, tuberculosis or tumor of the spine or spinal
cord.
3. Arthritic
- caused by RA, AS, or OA.
4. Cicatricial
-caused by the contracture of scar tissue after a burn
5. Paralytic
-caused by flaccid or spastic paralysis of the neck muscles
6. Hysterical
-caused by psychogenic inability of the patient to control the neck
muscles.
7. Spasmodic
-caused by central nervous system or cervical root lesion and
manifested by involuntary rhythmic contractions of the neck muscles.
DIAGNOSIS:
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
Like the congenital torticollis but more often accompanied by pain
and stiffness as well as bizarre deformities of the neck.
TREATMENT:
1. Hot packs for pain and stiffness
2. Gentle Massage
3. Horizontal or Vertical neck traction
4. Cervical Orthoses
REGION: NECK
CONDITION: Spontaneous Atlantoaxial Subluxation
DESCRIPTION: Anterior displacement of the atlas on the axis
ETIOLOGY:
1. Forward inclination of the facet surfaces of the atlantoaxial
ligaments.
2. Hyperaemia from the local inflammation of an antecedent
throat infection.
3. May o u i hild e ith Do ’s “ d o e, Mo uio’s
Syndrome, osteogenesis imperfect and other bone dysplasias
and in patients with RA in cervical spine
4. Congenital hypoplasia of the odontoid process and an os
odontoideum
PATHOPHYSIOLOGY:
1. Developmental failure of the fusion of the odontoid process
to the axis.
DIAGNOSIS:
1. Hyperactive reflexes
2. Lateral xray
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. Abnormal motion and sublaxation of the atlas on the axis
TREATMENT:
1. Recumbency of the head traction
2. Brace or cast for about 6 weeks
3. Atlantoaxial arthrodesis
REGION: NECK
CONDITION: Degenerative Disk Disease of cervical IV disks
DESCRIPTION: Compression of cervical nerve roots in or about
the IV foramina
ETIOLOGY:
1. Precipitated by injury
2. Sprain in the neck
3. Simply twisting the neck
PATHOPHYSIOLOGY:
1. Hypertrophic spurring in the cervical spine (C4-C5, C5-C6)
2. Disk herniations (C6-C7)
DIAGNOSIS:
1. Lateral X-ray
2. Myelography
3. Computerized Tomography
4. Electromyography and Diskography
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. Pain in the neck and arm with cough and sneezing may
radiate into fingertips with paresthesia
2. Headache, Vertigo and Grip weakness
3. LOM, stiffness, muscle atrophy and weakness
4. Sensory disturbances
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5. If 6 root is involved, hypesthesia of the thumb and radial
side of hand, weakness of biceps muscle, and decreased in the
deep tendon reflexes of the biceps and brachiorads muscle.
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6. If 7 root is involved, triceps weakness and diminished
triceps muscle reflex and sensory changes in the middle and
ring fingers.
7. Blurring of vision, dilatation of the pupils, loss of balance and
headache if persistent irritation of cervical roots produce.
TREATMENT:
1. Reflex Heating
2. Intermittent traction (15-25 lbs with head halter)
3. Cervical Collar
4. Postural Exercises
5. Surgical measures (foraminotomy, arthrodesis, laminectomy)
REGION: NECK
CONDITION: Thoracic Outlet Syndrome (Cervical Ribs and Scalenus
Syndrome)
DESCRIPTION: cervical compression that causes radiating pain up to
upper limb
ETIOLOGY:
1. pressure on nerves and vessels
PATHOPHYSIOLOGY:
1. Congenital Anomalies of supernumerary, independent units
growth similar to the first dorsal ribs
2. Enlarged transverse process of C7 with a fibrous band
connecting it to the first rib
DIAGNOSIS:
1. X-ray
SPECIAL TEST:
1. Adson Test
2. Roos test
3. Costoclavicular Syndrome Test
CLINICAL MANIFESTATION/S:
1. Women > men
2. Fullness in the neck
3. Loud bruit on supraclavicular area
4. Postural deviation
5. Definite Brachial Neuritis with pain
6. Muscle atrophy and weakness
7. Claw hand deformity, Paresthesia on hand especially on ulnar
side
8. Pallor, cyanosis and pulselessness
TREATMENT:
1. Rest
2. Procaine Injection
3. Sling or Brace
4. Strengthening exercises
5. Surgery
REGION: NECK
CONDITION: Costoclavicular Syndrome
DESCRIPTION: neurovascular compression that may occur in the space
between the clavicle and the first rib
ETIOLOGY:
1. Postural deviation that causes compression
2. Holding the back in military position
3. fracture of clavicle
PATHOPHYSIOLOGY:
1. Narrowing of ther space that may result from tumors of the
clavicle or the first rib or from excessive callus about an united
or malunited fracture of the clavicle
DIAGNOSIS:
1. Obliteration of the radial pulse
2. Angiography
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. Women > men
2. Fullness in the neck
3. Loud bruit on supraclavicular area
4. Postural deviation
5. Definite Brachial Neuritis with pain
6. Muscle atrophy and weakness
7. Claw hand deformity, Paresthesia on hand especially on ulnar
side
8. Pallor, cyanosis and pulselessness
TREATMENT:
1. postural exercises
2. Trapezius and levator scapulae strengthening
3. Surgery
REGION: SHOULDER
CONDITION: Supraspinatus Tendinitis
DESCRIPTION: Inflammation of the supraspinatus tendon
ETIOLOGY and PATHOPHYSIOLOGY:
1. Result of degenerative changes in the SITS muscles especially
on anterosuperior and lateral segment.
2. Over trauma of abduction of arms
3. Flexion of the internally rotated arm that causes greater
tuberosity of the humerus to impinge on the overlying
acromion process and against the coracoacromial ligament
4. degenerative and inflammatory changes in the rotator
cuff and overlying subacromial bursa collectively termed as
subacromial syndromes
5. degeneration of the collagen fibers within the cuff
DIAGNOSIS:
1. X-ray
-shows amorphous mass of calcium phosphate salt in area of
supraspinatus tendon varying in size from a few mm to cm.
-osteophyte formation and roughness of the anteroinferior
surface of the acromion and degenerative changes of the
acromioclavicular joint
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
Acute Calcific Tendinitis
1. Pain upon movements noted on subacromial area that may
radiate toward deltoid insertion
2. LOM due to pain aggrevation
3. Sleep disturbances
4. Mild diffuse tenderness on shoulder upon palpation
Chronic Degenerative Tendinitis
1. Strain on shoulder
2. The pain is less intense that acute tendinitis
3. night-time discomfort
TREATMENT:
1. Rest and protection with a sling
4. Heat modalities
2. ROMExercises
5. Aspiration of deposits
3. Analgesics
6. Steroid injection
REGION: SHOULDER
CONDITION: Bicipital Tenosynovitis
DESCRIPTION: inflammation of the tendon-tendon sheath
gliding mechanism of the long head of the biceps muscle
ETIOLOGY and PATHOPHYSIOLOGY:
1. Anomalies (inadequate depth of the bicipital groove or
abnormal ridges)
2. Fasciculation of the tendon and roughening of bicipital
Groove
3. irritated long head of the biceps and rotator cuff due to
repeated compression beneath the acromion and
coracoacromial ligament.
DIAGNOSIS:
1. X-ray
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. Insidious pain
2. anterior pain and may radiate into the belly of shoulder
3. Exquisite tenderness over the intertubercular sulcus
TREATMENT:
1. Rest
2. Moist heat
3. Procaine and Hydrocortisone injection
4. Surgical Treatment
REGION: SHOULDER
CONDITION: Adhesive Capsulitis
DESCRIPTION: chronic affectation characterized by pain and limitation of
the shoulder motion that slowly becomes worse. Also called
as frozen shouder, periarthritis, obliterative bursitis and
diffuse rotator cuff tendinitis
ETIOLOGY and PATHOPHYSIOLOGY:
1. Changes in the joint capsule including edema, fibrosis and
round cell infiltration.
2. the periarticular tissues lose elasticity and become shortened
and fibrotic, firmly fixing the humeral head in glenoid cavity
DIAGNOSIS:
1. X-ray
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. Pain upon external rotation, abduction and extension
movements
2. Night time pain
3. Sleep disturbances
4. Decreased active and passive mobility of the scapulohumeral
joint
5. Stiffness
TREATMENT:
1. moist heat
2. Gravity Free Exercises
3. Finger ladder exercises
4. Adhesive traction of the shoulder
5. Analgesics and NSAIDS
6. Acromioplasty
REGION: SHOULDER
CONDITION: Rupture of the Supraspinatus Tendon and Rotator Cuff Tear
DESCRIPTION: extensive tear on the supraspinatus tendon as well as the
musculotendinous muscles
ETIOLOGY:
1. History of trauma
2. Anterior dislocation of the shoulder
3. Sudden powerful elevation of the arm
4. The presence of heavy object in the hand
5. Degenerative changes in the cuff
PATHOPHYSIOLOGY:
1. Retraction of the muscle after full-thickness tears leaves a
direct opening between the subacromial bursa and the
shoulder joint
2. The distal stub of the tendon, at first a sharply outlined
mass, becomes atrophic and may disappear, and the edge of
the tubercle gradually becomes rounded and smooth
DIAGNOSIS:
1. X-ray
2. Physical Examination
SPECIAL TEST:
1. Empty Can Test
2. D op A
Cod a ’s Test
CLINICAL MANIFESTATION/S:
1. Transient, sharp pain in the shoulder
2. Weakness of active abduction
3. (+) slight crepitus
TREATMENT:
1. Heat modalities
2. Splinting in abduction
3. Anterior acromioplasty
4. Excision of the coracoacromial igament
5. Resection of the AC joint
6. Active Exercises of the shoulder joint
REGION: SHOULDER
CONDITION: Shoulder Hand Syndrome
DESCRIPTION:
painful shoulder disability associated with swelling and
pain in the homolateral hand
ETIOLOGY and PATHOPHYSIOLOGY:
1. Reflex sympathetic dystrophy
2. Sequel to Myocardial Infarction
3. Impaired venous and lympathic return from the inactive and
dependent upper limb
DIAGNOSIS:
1. X-ray
-the bones may become osteoporotic
SPECIAL TEST:
CLINICAL MANIFESTATION/S:
1. fifth decade of life or older
2. dull, burning, ache, exacerbated by motion pain, tenderness
and stiffness in the shoulder and in the hand
3. atrophy and stiffness in the hand, with flexion deformity of
the fingers and extension contracture of the MCP joints
4. Shoulder swelling
TREATMENT:
1. Daily ROM exercises of the shoulder
2. Active and passive Exercises of the hand
3. Heat or cold applications
4. Procaine Blocks of the brachial plexus
REGION: SHOULDER
CONDITION: Snapping shoulder and habitual subluxation
DESCRIPTION:
A condition which shoulder has an audible click ar snap that can
be elicited by musculocontractions.
ETIOLOGY:
1.The sound is produced by an incomplete luxation of the joint or by
slipping of a taut tendon over a bony prominence
DIAGNOSIS:
1. X-ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
1. individuals with lax ligamentous structure may dislocate the
shoulder voluntarily.
TREATMENT:
No treatment required
CONDITION: Old acromioclavicular dislocation
DESCRIPTION: previous dislocation of acromiclavicular joint
ETIOLOGY:
Result usually from fall on the lateral aspect of the shoulder.
DIAGNOSIS:
X-ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
1.May develop painful degenerative arthritis on the acromioclavicular
joint. There is presence of upward displacement and instability on the
lateral end of clavicle that causes impairment function of it
TREATMENT:
1. Surgery
REGION: SHOULDER
CONDITION: Recurrent shoulder dislocation
DESCRIPTION:
Condition often followed by repeated dislocation
ETIOLOGY:
Incompletely healed tears or relaxation of capsular ligaments,
weakness of the surrounding musculature and congenital or acquired
PATHOPHYSIOLOGY:
Avulsion of the glenoid labrum from the anterior rim of the glenoid
cavity together with erosion of the glenoid rim together with the
posterior traumatic grooved defect of the posterolateral aspect of the
head of the humerus.
DIAGNOSIS:
X ray
SPECIAL TEST:
1. load and shift test,
2. anterior instability test
CLINICAL MANIFESTATION:
1.More frequently seen in young adults especially in young athletes,
military serviceman and persons subject to trauma of epileptic
seizures.
2. Dislocation may follow movement involuntary such as abduction
and external rotation.
TREATMENT:
1. bankart suture of the labrum and capsule of the glenoid rim;
2. putti platt operation to limit ER of the shoulder
REGION: SHOULDER
CONDITION: Old dislocation of the shoulder
DESCRIPTION:
neglected anterior or posterior dislocation of shoulder of long
duration.
ETIOLOGY:
Previous anterior and posterior dislocation of the shoulder
PATHOPHYSIOLOGY:
1. Displacement of the humeral head from the glenoid cavity.
2. The glenoid cavity fills with granulation tissue and torn capsule
contracts.
3. The head of the humerus become bound down by the scar tissue
and the muscle about the joint shortened and fibrotic.
DIAGNOSIS:
X-ray
SPECIAL TEST:
1. load and shift test
2. anterior instability test
CLINICAL MANIFESTATION:
There is pain in shoulder motion. This may also show deformity with
severe deltoid muscle atrop
TREATMENT:
1. anaesthesia
2. Closed Manipulation
REGION: ELBOW
CONDITION: Olecranon u sitis/ i e ’s el o / stude ts el o
DESCRIPTION: inflammation of the olecranon bursa
ETIOLOGY:
continue traumatisation of slight degree such as habitual leaning on
elbows
PATHOPHYSIOLOGY:
the olecranon bursa that is situated between the tip of the olecranon
and skin is frequently involved by inflammatory changes
DIAGNOSIS:
history of injury
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
1. inflammation on the olecranon bursa.
2. Pain
TREATMENT:
1. heat and rest
2. aspiration
3. antibiotics
4. incision
5. drainage
REGION: ELBOW
CONDITION: Tennis elbow (lateral epicondylitis)
DESCRIPTION: Inflammation on the lateral epicondyle
ETIOLOGY:
Overusing of elbow and hand, particularly with activities that involve
repeated force grasping and pronation supination.
PATHOPHYSIOLOGY:
Lesion is a partial rupture of the extensors tendon near their origin
from the lateral epicondyle, extensor carpi radialis brevis is usually
involved.
DIAGNOSIS:
physical examination
SPECIAL TEST:
1. oze ’s test,
2. ill’s test
CLINICAL MANIFESTATION:
1. Onset is gradually increasing discomfort after continued overuse of
the hand and wrist
2. highest in the fourth decade of life;
3. pain is experienced in the lateral aspect of the elbow, particularly
when the patient reaches forward to pickup object or turning a door
knob.
4. The discomfort may spread down the entire forearm and may be
very persistent and annoying;
5. Tenderness is experienced along the lateral epicondyle of the
humerus;
6. Grip Weakness
TREATMENT:
1. immobilization (sling);
2. Adhesive dressing or plaster;
3. dorsiflexion splint on wrist;
4 procaine
5. Hydrocortisone
REGION: ELBOW
CONDITION: Golfe ’s el o Medial epi o d litis
DESCRIPTION: Inflammation of the medial epicondyle
ETIOLOGY:
Overusing of elbow and hand, particularly with activities that involve
repeated force grasping and pronation supination.
PATHOPHYSIOLOGY:
rupture or tear of the flexor tendons arising from the medial
epicondyle.
DIAGNOSIS:
physical examination
SPECIAL TEST:
CLINICAL MANIFESTATIONS:
1. Onset is gradually increasing discomfort after continued overuse of
the hand and wrist
2. highest in the fourth decade of life;
3. pain is experienced in the medial aspect of the elbow, particularly
when the patient reaches forward to pickup object or turning a door
knob.
4. The discomfort may spread down the entire forearm and may be
very persistent and annoying;
5. Tenderness is experienced along the medial epicondyle of the
humerus;
6. Grip Weakness
TREATMENT:
1. immobilization (sling);
2. Adhesive dressing or plaster;
3. dorsiflexion splint on wrist;
4 procaine
5. Hydrocortisone
REGION: ELBOW
CONDITION: Pulled el o , u se aid’s el o
DESCRIPTION: Locking of the forearm from pronation or neutral position
ETIOLOGY:
sudden direct pull on the elevated limb with the elbow extended and
the forearm pronated.
PATHOPHYSIOLOGY:
due to pain chid refuses to use the arm, and elbow is held slightly in
flexed position. Because of failure to use the arm the condition may
be mistaken for a paralysis such as that caused by injury of the
brachial plexus.
DIAGNOSIS:
1. x-ray
2. physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATIONS:
1. all movements are of essentially normal range except supination.
2. Attempts to supinate cause pain and sensation of mechanical
blocking.
TREATMENT:
1. Elbow is flexed in right angle
2. The forearm supinated quickly while pressure while pressure is
e e ted o the adial head the ope ato ’s thu
REGION: ELBOW
CONDITION: Volk a ’s Is he i Co t a tu e
DESCRIPTION: result of ischemia caused by the volar compartment syndrome
ETIOLOGY:
caused by supracondylar fracture
PATHOPHYSIOLOGY:
infarction may be produced by any change that causes loss of blood
supply. Brachial artery may be compressed, contused, or lacerated as
a result of supracondylar
DIAGNOSIS:
used of nanometer
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
1. contracture on the lower end of humerus,
2. absent radial pulse
TREATMENT:
1. prophylactic treatment
2. splinting
REGION: WRIST AND HAND
CONDITION: Tendon Laceration
DESCRIPTION: tear of a tendon
ETIOLOGY:
1. caused by any sharp instrument that penetrates the skin over a
course of a tendon.
2. They frequently results from accidents such as grasping sharp blade
in the hand or falling on a pieces of glass or from careless use of a
power tool.
PATHOPHYSIOLOGY:
sharp instrument that penetrates the skin can rupture a tendon
DIAGNOSIS:
physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
inability to move the joint
TREATMENT:
surgery
CONDITION: Rupture of the extensor pollicis longus tendon
DESCRIPTION:
rupture caused by inflammation
ETIOLOGY and PATHOPHYSIOLOGY:
the rupture is caused from chronic inflammation or from friction
a out the liste ’s tu e le o f ag e ts of a i pe fe tl edu ed
fracture
DIAGNOSIS:diagnostic exam
SPECIAL TEST: none
CLINICAL MANIFESTATION:
1. separation may occur without pain or sensation of snapping.
2. The patient experienced inability to extend distal phalanx of the
thumb against the resistance and absence of the subcutaneous
bowstring formed by the normal tendon when the thumb is actively
extended.
TREATMENT:
1. Sutures and grafts
REGION: WRIST AND HAND
CONDITION: Jammed Finger
DESCRIPTION:
avulsion of the flexor profundus tendon
ETIOLOGY:
Forced extension of firmly flexed finger
PATHOPHYSIOLOGY:
tendon avulsed from its insertion on the distal phalanx
DIAGNOSIS:
1 .x ray
2. Physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
1. Loss of active flexion of the distal joint
2. Tenderness
3. Swelling on the volar aspect of the finger
TREATMENT:
1. Surgery
CONDITION: Bouto ie e’ o utto hole defo it
DESCRIPTION: rupture of the central extensor slip
ETIOLOGY:
1. Rheumatoid Arthritis
PATHOPHYSIOLOGY:
1. lateral band on each side of the central slip gradually subluxate to
the side of the joint
DIAGNOSIS:
1. x-ray
2. physical examination
SPECIAL TEST: none
CLINICAL MANIFESTATION:
1. DIP becomes hyperextended
TREATMENT:
1. Splinting
REGION: Wrist and hand
CONDITION: Mallet finger, baseball or dropped finger
DESCRIPTION: avulsion of the extensor tendon at its insertion
ETIOLOGY:
1. Sudden forcible flexion of the distal phalanx
PATHOPHYSIOLOGY:
1. Small portion of the posterior lip of phalangeal base is often torn
away from the tendon
DIAGNOSIS:
1. X-ray
SPECIAL TEST:
none
CLINICAL MANIFESTATIONS:
1. Inability to extend actively the distal phalanx.
2. Swelling and tenderness may obscure the loss of power in the
finger.
3. Mallet finger is common among athletes.
TREATMENT:
1. splinting of affected limb, held in hyperextension for 6wks;
2. in late cases, suture is required
REGION: WRIST AND HAND
CONDITION: Traumatic Tenosynovitis
DESCRIPTION:
is an inflammation of the synovial sheaths covering the tendon, often
on the flexor carpi radialis but may occur in any of the flexor or
extensor tendons
ETIOLOGY:
1. result of strenuous, oft- repeated or unaccustomed use of the
adjacent joint
PATHOPHYSIOLOGY:
1. serous or fibrinous accumulate the affected tendon sheath causing
chronic scleroting changes and stenosis
DIAGNOSIS:
1. X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATIONS:
1. Pain upon motion on the affected tendon.
2. Swelling may occur but not conspicuous and tenderness upon
pressure over the tendon sheath.
3. On motion of the affected tendon unmistakable crepitation is often
be elicited.
TREATMENT:
1. immobilization
REGION: WRIST AND HAND
CONDITION: “te osi g Te os o itis, de Que ai ’s Te os o itis
DESCRIPTION: stenosis on the tendon sheaths of the extensor pollicis brevis
and pollicis longus
ETIOLOGY: trauma
PATHOPHYSIOLOGY:
repeated gliding of the tendon or friction may damage the tendon
sheath
DIAGNOSIS:
X ray
SPECIAL TEST:
1. finkelstein test
CLINICAL MANIFESTATIONS:
1. Most common seen on middle aged and elderly women. There may
be local swelling.
2. Patient complains of severe pain near the styloid process of the
radius and present in moving wrist and thumb (deviation and
opposition of thumb to little finger.
3. There is presence of tender nodules over the styloid process of the
radius. Frequently bilateral in involvement.
TREATMENT:
1. Splinting of the wrist and thumb
REGION: WRIST AND HAND
CONDITION: snapping finger or trigger finger
DESCRIPTION:
partial obstruction in movement of flexion and extension of finger
and thumb.
ETIOLOGY:
unknown cause; trauma may be a contributing factor
PATHOPHYSIOLOGY:
localized stenosis of the tendon sheath usually located at the A-1
pulley near to the MCP joint and nodular thickening of the tendon
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATIONS:
when found in young children usually in the thumb, thought to be
in origin; over the age of 40; commonly in women; associated with ]
diabetes and RA; digit becomes flexed and cannot be extended.
TREATMENT:
immobilization; surgery
REGION: WRIST AND HAND
CONDITION: Acute suppurative tenosynovitis
DESCRIPTION:
infection usually by staphylococci or streptococci commonly
introduced into the tendon sheath through a puncture wound.
ETIOLOGY:
results from infection of staphylococci and streptococci commonly
introduce in puncture wound
PATHOPHYSIOLOGY:
occasionally an infection of the pulp space of the fingertip or felon
(secondary to a phalangeal osteomyelitis) may extend to the synovial
sheath
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATIONS:
painful swollen tense finger in a partially flexed position; acute
tenderness over the course of the tendon sheath, and any attempt to
extend the finger is extremely painful. Px has leukocytosis and
moderate fever. If untreated an extensive infection may result in
useless hand.
TREATMENT:
antibiotic; splinting of fingers
REGION: WRIST AND HAND
CONDITION: tuberculosis tenosynovitis
DESCRIPTION:
diffuse granulomatous and often purulent in involvement of the
tendon sheath or as cystic expansion of the sheath containing particle
of fibrin known as rice bodies.
ETIOLOGY:
caused by infection
PATHOPHYSIOLOGY:
purulent involvement of tendon sheath containing particles of fibrin
known as rice bodies
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
begins insidiously as an almost painless swelling that gradually
enlarges.
TREATMENT:
surgery
CONDITION: Acute calcific tendinitis or peritendinitis calcarea
DESCRIPTION:
calcium deposits occur in the wrist and hand
ETIOLOGY:
trauma
PATHOPHYSIOLOGY:
calcium deposition on the affected area
DIAGNOSIS:
X ray
SPECIAL TEST:
CLINICAL MANIFESTATION:
1. commonest site is on flexor carpi ulnaris near to the pisiform bone;
sudden in onset;
2. hx of acute and chronic trauma; swelling;
3. localized tenderness as well as the motion of the involved tendon.
TREATMENT:
1. local anesthetic; hydrocortisone
REGION: WRIST AND HAND
CONDITION: Ganglion
DESCRIPTION: small smooth cystic structure containing a thick, clear mucinous
fluid.
ETIOLOGY:
cyst result from herniation of the lining membrane of a joint or to
tendon sheath or tendon joint; produced by colloid degeneration
which occurs locally to the connective tissue,
PATHOPHYSIOLOGY:
usually connected to the capsule of an adjacent joint or to a tendon
sheath by a narrow pedicle without a lumen
DIAGNOSIS:
x ray; physical examination
SPECIAL TEST: none
CLINICAL MANIFESTATION:
most common in ages between 15 and 35; frequently on the radial
side of the back of the wrist but also on the volar aspect; small ganglia
near the joint of the fingers; knee( found on popliteal space); swelling
is tense, flactuant, rounded, and not fixed to the skin
TREATMENT:
combination of aspiration, chemical cauterization; application of
bandage
REGION: WRIST AND HAND
CONDITION: dupu t e ’s o t a tu e
DESCRIPTION: flexion deformity of the finger (ring)
ETIOLOGY:
cause is unknown; possible cause of chronic trauma; in some cases
there is hereditary factor.
PATHOPHYSIOLOGY:
chronic inflammation of the palmar fascia with progressive fibrosis
and contracture myofibroblast proliferate in the lesion
DIAGNOSIS:
physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
1. appearance of a small nodular ,
2. painless thickening in the palmar fascia overlying a flexor tendon in
MCP joint; thickened longitudinal band is gradually formed and
flexion contracture of the finger progressively increases;
3. MCP and adjacrnt IP joints are flexed ;
4. bilateral in involvement ;
5. one hand appears earlier than other.
TREATMENT:
1. passive stretching;
2. complete fasciectomy;
3. splinting
REGION: WRIST AND HAND
CONDITION: adelu g’s defo it
DESCRIPTION:
characterized by dorsal prominence of the lower end of ulna,
instability of the radioulnar articulation and local changes in
conformation of the radius and ulna
ETIOLOGY:
caused by local growth and disturbance resulting from changes
produced by congenital abnormality
PATHOPHYSIOLOGY:
growth at the ulnar and volar parts of distal epiphyseal plate is
retarded resulting in progressive volar and ulnar tilting of distal end of
radius
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
1. first noted in adolescence;
2. slow progressive deformity; commonly seen in girls; often bilateral
in involvement;
3. px complains of deformity and feeling of wrist weakness and
insecurity; wrist may appear enlarged;
4. instability of the radioulnar joint upon palpation;
5. decreased motion of wrist dorsiflexion, pronation and supination
TREATMENT:
splinting;
surgery
REGION: WRIST AND HAND
CONDITION: ga ekeepe ’s thu
DESCRIPTION: rupture of the ulnar collateral ligament of the first MCP joint
ETIOLOGY:
rupture or avulsion of ligament from a blow or fall on a extended
hand
PATHOPHYSIOLOGY:
ligament gradually become lax after repeated abduction stresses
DIAGNOSIS:
physical examination; x ray
SPECIAL TEST:
milking maneuver
CLINICAL MANIFESTATION:
local pain, swelling and tenderness; small fleck of bone may avulsed
with the ligament; in severe cases there is weakness of thumb- index
pinch accompanied by slight thickening and tenderness over the MCP
joint.
TREAETMENT:
immobilization for 4-6 wks; MCP arthrodesis
CONDITION: osteo e osis of the a pal o es p eise ’s dse
DESCRIPTION: necrosis of the scaphoid bone
ETIOLOGY:
trauma
PATHOPHYSIOLOGY:
death and fracture of bone tissue due to interruption of blood supply
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
limited wrist motion; aching pain felt on jarring or exertion; localized
swelling and tenderness
TREATMENT:
immobilized in an short wrist extension splint
REGION: WRIST AND HAND
CONDITION: osteo e osis of the a pal o es kie o k’s dse
DESCRIPTION: necrosis of the lunate bone
ETIOLOGY:
traumatic dislocation of the lunate
PATHOPHYSIOLOGY:
repetitive trauma associated with shortening of the ulna
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
men is commonly affected; between ages 20 and 40; pain and
swelling that persist for several days to weeks
TREATMENT:
immobilized in an short wrist extension splint
CONDITION: osteo e osis of the a pal o es p eise ’s dse
DESCRIPTION: necrosis of the scaphoid bone
ETIOLOGY:
trauma
PATHOPHYSIOLOGY:
death and fracture of bone tissue due to interruption of blood supply
DIAGNOSIS:
x ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
limited wrist motion; aching pain felt on jarring or exertion; localized
swelling and tenderness
TREATMENT:
immobilized in an short wrist extension splint
REGION: WRIST AND HAND
CONDITION: posttraumatic carpal instability
DESCRIPTION:
ligamentous tear that may lead to abnormal movement of one or
more carpal bones in relation to others
ETIOLOGY:
caused by disruption of the
PATHOPHYSIOLOGY:
DIAGNOSIS:
x ray; physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
chronic wrist pain, limitation of motion, clicking or popping of wrist
and weakened grasp
REGION: HIP
CONDITION: Osteonecrosis of the femoral head
DESCRIPTION: Necrosis of the femoral head as the result of impairment of its
blood supply
ETIOLOGY:
1. Fracture of the neck of the femur
2. Tearing of retinacular vessels (20-30%)
3. Traumatic dislocation of the hip
4. Forceful manipulation or wringing out of the joint capsule by fixing
hip in ER position
5. Forced manipulation of slipped under upper femoral epiphysis
6. Microfractures of the trabeculae bone of femoral head associated
severe osteoporosis or osteomalacia
PATHOPHYSIOLOGY:
1. Infarction results in death of marrow elements (fat elements)
2. Death of cancellous bone
- manifested by degeneration and disappearance of
osteocytes from the lacunae within bone trabeculae
- Necrosis results in marked hyperaemia of the tissues
adjacent the infarct.
DIAGNOSIS:
1. Roetgenogram picture
Resorption may be extensive at the periphery of the infarct,
weakening the cartilage support and resulting in fracture in
su ho d al a ea, hi h p odu es es e t sig .
The process of removal of dead bone and its replacement of
new bone is referred as creeping substitution.
SPECIAL TEST:
CLINICAL MANIFESTATION/S: In child, a limp and slight spasm in the hip,
followed by pain present on weight bearing and often referred to the
thigh. In adult, pain on groin (first symptom), spasm about the hip
(early sign). In late stages, muscle atrophy and restriction of
abduction and IR may be noticeable
TREATMENT:
Hip protection in abduction
Surgical Treatment:
THR
Osteotomy
Arthrodesis
REGION: HIP
CONDITION: legg calve parthes dse/ coxa plana
DESCRIPTION: osteonecrosis of the femoral head/flattening of the femoral
head
ETIOLOGY:
ischemia of head due to increase intrarticular pressure or trauma that
occlude the retinacular vessel
PATHOPHYSIOLOGY:
1. disruption of the epiphyseal plate with subsequent growth
disturbance.
2. Collapse of the head may occur during the resorptive
phase, producing characterisitic of flattening.
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
pain; ms spasm; limitation in hip motion
TREATMENT:
surgery; bilateral long leg cast
REGION: HIP
CONDITION: Coxa vara
DESCRIPTION: decrease on the neck shaft angle (angle of torsion)
ETIOLOGY:
congenital; acquired; chronic disability such as severe paralytic
disorder; secondary deformity in congenital dislocation of the hip
PATHOPHYSIOLOGY:
demarcation of a triangular area of bone in lower side of the femoral
head close to the neck
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATIONS:
seen after interthrochanteric fx; slipping of the capital femoral
epiphysis; and fx of the head of the femur;
(unilateral)painless and wadlling gait; bilateral (lurching)
TREATMENT:
surgery; osteotomy
REGION: HIP
CONDITION: slipping of the capital femoral epiphysis
DESCRIPTION: capital femoral epiphysis slipped
ETIOLOGY:
unknown; but may due to trauma or strain
PATHOPHYSIOLOGY:
periosteum becomes thinner in the adolescent and may yield to shear
forces associated with increase body weight and a more vertical slope
of growth plate
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
common in children between 10 and 16 years of age ; more common
in boys; in girls its occur 2 years earlier (after menarche); aching
fatigue and feeling of stiffness; after standing or walking;limp
TREATMENT:
traction in mild abduction and IR;
Skeletal or split
REGION: HIP
CONDITION: chondrolysis /cartilage necrosis
DESCRIPTION:
progressive narrowing of the joint space due to loss of cartilage from
acetabular and femoral surfaces
ETIOLOGY:
unknown
PATHOPHYSIOLOGY:
matrix loss and degeneration of articular cartilages and mild
inflammatory changes in the synovial membrane; elevation of the
synovial fluid and serum immunoglobulins and c3 component
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
hip pain with progressive loss of mobility; hip flexion and adduction
contractures; osteoporosis of the femoral head and acetabulum;
fibrous ankylosis
TREATMENT:
rest; restrictions of activities; use of crutches; gentle active exercise;
salicylates; NSAIDs; surgery; arthrodesis; arthroplasty
REGION: HIP
CONDITION: intrapelvic protrusion of the acetabulum; protrusion acetabuli
DESCRIPTION: deepening or inward protrusion of the ecetabulum
ETIOLOGY:
unknown; congenital or acquired
PATHOPHYSIOLOGY:
thinning of the wall of the acetabulum but ocassionaly there is
evidenced of increase bone formation; there may be narrowing of the
cartilage space
DIAGNOSIS:
X ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
discomfort; limitation of motion (abduction and rotation); pain until
osteoarhtritic changes is superimposed; end stage AS may be result
TREATMENT:
rest; night traction; crutches; arthroplasty
REGION: HIP
CONDITION: transient synovitis of the hip
DESCRIPTION: transient inflammation of the synovium of the hip
ETIOLOGY:
trauma or low grade, short lived infection that subsides after 1 or 2
wks
PATHOPHYSIOLOGY:
distension of the joint capsule
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
commonly seen in boys between age of 4 and 10; unilateral
involvement; pain on hip,, thigh or knee; tenderness over the hip
joint; restriction of passive hip mobility due to spasm; limp; hips
often flexed and abducted position; infection is slight or absent
TREATMENT:
rest; hot application; traction
REGION: HIP
CONDITION: bursitis of the hip
DESCRIPTION: inflammation of the bursa of the hip (iliopectineal or iliopsoas
bursa; deep throcanteric bursa; superficial throcantheric;
ischiogluteal bursa or weavers bottom)
ETIOLOGY:
ischiogluteal bursa (prolonged sitting in hard surfaces)
PATHOPHYSIOLOGY:
deep throcanteric bursa (normal depression behind the greater
trocanter is obliterated
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
1. iliopectineal bursa (tenderness over the anterior aspect of the hip;
pain caused by pressure on the femoral nerves that radiates up to the
front of lower leg;
2. Deep trochanteric bursa (tenderness; abducted and ER position;
pain radiates down to the back of the thigh; superficial throcantheric
bursa (tenderness; swelling; pain on extreme adduction of the hip;
3. ischiogluteal bursa (tenderness over the tuberosiy of the
ischium;pain radiating down to the back of the thigh along the course
of hams ms; mimic herniated IV disk)
TREATMENT:
1. iliopectineal (rest; traction; hot application);
2. deep throchanteric (rest; heat; antibiotic; drainage);
3. superficial throchnteric (rest; heat; antibiotic; drainages)
4 ischigluteal bursa (rest; used of pillow or cushioned seat; procained
and hydrocortisone injection; incision of bursa)
REGION: HIP
CONDITION: snapping hip
DESCRIPTION: clicking sound upon movement that is heard over the hip
ETIOLOGY:
slipping to and fro over the greater throcahanter of the tibial band
PATHOPHYSIOLOGY:
fibrous thickening on the deep surface of the gluteus maximus ms
DIAGNOSIS:
x ray
SPECIAL TEST:
None
CLINICAL MANIFESTATION:
Annoying sound
TREATMENT:
explain to px that snapping is harmless
REGION: KNEE
CONDITION: Lesions of the menisci
DESCRITION: Lesion of the fibrocartilaginous wedge shaped structure of the
knee
ETIOLOGY:
result from athletic or occupational injury; rotational movement of
tibia from femur in a flexed position
PATHOPHYSIOLOGY:
varus and valgus moment causes slight opening of the joint and
permits the medial or lateral meniscus to pulled between the
econdyles
DIAGNOSIS:
history of injury
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
commonly on young athlete (partially flexed knee and twisted
inward); acute pain on inner and outside of knee; swelling; commonly
on middle aged; coal miner or a roofer working on his knees and feel
something give way in knee when turning ; referred pain on lateral
and medial aspect of the joint.
TREATMENT:
Ice; traction; aspiration; immobilized in extension for 3 weeks;
application of cotton rolls, spints, bandage, light plaster cast or
commercial knee splint; exrcise ( quads ms, patella setting, weight
lifting); surgery
REGION: KNEE
CONDITION: degenerative meniscal tear
DESCRITION: narrowing of the joint space and tear of the fibrocartilaginous
wedge shaped structure of the knee
ETIOLOGY:
Aging
PATHOPHYSIOLOGY:
narrowing of the joint space resulting to ligamentous laxity increase
shearing forces and tear to the mnisci
DIAGNOSIS:
physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
often horizontal cleavage tears; occur 50% in people over the age of
65.
REGION: KNEE
CONDITION: Pelligrini-steida dse
DESCRIPTION: ossification of the tibial collaretal ligament
ETIOLOGY:
trauma; repeated minor injury on the knee joint
PATHOPHYSIOLOGY:
deposits of a new bone overlie the medial femoral condyle and in the
middle portion of the medial collateral ligament just proximal to the
level of the joint space
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
medial aspect of knee become sensitive to pressure (adductor
tubercle); flexion and extension are painful and the joint is usually
held in a slight flexion; slight sweeling on the knee
TREATMENT:
rest; support; surgery (rare)
REGION: KNEE
CONDITION: Loose bodies
DESCRIPTION: small fibrinous bodies found in joints
ETIOLOGY:
trauma; disease
PATHOPHYSIOLOGY:
DIAGNOSIS:
physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
commonly found in knee and lessfrequently on ankle, hip, elbow.
shoulder,and other joints; chronic intraarticular inflammation that is
attended by increased joint fluid; intense pain upon motion;
occasional vague discomfort to sharp pain sweeling, and locking
TREATMENT:
arthroscopic surgery; immobilization; active exercise
CONDITION: synovial chondromatosis
DESCRIPTION: pedunculated and loose osteocartilaginous bodies arise between
the synovial membranes
ETIOLOGY:
deposition of calcium salts
PATHOPHYSIOLOGY:
cartilage cell develop in the synovial villi, as a result of metaplasia of
the connective tissue cells
DIAGNOSIS:
x ray; physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
knee joint is commonly invlolved pain and chronic swelling; locking
may occur
TREATMENT:
surgery; synovectomy
REGION: KNEE
CONDITION: osteochondritis dissecans
DESCRIPTION:
partial or complete detachment of a fragment of cartilage and
subchondral bone from the articular surface
ETIOLOGY:
osteochondral or subchondral fracture with nonunion; blow against
patella causing it to strike the medial femoral condyle when the knee
is acutely flexed ; infarction resulting from embolism of minute blood
vessels supplying the affected area of bone and cartilage
PATHOPHYSIOLOGY:
fragement is detached and its area of origin is recognizable as a
shallow crater in one of the articular surfaces
DIAGNOSIS:
x ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
bilateral and symmetric in involvement; common site is lateral
portion ofarticular surface of the medial condyle of the femur;
commonly on adolescent or early adult but may also seen on
children; male is more affected
REGION: KNEE
CONDITION: Myositis ossificans and quadriceps contusuin
DESCRIPTION: formation of heterophic bone in quadriceps muscle
ETIOLOGY:
direct blow to the thigh by a hard object
PATHOPHYSIOLOGY:
associated with formation of the heterotrophic bone; calcification
within the quadriceps muscle.
DIAGNOSIS: x ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
commonly site is the anterior thigh another is the brachialis muscke,
pectoralis major (riflemen) and adductor muscle ( riders bone);
tender, painful nad swollen; knee flexion is restricted by pain; sxs
persist 3 to 4 wks after the injury; thigh may become indurated and
hard
TREATMENT:
Ice; rest; analgesics; active exrercise (active flexion and extension)
REGION: KNEE
CONDITION: Osgood Schlatter dse
DESCRIPTION: Partial separation of tibial tuberosity
ETIOLOGY:
sudden or continued strain placed on it by the patellar ligament
during exercise
PATHOPHYSIOLOGY:
disturbance of the circulation of the epiphysis; presence of the
necrotic bone and avascular necrosis as a result of separation of the
tibia
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
pain over the tibial tuberosity; tuberosity become enlarged and often
tender.
there is aching on the tuberosity during exercise particularly on
climbing stairs and running.
TREATMENT:
restriction of activity; avoiding running, jumping, and bicycle riding;
splint and plaster cast for 5 weeks, surgery.
REGION: KNEE
CONDITION: Recurrent dislocation and subluxation of the patella
DESCRIPTION: displacement of patella into its tendon
ETIOLOGY:
inherited predisposition; underdevelopment of the patella; high
positioning of the patella (patella alta), genu valgum, abnormal
fibrous attachment attachment of vastus lateralis, external tibial
torsion, a shallow patellar groove on femur and joint laxity or a be a
glancing blow on the medial side of the patella; sudden contraction of
the quadriceps ms when tibia is ER
PATHOPHYSIOLOGY:
hypoplasia of the lateral condyle of the femur
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
sharp pain cause px to fall instability or giving way of the knee;
tenderness along the medial border of the patella; abnormal tracking
of the patella
TREATMENT:
strengthening of the vastus medialis and quadriceps ; brace with
opening cut to the patella; surgery
REGION: KNEE
CONDITION: chondromalacia patellae
DESCRIPTION: degenerative changes of the cartilage of the articular surface of
patella
ETIOLOGY:
unknown
PATHOPHYSIOLOGY:
fibrillation and fissuring; thinning and erosion of the cartilage that
may expose the subchondral bone
DIAGNOSIS:
x ray; physical examination
SPECIAL TEST:
Cla ks’s “ig ; M o el Test
CLINICAL MANIFESTATION:
pain, catching feeling and weakness of the knee; difficulty on climbing
and descending stairs; tenderness on the patella when knee is slightly
flexed; crepitation when knee is actively extended against resistance.
TREATMENT:
in mild cases, treated by heat and rest; trapping or brace; isometric
quadriceps strengthening exercise; surgery
REGION: KNEE
CONDITION: patella te di itis’ ju pe ’s k ee
DESCRIPTION:
inflammation of the patellar tendon
ETIOLOGY:
trauma
PATHOPHYSIOLOGY:
tears of a few fibers of the patellar tendon may result to the
formation of a small area of granulation tissue within the tendon.
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
tenderness at the attachement of the tendon to the inferior pole of
the patella, seen in the adolescent boys known as sinding Larsen
Johansson dse
TREATMENT:
rest and restriction of forceful knee extension; splints or cast may be
necessary; surgical debriment of the lesion
REGION: KNEE
CONDITION: bursitis
DESCRIPTION:
i fla
atio of the u sa p epatella u sa/ house aid’s k ee ,
infrapatellar bursa, superficial pretibial, popliteal bursa,
gast o e ius u sa, popliteal / ake ’s st, a se i e u sa
ETIOLOGY:
prepatellar bursa (puncture wound made by a neddle o
Splinter when px crawls on knees or prolonged kneeling) popliteal
bursa (trauma and strain)
PATHOPHYSIOLOGY:
prepatellar bursa (bursal wall may become greatly thickened, fibrous
and prominent anteriorly; pyogenic infection is present)
DIAGNOSIS:
physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
enlarged without causing discomfort; if infected it become painful
and tender
TREATMENT:
rest and knee joint hot application; pyogenic infection is present,
aspiration, culture, and antibiotic therapy is indicated; surgery
(excision)
REGION: KNEE
CONDITION: genu varum/ bowleg
DESCRIPTION: convexity of the limb laterally
ETIOLOGY:
mild to moderate bowleg is normal in infancy and persist until the 24
mos after birth, after which leg gradually becomes straight.
rd
th
Development of knock knees when reaches the 3 to 4 decade of
year of life and thereafter gradually corrects itself; obesity; condition
such as rickets, osteomalacia, bone dysplasia, osteogenesis imperfect
and hyperthyroidism
PATHOPHYSIOLOGY:
lateral yielding of the knee joint while the shaft of the femur and tibia
remains straight; internal tibial torsion accentuates the apparent
deformity of bowleg as a child attempts to compensate in walking
with the knee turned outward and slightly flexed.
DIAGNOSIS:
physical examination; x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
present if the extended knees are separated when medial malleoli of
the ankles are approximated; knee and inward rotation at the ankle,
the child tends to walk with the feet widely separated and the toes
turned in; waddling type of gait ; associated with pain and and
disability of chronic arthritis of knee.
TREATMENT:
postural influences must be avoided; obesity should be avoided;
bracing; denise brown splint; ; osteotomy
REGION: KNEE
CONDITION: Tibia vara/blounts dse
DESCRIPTION:
retardation of growth at the medial side of proximal tibial epyhpyseal
plate
ETIOLOGY:
abnormal stress on the medial side of the epihpyseal plate
PATHOPHYSIOLOGY:
retardation of growth at the medial side of proximal tibial epiphyseal
plate and normal growth on lateral aspect leading to progressive
bowleg deformity
DIAGNOSIS:
x ray; physical examination
SPECIAL TEST: none
CLINICAL MANIFESTATION:
onset is between 1 to 3 yrs of age; bilateral in involvement;
overweight; tibial torsion
TREATMENT:
osteotomy of tibia and fibula; surgical correction before age of 8
REGION: KNEE
CONDITION: Genu valgum/ Knock knees
DESCRIPTION: curvature or convexity of the limb on the medially
ETIOLOGY:
mechanical axis of the limb passes laterally to the femur
PATHOPHYSIOLOGY:
progressive knock knee may develop erosion of the articular cartilage
on the lateral side of the knee joint
DIAGNOSIS:
x ray; physical examination
SPECIAL TEST: none
CLINICAL MANIFESTATION:
overlapping knees view anteriorly; the gait is altered by internal
rotation of the leg and foot; associated with chronic arthritis in later
decades of life; seen on obese patient; excessive ligamentous laxity.
TREATMENT:
no tx for slight to moderate genu valgum in 3 to 7 years of age; 1 inch
raise of medial border of the heel ; night splint; osteotomy in severe
cases in children; removal of the small wedge of the bone in older
p ’s
REGION: KNEE
CONDITION: Leg length discrepancy
DESCRIPTION: inequality of the leg
ETIOLOGY:
asymmetric paralysis after poliomyelitis; paralysis in childhood result
of congenital defects, malunited fracture, epipyseal injuries, fractures
a d i fe tio s, postu al p o le su h as ha i g s oliosis’
DIAGNOSIS:
physical examination
SPECIAL TEST:
ALL and TLL
CLINICAL MANIFESTATION:
limp; on ambulation px show tip toe walking on the short side to
compensate by flexion of the opposite knee. In standing, pelvis is
lower on the short side; there is presence of the asymmetric flank
folds, and scoliosis and disappears when lifting the short side of the
limb.
TREAMENT:
Under mild discrepancy with 2 cm, a simple lift to the heel of the
shoe; for > 2 cm surgery is needed; lengthening may be considered in
child with severe shortening for approximately > 6-8 cm ; in adult
with severe shortening the longer limb must be shorter; in congenital
deformities it may be treated by modified shyme amputation.
REGION: KNEE
CONDITION: shin splint/ medial tibial stress syndrome
DESCRIPTION: common disorder often seen in distance runners
ETIOLOGY:
excessive stress brought on by running or jumping
PATHOPHYSIOLOGY:
chronic traction at the muscles origin
DIAGNOSIS:
MRI, X-ray, bone scan
SPECIAL TEST: none
CLINICAL MANIFESTATION:
pain and tenderness along the anterior surface of the leg
TREATMENT:
cutting back on running activities; arch support and heel wedges.
CONDITION: Cyst
DESCRIPTION: ganglion like structure found in the cartilages
ETIOLOGY:
end result of the mucoid degenerative process within the cartilage;
congenital defect in the development of the cartilage; trauma
between the peripheral surface of the cartilage and synovial
membrane
PATHOPHYSIOLOGY:
gelatinous material and are sometimes lined by cells resembling
endothelium.
DIAGNOSIS:
physical examination
SPECIAL TEST:
CLINICAL MANIFESTATION:
may follow injury to the knee; continous dull ache in affected joint
and felt at night; discomfort is aggreviated upon movement and
relived by rest; found at the level of the joint line on the lateral side of
the knee; swelling; tenderness
TREATMENT:
aspiration of the cyst; removal of the meniscus and tears.
REGION: FOOT and ANKLE
CONDITION: foot strain
DESCRIPTION: strain over the ms of the foot
ETIOLOGY
prolonged standing; obesity;
DIAGNOSIS:
Physical examination
SPECIAL TEST:
CLINICAL MANIFESTATION:
pain; trnderness on the longitudinal arch of the foot; result to
excessive unaccostumed standing or walking; fatigue and acjing on
the feet. Feet may feel tight and swollen; localized tenderness
beneath the navicular bone at the apex of the longitudinal arch
TREATMENT:
hot soaks; contrast bath; adhesive; Thomas heel; exercise of the long
and short ms of the foot; weight reduction
CONDITION: shortening of the achilles tendon
DESCRIPTION: shortening of the Achilles tendon
ETIOLOGY:
congenital anomaly
PATHOPHYSIOLOGY:
weak and everted foot leads to development of foot strain
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
local discomfort; sharp pain; ms spasm on attempting to dorsiflex;
TREATMENT:
stretching by wedge plaster cast; raising the heel of the shoe
REGION: FOOT and ANKLE
CONDITION: claw foot
DESCRIPTION: dorsiflexion of the MTP jts and plantarflexion of the IP jts
ETIOLOGY:
peroneal muscular athophy; myelomenigoceole; spinal dysraphism;
poliomyelelitis; imbalance of the motor power involving the intrinsic
and extrinsic ms of the foot
PATHOPHYSIOLOGY:
impairment of blood supply as in the fascial compartment syndrome
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
fatigue with exercise; calusses beneath the metatarsal heads over the
PIP jts
TREATMENT:
stretching of the plantar fascia; wearing of proper shoes; metatarsal
pads or bars; surgery
REGION: FOOT and ANKLE
CONDITION: kohle ’s disease
DESCRIPTION: osteonecrosis of the navicular bone
ETIOLOGY:
unknown
PATHOPHYSIOLOGY:
the bone become small, densed and of irregular outline and
disordered internal structures
DIAGNOSIS:
X ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
local discomfort and limping; tenderness and slight thickening of the
navicular bone
TREATMENT:
support on the longitudinal arch; restriction of activity; plaster cast
for 6 to 8 wks.
CONDITION: o to ’s eu o a/ i te digital eu o a
DESCRIPTION: a type of metatarsalgia characterized by attacks of sharp pain
that usually is well localaized.
PATHOPHYSIOLOGY:
localized thickening of common digital nerve at its bifurcation in the
web space
DIAGNOSIS:
X ray; physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
rd
th
localized sharp pain between thw web spaces of the 3 and 4 toes;
tenderness; numbness
TREATMENT:
metatarsal arch support; surgery
REGION: FOOT and ANKLE
CONDITION: metatarsalgia
DESCRIPTION: pain on the metatarsal heads
ETIOLOGY:
everted or abducted foot; short Achilles tendon; high longitudinal
arch
PATHOPHYSIOLOGY:
short and thight shoes compresses the anterior part of the foot,
th
elevates the head of the 5 metatarsal bone, and throws more
weight on the metatarsal
DIAGNOSIS:
x ray, physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
burning cramping pain on the anterior aspect of the foot; tenderness
over the middle metatarsal heads (fourth); pain on standing and
walking; cannot flex the toe fully
TREATMENT:
support beneath the metatarsal heads; strengthening of the ms of
foot and ankle; wear shoe the=at has thick sole; pads; circular
adhesive strapping; transverse and metatarsal bar; surgery
CONDITION: March/ fatiue fx
DESCRIPTION: stress fracture of the metatarsal heads
ETIOLOGY:
st
congenital shortening of the 1 metatarsal bone; increased leverage
nd
of the shaft of the 2 metatarsal bone;
DIAGNOSIS:
x ray
CLINICAL MANIFESTATION:
callus formation; pain; swelling tenderness
TREATMENT:
rest; adhesive strapping; use of an anterior arch pad; plaster cast for 3
to 4 wks
REGION: FOOT and ANKLE
CONDITION: frei e g’s disease
DESCRIPTION: osteonecrosis of the metatarsal heads
ETIOLOGY:
degenerative changes in the second metatarsal head
PATHOPHYSIOLOGY:
imbalance of circulation that result in the localized ischemic necrosis
DIAGNOSIS:
X ray; physical examination
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
pain upon weight bearing; tenderness over the affected metatarsal
heads
TREATMENT:
plaster boots; anterior arch pad; surgery
CONDITION: hallux valgus
DESCRIPTION: lateral angulation of the great toe at its MTP joints
ETIOLOGY:
familial; narrow pointed shoes
PATHOPHYSIOLOGY:
contracture of the flexor and extensor hallucis longus muscles with a
lateral displacement of tendons
DIAGNOSIS:
x ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
pain is aggravated by arthritic changes
TREATMENT:
properly shoes; stretching; aspiration; antibiotic; rest; hot compress;
silver operation (extensor hallucis longus sectioned or lengthened;
st
keller/ schanz operation (resection of the 1 phalanx); cast
REGION: FOOT and ANKLE
CONDITION: hallux varus
DESCRIPTION: medial angulation of the great toe at the MTP jt
ETIOLOGY:
congenital; trauma; infection; ms imbalance from paralysis of the
adductor hallucis; bunion
PATHOPHYSIOLOGY:
paralysis of of adductor hallucis or a bunion operation in which the
outer capsule and insertioin of adductor hallucis tendon
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
pain is aggravated by arthritic changes
TREATMENT:
surgery; osteotomy
CONDITION: hallux rigidus
st
DESCRIPTION: restriction of dorsiflexion of the 1 MTP joint
ETIOLOGY:
degenerative arthritis, trauma, or disuse associated with chronic foot
pain
PATHOPHYSIOLOGY:
arthritis and stiffness due to bone spurs that affects the MTP joint at
the base
DIAGNOSIS:
x ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
limited dorsiflexion of he toe; pain upon stance phase of walking
TREATMENT:
wearing a thick; inflexible type of shoe; long steel strip inserted
between the inner and outer soles of the shoe to restrict the motion
in the affected MTP joint; use of metatarsal bar; surgery
REGION: FOOT and ANKLE
CONDITION: hammer toe and claw toe and mallet toe
DESCRIPTION:
Hammer toe (dorsiflexion of the MTP; plantarflexion of the PIP jt)
claw toe (hyperextension of the MTP jt; flexion of PIP and DIP jt);
mallet toe (flexion of the DIP jt)
ETIOLOGY:
Hammer toe (over activity or tightness of the long flexor tendon)
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
nd
Hammer toe (2 toe is most frequently involved; tender corns;
calluses) mallet toe (painful callus; ulceration ot the tip of the toe
TREATMENT:
Manipulation; splingting; wide toe shoe; metatarsal pad or bar
CONDITION: in toeing/ pigeon toe
DESCRIPTION: habitual turning in of feet
ETIOLOGY:
medial tibial torsion
DIAGNOSIS:
x ray
SPECIAL TEST: none
CLINICAL MANIFESTATION:
abnormality in the hip, leg and feet; metatarsus varus; internal tibial
torsion; inward rotation of the axis of the ankle joint; femoral
anteversion
TREATMENT:
raising the outer borders of shoes 3 to 6 mm; walk with toes pointed
out; denise brown night splint; osteotomy
REGION: FOOT and ANKLE
CONDITION: out toeing
DESCRIPTION: habitual turning out of feet
ETIOLOGY:
external tibial torsion; forefoot abduction associated with flatfoot;
retroversion of the femoral neck
PATHOPHYSIOLOGY:
External rotation contracture of the extended hip
DIAGNOSIS:
x ray
SPECIAL TEST:
none
CLINICAL MANIFESTATION:
external tibial torsion; forefoot abduction associated with flatfoot;
retroversion of the femoral neck
TREATMENT:
3 or 5 mm raise of medial border of the heel; denise brown splint
CONDITION: tenosynovitis
DESCRIPTION: inflammation tendon sheath
ETIOLOGY:
precursor to tendon rupture
DIAGNOSIS:
Physical Examination
CLINICAL MANIFESTATION:
crepitation; acute local tebderness
TREATMENT:
rest; cast; application of heat; avoidance of pressure on the tender
area; pad on heel to lessen excursion of the tendon
REGION: FOOT and ANKLE
CONDITION: bursitis (retrocalcaneal bursa)
DESCRIPTION: inflammation of the bursa
ETIOLOGY:
tight shoe
PATHOPHYSIOLOGY:
prominence of the superior tuberosity of the calcaneus may irritate
the overlying bursa
DIAGNOSIS:
Physical Examination
SPECIAL TEST:
CLINICAL MANIFESTATION:
local tenderness
TREATMENT:
rest; heat; elevation of heel
REGION: FOOT and ANKLE
CONDITION: exostoses of the bone of the foot
DESCRIPTION:
ETIOLOGY:
Pressure from shoes
PATHOPHYSIOLOGY:
exostosis beneath the toenail; such localized proliferation.
DIAGNOSIS:
X ray
SPECIAL TEST:
CLINICAL MANIFESTATION:
th
seen on lateral side of the 5 metatarsal head, medial aspect of the
navicular bone, and posterior aspect of the calcaneus
TREATMENT:
surgery
CONDITION: al a eal apoph sitis o epiph sitis/se e ’s/ haglu d’s
DESCRIPTION:
low-grade inflammation reaction occurring in posterior calcaneal
apophysis
PATHOPHYSIOLOGY:
irregular or segemented with areas of increased density
DIAGNOSIS:
X-ray
SPECIAL TEST:
CLINICAL MANIFESTATION:
pain; swelling
TREATMENT:
12 mm raising of heel; rest; plaster cast
CONDITION: abnormal accessory bone of the foot
DESCRIPTION:
os trigonum (post to the talus); os tibiale externum/ accessory
navicular (medial aspectof the navicular bone); os perineum
(peroneus longus tendon on the lateral side of the foot)
DIAGNOSIS:
Physical Examination
SPECIAL TEST:
CLINICAL MANIFESTATION:
pain; weakness on the longitudinal part; tenderness
TREATMENT:
surgery; kidner operation (fixation of the tibial tendon)
REGION: FOOT and ANKLE
CONDITION: displacement of the peroneal tendon
DESCRIPTION: laxity of the retinaculum behind the lateral malleolus
ETIOLOGY:
trauma
DIAGNOSIS:
Physical examination
SPECIAL TEST:
CLINICAL MANIFESTATION:
pain upon active dorsiflexion and eversion
TREATMENT:
increasing height of heel; immobilization; surgery
CONDITION: diabetic foot
DESCRIPTION: foot ulceration and infections
ETIOLOGY:
diabetes
PATHOPHYSIOLOGY:
vascular disease of both large and small vessels
DIAGNOSIS:
droopler ultrasound
SPECIAL TEST: none
CLINICAL MANIFESTATION:
neurophatic arhtropathy; ischemia; occurs in metatarsal area;
fragmentation and collapse of the navicular, cuboid, and cuneiform
bones
TREATMENT:
phropylactic care; special shoes or cast; surgucl debridement
SHOULDER
ELBOW, WRIST
AND HAND
HIP
KNEE
FOOT AND
ANKLE
LOW BACK
NECK
THORACIC