12.08.08: Common Musculoskeletal Problems
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Transcript of 12.08.08: Common Musculoskeletal Problems
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Author(s): Clifford Craig, M.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution–Noncommercial–Share Alike 3.0 License: http://creativecommons.org/licenses/by-nc-sa/3.0/
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COMMON MUSCULOSKELETAL
PROBLEMS
C. CRAIG M2 - MUSCULOSKELETAL
Fall 2008
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ANGULAR and TORSIONAL DEFORMITIES of the
LOWER EXTREMITIES
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TERMS
Valgus - deviation away from midline Varus - deviation toward midline Torsion (rotation) Internal External Version (rotation) Anteversion/retroversion
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EXAMINATION
Relaxed Supine/sitting/walking Each individual joint Beware any asymmetry
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IN - TOEING
Metatarsus adductus Newborn – 18 months Limited to forefoot 80 % improve spontaneously Casting Surgery - rare
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Allison Gilmore, MD, ET AL
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IN - TOEING
Internal tibial torsion 6 – 18 months 85 % improve spontaneously Defined by transmalleolar axis Infant +5 /adult + 22 degrees
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!!!
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FEMORAL ANTEVERSION
3 – 9 years Not “hip problem” Improves spontaneously until age 12
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The Internet Journal of Biological Anthropology 2009 : Volume 3 Number 1
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Source Undetermined
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Source Undetermined
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DIFFERENTIAL DIAGNOSIS
Equinovarus (clubfoot) Neurologic problems Cerebral palsy Myelodysplasia
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Source Undetermined
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Source Undetermined
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Source Undetermined
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Source Undetermined
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OUT-TOEING
Calcaneovalgus foot Usually improves spontaneously External tibial torsion Uncommon – neurologic problems Myelodysplasia Cerebral palsy
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Source Undetermined
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Source Undetermined
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OUT - TOEING
External rotation contractures hips Seen in newborn Improve spontaneously first year
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Please see: http://www.cssd.us/body.cfm?id=1218
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BOWLEGS / KNOCK KNEES
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EVALUATION
Clinical Knee joint laxity Range of motion Location of angulation – femur/joint/tibia Assess alignment – AP/lateral/rotation
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EVALUATION
Radiographic Long films – standing Neutral alignment
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Source Undetermined
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EVALUATION
Laboratory Renal function studies – BUN/creatinine Calcium/Phosphorus/Alk.phos.
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BOWLEGS (GENU VARUM)
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Differential diagnosis
Physiologic (most common) Blount’s Disease Rickets Skeletal dysplasia
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PHYSIOLOGIC BOWLEGS
Normal in infants (15 degrees) Neutral by 18-24 months X-rays normal except for bowing
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Source Undetermined
Dr. C. Robert Dushack
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Source Undetermined
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INFANTILE BLOUNT’S DISEASE
Growth retardation proximal tibial epiphysis Medial / posterior Abnormal weightbearing stresses Early walkers Obesity Racial Bilateral 75 %
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IMAGING
Medial “beaking” initial sign Progressive depression medial tibial plateau Langenskiold stages I-V
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Source Undetermined
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Source Undetermined
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GENU VALGUM
Developmental most common Differential diagnosis Metabolic bone disease Renal osteodystrophy Trauma – proximal tibial fx. Tumor – fibrous dysplasia
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Source Undetermined
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DEVELOPMENTAL HIP DYSPLASIA
Etiology Multifactorial Not always congenital or dislocated “continuum of dysplasia”
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DDH - ETIOLOGY
Mechanical factors First born (small space) Breech presentation (60%) Left hip (60%) Torticollis (20%) Metatarsus adductus/calcaneovalgus
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DDH – ETIOLOGY
Physiologic factors Female (6:1) Hormones – estrogen Environment Cradle boards
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HIP AT RISK
Major Abnormal clinical exam Breech presentation First born female Family history DDH
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HIP AT RISK
Minor Limitation of abduction Sacral dimple Foot deformity Torticollis Scoliosis
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NEWBORN TO TWO MONTHS
Ortolani and Barlow tests most reliable X-rays unreliable (false neg. 50%) Ultrasound – non-invasive Age limited Operator dependent May be too sensitive (immaturity) Helpful for brace follow up
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Source Undetermined
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DDH - EXAM
Infant relaxed/supine Stabilize pelvis Flex hip 90 degrees Adduct past midline / gentle outward pressure Gentle abduction – lift toward socket Feel dislocation/relocation Not just abduction test
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Refer to: http://static.howstuffworks.com/gif/hip-dysplasia-screening.jpg
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!!!
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NEWBORN TO SIX MONTHS
Ortolani positive – reducible Reduce femoral head Maintain abducted and flexed 100 degrees flexion/60 degrees abduction Document reduction (x-ray/ultrasound)
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PAVLIK HARNESS
Maintains flexed/abducted posture Free motion within limited range Safe zone of Ramsey Flexion above 90 degrees Avoid excessive abduction Avascular necrosis
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Source Undetermined
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TWO MONTHS TO TWO YEARS
Radiographic findings Shenton’s line broken Proximal/lateral migration femoral head False acetabulum (acetabular dysplasia)
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Source Undetermined
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DDH EXAM
EVERY WELL BABY EXAMINATION
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IDIOPATHIC SCOLIOSIS
Incidence - 22/1000 4/22 require treatment Sorting Discovery – school screening Initial exam – family MD/pediatrician Disposition - orthopaedist
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SCOLIOSIS ETIOLOGY - GENETIC
80% Positive family history Variable expression High degree penetrance Equal sex distribution
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SCOLIOSIS CLINICAL EVALUATION
A-P alignment Curve types Right thoracic/left lumbar most common Double major/thoracolumbar Trunk alignment Rib hump (forward bending test)
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!!!
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!!!
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!!!!
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Source Undetermined
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SCOLIOSIS CLINICAL EVALUATION
Sagittal alignment Thoracic lordosis Kyphosis Lumbar lordosis
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Source Undetermined
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Source Undetermined
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SCOLIOSIS RADIOLOGIC EVALUATION
Standing PA and lateral films (initial) Entire spine Cobb measurement method Minimize follow up films Risser grading – skeletal maturity
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Radiology at the University of Washington
Zorkun at Wikidoc.org
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Xray2000
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Source Undetermined
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SCOLIOSIS
BEWARE Painful scoliosis/neurologic findings Progressive curve in males Unusual pattern (left thoracic) Rapid progression (> 1 degree/month) INTRADURAL ABNORMALITY Tumor/syrinx/ruptured disc
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SUMMARY
Most angular deformities resolve with growth Exam best screen for DDH in newborn Caution “hip at risk” Majority of scoliosis non-progressive Beware “unusual scoliosis”
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Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy
Slide 8: Allison Gilmore, MD, ET AL, http://www.consultantlive.com/display/article/10162/33387 Slide 12: The Internet Journal of Biological Anthropology 2009 : Volume 3 Number 1,
http://www.ispub.com/journal/the_internet_journal_of_biological_anthropology/volume_3_number_1_63/article_printable/femoral-anteversion-comparison-by-two-methods.html
Slide 13: Source Undetermined Slide 14: Source Undetermined Slide 16: Source Undetermined Slide 17: Source Undetermined Slide 18: Source Undetermined Slide 19: Source Undetermined Slide 21: Source Undetermined Slide 22: Source Undetermined Slide 28: Source Undetermined Slide 33: Dr. C. Robert Dushack, http://www.pffcpc.com/flatfoot.shtml; Source Undetermined Slide 34: Source Undetermined Slide 37: Source Undetermined Slide 38: Source Undetermined Slide 40: Source Undetermined Slide 47: Source Undetermined Slide 49: Refer to http://static.howstuffworks.com/gif/hip-dysplasia-screening.jpg Slide 53: Source Undetermined Slide 55: Source Undetermined Slide 62: Source Undetermined Slide 64: Source Undetermined Slide 65: Source Undetermined Slide 67: Zorkun at Wikidoc.org, http://www.wikidoc.org/index.php/Image:Scoliosis_cobb.gif Slide 68: Xray2000, http://www.e-radiography.net/radpath/r/risser-sign.htm#TOP Slide 69: Source Undetermined