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PERTHES DISEASE

Posted on: September 25th, 2016 by admin No Comments

INTRODUCTION:

Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood to the round head of the femur (thighbone) is temporarily disrupted. Without an adequate blood supply, the bone cells die, the process is called avascular necrosis or osteonecrosis. This disease otherwise known as “Legg-Calve-Perthes syndrome”

perthes-disease

CLASSIFICATION IF PERTHES DISEASE:

There are four stages in Perthes Disease:

    • INITIAL/Necrosis: In this stage of the disease, the blood supply to the femoral head is disrupted and bone cells die. The area becomes intensively inflamed and irritated and your child may begin to show signs of the disease, such as a limp or different way of walking. The initial stage may last for several months.

classification-if-perthes-disease

In the FIRST STAGE of Perthes disease, the bone in the head of the femur slowly dies.

  • Fragmentation: Over a period of 1 to 2 years, the body removes the dead bone and quickly replaces it with an initial, softer bone. It is during this phase that the bone is in weaker state and the head of the femur is more likely to break apart and collapse.
  • Reossification: New, stronger bone develops and begins to shape in te head of femur. The Reossification stage is often the longest stage of the disease and can last a few years.
  • Healed: In this stage, the bone growth is complete and the femoral head has reached its final shape. How close the shape is to round will depend on several factors, including the extent of damage that took place during the fragmentation phase, as well as the child’s age at the onset of disease, which affects the potential for bone regrowth.

                                                 Lateral Pillar (HERRING) CLASSIFICATION:

lateral-pillar

CAUSES:

The cause of Perthes disease is not known. Some recent studies indicate that there may be a genetic link to the development of Perthes, but more research need to be conducted.

SIGNS & SYMPTOMS:

One of the earliest signs of Perthes is a change in the way our child walks and runs. This often most apparent during sport activities. Your child may limp, or develop a peculiar running style. Other common symptoms may include:

  • Pain in the hip or groin or in other parts of the leg, such as the thigh or knee (called “referred pain”).
  • Pain that worsens with the activity and is relived with rest.
  • Painful muscle spasms that may be caused by irritation around the hip.

Depending upon your child’s activity level, symptoms may come and go over a period of weeks or even months before a doctor visit is considered.

DIAGNOSTIC AND EXAMINATIONS:

After discussing your child’s symptoms and medical history doctor will conduct a thorough physical examination.

  • PHYSICAL EXAMINATION TESTS:Doctor will assess your child’s range of motion in the hip. This disease usually causes limitation in the movements (typically limits the ability to move the leg

away from the body {abduction}, and twist the leg toward the inside of the body {internal rotation}).

  • X-Rays: Perthes can be diagnosed with X-rays study of the hip. X-rays will show the condition of the femoral head.

diagnostic-and-examinations

In this x-ray, Perthes disease has progressed to a collapse of the femoral head (arrow). The other side is normal.

TREATMENT:

The goal of the treatment is to relieve painful symptoms, protect the shape of the femoral head and restore normal hip movement. If left untreated, the femoral head can deform and not fit well within the acetabulum, which can lead to further hip problems in adulthood.

There are many treatment options for Perthes disease. Doctor will consider several factors when developing a treatment plan for your child, including:

  • Your child’s age. Younger children (age 6 and below) have a greater potential for developing new, healthy bone.
  • The degree of damage to the femoral head. If more than 50% of the femoral head has been affected by necrosis, the potential for regrowth without deformity is lower.
  • The stage of disease at the time your child is diagnosed. How far along your child is in the disease process affects which treatment options your doctor will recommend.
  • NONSURGICAL TREATMENT:
  • Observation. For very young children (those 2 to 6 years old) who show few changes in the femoral head on their initial x-rays, the recommended treatment is usually simple observation. Doctor will regularly monitor your child using x-rays to make sure the regrowth of the femoral head is on track as the disease runs its course.
  • Anti-inflammatory medications.  Painful symptoms are caused by inflammation of the hip joint. Anti-inflammatory medicines are used to reduce inflammation, and doctor may recommend them for several months. As your child progresses through the disease stages, doctor will adjust or discontinue dosages.
  • Limiting Activity.  Avoiding high impact activities, such as running and jumping, will help relieve pain and protect the femoral head. Doctor may also recommend crutches or a walker to prevent your child from putting too much weight on the joint.
  • Physical therapy exercises.  Hip stiffness is common in children with Perthes disease and physical therapy exercises are recommended to help restore hip joint range of motion. These exercises often focus on hip abduction and internal rotation. Parents are often needed to help the child complete the exercises
  • Hip abduction. The child lies on his or her back, keeping knees bent and feet flat. He or she will push the knees out and then squeeze the knees together. Parents should place their hands on the child’s knees to assist with reaching a greater range of motion.
  • Hip rotation. With the child on his or her back and legs extended out straight, parents should roll the entire leg inward and outward.
  • Casting and bracing. If range of motion becomes limited or if x-rays or other image scans indicate that a deformity is developing, a cast or brace may be used to keep the head of the femur in its normal position within the acetabulum.

casting-and-bracing

Petrie casts keep the legs spread far apart in an effort to maintain the hips in the best position for healing.

  • Arthrogram. During the procedure, doctor will take a series of special x-ray images called arthrograms to see the degree of deformity of the femoral head and to make sure he or she positions the head accurately. In an arthrogram, a small amount of dye is injected into the hip joint to make the anatomy even easier to see.
  • Tenotomy. In some cases, the adductor longus muscle in the groin is very tight and prevents the hip from rotating into the proper position. Doctor will perform a minor procedure to release this tightness called a tenotomy before applying the Petrie casts. During this quick procedure, your doctor uses a thin instrument to make a small incision in the muscle.

After the cast is removed, usually after 4 to 6 weeks, physical therapy exercises are resumed. Your doctor may recommend continued intermittent casting until the hip enters the final stage of the healing process

  • SURGICAL TREATMENT:

Doctor may recommend surgery to re-establish the proper alignment of the bones of the hip and to keep the head of the femur deep within the acetabulum until healing is complete. Surgery is most often recommended when:

  • Your child is older than age 8 at the time of diagnosis. Because the potential for deformity during the reossification stage is greater in older children, preventing damage to femoral head is even more critical.
  • More than 50% of the femoral head is damaged. Keeping the femoral head within the rounded acetabulum may help the bone grow into a functional shape.
  • Nonsurgical treatment has not kept the hip in correct position for healing.

The most common surgical procedure for treating Perthes disease is an osteotomy. In this type of procedure, the bone is cut and repositioned to keep the femoral head snug within the acetabulum. This alignment is kept in place with screws and plates, which will be removed after the healed stage of the disease.

surgical-treatment

An osteotomy of the femur places the femoral head in a better position to heal

In many cases, the femur bone is cut to realign the joint. Sometimes, the socket must also be made deeper because the head of the femur has actually enlarged during the healing process and no longer fits snugly within it. After either procedure, the child is usually placed in a cast for 6 to 8 weeks to protect the alignment.

After the cast is removed, physical therapy will be needed to restore muscle strength and range of motion. Crutches or a walker will be necessary to reduce weight bearing on the affected hip. Doctor will continue to monitor the hip with x-rays through the final stages of healing.

DIFFERENT SPLINTS AND TRACTION USED IN ORTHOTEDICS

Posted on: September 20th, 2016 by admin No Comments

SPLINT:

Any material used to support a fracture is known as splint.

  • Unconventional.
  • Conventional.

INDICATIONS:

  • Temporary immobilization of sprains, fractures and reduced dislocations.
  • Control pain
  • Prevention of further soft tissue or neurovascular injuries.

CRAMER-WIRE SPLINT:

cramer-wire-splint

  • Ladder splint.
  • Used temporary splint for fractures during transportation.
  • Made of 2 thick parallel wires with interacting wires.
  • Can be bent into different shapes.

THOMAS KNEE-BED SPLINT:

  • Initially used for immobilization for tuberculosis of the knee.

thomas-knee-bed-splint

BOHLER BRAUN SPLINT:

bohler-braun-splint

  • ADVANTAGES: Angle of traction can be changed without changing traction arrangements. Simultaneous tractions possible.
  • DISADVANTAGE: Not suitable for transportation.

DENNIS BROWN SPLINT:

dennis-brown-splint

dennis-brown-splint-1

COCK-UP WRIST SPLINT:

cock-up-wrist-splint

TAYLOR’S BRACE:

taylors-brace

CARE OF A PATIENT IN A SPLINT:

  • Splint should be properly applied, well-padded at bony prominences and at the fracture sites.
  • Bandage of the splint shouldn’t be too tight nor too loose.
  • Patient should be encouraged to actively exercise the muscles and the joints inside the splint as much as permitted.
  • Any compression of nerve or vessel should be detected early and managed accordingly.
  • Daily checking and adjustments should be made.

AEROPLANE SPLINT:

aeroplane-splint

MILWAUKEE BRACE:

milwaukee-brace

TRACTION:

Traction is a method of restoring alignment to a fracture through gradual neutralization of muscular forces.

USES:

  • Reduction of fractures and dislocations.
  • Immobilizing painful and inflamed joint.
  • Preventing deformities.
  • Correction of soft tissue contractures.

TYPES OF TRACTION:

  • FIXED TRACTION

Counter traction is provided by the part of the body.

  • SLIDING TRACTION

Weight of the body under influence of gravity provides counter-traction.

types-of-traction

METHODS OF APPLYING TRACTION:

  • Skin traction:
  • Adhesive/non adhesive strap is applied on the skin and traction is applied.
  • Acts over large area.
  • Maximum weight permissible 6-7kg.

methods-of-applying-traction

  • Skeletal traction:

Traction applied through pin/wire driven through bone.

skeletal-traction

SKIN TRACTION SKELETAL TRACTION
AGE Children Adults
APPLIED WITH Adhesive plaster Pin,wire
APPLIED Skin Bone
SITE Below knee Upper tibial pin traction
Wt.PERMITTED 3-4 kg 20kg
DURATION Short long

COMPLICATIONS OF TRACTION:

  • Over distraction.
  • Loss of position.
  • Pressure sores.
  • Tin track infection.
  • Injury to vessels or nerves.

CARE OF PATIENT IN TRACTION:

  • Traction should be made comfortable.
  • Proper functioning of traction unit must be ensured.
  • Sensation over toes and fingers should be normal.
  • Proper position of fracture ensured by taking check x-rays in traction.
  • Physiotherapy of limb should be continued to minimize muscle strength(wasting).

SMITH’s FRACTURE

Posted on: September 15th, 2016 by admin No Comments

Smith’s Fractures is also known as a Goyrand Fracture in French literature. Smith’s fracture is palmarly displaced distal radius fracture. It is referred to as “GARDEN SPADE” deformity. Smith’s fracture is a reversed Colles fracture.

smiths-fracture

EIPDEMOLOGY

Smith’s fracture account for less than 3% of all fractures of the radius and ulna and have a bimodal distribution: young males (most common) and elderly females.

MECHANISM

Smith’s fractures usually occur in one of the 2ways:

  1. A fall onto a flexed wrist
  2. Direct blow to the back of the wrist

smiths-fracture1

 

SIGNS AND SYMPTOMS

  1. Typically acute pain in the wrist from an impact or a fall.
  2. Tenderness in the affected area.
  3. Pain is felt while moving the wrist.
  4. Development of swelling.
  5. Wrist may become deformed.
  6. Appearance of hand being downwards.
  7. Fractured may develop a cracking noise.
  8. Symptoms of fever few hours after injury.

CLASSIFICATION

SMITH’S FRACTURE can be broadly be classified into two types.

    1. NONDISPLACED FRACTURE

This is frequently called as mild fracture. The treatment for this condition is casting. Once the problem is diagnosed immediate attention must be given. The area of the fracture gets healed in few weeks.

    1. DISPLACED FRACTURE

This type of fracture is very severe in nature. Displaced generally leads to very serious and dangerous damage to the bone. In this condition the joint of the wrist is often displaced forward creating discomfort over the wrist while moving in some angles.

Types of SMITH’S FRACTURE classified based on the type of injury.

smiths-fracture2

 

INVESTIGATION

  1. X-ray of the wrist.
  2. CT/MRI in rare cases

smiths-fracture3

 

TREATMENT

Smith’s Fractures can be treated with manipulation and reduction.

    1. NONSURGICAL TREATMENT:

Conservatives measures involve closed reduction with use of local anesthesia and then casting of hand to thumb. It takes about 10 weeks for complete recovery, which involves period of immobilization for about a month and then splinting for 6 weeks.

    1. SURGICAL TREATMENT

Surgery is needed in majority of cases with Smiths Fracture as the deformity cannot be treated with nonsurgical means. This method is termed as OPEN REDUCTION.
This is done by creating an incision for interpretation of fracture and to get it back to its normal place. This at times requires pins, screws, etc for fixation.

PHYSIOTHERAPY

This is essential for everyone for appropriate healing and normalizes function of wrist and hand can include:

  1. Joint mobilization.
  2. Soft tissue massages.
  3. Electrotherapy.
  4. Ice and heat.
  5. Therapy focusing on improving the strength.
  6. Activity modifications.
  7. Attempts at returning to activity.

SCOLIOSIS

Posted on: September 10th, 2016 by admin No Comments

scoliosis

Scoliosis is a lateral (toward the side) curvature in the normally straight vertical line of the spine. When viewed from the side, the spine should show a mild roundness in the upper back and shows a degree of swayback (inward  curvature) in the lower back. When a person with a normal spine is viewed from the front or back, the spine appears to be straight. When a person with scoliosis is viewed from the front or back, the spine appears to be curved.

 

What Causes Scoliosis?

There are many types and causes of scoliosis, including:

  1. Congenital Scoliosis. Caused by a bone abnormality present at birth.
  2. Neuromuscular Scoliosis. A result of abnormal muscles or nerves. Frequently seen in people with spina bifida or cerebral palsy or in those with various conditions that are accompanied by, or result in, paralysis.
  3. Degenerative Scoliosis. This may result from traumatic (from an injury or illness) bone collapse, previous major back surgery, osteoporosis (thinning of the bones).
  4. Idiopathic Scoliosis. The most common type of scoliosis, idiopathic scoliosis, has no specific identifiable cause. There are many theories, but none have been found to be conclusive. There is, however, strong evidence that idiopathic scoliosis is inherited.

 

Who Gets Scoliosis?

Approximately 2% to 3% of Americans at age 16 have scoliosis. Less than 0.1% have spinal curves measuring greater than 40 degrees, which is the point at which surgery becomes a consideration. Overall, girls are more likely to be affected than boys. Idiopathic scoliosis is most commonly a condition of adolescence affecting those ages 10 through 16. Idiopathic scoliosis may progress during the “growth spurt” years, but usually will not progress during adulthood.

 

How is Scoliosis Diagnosed?

Most scoliosis curves are initially detected on school screening exams, by a child’s pediatrician or family doctor, or by a parent. Some clues that a child may have scoliosis include uneven shoulders, a prominent shoulder blade, uneven waist, or leaning to one side. The diagnosis of scoliosis and the determination of the type of scoliosis are then made by a careful bone exam and an X-ray to evaluate the magnitude of the curve.

 

What is the treatment for Scoliosis?

The majority of adolescents with significant scoliosis with no known cause are observed at regular intervals (usually every four months to six months), including a physical exam and a low-radiation X-ray.

 

Treatments for Scoliosis Include:

 

Braces

Bracing is the usual treatment choice for adolescents who have a spinal curve between 25 degrees to 40 degrees — particularly if their bones are still maturing and if they have at least 2 years of growth remaining.
The purpose of bracing is to halt progression of the curve. It may provide a temporary correction, but usually the curve will assume its original magnitude when bracing is eliminated.

 

Surgery

Those who have curves beyond 40 degrees to 50 degrees are often considered for scoliosis surgery. The goal is to make sure the curve does not get worse, but surgery does not perfectly straighten the spine. During the procedure, metallic implants are utilized to correct some of the curvature and hold it in the correct position until a bone graft, placed at the time of surgery, consolidates and creates a rigid fusion in the area of the curve. Scoliosis surgery usually involves joining the vertebrae together permanently– called spinal fusion.

CERVICAL RIP

Posted on: September 6th, 2016 by admin No Comments

Introduction

A cervical rib is an extra rib that forms above the normal first rib, growing from the base of the neck just above the collarbone. The defect is present at birth, but usually not noticed until later in life.

It may be a fully-formed bony rib or just a thin strand of tissue fibers, which will not always show up on any X-ray or MRI scans you may have. If the extra rib is only partially formed, it may either end in a swelling that shows as a lump in the neck or it may tail off into a fibrous band of tissue that connects to the first proper rib.

A cervical rib can sometimes squash one of the nearby blood vessels or nerves, causing problems such as neck pain and numbness in the arm. These symptoms are collectively known as thoracic outlet syndrome.

Thoracic Outlet Syndrome

Not all people with a cervical rib will develop thoracic outlet syndrome, and thoracic outlet syndrome can also be caused by other conditions.

Two major blood vessels (the subclavian artery and subclavian vein) and a bunch of nerves called the brachial plexus pass over the cervical rib. They run through a narrow space at the base of the neck towards the armpit and arm.

A cervical rib will only cause any symptoms if it is squashing these blood vessels or nerves.

Symptoms of Thoracic Outlet Syndrome

If the extra rib does press on a vessel or nerve, you may have any of the following symptoms:

    1. pain in the shoulder and neck, which spreads into the arm – this may come and go or be constant
    2. moments where you lose feeling and have weakness or tingling in the affected arm and fingers
    3. moments where you can’t carry out fine hand movements, such as doing up buttons Raynaud’s phenomenon, where the blood vessels go into a temporary spasm, affecting blood supply to the fingers and toes (turning them white)
    4. a blood clot forming in the artery supplying the hand, which can affect the blood supply to the fingers, causing small patches of red or black discolouration
    5. swelling in the affected arm (although this is rare)

These symptoms vary widely from person to person: they may be mild or severe, be persistent or come and go.
Thoracic outlet syndrome usually starts between the ages of 20 and 50 years old, and women are more likely than men to have it.

Treatment

Most people diagnosed with a cervical rib will find their symptoms get better with time, without treatment. Your GP may refer you to a physiotherapist for shoulder exercises designed to stretch and strengthen the neck region and correct any poor posture. The area may be massaged to release any tight or shortened neck tissues. A referral to an occupational therapist may also be useful, for advice on techniques to protect your back and neck while at work.

To relieve any pain and inflammation, your doctor may prescribe you an NSAID painkiller such as naproxen or diclofenac. If you develop thoracic outlet syndrome you may also be prescribed thrombolytic to break up any blood clots, and anticoagulantsto prevent further clots developing. If the above measures don’t help and the symptoms persist, you may wish to consider surgical treatment to remove the extra rib, although this is often a last resort.