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Both polydactyly and syndactyly can involve bone or soft tissue and both may require surgery in later childhood for cosmetic purposes stromectol 3 mg low cost. The spine Back pain in children is uncommon5 and because of the potential for spinal disease to result in considerable disability cheap stromectol 3mg otc, accurate assessment and diagnosis of all spinal complaints is essential and MRI purchase 3mg stromectol visa, in the majority of cases buy 3 mg stromectol amex, is the imaging modality of choice14. Discitis 15 Discitis is an infrequent problem of the paediatric thoracolumbar spine that results from bacterial infection of the intervertebral disc spreading to the verte- bral endplates of the adjacent vertebrae over a period of several weeks12. Clini- cal symptoms are dependent upon patient age and include fever and vomiting in the younger child, while in adolescents back pain is the most common presentation. Plain film radiography of the spine will demonstrate a reduced Orthopaedics 181 Fig. Kyphosis and lordosis Paediatric kyphosis and lordosis are uncommon when compared to scoliosis. A possible cause of increased kyphosis and reduced lumbar lordosis during early adolescence is Scheuermann’s disease which results in the anterior compression of the vertebral body. Plain film radiographic examination should include an antero-posterior and a lateral projection. However, it is essential that the arms are not raised above the level of the lower costal margin as this will con- siderably alter the normal spinal curvature and invalidate the diagnostic accu- racy of the examination16. Scoliosis Scoliosis is defined as the lateral curvature of the spine although a sagittal or transverse component to the curve may also be present. The majority of child- 17 hood scoliosis cases are idiopathic in nature (i. Despite technological advancements, plain film radiog- raphy is still the examination of choice to provide the initial diagnosis and evaluate the degree of the curve. However, MRI also has a significant role to play, particularly in the assessment of intraspinal anomalies and pre-surgical planning18. Plain film radiographic examination of the spine for scoliosis should be per- formed with the patient erect, and a single antero-posterior or postero-anterior projection of the whole spine is sufficient for diagnosis and observational mon- 16 itoring of curves less than 20°. However, as patients with progressive scoliosis may have regular imaging to assess the progression of the curve, it is important that the radiation dose is minimised and to facilitate this, the postero-anterior projection is preferred as it will reduce the dose to the sensitive anterior organs. The adoption of a high kilovoltage technique will also reduce patient dose whilst facilitating the visualisation of the whole spine. The lower border of the cassette should be positioned at the level of the anterior superior iliac spines and collimation opened to include the whole of the spine and the iliac crests. Skeletal maturity is achieved when the iliac crest apophyses reach the posterior superior iliac spines and therefore these 7 should be included on all assessment radiographs. Where radiographs of non- ambulatory patients are requested then these should be undertaken with the spine in its normal functional position (i. Infection Infection of the musculoskeletal system can cause severe disability if not detected and treated at an early stage and all imaging modalities may have a role to play (Box 8. The clinical history provided by the patient or their family can provide impor- tant clues to infection, and signs of systemic illness, localised swelling, erythema, reduction in limb movement or unusual limb position are all suggestive of an infective process. Osteomyelitis Osteomyelitis commonly occurs as a result of haematogenous spread (via the blood) and may be acute, subacute or chronic in presentation. It is typically seen 184 Paediatric Radiography Box 8. Plain film radiography Preliminary examination to exclude trauma or other pathologies Ultrasound Useful in the detection of joint effusions and fluid collections in the soft tissues and sub-periosteal regions May guide aspiration or drainage of fluid collections or effusions Scintigraphy Has a high sensitivity rate and is useful in the identification of multifocal infection Magnetic resonance imaging (MRI) High sensitivity Can accurately assess soft tissues and bones to evaluate the local extent of musculoskeletal infections Computed tomography (CT) Can detect osseous or soft tissue abnormalities, particularly gas in the soft tissues in the metaphyseal region of long bones as a result of the slow movement of blood through the sinusoidal vessels which allows bacteria to adhere to the vas- cular membranes. Clinical symptoms of osteomyelitis include localised pain and swelling and a recent history of systemic illness (e. Radi- ographic findings depend upon the age of the patient and the time of infection onset. However, plain films are not sensitive to early osteomyelitic changes and although they may be requested to exclude other causes of the patient’s symp- toms, scintigraphy is the initial imaging investigation of choice in cases of sus- pected skeletal infection7 (Fig. Septic arthritis Septic arthritis is the inflammation of a joint as a result of infection. The infec- tion may enter the joint directly (traumatic or surgical infection), or indirectly from an adjacent osteomyelitic infection or by haematogenous spread. Clinical symptoms include local or systemic illness and localised swelling and tender- ness. The child may also resist movement of the affected limb and maintain it in a flexed position.
Much attention has been paid to the shape of the patella as observed on axial views discount stromectol 3mg with amex. The classification according to Wiberg is based on differences in the medial patellar facet buy cheap stromectol 3mg line. However cheap 3 mg stromectol amex, these differing shapes are of no relevance to the course of the painful symptoms and generic 3 mg stromectol overnight delivery, therefore, to the treatment. If a CT scan is ordered and a rotation anomaly is clinically suspected, then the corresponding rotations should, if possible, be measured by means of appropriate sections (⊡ Fig. In view of the generally benign course of anterior knee pain during adolescence, we would explicitly warn against any overtreatment! A knee supportwith a pad surrounding the patella can be Useful measures include strengthening of the quadriceps used in patients with ligament laxity and peripatellar pain muscle, and possibly also the stretching of this muscle, since the etiology assumes the presence of an imbalance between muscle strength and the growing lever arm. This can be achieved (in the short term) by physical had never seen a patient who had not undergone surgery therapy. In the long term, however, graduated sports- become disabled as a result of anterior knee pain. Although the pain sentence implies that the opposite is perfectly possible occurs mainly after sporting activities, a complete ban. Such patients often undergo further surgical proce- on sports should not be ordered. Rather, the quadriceps dures, because of the unsatisfactory initial result, eventu- muscle should be strengthened in a targeted and gradu- ally impairing the circulation in the patella and causing ated manner. In such cases, the ultimate (and very bad) a particular role is the subject of debate. Another conservative treatment option is the use pared to patellar dislocation) has a better prognosis if left of a knee support incorporating a pad surrounding the untreated. Since this pad is designed to guide adolescents in Oxford who had previously been investi- the patella it is particularly indicated for patients with gated for anterior knee pain showed that, while 90% flaccid ligaments. Although its efficacy is based more on were still taking part in sports after an average of 16 years, psychological than mechanical factors, we have neverthe- 3/4 of the patients still had significant symptoms. On less been able to achieve success with such supports in a the other hand, there is no evidence to date to indicate few intractable cases. Al- Extreme caution is indicated when it comes to sur- though a link appears to exist between rotation anomalies gery. The English surgeon Goodfellow once said that he and anterior knee pain we cannot generally recommend 289 3 3. A lateral x-ray however, we describe the correction of a pathologically is non-specific in most cases, although fragmentation of increased tibial torsion in a patient under 10 years of age the tibial tuberosity is sometimes observed (⊡ Fig. On the other hand, fragmentation of result, and the femoral anteversion still has time to nor- this apophysis is also occasionally seen in completely malize itself spontaneously. More extensive imaging investiga- On the other hand, children with anterior knee pain tions are not necessary. Insufficient data are Osgood-Schlatter disease is treated conservatively. The available concerning osteoarthritis of the knee in later life parents and child should understand that the healing to enable such a procedure to be recommended. In the acute stage, ice treatments, physical therapy and massaging with oint- 3. Anti-inflammatory drugs are not advisable since they hardly influence the course of > Definition the disease and have to be taken for a very long time. Avascular necrosis and traction-induced inflammation By contrast, a cylinder cast worn on the extended leg for in the area of the tibial tuberosity in adolescents. The efficacy is based less on the immobilization itself, ▬ Synonym: Osteochondritis of the tibial tuberosity than the fact that the – usually very sporting adolescents – are prevented from practicing their sport for a pro- Historical background longed period and thus subjecting the apophyseal plate The disease was first described by Osgood and Schlatter, independently of each other, in 1903.