By I. Hjalte. Massachusetts School of Professional Psychology.
The degree of knee and hip joint contracture commonly seen at foot and ankle will be a direct reflection of birth buy discount citalopram 20 mg line. Consequently discount 40 mg citalopram mastercard, equinovarus generic 40mg citalopram with visa, equinovalgus generic citalopram 20mg with mastercard, calcaneovalgus, and calcaneovarus are all normal accompaniments providing that the deformity is fully flexible and passively correctable beyond the neutral position. Intrauterine postural deformities secondary to normal intrauterine compression will generally unwind and spontaneously correct, usually by three months of age, in well over 90 percent of all children. Treatment of these deformities by Lower extremity developmental attitudes 10 parental positioning, stretching, splints, casts, or braces will be universally successful, with little more scientific merit than having the parents pay periodic visits to the zoo until the child is four months of age. Although hip contracture generally spontaneously improves, a mild contracture of 15–20 degrees is common even at six to nine months of age, until the child begins standing through much of his or her waking day. Likewise, the knee contracture will unwind, although full straightening is uncommon until standing is achieved. Internal tibial torsion also will spontaneously improve (this process will be covered in a later discussion). Intrauterine foot and ankle deformation has an identical evolution, with flexibility increasing rapidly through the first three months of extrauterine life. The 10–15 percent of children who persist beyond that age with contracture will be dealt with subsequently. It is conceptually easy to envision the rationale for these postural attitudes. There is little necessity for “straight” hips, knees, ankles, and feet in a child who is rolling over, sitting, and crawling. When “mother nature” determines that it is time to stand and eventually walk, the bones and joints will then allow for that attitude without our interference. Out-toeing Nearly 90 percent of all adults who have been clinically measured will have zero to ten degrees of out-toeing as a part of their normal gait pattern. So common is this complaint seen by primary care physicians and pediatric orthopedists, that I have devoted a separate discussion to the topic. At birth, nearly all children have 70–90 degrees of passive and active external rotation of the hip, regardless of the degree of hip flexion contracture. The normal crowded intrauterine position does not allow the infant to “stand up,” or to internally rotate the lower limbs. Consequently, external 11 Out-toeing rotation at the hip level is the “norm” and this contracture deformation persists until it is no longer needed. There is little need for internal rotation of the hip until children begin to crawl and particularly until they begin to stand. Lower limbs that are externally rotated and abducted are helpful for initially achieving appropriate standing balance and stability. Considering the needs that our body has for the age that we are, it is amazing that we are “lined up and ready to go” when we achieve that next developmental milestone. Just as a mechanical engineer would design a modern sports car for stability and balance by lowering the center of gravity and widening its base, so do we humans spread our legs (widen the base), externally rotate our hips, crouch or squat (lower our center of gravity), and even pronate or “inroll” our ankles to achieve a maximally stable weight bearing surface for our feet (Figure 2. Nearly every grandmother will recognise this posture, as all of her “normal” grandchildren will have demonstrated it when they began to stand and walk. Developmental displacement of the hips (formerly termed congenital dislocation of the hip), congenital coxa vara, partial absence of the femur, and neurologic disorders of the lower extremity are uncommon causes of external rotation that should be considered. However, a properly conducted history and physical, and perhaps a radiograph if clearly clinically indicated, will establish the benign nature of the observation. In addition to the expense of unnecessary braces, splints, and adaptive shoe wear to treat this condition, there is a psychological impact of implanting within families’ minds the idea that their “loved one” is “diseased,” and this should provide adequate caution to all of us. There is nothing medically demeaning in simply reassuring the family, particularly when the consequences of treatment will only perpetuate the fallacy. Lower extremity developmental attitudes 12 Genu varum (“bowlegs”) and genu valgum (“knock-knees”) From the 1940s to the present, “bowlegs” and “knock-knees” have enjoyed the distinction of being one of the most common complaints seen by primary care physicians and orthopedic surgeons. A far greater understanding of the natural evolution of these conditions in childhood has resulted in a dramatic reduction in the number of these cases currently seen by physicians. In addressing the natural history of these two conditions in the growing child, it is important Figure 2.
Initially after injuries 20 mg citalopram for sale, breathing and pulmonary gas exchange may not be significantly impaired but knowledge of an inhalation injury at this time can influence a number of management decisions including airway manage- ment cheap citalopram 20 mg without a prescription, fluid resuscitation purchase citalopram 10mg without a prescription, and diagnosis of systemic toxicity from inhaled sub- stances purchase citalopram 40 mg with amex. Inhalation Injury 61 History Definitive diagnosis of inhalation injury will ultimately depend on endoscopic observations of damaged airway mucosa or development of respiratory failure. Timely management, however, begins with a heightened suspicion based on clini- cal evaluation. Information from a history and physical examination can be used to identify many patients with inhalation injury. A number of historical features identify victims at increased risk for inhala- tion injury (Table 2). One of the most important is a history of smoke exposure in an enclosed space, which prevents dilution of the smoke and impairs the vic- tim’s ability to escape. Some forms of physical or mental impairment likewise prevent avoidance behavior and increase the risk of smoke inhalation. Physical impairment might be due to traumatic injury, while mental impairment could include extremes of age or depressed consciousness due to hypoxia or intoxication (substance abuse or toxic smoke components). Information regarding duration should be sought: prolonged exposure implies higher risk. Flash or explosive fires can result in thermal injury to both the upper and lower airways. The trachea may be burned if the upper airway heat exchange capacity is over- whelmed and hot gases are forced through the glottis before laryngeal closure is possible. As mentioned earlier, inhalation of steam can cause thermal injuries distal to the larynx. Aspirated or swallowed hot liquids may also cause pharyngeal and laryngeal burns. Exposure to caustic fumes may cause serious injury to the airways and lung parenchyma. If the composition of inhaled fumes is known, the harmful effects of the chemical irritants can be predicted from knowledge of the chemicals’ solubility. Effects of water-soluble irritants are generally seen in the airways because they dissolve in and are sequestered in airway secretions more proximately. Less soluble irritants are carried more distally and may cause delayed pulmonary edema from parenchymal injury. TABLE 2 Features of patient history associated with increased risk of inhalation injury Smoke exposure in an enclosed space Prolonged exposure to smoke Physical or mental impairment Fire conditions and fuel Explosions Steam Caustic Fumes Pre-existing pulmonary disease Aspirated or swallowed hot liquid 62 Woodson et al. The impact of an inhalation injury depends in part on the patient’s physiological reserve, which may be limited by the presence of pre-existing disease. Physical Examination Physical examination also reveals clues to underlying inhalation injury. Injuries of a critical nature are generally picked up during the initial trauma survey (advanced trauma life support protocol). Respiratory distress from airway obstruction or impaired pulmonary gas exchange usually presents with obvious signs and symp- toms. Other patients with serious inhalation injury may present without respiratory distress and the insidious nature of the progressive respiratory failure may make inhalation injury less obvious initially. Physical examination can identify individ- uals at increased risk (Table 3). Soot covering the face is clear evidence of exposure to smoke but not necessarily inhalation injury. Carbonaceous sputum is stronger evidence of smoke inhalation but may also be a false-positive indicator. Coughing up cabonaceous secretions can occur when soot deposits are restricted to the nasal passages. Carbonized nasal secretions may be aspirated and appear in tracheal aspirates. In addition, smoke inhalation and smoke inhalation injury are not always synony- mous. Damage to the tissues in the airways or lung parenchyma does not always occur when smoke is inhaled.
The valgus deformities of the knees occasionally require Clinical features order 40 mg citalopram overnight delivery, diagnosis a varization osteotomy [109] generic citalopram 10 mg visa. There is proportionately short lower legs in order to improve disproportionate dwarfism with contractures of the joints generic 10 mg citalopram, the proportions may be appropriate buy citalopram 10mg lowest price. Recentering of severe clubfeet, characteristic deformities of the ears and the patella is indicated if it has dislocated laterally, and abduction of the thumb. A cleft palate is also frequently sometimes requires the detachment and medial trans- present. The abduction of the thumb fer of the whole quadriceps muscle ( Chapter 3. The rearfoot is Atelosteogenesis (3 types) is an extremely rare autosomal- in an extreme varus and equinus position. The joints can recessive syndrome with short extremities and character- either be very stiff or very lax. Contractures predominate istic, wide face with widely spaced eyes and a hypoplastic in most cases. Multiple joint dislocations, cleft lip and palate, tures, which can severely interfere with walking ability. Omodysplasia (autosomal-dominant inheritance) is The elbow joints may be contracted. The spinal chang- characterized by short upper arms, facial abnormalities es are particularly severe. Photographs and x-rays of the hands (a, b) and legs short phalanges and the genua valga resulting from the excessively (c, d) of a 16-year old boy with Ellis-van-Creveld syndrome. Some- kyphosing of the cervical spine is particularly problematic, times the dwarfism is extreme, with a final height as low potentially reaching 180° during the first few years of life. The vertebral arches are at a late stage, and are deformed, flattened or triangular in usually abnormally shaped (⊡ Fig. A coxa vara is often Moreover, the interpedicular distance can decline towards observed, with widening and irregularities of the femoral the lumbar level, and the pedicles may be short, as in neck. The long bones are short and thick, resembling achondroplasia, resulting in the development of spinal those in achondroplasia. Thoracic or thoracolumbar kyphosis is almost plasia, the appearance of the epiphyseal centers is delayed. At the lumbar level this is accentuated The flat bones do not show any changes. In view Since both forms are lethal they will not be discussed any of the joint contractures it must also be differentiated further at this point. Milder This group includes the lethal forms of achondrogene- 4 forms are often observed in Finland. Patients with sis II (Langer-Saldino) and hypochondrogenesis and the severe forms are greatly disabled, although life expectancy congenital forms of spondyloepiphyseal dysplasia, the does not appear to be significantly restricted. These disorders affect type II collagen, which makes Orthopaedic treatment: Numerous orthopaedic prob- up 80% of the collagen in the cartilage matrix. The loca- lems are posed by diastrophic dwarfism and the treat- tion of the gene defect is 12q13. The deformities are difficult to treat and have a great tendency to recur. Achondrogenesis II and hypochondrogenesis The clubfeet, with the extreme equinus deformity, Very severe, disproportionate stunted growth, hydrops, should be surgically corrected during the first year death at birth or the neonatal period. If, Spondyloepiphyseal dysplasia as often occurs, the patella is dislocated, this should > Definition be reduced to its normal position with a soft tissue Inherited disorder with disproportionate dwarfism that release. This procedure should be performed at a rela- mainly affects the spine, but also involving the epiphyses tively early stage since the reduction is always more of the long bones. In view of the cartilage Classification, etiology, occurrence: Although a clear in- changes the prognosis for the hips is poor even when heritance pattern has been found for both forms, most they are centered. Histochemical investigation has shown a tients develop a very severe kyphosis even in infancy, degenerative lysosomal process in the formation of particularly at cervical level. As mentioned above, type II collagen is influence the kyphosis with a cervical collar or a halo. In some cases, however, an early anterior and poste- Certain cases show similarities with mucopolysac- rior spondylodesis cannot be avoided.
J Bone Joint Surg (Am) 74: 278–84 tumors have been registered in under-20-year-olds during 11 generic citalopram 40 mg line. Meurer A purchase citalopram 10mg, Eysel P order citalopram 40 mg visa, Heine J (1995) Ergebnisse der operativen Behan- this time cheap citalopram 20 mg amex, compared to 183 primary bone tumors in adults. Upadhyay SS, Saji MJ, Sell P, Sell B, Hsu LC (1994) Spinal deformity tumors were malignant (3 Ewing sarcomas, 1 osteosar- after childhood surgery for tuberculosis of the spine. The commonest tumors were osteoblastoma and 91–8 aneurysmal bone cyst, which each occurred in around a quarter of cases. Even giant cell tumor of the sacrum and chordoma, which were fairly common in adults, were extremely rare 3. Osteoblastoma was slightly less predominant in adults than in adolescents, while an- > Definition eurysmal bone cysts were hardly observed in adults at all. Primary bone tumors originating in the vertebral bodies The tumors are distributed very regularly across all or vertebral arches, or soft tissue tumors arising from mu- segments, without any one preferred region. Only the scles, connective tissues, blood vessels or nerve tissues in sacrum is affected to a slightly greater extent (particularly the immediate vicinity of the spine. Osteoblastomas are slightly more likely to affect the lumbar area than the Occurrence thoracic or cervical spine. Only 10% of all primary bone tumors are located in the Of the malignant tumors, osteosarcomas and chon- spine, 85% of which are benign. Diagnoses of primary tumors of the spine in children and adolescents (n=80) compared to adults (n=183) (Basel Bone Tumor Reference Center) Children and adolescents Adults Osteochondroma 3 3. Our register only records tissue infiltration (particularly intraspinal infiltration). In an overview of the European multicenter larly applies to the relatively common spinal tumor of study on the treatment of osteosarcoma (COSS), 22 of osteoblastoma. Out of 975 Ewing sarcomas recorded in Differential diagnosis 3 the European multicenter EICESS study, 78 (8. The common symptom is non-load- Diagnosis related pain that can also occur at night. The laboratory We know from a study on benign tumors of the cervi- results usually indicate whether an infection is present cal spine, that only 70% of the tumors are visible on a or not, but it should be borne in mind that chronic conventional x-ray, even when other imaging techniques infections often show only minimal, or even no, changes have shown a tumor to be present. This also applies to tuberculosis and difficult, therefore, to diagnose tumors of whose existence brucellosis. Severe back symptoms are rare in children and ado- Benign and semi-malignant tumors lescents. In view of the difficulty with radiographic Osteoblastoma diagnosis, a bone scan should be arranged within a Next to aneurysmal bone cysts, osteoblastomas are the reasonable period if the patient complains of pain commonest bone tumors found in the spine in children that is not load-related. Osteoblastomas cause diffuse pain with osteoblastomas of the spine, which were only diag- that frequently occurs at night. As with osteoid osteomas, nosed, on average, some 16 months after the start of the pain responds well to aspirin, although the effect is symptoms. In histological respects, A bone scan is a cost-effective investigation for dem- an osteoblastoma is identical to an osteoid osteoma. An onstrating the presence of a neoplastic process with a osteoid osteoma is located in the cortex of long bones very high probability and also for indicating its location. The tumor Only if the scan shows a positive uptake should further itself remains as small as a grain of rice (»nidus«). Bone scan (left) and CT (right) in a 7-year old girl with osteoblastoma in the vertebral arch of C6 153 3 3. Certain authors also make a distinc- granuloma has also been described. The recurrence tion in the spine between clearly demarcated osteoid rate for the solid variant appears to be rather lower than osteomas and osteoblastomas with their more diffuse that for a standard aneurysmal bone cyst. Active aneu- margins and which can also project from the bone into rysmal bone cysts can grow very rapidly and destroy the the soft tissues. Making this distinction can often bone within a correspondingly short period (⊡ Fig. However, since both Simple curettage is often not sufficient in such cases and tumors are histologically identical, this distinction is not frequently results in recurrences.
In adolescent scoliosis there is a disparity be- tween the growth of the vertebral bodies anteriorly and that of the posterior elements generic citalopram 20mg. The vertebral bodies grow faster than the posterior elements discount 20 mg citalopram free shipping, resulting primarily in a lordosis purchase citalopram 40 mg with visa. The diminished dorsal growth impedes the 3 ventrally located vertebral bodies from increasing in height cheap citalopram 40 mg amex, forcing them to become distorted, i. The idea of looking at in this way dates back to Somerville, and many more recent studies have con- firmed this theory [32, 59, 78, 93]. Lordosis is almost al- ways present in adolescent scoliosis, even when the spine appears kyphotic on the x-ray in a particular projection. It is conceivable that the spinal cord is protecting itself against the stretching stimulus of growth. Several investigations in recent years have reported the existence of intraspinal anomalies or neurological problems in a certain propor- tion of »idiopathic« scolioses. MRI studies have shown an intraspinal syrinx in 8% of typical idiopathic thoracic adolescent scolioses [23, 91]. Other investigators have found pathological somatosensory potentials in over 50 percent of cases of idiopathic adolescent scoliosis. Anteroposterior and lateral x-ray of an idiopathic thoracic does not appear to be relevant to such findings. Note the pronounced thoracic »handedness« responsible for the direction of the lateral lordosis a b c d ⊡ Fig. Principle of the development of idiopathic adolescent from a rod (a, c). The cherries and the stems represent the vertebral bodies and is reduced, the cherries make space for themselves by rotating (b, d). They are suspended next to each other The lateral curvature is the ultimate consequence of this rotation 75 3 3. The fact that idiopathic thoracic adolescent are extremely common and are of no relevance to scoliosis tends to have a right-sided convex curve is the formation of scoliosis. Differences of 2 cm and rather attributable to the site of the mediastinal organs. However, sagittal plane, the distorted side is essentially dependent the correlation between leg length discrepancy and on the anatomical configuration. As confirmation of this scoliosis is not very close [44, 100], nor is the clinical theory we have found a left convex thoracic scoliosis in measurement of leg length discrepancy very reliable. Thoracic scolioses that are Several studies have investigated whether an anomaly not right convex must therefore be investigated by MRI or asymmetry of the muscles is present. In most for the possibility of intraspinal anomalies before surgery cases, biopsies were taken from scoliosis patients at (we now routinely arrange an MRI scan of the spine be- operation and the muscle samples were examined fore every scoliosis operation). All authors found The causes of early onset scoliosis likewise remain an increased proportion of type 1 muscle fibers on the unknown. Some cases of juvenile scoliosis show a pro- convex side of the scoliosis compared to the concave gression similar to that of adolescent scoliosis, while side. It is generally agreed, however, that these are others, primarily cases with a very early onset, behave dif- secondary changes and do not involve a primary asym- ferently – as described above. A corresponding investigation play a certain role in terms of the etiology. Following the before the onset of scoliosis has not been implemented introduction of the practice of placing the infant in the for obvious reasons. Since the 1990’s, however, pediatricians but has been induced in animal experiments by a wide have been advising parents to place their babies on their variety of manipulations, e. Unfortunately, none of ing incidence of sudden infant death syndrome observed these experiments has provided any significant find- for the prone position. However, since resolving infantile ings concerning the etiology of idiopathic scoliosis.