wk 5 - rotational Flashcards
what causes positional deformities in fetus
intrinsic cause:
-neuromuscular disorders causing decreased fetal movement
-renal disease resulting in decreased production of amniotic fluid and oligohydramnios, this increases fetal compression from outside forces
extrinsic cause:
-things that cause fetal crowding and restrict fetal movement
2 elements that cause deformations to fetus
- restricted fetal movement
- fetal compression
fetal movement is required for normal musculoskeletal development in extremities
during what period do external compression increase and amniotic fluid decrease
third trimester where deformities most commonly arise
developmental dysplasia of the hip
abnormal development/ contact of the acetabulum and proximal femur causing mechanical instability of the hip joint
risk factors for developmental dysplasia of hip
-female gender
-breech position (baby hasnt turned in womb)
-family history
assessments of dysplasia
- ortolani maneuver
- barlow maneuver
- galeazzi test
4.US/ radiographs after 4-6months of age (before this time the structures are unossified)
what are rotational deformities of the legs
internal tibial torsion
external tibial torsion
physiological genu varum
internal tibial torsion caused by and causes what?
caused by intauterine (womb) positioning, typically bilateral
when its unilateral presentation its usually the left leg for unknown reasons
causes in toeing
it can be associated with metatarsus adductus and genu varum
does internal tibial torsion require treatment
usually resolves after normal growth, intervention isn’t usually required
surgery is only required for an older child where there is obvious functional deformity
external tibial torsion causes and what does it cause
caused by intrauterine positioning
causes out toeing
it is more likely to persist throughout teenage years than internal
genu varum what causes it
caused by womb positioning
caused by external rotation at the hip due to tight posterior hip capsule and internal tibial torsion
treatment for genu varum
usually resolves spontaneously but must be differentiated from pathological caues like blounts disease or rickets
what could genu varum also be? Dx:
blounts disease
rickets
rotational deformities of the feet
metatarsus adductus
positional calcaneovalgus
club foot
skew foot
metatarsus adductus what is it and is it bilateral or uni
forefoot that is adducted at the tarsometatarsal joints in relation to hindfoot that remains in a normal position
often bilateral, if unilateral occurs more on left for unknown reasons
whats the most common cause of intoeing in toddlers
internal tibial torsion
whats the most common cause of intoeing in infants
metatarsus adductus
blecks scale for classifiying matarasus adductus
drawing a line straight down the middle of the heel to toes:
Normal – bisection of 2nd Digit
* Mild – Bisection of 3rd Digit
* Moderate – Between 3rd/4th Digits
* Severe – Between 4th/5th Digit
if youre going to get a radiograph what do u need to remember
ossified bones
primary ossifications present at birth
visible on x ray at birth
calc
talus
cuboid
metarsals
phalanges
primary ossifications developed after birth and when
visible on x ray
lateral cuneiform- 1st year
medial cuneiform- 3rd year
intermediate cuneiform- 4th year
navicular- 4th year
what could metatarsus adductus also be? Ddx:
skewfoot
what are u looking for on radiograph to diagnose metatarsus adductus
medial deviation of 1st met from the talus - first metatarsal line
skewfoot shows what on a radiograph
the same as metatarsus adductus: medial deviation of 1st met from the talar fitst met angle
AS well as
valgus deformity of the hindfoot, with a talocalconeal angle more than 35 degs on AP radiograph and 45 degs on lateral radiograph
what digit deformity do MTA typically have
HAV
what do you need to find out about an metatarsus adductus
positional - using blecks classification
flexibility- rigid, semi rigid, flexible
grading flexibility of metarasus adductus
grade 1 (flexible)- deformity correctable past midline
grade 2- (semi rigid)- deformity correctable to midline
grade3 - (rigid)- deformity cannot be corrected to midline
treatment for mild blecks scale/flexible MA
nil
treatment for mod blecks scale/flexible MA at 4-8months, 8-10 months, walking
4-8months: brace/splint
8-10months: casting and SLS/night splint
walking: 1-2 casts and SLS, orthoses and night splint
treatment for severe blecks scale and semi rigid MA
4-8months: serial casts followed by abduction orthoses /night splint
8-10months: casting and SLS/night splint
walking: 1-2 casts and SLS, orthoses and night splint
treatment for skew foot
footwear, orthoses, surgery
SLS stands for
straight last shoes
if you dont treat MA what could happen
deformities
-metatarsus primus vaurs (abduction of great toe)
-hallux valgus
-hammer toes
-medial tibial torsion
-in toeing
functional
tripping
shoe fitting
aesthetic concerns
plantar pressure differences
flexible metatarsus adductus, do u need to treat?
good evidence that you dont need to and that the child will continue to derotate as they get older
recommendations could be stretching, SLS
can a rigid MA get better after the 1st year?
low evidence showing it gets better as bones start to ossify
what is serial casting
cast below the knee holding the forefoot in a rectus position
cast is changed every 1-2 weeks for a period of up to 6-12weeks
what is serial casting good for
semi rigid MA
and rigid MA if <1 years old
cons of serial casting
-time, multiple visits
-skin irritation/cut flow off
-child not able to give feedback
-emotional trauma/quality of life
what is weaton brace and what is it good for
mod to severe MA
piece of thermoplastic that is moulded to the desired correction of the patients foot
worn for 24 hours a day until correction then suggested 4 weeks of night use to maintain
pros and cons of wheaton brace
pros
-dont need to revisit clinic
-can remove for hygiene
-same results as serial casting
cons
-non weightbearing device
what is bebax orthotics, how are they used, when is correction seen
leather shoe with two parts thats adjusted with a multidirectional hinge
1.worn 21-24hours at 20-25degrees outflare (4-6weeks)
2. increased to 45 degress outflare for 16-18hours per day
correction is seen around 3 months
bebax orthotics good for
semi rigid and rigid MA early in life
pros and cons of bebax orthotics
pros
-less expensive than casting
-can be adjusted
cons
-requires high parent paritcipation
-not for weightbearing (6-12 months or earlier is good for)
what is corrective bandage
starts with corrective manipulation to flex retracted muscles of foot for 5 days per week for 15mins
after which, cotton bandage is applied from toe to knee.
what is corrective bandage good for
semi rigid MA in 1st month of life
pros and cons of corrective bandage
pros
-cost effective
-can be removed
cons
-training in manipulation
-low efficacy
-best done in 1st month of life
what is a denis browne bar
holds foot in externally rotated position
what is denis browne bar good for
all types of MA, skewfoot, gold standard for maintaining correction after casting for talipes equino varus
pros and cons of denis browne bar
pros
-good for babies that sleep in prone position
-good for babies with internal tibial torsion also
cons
-used with caution as holding foot in rearfoot valgus position so there is increased risk of having flat foot deformity after treatment
what are reverse last shoes
opposite shoe wearing
what do reverse last shoes cause
Hallux valgus deformity
other footwear devices for MA
UCBL- high heel cup, medial/lateral flange
SMO- around lat and medial mall
not enough studies done to prove efficiacy
what is a turtle brace and what could it help with
heat mouldable thermoplastic cast that allows walking on
similar to serial casting but removable and can be walked on
talipes calcaneovalgus feet are
hyperdorsiflexion of the foot with abduction of the forefoot which often results in the forefoot resting on the anterior surface of the lower leg
what is associated with calcaneovalgus feet and what do you need to rule out and why
associated with external tibial torsion
Calcaneovalgus resolves spontaneously on its own usually but needs to be differentiated from more severe conditions like congential vertical talus
talipes equino varus (clubfoot)
foot excessively plantarflexed with forefoot swinging medially and soles facing inward
types of clubfoot
- positional (breech)
2.congential -most common - syndromic
treatment for clubfoot
- serial casting with denis browne bar at night to maintain correction
- surgery (tenotomy)- lengthening of achilles tendon
causes of intoeing in infants, toddler and children
infants (1-2): MTA
toddler (2-3): internal tibial torsion
children (3 or mroe): femoral torsion
also CP is a common cause
if a child is intoeing or outtoeing what examinations would you complete
-hip internal/external rotation: lateral range (internal rotation) should be greater than medial (external rotation), at age 2 its symmetrical
test in flexion and extension to check for bony or soft tissue
-femoral torsion (ryders test)
-knee reduced extension
observe position of patella in stance and gait
0-2yrs- laterally rotated
2 years and more - straight
-tibial torsion
1. (foot thigh angle) measuring longitudinal angle of thigh and foot
more than 30deg is external tibial torsion, less than 0deg is internal tibial torsion
- transmalleolar axis
-measuring longitudinal angle of thigh and
feet- blecks/ruler measurement on side of foot
ryders test does what
tests femoral torsion
foot thigh angle tests what
tibial torsion
trans malleolar axis tests what
tibial torsion
if the patella is medially rotated then
there is a femur component thats cause intoeing
if the patella is straight and feet adducted then it could be
medial genicular bias
medial tibial torsion
psudeomalleolar torsion
MTA
if knee extension is limited and foot is adducted what could this be due to
tight hamstrings
tight gastroc
tight ligaments
Difference between tibial torsion and medial genicular bias during gait
in-toe due to medial tibial torsion is usually consistent whereas, in-toeing
due to medial genicular position tends to be more variable (step to step
medial genicular bias is caused by, at what age should become symmetrical
intrauterine confinement, should become symetrical by age 3 but may be maintained if
1. severe
2. postures perpetuate position
3. neuromotor dysfunction impedes normal modelling
most common causes of out toeing
- external rotation contracture of hip
- External tibial torsion
- femoral retroversion (rare)
external rotation contracture of the hip clinical features
- bilateral and symmetrical out toeing
-standing/walking both patella and feet are externally pointing out - increased hip external rotation compared with internal hip rotation
resolves around 12 months of age
external tibial torsion caused by clinical features
caused by intrauterine positioning
-often unilateral and more common on right side
-standing/walking foot externally rotated (external foot progression angle)
-medial mall anterior to lateral mall while seated with thigh in front of hip joint and knee straight ahead
-FTA is external
femoral retroversion clinical features
rare
-obese children
-bilateral an symmetrical out toeing
-external foot and patella progression
-increased hip external rotation compared to internal
-may be assocaited with OA, stress fractures and slipped capital femoral epiphysis
treatment for external rotation contracture of hip
reassure parent that it is physiological and resolves spontaneously
treatment for femoral tretoversion
unlikely to resolve spontaneously
derotational osteotomy may be indicated in patients with hip pain, severe gait disturbances or deformity
external tibial torsion treatment
most can be managed with observation and parental reassurance
derotational tibial osteotomy is the only effective treatment but should only be for patients with knee pain, severe deformity and an external FTA greater than 40 degrees
