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By H. Pranck. University of California, Irvine.
Although treatment is often conservative discount 60 mg levitra extra dosage visa erectile dysfunction meds list, with exercises to maintain quadriceps strength generic 60mg levitra extra dosage free shipping erectile dysfunction hernia, and occasional bracing to inhibit lateral subluxation, a number of youngsters will fail conservative care and will require surgical realignment. A variety of surgical realignment approaches are available, with satisfactory results to be anticipated in the majority of cases if performed prior to the development of patellofemoral arthritis. Pain syndromes of adolescence Patellofemoral pain syndrome Traditionally patellofemoral pain syndrome had been termed chondromalacia patella and probably accounts for the greatest number of all cases of knee pain seen in adolescents. The Adolescence and puberty 96 reason for the terminology change relates to the fact that most cases of the patellofemoral pain syndrome do not show pathologic evidence of true chondromalacia of the patella, by either gross anatomic or histologic changes. Characteristically, it is seen more commonly in females although it is often seen in males. The pain is always of a mechanical nature, commonly occurs with activity, and particularly is exacerbated by traveling up and down stairs. Bike riding, running, jumping, and knee squats will frequently reproduce the symptoms. This condition is quite commonly seen in association with recurrent subluxation or dislocation of the patella, and these conditions must be differentiated from the more commonly seen patellofemoral pain syndrome. In contrast to the anatomic malalignment seen in recurrent subluxation and dislocation, this condition tends to spontaneously resolve in the vast majority of patients. It has been estimated that nearly 90 percent of all cases will resolve by the end of the second to third decade. Probably less than 10 percent of patients develop prolonged disabling symptoms requiring surgical treatment. It has been found from experiences with open arthrotomy and arthroscopic examination that true chondromalacia of the patella is generally not part of this pathologic process. Although joint effusion may be noted on physical examination, with pain on compression of the patella laterally, and Figure 5. Compression of the patella in the intercondylar groove tenderness over the medial retinaculum, the producing the characteristicpain. As 97 Pain syndromes of adolescence the patient begins to fully contract the quadriceps, the patella is compressed against the synovial lining with reproduction of typical pain. There are no radiographic features diagnostic of the condition, but radiographs should be taken to differentiate other causes of knee pain. Treatment is clearly conservative, consisting of a combination of ice, heat, short-arc quadriceps exercises, nonsteroidal Figure 5. Lateral radiograph showing ossiﬁcation within the upper tibial anti-inﬂammatory pain medication, and epiphysis not uncommonly seen in association with Osgood–Schlatter occasionally stretching exercises of the disease (such ossiﬁcation occurs innormal children and is not diagnosticof hamstrings and gastrocnemius muscles to Osgood–Schlatter disease). Cases recalcitrant to conservative treatment may occasionally require arthroscopic investigation and perhaps patellofemoral “shaving” if true chondromalacia is present. Osgood–Schlatter disease Osgood–Schlatter disease is an eponym for a condition described by these authors nearly 90 years ago. It is one of the most frequently encountered pain syndromes of adolescence, and is most commonly seen in males (roughly three to one to females). The etiology of the condition is mechanical, and it is basically a tendonitis of the distal insertion of the infrapatellar tendon. It may be accompanied by a minute avulsion fracture of the cartilaginous or bony “tongue” epiphysis of the upper tibia. The anterior portion of the upper tibial epiphysis has a “tongue-like” shape and serves as the site of insertion for the distal end of the patellar tendon. With repetitive contracture of the quadriceps mechanism a small fragment of bone or cartilage may be elevated from the distal portion of the proximal tibial epiphysis, and may secondarily induce an associated inﬂammatory process within the tendon, or around the tendon surface (Figure 5. Clinically the youngsters present Adolescence and puberty 98 with pain in the anterior aspect of the proximal tibia, characteristically aggravated by running, jumping, or knee squats. There is no evidence of intraarticular pathology on examination, and the pain is reproduced by direct compression over the bony prominence at the site of insertion of the patellar tendon (Figure 5. Although radiographs are routinely obtained and may, on occasion, provide some useful information concerning other knee pathology, the diagnosis is a clinical one and should not rest with radiographs. Findings commonly associated with Osgood–Schlatter disease are bony ossicles or fragmentation of the anterior tibial epiphysis and irregularities of the ossiﬁcation center. Treatment is conservative, and routinely effective inasmuch as the disorder subsides on fusion of the upper tibial epiphysis to the shaft Figure 5. Point tenderness at the site of pain in Osgood–Schlatter to the metaphysis. Ice, heat, and nonsteroidal anti-inﬂammatory agents combined with restriction in physical activities, particularly running, jumping, and knee squats, generally result in relief within six to eight weeks. Occasionally physiotherapy, steroid injections and casting may be necessary for recalcitrant cases.
The lateral malleolus cannot be palpated in aplasia of the fibula (type II) and is abnormally high in hypoplasia (type IB; ⊡ Fig discount levitra extra dosage 40 mg on-line erectile dysfunction psychological treatment. X-rays of the left lower leg of a 1 1/2-year old girl with a equinovalgus position as a result of contracture of the calf type IB fibular deficiency and peroneal muscles buy 40 mg levitra extra dosage otc erectile dysfunction boyfriend. Sometimes the rearfoot is also dis- located laterally and may be at a higher level than the end of the tibia. The rearfoot, and occasionally the metatarsal bones as well, are frequently very rigid as a result of coali- should be attempted up until the completion of growth, tion of the talus and calcaneus. For very severe deformities, leaving the leg length unchanged Treatment with or without amputation of the forefoot with prosthetic The treatment of congenital anomalies of the fibula and management or a rotationplasty with a lower leg prosthe- lower leg is very complicated and requires considerable sis is usually a better solution in functional respects than experience. However, parents and patients able: often find this the more difficult option to accept in psy- ▬ shoe elevation, chological respects [32, 33]. If 3 or more rays are present, ▬ surgical leg lengthening, preservation of the limb with a lengthening procedure is ▬ rotationplasty, recommended. Any treatment of patients with an outwardly visible cases, the parents and child should be carefully guided disability should be accompanied by good psycho- towards other options and helped to accept the disability. The therapeutic strategy is based not just on the defor- The therapeutic strategy should be discussed with the mity, but also the age of the patient. Preschool age (up to 6 years) The main problem to be resolved is whether preservation Depending on the extent of the shortening in each case, of the complete extremity and leg length equalization a leg length equalization procedure followed by a shoe 310 3. If pos- sible, the orthosis should place the foot in a plantigrade Good indications for lower leg lengthening position. In this case a shoe wedge will no longer be suffi- type I B (hypoplasia of the fibula with dysplastic cient as an orthopaedic appliance, but a lower leg orthosis or absent ankle mortise), with a foot support and a separate orthotic foot section preserved rays I and II on the foot, (⊡ Fig. While this type of orthosis is less attractive leg length discrepancy at 8 years between 8 and cosmetically than if the foot is placed in the orthosis shaft 15 cm. We always equalize a lower leg length discrepancy of more than 8 cm in several steps, with a maximum of 8 cm (better: 6 cm) in each case. Instability of the ankle mortise is not an absolute con- traindication for leg lengthening. Ring fixators (of the Ilizarov type or the Taylor Spatial Frame) can be used to incorporate the foot in the extension and thus prevent dislocation of the ankle (see chapter 3. Procedure if lengthening is not performed The foot can basically be fitted in the lower leg prosthe- sis in an equinus position. Cosmetically more satisfying prosthetic management is possible if the forefoot is ampu- tated, although the children and parents find this very dif- ficult to accept. Amputation also has the disadvantages of possible phantom pain and more difficult guiding of the prosthetic foot (shorter lever arm, loss of the important sensory function of the toes). The decision to have a part of the body cut off is a psychologically painful process, even if the body part in ⊡ Fig. Lower leg support with separate foot section on a 12-year question hinders the patient in functional or cosmetic old patient with a fibular deficiency and leg shortening of 8 cm. The children foot is in a plantigrade position and their parents must be informed about this option very 311 3 3. If femoral hypoplasia is also present (as is the case ▬ Synonyms: Tibial hemimelia, longitudinal deformity of in the majority of patients; chapter 3. This further spoils the cosmetic appearance because the difference in the heights of the knees is clearly visible as Classification soon as the difference exceeds 5 cm. A lower leg prosthe- The best classification was proposed by Kalamchi and sis worn beneath the clothing, on the other hand, is hardly Dawe in 1985 (⊡ Fig. In these cases the possible alternative deficiency are listed in ⊡ Table 3. Lengthening is hardly ever possible if (According to Kalamchi & Dawe) simultaneously a proximal femoral deficiency is present. The condition of the hip and knee will also influence the Type Parameter decision. II Hypoplasia of the tibia with absence of the distal half, femorotibial joint preserved (rarest type) Amputation methods III Dysplasia of the distal part of the tibia with dias- Despite the understandable desire to amputate as little tasis of the tibiofibular syndesmosis, foot in varus as possible, a warning should be given about amputation position, prominence of the lateral malleolus (also known as tibiofibular diastasis) of the forefoot. The Lisfranc or Chopart amputation can cause numerous problems in prosthetic management. The stump mobility cannot be used functionally but rather leads to constant rubbing in the prosthesis shaft and to repeated pressure sores. Better amputations are the rear- foot amputations according to Boyd or Pirogoff, in which the talus, calcaneus and heel pad are preserved but fused together and with the lower leg, or the lower leg amputa- tion according to Syme ( Chapter 3. Adolescence (10–16 years) If major discrepancies in length at still present at this age, a second and possibly third extension operation are per- formed. I II III Instability of the ankle mortise If the ankle mortise is very unstable (types IB and II), this can be eliminated by arthrodesis of the upper, and possibly also the lower, part of the ankle when growth is ⊡ Fig. Type I: Complete absence of the tibia; Type II: Hypoplasia of the the foot should be fused in a plantigrade rather than an tibia with absence of the distal half; Type III: Dysplasia of the distal part equinus position.
Knee extension Quadriceps (vastus Femoral nerve lateralis levitra extra dosage 60 mg line erectile dysfunction drugs free trial, vastus medialis order levitra extra dosage 40mg on-line erectile dysfunction causes prescription drugs, (primarily L4). Plan Having completed your history and physical examination, you have a good idea of what is causing your patient’s symptoms. Here is what to do next: Suspected lumbosacral radiculopathy Additional diagnostic evaluation: X-rays, including anteroposterior (AP) and lateral views, are indicated. Electrodiagnostic studies may be used to better localize the exact lesion and evaluate for a potential peripheral neuropathy. Treatment: Conservative treatment, including physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and fluoroscopically guided epidural steroid injections, have shown good efficacy for treat- ing most radiculopathies. Surgery is reserved for refractory cases or cases with progressive neurological deficiencies (i. Instructions on good back hygiene, including sleeping with a pillow beneath the knees when supine and using a pillow between the knees when sleeping on the side, should also be offered. If any specific muscle tightness was iden- tified during the exam, special attention should be paid to stretching for those muscles. If trigger points are identified, trigger point injections of a local anesthetic and normal saline with or without corticosteroids may be helpful. The physical exam may suggest a particular cause for chronic low back pain, but the physical exam will not be able to offer a conclusive diag- nosis in the majority of cases of chronic low back pain. For example, in order to diagnose discogenic chronic low back pain (which accounts for approximately 39% of all chronic low back pain), it is necessary to perform a discogram (a needle procedure in which dye is injected into the intervertebral disc). In order to diagnose sacroiliac joint disease (which accounts for approximately 15% of all chronic low back pain), it is necessary to anesthetize the sacroiliac joint. In order to diagnose chronic low back pain caused by Z-joint disease (which accounts for approximately 30% of chronic low back pain), it is necessary to per- form controlled blocks of the nerves innervating the putative joint(s). All of these diagnostic procedures are routinely done by an orthope- dist, interventional physiatrist, or pain medicine specialist. Your his- tory, physical exam, and radiographic findings are important in helping to guide your decision of which needle procedure to perform first. Additional diagnostic evaluation: Needle procedures should be per- formed as mentioned. Oblique X-ray should be obtained if a pars interarticularlis fracture is suspected. Treatment: Conservative care similar to that for acute low back pain may be tried if the patient has not previously had a trial of conservative modalities. If a discogram reveals that the disc is the source of pain, intradiscal electrothermal annuloplasty is a minimally invasive needle procedure that has been shown to help more than half of all patients. If con- Low Back, Hip, and Shooting Leg Pain 89 trolled blocks reveal the Z-joint to be the source of pain, radiofre- quency neurotomy is an effective needle procedure for denervating the joints and relieving the pain. Computed tomography (CT) may also be necessary, particularly if the lesion is suspected (e. Treatment: Physical therapy with emphasis on posture and body biomechanics training is instituted. Surgery should generally be consid- ered only in those patients who have failed conservative care. If surgi- cal fusion of the lesion is considered, a successful diagnostic block of the pars defect is a good predictor of a successful response to fusion. Treatment: Ice, NSAIDs, heat, and physical therapy with emphasis placed on stretching the iliotibial band, hip flexors, and hip extensors may be used. A trochanteric bursa injection of anesthetic and corticos- teroid injection should be considered. The corner- stone of conservative care includes reducing stressful activities, rest- ing, weight reduction (when appropriate), using ambulatory aides (e. Oral glucosamine sulfate (1500 mg) and chon- droitin sulfate (1200 mg) are useful when taken daily. Intra-articular injections of anesthetic and corticosteroid may also be helpful. The 90 Musculoskeletal Diagnosis decision to treat surgically is largely guided by the patient’s comor- bidities, expectations, and degree of symptoms. The most common sur- gery for hip osteoarthritis is total hip replacement. Acetabular fractures are less common and typically require a high energy trauma. Additional diagnostic evaluation: X-rays, including AP and lateral views, are indicated. Treatment: Surgery is indicated, and the sooner the fracture is reduced, the better. Treatment: Surgery is indicated, and the sooner the hip is reduced, the better.
Since the If marked scoliosis is already present in childhood we cur- scarred skin lies directly over the kyphotically projecting rently use the VEPTR instrumentation according to Camp- bone discount 60mg levitra extra dosage with visa impotence hernia, a decubitus ulcer can rapidly develop in patients bell ( Chapter 3 purchase levitra extra dosage 60 mg with visa erectile dysfunction pills at walgreens. This straightens Congenital deformities and segmentation defects are the spine and preserves mobility without the need for present in all myelomeningoceles. However, the instrumentation must be extended is already, by definition, a deformity. Preserving mobility is particularly im- fects are also almost invariably present, although these portant in cases of myelomeningocele as such patients are frequently symmetrical and do not pose too great a are only slightly restricted, if at all, as regards intelligence problem, except for the disrupted growth in this area. They must Occasionally, however, the segmentation defect is also be able to pick up objects from the floor, get up onto the unilateral, and in these cases a very progressive and ex- wheelchair from the floor and transfer themselves onto a tremely rigid scoliosis can develop. The progres- If an adolescent patient presents with a scoliosis of sion of a scoliosis resulting from such deformities is not >60° with decompensation, surgical treatment may be ⊡ Fig. The titanium rib is anchored to the ribs and, at the bottom, to the iliac crest on the concave side of a b the curve (for details of this procedure see 132 3. However, this decision requires much careful thought as the possible functional loss must be taken into account. In contrast with patients with normal sensory function, patients with a (high) myelo- meningocele do not experience pain when the ribs come into contact with the pelvis. For these reasons we, together with patients and caregivers, tend increasingly to decide 3 against an operation. If surgical straightening and fusion are indicated, however, the surgeon should if possible combine a an- terior and posterior approach in view of the prevailing forces and the invariable presence of osteoporosis. A special situation applies in severe lumbar kyphoses, as the scarred skin produced by the closure of the cele often results in decubitus ulcers that may subsequently require surgical restoration. In such cases correction will a b only be successful if the surgeon performs a kyphec- tomy with a wedge resection of several vertebral bodies ⊡ Fig. Even if after kyphectomy (wedge resection of vertebral bodies) and stabiliza- no neurological residual function is detected, the cord tion with the Spinefix instrumentation should not simply be ligated as the dural sac usually still possesses a certain drainage function and there is a risk of an increase in pressure. Serious complications can occur in connection with the often present Arnold-Chiari mal- formation. The kyphosis can be straightened by the wedge syndrome, neurological function may be impaired. Pulmonary function tends to be rection of the kyphosis of around 50%–60% is perfectly improved by the scoliosis surgery. As mentioned above, the procedure scoliosis as a result of the muscle weakness. The various involving VEPTR instrumentation is increasingly used types of muscular dystrophy are described in detail in nowadays. Complication risks The surgical treatment of spinal deformities associated Occurrence, etiology with myelomeningoceles involves technically difficult Almost all patients with the more severe forms of muscu- procedures. Since pulmonary function is not usually lar dystrophy (particularly Duchenne dystrophy, chap- impaired, the perioperative anesthetic risks are not es- ter 4. Since latex allergy is known to occur more frequently in such patients [4, 13], latex-free ma- Clinical features terials, particularly gloves, will need to be used. The The course of spinal problems in these clinical conditions skin complications associated with the scarred skin fol- is characterized by an initial regular development of the lowing closure of the myelomeningocele and the lack spine as the muscles largely possess normal strength. If distraction is applied age (usually around 10 years in the commonest form, the during the operation on a patient with tethered cord Duchenne dystrophy), the patients lose their capacity to 133 3 3. J Bone Joint Surg Br 83: This loss of power is also associated with instability in the 22–8 2. While the spine largely retains adequate stability (1996) Spinal fusion in Duchenne’s muscular atrophy. J Pediatr in the sagittal plane thanks to the ligamentous apparatus, Orthop 16: 324–31 such a corrective anatomical element is lacking in the 3. Brown JC, Zeller JL, Swank SM, Furumasu J, Warath SL (1989) frontal plane. If the spine deviates slightly to one side dur- Surgical and functional results of spine fusion in spinal muscu- ing standing or sitting, a progressive scoliosis can develop lar atrophy. Emans JB (1992) Allergy to latex in pateints who have myelo- under the influence of gravity. J Bone Joint Surg (Am) 74: lapse into a very severe scoliosis within two years. Conse- 1103–9 quently, patients with this underlying disorder should be 5. Galasko CSB, Delaney C, Morris P (1992) Spinal stabilisation in examined regularly for spinal deformities after they have Duchenne muscular dystrophy. Hefti F (1989) Vertebral rotation in different types of scolio- sis and the influence of some operative methods of rotation.
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