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Monday, November 26, 2012

Hallux varus

It is medial deviation of big of big toe from the midline of foot.
Hallux varus


o   Congenital
o   Trauma
o   Sometime Bunion surgery (swelling of joint between great toe and 1st metatarso - pharyngeal joint)

Clinical features:

o   Deformity
o   Pain
o   Decrease ROM
o   Problems with shoe wear
o   Clawing of great toe


Depends on severity, if deformity is mild and the toe remain flexible, no treatment is required.

Genu Valgum

It is also called knock knees. It is a condition in which the knee angle is in and they touch each other when the legs are straightened. Females have a wider pelvis than males and relatively shorter length of thigh bone and as a result have a greater static genu valgum than men. Individuals with severe Valgus deformity are typically unable to touch their feet together while simultaneously straightening the legs. Valgus actually mean bent outwards. But here the distal portion bends outwards and the proximal portion seems bend inwards.


         i.            Idiopathic
       ii.            Congenital
      iii.            Osteogenesis imperfecta

     iv.            Rickets


·         X – rays
·         Clinical examination


Medical treatment for Rickets is optimum vitamin D, for Osteogenesis imperfecta is Bisphosphonates.
Surgical options:

Osteotomy using extaperiosteal two holes plate for 12 month, sometimes repeated osteotomies might be required.

Genu vara

It is also called bow legs. There is a medical angulation of leg in relation to thigh. There is outward curvature of femur and up to the age of 3 – 4 years children have a degree of varus normally.


1.       Rickets
2.       Infections
3.       Tumor
4.       Trauma
Genu varum


·         One should always identify the cause and if possible should be treated.
·         Surgical osteotomy (Multi – disciplinary team)

Proximal Femoral deficiency

Basically there is proximal femoral deficiency, the proximal femur is partially absent and the entire limb is shortened.


Incidence ranges from one case per fifty thousand to one case per two Lac populations.


·         No exact known cause
·         Injury to neural crest cells (embryonic cells of spinal cord and brain)
·         Defect in proliferation and maturation of chondrocytes in proximal growth plate due to anorexia, ischemia, irradiation, bacterial, viral infection, toxins, hormones, mechanical injury, thermal injury, thalidomide (anticancer drugs). No genetic etiology. There is associated high incidence of other anomalies like fibula deficiency, Valgus feet, cleft palate, and club foot.

AITKEN classification of proximal femoral deficiency:

AITKEN divided it into the following four categories.

Class A:

Femoral head is often absent

Class B:

Femoral head is absent + proximal femur

Class C:

Absent femoral head dysplastic acetabulum, tronchanter doesn’t develop.

Class D:

Severe shortened shaft, No acetabulum present
Proximal Femoral deficiency
Remember in the 1st two categories ossification may occur


Radiographic studies


·         Prosthesis (head of femur)

  • Treatment is delayed in child after 3 years.

Coxa valga

Normally the angle between the head of femur and shaft is 120° - 135°. An angle above 135° is coxa valga.


1)      Skeletal disease (Osteomyelitis, Paget’s disease, Osteogenesis Imperfecta)
2)      Spasticity of adductor muscles of hip

3)      Cerebral palsy (a disorder of movement and or posture as a result of permanent damage to the developing brain. This damage may occur before, during, or immediately after the delivery and has many causes)
4)      Spinal dystrophism (Spina bifida)
5)      Poliomyelitis (an infectious virus disease affecting the CNS. The virus responsible is RNA, transmission through orofaecal, and 90 – 95% polio affected people will not develop polio disease)


Non surgical:

a.      Physiotherapy:

Aim is stretching the spastic agonist muscles.

b.      Orthotic devices:

These help in maintaining adequate positioning


Valgus osteotomy

Coxa vara

Normally the angle between the head of femur and shaft is 120° - 135°. An angle below 120° is coxa vara.


1)   Trauma
2)   Congenital
3)      Paget’s disease (also known as osteitis deformans ,a chronic disease of bones, occurring in the elderly and most frequently affecting the skull, backbone, pelvis, and long bones. There is 1% risk to develop osteosarcoma. Treatment is with bisphosphonates or calcitonin)
4)      Perthes disease (avascular necrosis, decrease supply to the epiphyseal plate of femur or necrosis of head of femur due to interruption of its blood supply)
5)      Osteomyelitis (inflammation of bone due to infection)
6)      Osteogenesis imperfecta (fragilitas ossium is a congenital disorder in which the bones are usually brittle and fragile. No treatment, there is abnormal; collagen type I, type II, type III, and type IV. Patient involving type I, IV live normal, with type II die early and with type III has severe disease.)
7)   Tumors


In unilateral condition the limb may be small. There will be gait problem.


o   X – rays
o   MRI/CT scan


·         Varus Osteotomy
·         Hip dynamic screws
·         One should identify causes and if possible should be treated
·         Physiotherapy


In this condition the front half of the foot is deviated inwards contrary to Talipes Equinovarus which is deviation at the ankle. In this condition the ankle is spared.
Intoeing between the ages of one and two ears is usually a result of an abnormal in alignment of upper (thigh) and lower leg. While Intoeing developing around 18 months may be the result of abnormality in pelvis and hip.

Causes of intoeing:

1)      Neurological abnormality (Cerebral Palsy, Multiple Sclerosis, Polio etc)
2)     Metatarsus adductus (A foot deformity in which the bones in the front half of the foot bend or turn in toward the body)
3)      Hallux Varus (medial deviation of the great toe)
4)      Club foot
5)      Pes cavis (high instep arch)
All of these exhibit intoeing between the ages of 1 to 2 years. The abnormality is in alignment of upper and lower leg.


·         Applied at 6 months beneficial up to 2 years
·         Success rate drops dramatically after age of two years

·         Ligaments released
·         Metatarsal Osteotomy

Talipes Equinovarus (Clubbed foot)

It is a congenital deformity involving one or both feet. The affected foot appears rotated internally at ankle. The person appears to walk on their ankles. Approximately 50% are bilateral. It occurs commonly in female i.e. 2:1


·         Edward syndrome (extra chromosome on 13 number)
·         Ehlers danlos syndrome (disorder of connective tissue involving deficient or abnormal collagen)


a.    Tenotomy:
Need in 80% cases
b.    Anterior tibial tendon transfer:
The tendon is moved from first toe to 3rd in order to release inward traction on foot.
c.    Ponsiti method:

It is a conservative approach in which serial cast applied over 4 weeks then Mini incision in Achilles tendon.

Neural tube defects

It is an embryonic tissue which covers the brain and spinal cord. The defect in neural tube can involve the cranial (cephalic) or the caudal end. It can be mild, moderate or severe.


                When the head (cephalic) end fails to close resulting in absence of major portion of brain and skull is called anencephaly. Infants born with this condition are usually blind, deaf and unconscious. They die within few hours and days after birth.


Sac like protrusion of brain through opening in skull is called encephalocele.


Spina bifida:

A condition which involves the caudal end of neural tube is called spina bifida. There is incomplete development of spinal arch. It can be divided into the following types.

Spina bifida occulta:

It is the mildest form (hidden spine deformity). Most patients have never any health problem. Rarely the skin has moles, hair tufts. Sometimes the spinal cord or nerves are tethered to the spine. The abnormality may involve single or multiple vertebrae which may need surgery.

Types of Spina Bifida

Spina Bifida Cystica:

Meningocele: The meninges (sac) protrude through opening.
Meningomyelocele: Both meninges and spinal cord protrude.


a.       Genetic factors
b.      Folic acid deficiency
c.       Drugs (Valporate, Methotrexate)
d.      Smoking


·         Physiotherapy
·         Neurosurgery (definitive)

Sprengel's deformity

A developmental abnormality in which the scapula doesn’t descend to its proper position or a high lying shoulder blade is called sprengel's deformity. In the intrauterine life it is lying in the cervical region then it descends. The associated muscles may be weak (trapezius, rhomboid muscles etc).

Sprengel's deformity


·         Shoulder asymmetry

·         Restricted shoulder abduction
·         Scapula is adducted and 2 – 10 cm elevated.
·         Inferior pole is deviated medially, the glenoid faces inferiorly, and the length of vertebral border is decreased.

Associated problems:

·         Poland syndrome
·         Klippel-Feil syndrome (short, webbed neck; decreased range of motion (ROM) in the cervical spine)
·         Scoliosis

Cavendish classification:

Based on the severity of the condition, a Sprengel deformity can be classified as follows (Cavendish grades).

Grade 1:

The deformity is very mild with clothes it cannot be seen. The shoulders are almost at level.

Grade 2:

This is mild deformity but the superomedial portion of the high scapula is visible as a lump.

Grade 3:

It is a moderate deformity. The affected shoulder is 2 – 5 cm higher than the opposite shoulder. It is visible.

Grade 4:

It is severe deformity. The scapula is very high with neck webbing and brevicollis.


Imaging Chest X – ray:

To confirm the diagnosis and to look for associated anomalies. 

 CT – Scan (thorax):

Omovertebral body can be seen, which is a bony bar that attaches the scapula to spine (cervical).


·         Physiotherapy to gain mobility
·         Definitive treatment is surgery
·         Repositioning of the scapula is done (modified green scapuloplasty and wood ward procedure)


In this condition the spinal cord look C – shape.


1.       Idiopathic
2.       Genetic factor play important role

Clinical features:

·         Uneven musculature on affected side
·         Prominent shoulder blade
·         Uneven hips, leg length, lung and heart can be affected

Associated conditions:

         i.            Charcot Marie tooth disease
       ii.            Prader – willi syndrome
      iii.            Ehleros danols syndrome
     iv.            Marfan syndrome
       v.            Arnold chiari malformation
     vi.            Kyphosis



History, examination, X – ray, MRI and look for associated conditions


·         Surgery
·         Physiotherapy
·         Occupational therapy

Flat feet (Pes Planus)(Fallen Arch):

The arch of the foot collapses, the entire sole coming into complete or near complete contact with ground. In 20 – 30 % of the population, the arch never develops unilaterally or bilaterally. Children usually have flat feet but as they grow it will correct by itself.


·         Most of the cases don’t require treatment

·         Arch support (orthotic)
·         Surgery: It is the last resort. It is also costly and time consuming.


Involuntary contraction of neck leading to abnormal posture and movement of head is called Torticollis. It is not a diagnosis but a sign of underlying disorder.


1.       Congenital
2.       Acquired

1.      Congenital:

·         Trauma (by birth) to sternocleiodomastoid
·         Spina bifida
·         Vertebral anomalies
·         Clavicle fracture
·         Arnold – chiari malformation (protrusion of lower brain stem and cerebellum through the opening for spinal cord at the base of the skull)

2.      Acquired:

o   Spasm of cervical muscles due to injury to muscles or nerves
o   Awkward position during sleep
o   Cervical spine trauma
o   Retropharyngeal abscess
o   Any infection involving surrounding tissue of neck
o   Drugs: Phenothiazines (piprazine), Metachlopromide


§  X – ray of neck
§  MRI/CT of spine



·         Check airway
·         Patient with trauma stabilize neck
Remember: Cause identification is primary aim and then treatment accordingly.


·         Benztropine
·         Benzodiazepine
·         Analgesics
·         Physiotherapy

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