Doctors Network

Congenital Talipes Equinovarus(Clubfoot)

The term talipes is derived from of the Latin words for ankle(talus) & foot (pes).

The term refers to the gait of severely affected
patients, who walked on their ankles.

Clubfoot is a severe fixed deformity of the foot characterized by fixed ankle plantar flexion (equinus), inversion of the subtalar (talocalcaneal) joint (varus), and medial subluxation of the talonavicular and calcaneocuboid joints (adductus)

Etiopathogenesis

Idiopathic majority , some secondary to muscle pathology
All the tissues of the foot i.e. bone, joint,ligaments and muscles have developmental abnormality
Bone: smaller in size, neck of talus is angulated so that head of talus is directed downwards and medially. Calcaneum is small and concave medially
Joints: equinus deformity occurs primarily at ankle joint. Inversion deformity occur in subtalar joint. Adduction occurs in midtarsal joints
Muscles and tendons: muscles of calf are underdeveloped.
Capsule and ligament: all the ligamentous structure on the postero-medial side of the foot shortened
Skin shows adaptive change
Callosities and bursae over bony prominences on the lateral side

Congenital Talipes Equinovarus

Bilateral in 60%.
General examination to rule out other deformities
Normally, the foot of newborn can be dorsiflexed until the dorsum touches the anterior aspect of shin of tibia
Components of the deformity:
Equinus.
Varus.
Adduction.

X-ray

AP view and a lateral view in a position of maximum dorsiflexion.
Kite angle is the angle subtended by the long axes of the calcaneus and the talus on the AP view.
This angle is normally between 20 and 40 degrees.
In the clubfoot, this angle is less than 20 degrees with relative parallel alignment of the talus and calcaneus.
The relationship of the talus and calcaneus should also be assessed on the lateral view. Again, in the clubfoot, this shows relative parallel alignment compared with the normal foot

Treatment

Nonoperative :

Best results are achieved with early manipulation.
(as early as first week of life) and serial casting (changed every 2 week). Adduction deformity is corrected first followed by inversion and then equinus deformity. If this sequence is not followed rocker bottom foot may result

Wearing Of Dennis-Browne(DB) splints for maintenance.

Good results may be achieved if previous technique is applied.

Operative Technique :

In less than 3 years only soft tissue release may be sufficient while older children require bony operations.
Indicated for manipulation failure cases, recurrence and neglected cases
Posteromedial soft tissue release (PMSTR)
Tendon transfer
Dwyer’s osteotomy- open wedge osteotomy of calcaneus
Dilwyn-Evan’s procedure : PMSTR with calcaneo-cuboid fusion
Wedge tarsectomy
Triple arthrodesis

What are the clinical manifestations of spongiform encephalopathies?

1. Creutzfeldt-Jakob disease CJD :85% cases are sporadic; 15% are familial

2.Middle age to elderly patients

3.Rapidly progressing dementia

4.Memory loss with startle myoclonus or other involuntary movements

5.Typical EEG changes

6.Death within 6-12 months.

Approach to limping child

Differential diagnoses:

0 to 5 years old

Septic arthritis
Osteomyelitis
Transient hip synovitis
DDH
Perthes disease
Toddler's fracture
Nonaccidental injury (child abuse)
Tumors (ALL)
Neuromuscular disorders (cerebral palsy, Duchenne's Muscular Dystrophy)
Discitis
Juvenile rheumatoid arthritis

5 to 10 years old

Septic arthritis
Osteomyelitis
Transient synovitis
Perthes
Limb length difference
Tumor (ALL, Ewing sarcoma, benign bone tumors)
Neurologic disorders (hereditary motor sensory neuropathy)
Discitis
Juvenile rheumatoid arthritis

10 to 15 years old

Osteomyelitis
Slipped capital femoral epiphysis (SCFE)
Tumor (osteosarcoma, Ewing's sarcoma, benign bone tumors)
Perthes disease
Hip dysplasia
Idiopathic chondrolysis

History

Acuteness of onset, pain, history of trauma or injury, constitutional symptoms such as fever, malaise, chills; early morning stiffness and motor milestone development (walked by 15-18 months).
Past medical history, Birth history and any previous surgery, injuries, or illnesses.
Family history of childhood lower extremity conditions such as developmental dysplasia of the hip (DDH).

Physical examination

An antalgic gait is characterized by a decreased stance period on the affected limb as well as a trunk shift over the affected limb during stance.
Evaluation for limb length difference: palpate the anterior superior iliac spine (ASIS) with the patient standing. Then, with the patient supine, compare lengths of the lower extremities with the legs extended. Also, compare lengths of the femurs by flexing the hips and comparing the relative heights of the knees.
Physical exam should also include the back, sacroiliac (SI) joints, and abdomen as well as the entire extremity involved.
Palpate the entire length of the limb.
Range of motion of the hip, knee, and ankle joints. Particular attention should be paid to any erythema, warmth, joint effusion, or focal tenderness.
A thorough neurologic examination should also be completed.

Investigation

Radiographic evaluation. Anteroposterior (AP) and lateral plain radiograph (x-ray) of the entire length of bone involved, including joint above and below the area of concern. Referred pain describes pain attributed to one site or location by the patient but the source of the pain is at a different site (e.g., knee pain in a patient with an SCFE involving the hip joint).
Laboratory studies. Complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). If rheumatologic conditions or spondyloarthropathies are being evaluated, include rheumatoid factor (RF), antinuclear antibody (ANA), anti-streptolysin (ASO) titer, Lyme titer, and HLA B-27.
Additional imaging studies.
Magnetic resonance imaging (MRI). Very sensitive and specific. Able to identify areas of bone marrow edema, soft tissue edema, or fluid collections such as abscesses.
Ultrasound. Useful to look for hip joint effusions, subperiosteal or soft-tissue abscesses. May also help guide aspiration of hip joint or soft tissue abscess.
CAUTION: If septic arthritis is suspected, a joint aspiration should be performed without wasting time waiting for the availability of other additional imaging studies.

Ulnar tunnel syndrome

Motion:

> Dorsiflexion- 0-50

Palmarflexion 0-60

Radial deviation 0-15

Ulnar deviation 0-50

Supination/Pronation 75-80 each

ULNAR TUNNEL SYNDROME

Compression of sensory, motor or both in Guyons canal at wrist

Guyons canal fibro-osseous triangular space ulnar aspect of volar wrist, roof volar carpal ligament and pisohamate ligament, lat. Wall TCL and hook of hamate, medial wall pisiform and fibrous structures

Ulnar nerve and artery

Causes- SOL like ganglions, aneurysms, lipoma

# hook of hamate, repeated trauma vibration tools, long distance cyclists

Symotoms – numbness and tingling ring and little finger, weakness of intrinsic muscles, pain at wrist

Sensory deficit – sparing of dorsal hand

Motor – weak intrinsics, clawing, Froments sign, confrontation test, Egawa test

Diagnosis – history, clinical tests, Tinels sign, Nerve Conduction study

Treatment – Cessation of provocative activities, NSAID, Local steroid injection, Surgery

CARPAL TUNNEL SYNDROME

Compression of median nerve at wrist in carpal tunnel

Carpal tunnel three sides by carpal bones, roof by Transverse Carpal Ligament

Causes– Secondary, Idiopathic

Clinical features:

aching and burning pain along median nerve distribution, night symptoms, aggravated by elevation, repetitive activities and prolonged wrist flexion, clumsiness of hand, female predominance

Physical signs :

Sensory loss, Motor weakness and atrophy