medical

1. MUSCULOSKLETAL SYSTEM DISORDERS

4. Anatomy of foot

5. CLUB FOOT
 Clubfoot is the term used to describe a deformity involving
malalignment of the calcaneotalar-navicular complex.
 Components of this deformity may be best understood using the
mnemonic CAVE (cavus, adductus, varus, equinus).
 Although this is predominantly a hindfoot deformity, there are
plantarflexion (cavus) of the 1st ray and adduction of the
forefoot/mid foot on the hindfoot.
• It is one of the most common orthopedic defect
• It occurs approximately 1 in 700 to 1 in 1000 live births
• It occurs more commonly in males (2 : 1) and is bilateral in 50% of
cases.

6. Club foot cont..
 The clubfoot deformity may be positional, congenital, or
associated with a variety of underlying diagnoses (neuromuscular
or syndromic).
 The positional clubfoot is a normal foot that has been held in a
deformed position in utero and is found to be flexible on
examination in the newborn nursery.
 The congenital clubfoot involves a spectrum of severity, while
clubfoot associated with neuromuscular diagnoses or syndromes
are typically rigid and more difficult to treat.
 Clubfoot is extremely common in patients with myelodysplasia
and arthrogryposis/congenital joint contracture.

7. Club foot cont..
• Congenital clubfoot is seen in approximately 1/1,000 births.
The etiology is multifactorial and likely involves the effects of
environmental factors in a genetically susceptible host.
• The risk is approximately 1 in 4 when both a parent and one sibling
have clubfeet.
• The pathoanatomy involves both abnormal tarsal morphology
(plantar and medial deviation of the head and neck of the talus)
and abnormal relationships between the tarsal bones in all three
planes, as well as associated contracture of the soft tissues on the
plantar and medial aspects of the foot.

8. Causes
• It is familial or the result of arrested or anomalous development in
utero.
• Family history
• Neuromuscular disorders like cerebral palsy, spina bifida.
• Amniotic band syndrome-congenital entrapment of fetal parts in
fibrous amniotic bands
• oligohydramnios

9. Pathophysiology
• Club foot is a foot that has been twisted out of its
normal shape or position in utero and is fixed.

10. Pathophysiology
.
Predisposing factors
Distal limb amniotic banding
Amnion forms a constructive bands around
a limb in utero
Cutting off the circulation to the limb
Arrest of the fetal development in the
fibular stage

11. Types of club foot
Various types of club foot , it is the combination of ,
Term Meaning
talipes Foot and ankle
varus Bending inward
valgus Bending outward
equinus Toes are lower than heel
calcaneus Toes are higher than the heel

12. Types of club foot

13. Types of club foot
• Talipes varus:
– It is due to the heels being turned inward from the
midline if the leg only outer portion of the sole rest on
the floor.

14. Types of club foot
• Talipes equino varus
 It is the type of clubfoot that occurs 95% of cases
 The foot is fixed in planter flexion and deviate medially, i.e. heel
is elevated.
 If the condition is not corrected the child walks on the toe and
outer border of foot.

15. Types of club foot
• Talipus equino valgus:
– It is due to the heel being elevated and turned
outward from the midline of the body.

16. Types of club foot
• Talipes valgus:
– It due to heel is being turned outward from the
midline of the leg only inner side of the sole rest on
the floor.

17. Types of club foot
• Talipes calcaneovarus:
– It is due to the heel being turned towards the midline
of the body and the anterior part of the foot being
elevated. Only heel rest on the floor.

18. Types of club foot
• Talipes calcaneous valgus:
• The calcaneovalgus foot is a common finding in the newborn and is
secondary to in utero positioning.
• Excessive dorsiflexion and eversion are observed in the hindfoot,
and the forefoot may be abducted. There may be an associated
external tibial torsion.
• The foot is dorsiflexed and deviate laterally. That is heel turned
outward from the midline of the body.
• If it is not corrected the child walks on outwardly turned heel and
the inner border of the foot.

19. CLINICAL MANIFESTATIONS
 The infant typically presents with the foot dorsiflexed and everted,
 occasionally the dorsum of the foot will be in contact with the
anterolateral surface of the lower leg.
 Plantarflexion and inversion are often restricted.
 As with other intrauterine positional deformities, a careful hip
examination should be performed; if there is any concern, hip
ultrasonography should be considered.
 The calcaneovalgus foot may be confused with a congenital vertical
talus and may rarely be associated with a posteromedial bow of the
tibia.

20. CLINICAL MANIFESTATIONS CONT..
 Examination of the infant clubfoot demonstrates forefoot cavus and
adductus and hindfoot varus and equinus .
 The degree of flexibility varies, and all patients will exhibit calf
atrophy.
 Both internal tibial torsion and leg-length discrepancy (shortening
of the ipsilateral extremity) will be observed in a subset of cases.

21. Diagnostic evaluation
Observation of the presence of club foot at birth.
It must be differentiated from metatarsus varus and paralytic
deformity occurring in congestion with meningomyelocele.
A complete physical examination should be performed to rule
out coexisting musculoskeletal and neuromuscular problems.
The spine should be inspected for signs of occult dysraphism.
Radiography

22. TREATMENT.
• It should be started as soon as possible after birth .
• Any delay makes correction more difficult.
• Mild cases of calcaneovalgus foot, in which full passive range of
motion is present at birth, require no active treatment.
• These usually resolve within the 1st weeks of life.
• A gentle stretching program, focusing on plantarflexion and
inversion, is recommended for cases with some restriction in
motion.
• For cases with a greater restriction in mobility, serial casts may be
considered to restore motion and alignment.
• Casting is rarely required in the treatment of calcaneovalgus feet.
• The management for those cases associated with a posteromedial
bow of the tibia is similar.

23. TREATMENT.
• Nonoperative treatment is initiated in all infants and should be
started as soon as possible following birth.
• Techniques have included taping and strapping, manipulation and
serial casting, and functional treatment.
• a significant percentage of patients treated by manipulation and
casting required a surgical release, which was usually performed
between 3 and 12 mo of age.
• Although many feet remain well aligned after surgical releases, a
significant percentage of patients have required additional surgery
for recurrent or residual deformities.
• Stiffness remains a concern at long-term follow-up.

24. TREATMENT.
• The Ponseti method of clubfoot treatment involves a specific
technique for manipulation and serial casting and may be best
described as minimally invasive rather than non-operative.
• The order of correction follows the mnemonic CAVE.
• Weekly cast changes are performed; five to 10 casts are typically
required.
• The most difficult deformity to correct is the hind foot equinus, and
approximately 90% of patients will require a percutaneous tenotomy
of the heel cord as an outpatient.
• Following the tenotomy, a long leg cast with the foot in maximal
abduction (70 degrees) and dorsiflexion is worn for 3 wk; the patient
then begins a bracing program.
• An abduction brace is worn full time for 3 mo and then at nighttime
for 3–5 yr.

25. Therapeutic management
• The treatment include
• Manipulation of the foot
– It is manipulation or exercise program to be done
several times a day by parents.
– Parents must be taught the procedure and
supervise in practice until they can do so correctly

26. Therapeutic management
• Care of infant in a Denis Browne splint
– This appliance is made of two foot plates attached to a cross
bar. When splint is fitted to the feet various positions of
angulations can be maintained.
– As the infants kicks the foot are automatically moved in to
correct position.
Denis Browne splint

27. Therapeutic management
• Care of infant or child in caste
– Use of caste provide gradual stretching of tight muscle and
contraction of previously relaxed muscle until a position of
overcorrection has been reached
– Caste has to be replaced every 1-2 weeks
Ponseti casting

28. Therapeutic management
• Once the club foot is corrected, the position of the foot should
be maintained through the use of corrective shoes.

29. Nursing management
• Provide knowledge based from which parents can make choices,
– Deformity and treatment options
– Prognosis
– Future complications
• Skin care
– Elevate the leg to prevent edema and improve venous return
– Check the toes every 1-2 hour for temperature, color,
sensations, motion and capillary refill,(why these all??)
– Stimulate movement of toes to promote circulations
– Teach exercise to care givers

30. DEVELOPMENTAL DYSPLASIA OF THE HIP
INTRODUCTION
• Developmental dysplasia of hip describes a spectrum of disorders
related to abnormal development of hip that may occur at any time
during fetal life, infancy or childhood.

31. DDH cont..
• Congenital hip dislocation consists of underdevelopment of the
acetabulum and head of the femur.
• Although dislocation usually occurs after birth, the abnormality of
the bones develops prenatally.
• Since many babies with congenital hip dislocation are breech
deliveries, it has been thought that breech posture may interfere with
development of the hip joint.
• It is frequently associated with laxity of the joint capsule.

32. DDH cont..
• Developmental dysplasia of the hip, occurs when a child is born
with an unstable hip due to abnormal formation of the hip joint
during early stages of fetal development.
• This instability worsens as the child grows

33. Incidence
• It occurs 10 per 1000 live births
• 16-25% of infant with DDH are born breech.
• The left hip involved in 60% of cases, right hip 20% and both hip in
20%
• 60% of cases are girls.
Causes
It is unknown, but certain factors such as gender, birth order, family
history, intrauterine position, delivery type and postnatal positioning
are believed to affect the risk of DDH.

34. Risk factors
• Physiologic factors
– Maternal hormone secretion
– Intra uterine positioning
• Mechanical factors
– Breech presentation
– Multiple fetus
– Oligohydramnios
– Large infant size
• Genetic factors
– DDH in siblings of affected infants

35. Degrees of DDH
1. Acetabular dysplasia or preluxation:
– This is the mild form of DDH ,in which there is subluxation or
dislocation.
– There is delay in the aceabular development.
– Femoral head remain in the acetabulam

36. Degrees of DDH
• Subluxation:It implies incomplete dislocation of hip .
– Femoural head remain in contact with the acetabulam , but a
stretched capsule and ligamentum teares causes the head of
the femour to be partially displaced.

37. Degrees of DDH
• Dislocation:
– Femoural head loses contact with acetabulam and is displaced
posteriorly and superiorly over the fobrocartilaginous rim.
– Ligamentum tears is elongated and taut.

38. Pathophysiology
• Developmental dysplasia of the hip (DDH) involves abnormal
growth of the hip.
• Ligamentous laxity is also believed to be associated with hip
dysplasia, although this association is less clear.
• Ligamentous laxity is a term given to describe "loose ligaments”
• Children often have ligamentous laxity at birth, yet their hips are
not usually unstable; in fact, it takes a great deal of effort to
dislocate a child's hip.

39. Pathophysiology
• At birth, white children tend to have a shallow acetabulum.
• This may provide a susceptible period in which abnormal
positioning or a brief period of ligamentous laxity may result in hip
instability.
• However, this characteristic is not as true for children of black
descent, who have a lower rate of DDH

40. Clinical manifestation
 Shortening of limb on affected side
 Restricted abduction of hip on affected side
 Unequal gluteial folds
 Positive ortolani test
 Positive barlow test

41. Clinical manifestation cont..
• Older infant and child
Affected leg shorter than the other
Telescoping or piston mobility of joint - Head of femur can be
felt to move up and down in buttock when extended thigh is
pushed first toward child’s head and then pulled distally
Trendelenburg sign – when the child bear weight on affected
hip, pelvis tilts downward on normal side instead of upward
Greater trochanter prominent appearing above the line from
anterior superior iliac spine to tuberosity of ischeam.
Marked lordosis

42. Diagnostic methods
DDH is not often detected at initial examination after birth.
Ortolani or barlow test
Ultrasonography
CT scan

43. Therapeutic management
• Treatment varies with the child's age and extend of dysplasia.
• The goal of treatment is to obtain and maintain a safe, congruent
position of the hip joint to promote normal hip joint development.
 Newborn to age 6 months:
• Pavlik harness is used to maintain a safe position of hip joint .
Harness is worn continuously until the hip is proved stable on
clinical examination, usually about 3- 5 months .

44. Pavlik harness

45. Therapeutic management
 Age 6 to 18 months:
 If child has shortening of limb and contracture of hip adductor and
flexor muscle became evident , the reduction by traction is used for
3 weeks.
 Child under go a closed reduction of hip using general anesthesia, if
the hip is not reducible, an open reduction is performed.
 After reduction child is placed in hip spica cast for 2-4 months until
hip is stable.

46. Therapeutic management
 Older children
– operative reduction which involve preoperative traction ,
tenotomy of contracted muscle .
– When open reduction is performed, the patient wears a spica cast
for 6 weeks
– Range of motion exercise for restore movement.

47. Nursing management
• Teaching the parents to apply and maintain the reduction device
• Skin care include
– Always put an undershirt??
– Check frequently the red areas under the stripes and clothing
– Gently massage the healthy skin under the strapes once a daily to
stimulate circulation
– Place diaper under the strapes
• Cast should be managed in routine care .
• Assess for irritation, and maintain cleanliness of child in cast
• Parental support

48. Birth trauma
• Birth injury is defined as an impairment of the neonate's body
function or structure due to an adverse event that occurred at birth.
• Injuries to the infant resulting from mechanical forces during birth
(compression, traction).
• Birth injuries are those sustained during the birth process, which
includes labour and delivery, after delivery, especially in neonates
who require resuscitation in the delivery room.
• They may be avoidable or unavoidable.
• It is a common problem with significant neonatal morbidity and
mortality

49. Birth trauma
• There is a wide spectrum of birth injuries ranging from minor and
self-limited problems (eg, laceration or bruising) to severe injuries
that may result in significant neonatal morbidity or mortality (ie,
spinal cord injuries)

50. Risk Factors
• Prematurity
• Small maternal stature (CPD)
• Maternal obesity (40 kg/m2)
• Prolonged or precipitated labour
• Malposition and presentation particularly breech presentation
• Instrumental delivery/ Operative vaginal delivery
• Versions and extraction
• Fetal macrosomia or large fetal head.

51. Evaluation
• Thorough examination , including a detailed neurologic
evaluation
• Examine the neonate for asymmetry of structure and function,
cranial nerves, range of motion of individual joints, and integrity of
the scalp and skin

52. Types of injury
1. Caput succedaneum
• It is an extra periosteal fluid collection that is occasionally
hemorrhagic and is commonly occurring in subcutaneous.
• It has poorly defined margins and can extend over the midline and
across suture lines (why do you think???)
• It extends over the presenting portion of the scalp and is usually
associated with molding
• The lesion usually resolves spontaneously without sequelae over
first several days after birth
• It rarely causes significant blood loss or jaundice

53. Caput succedaneum cont..

54. 2.Cephalohematoma
• It is a subperiosteal collection of blood resulting from rupture of
the superficial veins between the skull and periostum
• It is always confined by suture lines and cannot cross the suture
lines
• An Extensive cephalohematoma can result in significant
hyperbilirubinemia and rarely serious enough to necessitate blood
transfusion
• The risk of infection is very rare (justify the reason??)
• Skull fractures have been associated with 5 – 20% of cases

55. Cephalohematomacont…
• Occurs after prolonged labor and instrumentation
• Secondary to rupture of blood vessels traversing skull to
periosteum
• Often fluctuant swelling, well demarcated, does not cross suture
lines, no overlying skin discoloration
• Most often unilateral, but can be bilateral
• Possible skull fractures, sometimes elevated ridge
• With linear fractures, risk for leptomeningeal cyst

56. Cephalohematoma

57. Management
• Observation in most cases
• Incision and aspiration is contraindicated
• Anemia and jaundice should be treated as needed
3.Subgaleal hemorrhage
• It is hemorrhage under the aponeurosis of the scalp
• Because subaponeurotic space extends from the orbital ridges to
the nap of the neck and laterally to the ears,the hemorrhage can
spread across the entire calvarium.
• The initial presentation typically includes pallor (why?), poor tone,
and a fluctuant swelling on the scalp which cross the suture lines

58. Subgaleal hemorrhage cont..
• subgalialhemorrage is the most sever form and needs strict follow
up for shock and severe anemia and need proper management
• The hematoma may grow slowly or increase rapidly and result in
shock
• With progressive spread the ears may be displaced anteriorly and
peirorbital swelling can occur
• Ecchymosis of the scalp may develop and it is very painful on
manipulation
• The blood is desorbed slowly and swelling resolves gradually
• A Subgaleal hemorrhage associated with skin abrasions may
become infected, it should be treated with antibiotics and may need
drainage

60. Management and follow up
• New born with this lesion should be admitted
• Assess and treat shock
• Daily HC measurement and HCT follow-up
• Minimize manipulation because it is painful
• Manage anemia and jaundice if needed

61. Brachial Plexus Palsy
• .
• .
Cervical nerve root injuries

62. Brachial Plexus Palsy
• Three forms - depending on site and extent of trauma
5th and 6th cervical roots - upper arm (Erb-Duchenne) = most
common form
8th cervical and 1st thoracic roots - lower arm (Klumpke) =
extremely rare
Paralysis of entire arm = rare
• Evaluation :
X-rays to r/o fractures of clavicle or humerus and to r/o
epiphyseal detachment of humerus
US to r/o posterior dislocation of humerus epiphysis

63. Cervical nerve root injuries
• Brachial plexus injury
• The cause is excessive traction on the head, neck, and arm during
birth
• Risk factors include macrosomia, shoulder dystocia, breech
presentation
• Injury usually involves the nerve root, specially where the roots
come together to form the nerve trunk of the plexus
• Duchenne-Erb’s palsy
• Involves the upper trunks (C5,C6 and occasionally C7) and is the
most common type of brachial plexus injury.

64. Clinical presentation
• The arm is typically adducted and internally rotated at the
shoulder
• There is extension and pronation at the elbow and flexion at the
wrist and fingers in the characteristic “waiter’s tip(??)” posture
• Moro is absent on the affected side
• The grasp reflex is intact and sensation is variably affected

65. Klumpke’s palsy
• involves injury C7/C8 to T1 and is the least common injury
• In this case the grasp reflex is absent
• there is sensory impairment on the ulnar side of the forearm and
hand
Management of brachial plexus injury
• physical therapy and passive range of motion exercises prevent
contractures
• It should be started at 7 -10 days when the post injury neuritis
recovered
• Splinting should be avoided as contractures in the shoulder girdle
may develop
• Wrist and digits splints may be useful

66. Prognosis
• Full recovery varies with the extent of injury.
• If the nerve roots are intact and not avulsed, prognosis for full
recovery is excellent
• Notable clinical improvement in the first two weeks indicates that
normal or near normal function will return
• Most infants recover fully by three months of age
• In case with slow recovery, electromyography and nerve
conduction studies are indicated

67. Phrenic nerve injury (C3, 4 or 5 )
• Phrenic nerve injury leading to paralysis of the ipsilateral diaphragm
may result from stretch injury due to lateral hyperextension of the
neck at birth
• Risk factors include breech and difficult forceps deliveries
• At least 75%of patients also have brachial plexus injury
Clinical features
• Respiratory distress and cyanosis (why do you think?)
• Some infants present with persistent tachypnea and decreased breath
sounds at the lung base
• There may be decreased movement of the affected hemi thorax

68. Diagnosis
• confirmed by U/S or fluoroscopy that shows paradoxical (upward)
movement of the diaphragm with inspiration
• C-X-ray may show elevation of the affected hemi thorax
Management
• the initial treatment is supportive
• CPAP or mechanical ventilation may be needed
• Careful air way care to avoid atelectasis and pneumonia

69. Skull fracture
• Skull fracture may be either linear or depressed
• Depressed skull fractures are usually associated with forceps use
• Most infants with linear or depressed skull fractures are
asymptomatic unless there is an associated intracranial hemorrhage
(eg, subdural or subarachnoid hemorrhage)
• The diagnosis is made by skull X-ray
• Head CT scan should be obtained if intracranial injury is
suspected

70. Management
• Uncomplicated linear fractures usually requires no therapy
• Depressed fractures require neurological evaluation for possible
elevation needed
• Comminuted (what ??) or large fractures with neurologic findings
need immediate neurologic evaluation
• If leakage of CSF from the nares or ears is noted, antibiotic therapy
should be started and neurosurgical consultation obtained

71. BONE INJURIES
Clavicular (what??) fracture
• Is the most commonly injured bone during delivery
• This fracture is seen in vertex presentations with shoulder dystocia or in
breech deliveries when the arms are extended
• Macrosomia (what it is??) is a risk factor
• A green stick or incomplete fracture may be asymptomatic at birth
• The first clinical sign may be a callus at 7 – 10 days of age.
• Signs of a complete fracture include crepitus, palpable bony irregularity,
and spasm of the sternocleidomaseoid muscle.
• The affected arm may have a pseudo paralysis (what??) because of pain
on movement.

72. Diagnosis
Physical examination
Confirmed by chest X-ray
Management:
• Should be directed at decreasing pain with analgesics
• The infant’s sleeve should be pinned to the shirt to limit movement
until the callus begins to form
• Complete healing is expected and counsel the family

73. Long bone injuries
• Humeral (what??) fracture
• This fracture usually occurs during a difficult delivery of the arms in the
breech presentation and/or of the shoulder in vertex presentation
• Direct pressure on the hummers may also result in fracture
 Clinical presentation
• Loss of spontaneous arm movement on affected side
• Followed by swelling and pain on passive motion
Diagnosis
Physical examination
Confirmed by x-ray of the affected arm

74. Management
• The fractured humorous requires splinting for two weeks
• Displaced fracture require closed reduction and casting
prognosis
• complete healing is expected with the above managements

75. Femoral fracture
• This fracture follows usually a breech delivery
• Infants with congenital hypotonia are at increased risk
Clinical features
• obvious deformity of the thigh and swelling of thigh
• decreased movement and paint on palpation or passive motion

76. Diagnosis
• Physical examination
• conformed by x-ray
Management
• fractures, even if bilateral, should be treated with traction and
suspension of both legs with a spica cast.
• Casting is maintained for about four weeks.
• Complete healing without limb shortening is expected.