The ability to walk and For the functional form of abducted pes planovalgus in stand is then jeopardized with increasing age buy cheap zetia 10mg on-line cholesterol ratio diabetes, weight muscle weakness due to a paresis or myopathy zetia 10 mg otc cholesterol foods to eat, the same and height. The orthosis must be of a can be achieved only by means of an external appliance rigid design since it has to replace the absent muscle activ- (orthosis) or a surgical procedure. During walking, the orthosis prevents the premature throdesis of the lower ankles (usually an extra-articular forward movement of the tibia in relation to the foot in Grice operation) is performed to stop the foot from going contact with the ground and ensures adequate knee exten- over. For growing children there is no alternative to an ing valgus component of the foot. An excessive dorsiflex- orthosis, since an arthrodesis will inhibit foot growth and ion, as also observed in insufficiency of the triceps surae, leave the feet smaller than normal. Only on completion remains, and this is much more disruptive from the func- of growth can the orthosis be replaced surgically with an tional standpoint. Since an orthosis will still be required arthrodesis, which must incorporate the upper and lower the benefit for the patient from a procedure such as the ankle. Due to a lack of mobility, and hence of compensa- Grice arthrodesis is minimal. Maintaining mobility is therefore favorable Structural deformities in functional feet, especially if sensation is not normal. A Structural deformities in primarily flaccid locomotor disor- muscle transfer procedure to replace the absent plantar ders and muscular dystrophies are shown in ⊡ Table 3. Although good results have been Structural deformity of the foot caused by reduced or described, our everyday experience with our patients has absent muscle activity. The shortening of the Achilles tendon represents a Definition logical alternative. However, this procedure is reputed to A contracture of the triceps surae muscle is present, produce poor results. Although it can prove helpful in regardless of the muscle activity and power, which extreme cases, the chances of a good result in neuro-or- prevents dorsiflexion even with a flexed knee. This must be prepared difficult for the body to keep in balance over the flaccid leg. Otherwise the only bilizers that would have to keep the foot on tiptoe are also option for protecting the knee from giving way in flexion insufficient. The foot skeleton becomes deformed and fixes is by supporting it with the hand ( Chapter 4. The ability to A slight hyperextension of the knee of up to 5° is 3 walk and stand can be further impaired as a result. Ideally, the hyperextension should be permits weight-bearing without deformation of the foot prevented indirectly by a corresponding orthosis for the skeleton. If a functionally disruptive contracture is pres- lower leg and foot with an integrated heel. An overcorrection will lead to a pes calcaneus position with corresponding flex- ion at the knees and hips, thereby compromising walk- ing and standing. If the knee and hip extensors are not available for compensation (as in muscular dystrophies), a slight overcorrection will result in the loss of the abil- ity to walk and stand. Since the lengthening procedure does not need to take account of the muscle power, it can be implemented in the form of tendon lengthening. One surgical technique for correcting the equinus foot in flaccid paralyses is the rearfoot arthrodesis according to Lambrinudi (⊡ Fig. This procedure is risky to the extent that dorsiflexion is not blocked at the ankle. If the knee and hip extensor muscles are not strong enough to compensate for the lack of power in the triceps surae, a crouch gait will result. The equinus foot is an important aid to stabilization during standing and walking, particularly in muscu- lar dystrophy patients and patients with post-polio syndrome. A slight case of equinus foot blocks the upper ankle and prevents dorsiflexion. As a result, the knee is indirectly ex- tended and the patient is able to remain upright passively ⊡ Fig. Patient with left-sided poliomyelitis after a dorsally extending talar osteotomy (Operation according to Lambrinudi) to (»plantar flexion – knee extension couple«, chapter 4.
Type III (tibiofibular diastasis) is characterized The tibial deficiency is very much rarer than that of the by protrusion of the lateral malleolus with inversion and fibula cheap zetia 10 mg otc zoloft cholesterol levels, with an incidence of 0 buy zetia 10 mg with mastercard cholesterol lowering diet plan new zealand. Associated anomalies Treatment The foot is normal in only around half of the patients, and The treatment is based on the type of deformity present. Two- 3 thirds of children with longitudinal deficiency of the tibia Type I (aplasia of the tibia) show associated anomalies [28, 31], including syndactyly, The primary treatment is always orthotic provision. Quad- polydactyly, femoral hypoplasia, cryptorchism, cardiac riceps function and the condition of the distal femur are defects, varicocele, etc. The most elegant and functionally best solution is centralization of the Clinical features, diagnosis fibula [10, 14]. Preconditions are a largely normal distal The shortening and deformity of the lower leg is already femur and a sufficiently strong quadriceps muscle. If the tibia is absent (type I), the femur is severely deformed and a pronounced flexion lower leg is usually curved in a valgus position. Radio- contracture of the knee is present, a knee disarticulation graphic investigation reveals a hypoplastic distal femur should be performed before the patient starts to walk, but a thickened fibula. Occasionally, arthrodesis of the femur part of the ankle is unstable and the foot is inverted and and fibula can be useful (particularly if the fibula is also deformed), although it should be borne in mind that the growth plates can be adversely affected by an early arthrodesis. Type II (absence of the distal half of the tibia) The primary objective here is to preserve a stable knee. To this end, a side-to-side fusion of the tibia and fibula is recommended. At the distal end, the arthrodesis of the fibula and talus should be accompanied by amputation of the forefoot as part a modified Boyd procedure. The sur- geon should be careful to ensure that the epiphyseal plate of the distal fibula is preserved. Type III (tibiofibular diastasis) The main problem in this type of deficiency is the insta- bility of the talus beneath the tibia. The talus has a strong tendency to dislocate cranially, causing the Achilles ten- don to shorten since it is not stretched. The lateral mal- leolus protrudes strongly and tends to perforate the skin. An external fixator can be used to reduce the rearfoot back underneath the tibia. The talus and tibia should then be transfixed with a medullary nail and the distal section of the tibia and fibula should be fused. An MRI scan also provides evidence of The classification according to Leveuf is shown in the condition of the cruciate ligaments. Since this is not usually the A Danish study has calculated an incidence of 1. Etiology Treatment During pregnancy the knee remains in a hyperextended The treatment should start immediately after birth and position in some cases (approx. The lack of cruciate consists of intensive correction and stretching of the ligaments or fibrosis of the quadriceps can, in particular, quadriceps. Placing the infant in an appropriate position lead to dislocation of the knee. The hip is placed in 90° flexion aplasia of the cruciate ligaments is a triggering factor or a and the thigh supported down to the knee with a foam secondary phenomenon is not known. Most cases occur block; a weight is secured to the lower leg with bandages sporadically and are not hereditary. When the neutral position has been reached, corrective casts can Associated anomalies then be fitted in increasing flexion. This treatment is very Congenital dislocation of the knee can occur unilaterally successful during the first 3 months [16, 36]. By this stage, the quadri- with congenital hip dysplasia, clubfoot and other foot ceps can be surgically lengthened to permit flexion of anomalies. Naturally, the results of this treatment are Clinical features, diagnosis only moderate, whereas patients treated conserva- The dislocation of the knee is usually obvious at birth. An x-ray will confirm the diagnosis, and a lateral view will usually show increased inclination of the tibial plateau towards the back (⊡ Fig.
The child’s age and suspected pathology inﬂuence the choice of radiographic technique employed zetia 10mg mastercard cholesterol and exercise. When examining very young children order 10mg zetia visa cholesterol ratio 4.2, a single-contrast examination will provide a diagnosis in the majority of cases whereas in the examination of older children, or where inﬂammatory bowel disease is sus- pected, a double-contrast technique should be used. In a single-contrast examination, the patient should lie on their left side with their hips and knees ﬂexed. A soft rubber catheter is gently inserted into the rectum and taped into position. The patient maintains the lateral position while a 30–100g/100ml suspension of barium sulphate10, warmed to body tempera- ture, is introduced slowly under gravitational force. Progress of the contrast agent through the bowel is monitored ﬂuoroscopically and images taken to demonstrate large bowel anatomy. Routine images might include a lateral pro- jection of the rectum, right and left posterior oblique projections for the splenic and hepatic ﬂexures and an antero-posterior projection to demonstrate the caecum and terminal ileum. A double-contrast technique is similar to the above except that a higher con- centration barium sulphate suspension, 60–120g/100ml, is used and the tech- nique also includes air insufﬂation. Antero-posterior projections in the prone position, with 45° caudal angulation of the central ray to show the sigmoid colon, and lateral decubitus projections, may be required for a complete study, but are not routinely taken. In these cases, anti- spasmodic agents may be given prior to examination to relax the bowel after which air at a pressure not exceeding 80mmHg is insufﬂated over 3 minutes. The child should be rested for 3 minutes before repeating this procedure. At no time should the pressure exceed 120mmHg10 and a maximum of three attempts should be made. In a successful examination, ﬂuoroscopy will demonstrate air bubbling through the site of the intussusception. Surgical reduction may be required if the image-guided reduction attempt fails, and surgical staff should be made aware of the procedure in case of a surgical emergency. Contraindica- tions to the air enema are suspected perforation or peritonitis. Renal tract examinations Intravenous urography Ultrasound is the initial imaging examination of choice for renal tract pathology in the child and intravenous urography (IVU) is required only when less inva- sive procedures have failed to provide adequate diagnostic information. Prior to administration of a contrast agent, the child should be weighed and the dose calculated in accordance with the manufacturer’s instructions on 90 Paediatric Radiography volume and concentration in terms of iodine content per kilogram of body weight. A topical local anaesthetic should be applied to several potential injection sites at least 1 hour prior to radiographic examination to facilitate intravenous puncture or, alternatively, the contrast agent may be administered through an existing intravenous line where one is already in situ. It is standard practice to starve the patient for 4 hours prior to the adminis- tration of a contrast agent in order to ensure that the stomach is empty. However, it is important that patients, particularly children, remain well hydrated and clear ﬂuids should not be restricted. Flexibility in examination appointment times, particularly for infants and young children, will be necessary so that the examination can be timed for when the stomach is likely to be empty (i. Following contrast agent injection, infants may be bottle-fed to help pacify them. The ﬂuid-ﬁlled stomach will effectively form a radiographic ‘window’ facilitating the visualisation of the renal area. Each IVU examination should be tailored to the individual patient and directed to answer a speciﬁc clinical question13 thereby ensuring that the number of radiographic images taken is kept to a minimum. Ideally, the renal tract should be visualised free from overlying bowel gas and faeces, and the use of ureteric compression and oblique projections may be required to achieve this. Oral car- bonated drinks can be used in older children to distend the stomach and provide a gaseous ‘window’ through which the kidneys may be visualised; the antero- posterior projection with the patient supine demonstrating the left kidney while a right posterior oblique will demonstrate the right kidney. Alternatively, the kidneys may be visualised by an antero-posterior projection with the patient supine and 35° caudal angulation centred to the xiphisternum. Micturating cystourethrography Micturating cystourethrography (MCU) is the deﬁnitive method of assessing the lower urinary tract13. It is particularly valuable for the assessment of male urethral pathology (e. This examination requires a small catheter to be inserted into the bladder via the urethra and although this procedure is performed under strict asepsis, it is still associated with a ﬁnite risk of urinary tract infection.
A foreign body lodged within a main bronchus results in persistent hyperinﬂation of the affected lung or lobe as a result of the ‘ball valve effect’ where air is allowed to enter the lung on inspi- ration but is obstructed and unable to leave the lung on expiration zetia 10 mg amex remnant cholesterol definition. As in adults buy 10 mg zetia with visa yolk cholesterol in eggs from various avian species, inspired foreign bodies are usually identiﬁed in the right main bronchus as a result of it being wider and more vertical. However, in infants, the tracheal bifur- cation is more central and foreign bodies may be seen equally in the left and right main bronchi (Fig. Unless the foreign body is radio-opaque, plain ﬁlm 46 Paediatric Radiography Normal lobar positions Right upper lobe collapse Right middle lobe collapse Right lower lobe collapse Left upper lobe collapse Left lower lobe collapse Fig. Patients with an unidentiﬁed foreign body will present several days later with a persistent cough and signs of systemic illness as a result of a pul- monary infection at the sight of the foreign body obstruction. This infection will not resolve unless the foreign body is removed and therefore a persistent, un- resolving pneumonia in a young child should raise clinical suspicion of foreign body aspiration. Note the increased radiolucency of the right lung as a result of air trapping. Radiographic technique for the chest and upper respiratory tract Plain ﬁlm radiography remains the ﬁrst-line examination for the majority of respiratory conditions. However, alternative imaging modalities may be used to assess the extent of a disease or conﬁrm a diagnosis (Box 4. Its use is decreasing due to the recognition of high patient doses and the development of other imaging modalities. Ultrasound: Of little value for the respiratory system but extremely useful in the investigation of cardiac and mediastinal pathology. Computed tomography (CT): Second-line imaging modality after plain ﬁlms. It provides good contrast and spatial resolution of lung parenchyma, mediastinum and bony structures but has the disadvantage that sedation is often required due to the length of examination. Magnetic resonance imaging (MRI): Useful for examining the mediastinum and the chest wall but has the disadvantage that young children will require sedation and frequently general anaes- thetic due to the relatively long imaging times. Scintigraphy: Of value in the investigation of pulmonary embolisms and bony pathology (e. Its use is on the decline as a result of improve- ments in ultrasound and MRI but it has the advantage of facilitating interventional procedures. Age (approximately) Projection Patient position Under 3 months Antero-posterior Supine 3 months to 4 years Antero-posterior Erect 4 years and older Postero-anterior Erect Choice of projection There is no difference in the diagnostic value of an antero-posterior (AP) pro- jection compared to the postero-anterior (PA) projection of the chest in a child less than 4 years of age as the thoracic cage is essentially cylindrical in young children and magniﬁcation of mediastinal organs is insigniﬁcant11. However, the AP projection is associated with a higher radiation dose to the developing breast, sternum and thyroid, and radiographers should take this into consideration when choosing the radiographic projection. In children under 4 years of age, the AP projection is often preferred due to ease of positioning, immobilisation and maintenance of patient communication. Young children like to see what is going on around them and positioning for an AP projection allows the child to watch the radiographer. A disadvantage of the AP projection is the likelihood of lordosis but this can be prevented by careful technique. This is particularly important if the child’s condition is being mon- itored radiographically as subtle radiographic changes in their condition may be difﬁcult to interpret if the technical (positioning) factors are inconsistent. The fol- lowing descriptions of radiographic positioning are provided as a guide and may be modiﬁed depending upon equipment and accessories available. Antero-posterior (supine) The patient is positioned supine with the median sagittal plane at 90° to the image receptor. A 15° foam pad is placed under the upper chest and shoulders to prevent lordosis (Fig. The chin is raised and the arms are ﬂexed and held on either side of the head to prevent rotation (Figs 4. Sandbags and lead rubber are placed over the hips and legs to provide immobilisation of the Fig. The cut out area helps although a 15° pad has been used, the extension of the to prevent the chin obscuring the upper patient’s arms will still result in a lordotic radiograph. Note the use of a 15° foam pad and arms positioned with elbows ﬂexed to prevent hyperextension of the spine and lordosis. The primary beam should be centred to the area of interest thereby ensuring that effective collimation can be applied and dose reduction optimised. Antero-posterior (erect) This projection can be performed with the patient standing or seated erect. For younger children, correct positioning and immobilisation are easier to maintain with the child seated.