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By H. Grim. Baylor College of Medicine.

Varus and valgus at knee level is most readily measured by placing the ankles together at the medial malleoli generic dipyridamole 100mg overnight delivery prehypertension at 19, and measuring the number of “fingerbreadths” that can be placed between the medial femoral condyles (bowed legs or varus) (Figure 2 discount dipyridamole 100mg overnight delivery blood pressure unstable. Knock-knee or valgus deformity is most readily measured by bringing the medial femoral condyles together and then measuring the distance 13 Metatarsus adductus between the medial malleoli with the knees in the extended position. A simple recording of the number of fingers measured on each visit will provide irrefutable evidence of the natural evolution of the angular deviation. An alternative method of following the process clinically is to make drawings on a sheet of paper of the contour of the knees in relationship to the ankles, and then measuring the distance between the various anatomic landmarks on a sheet of paper (Figure 2. Historically these physiologic angular alterations have been treated by stretching, shoe adaptations, orthotics, medications, surgical epiphyseal stapling, and osteotomy of the long bones. The technique of measurement by centimeters or inches of genu medical disease or disorder (Pearl 2. Differential diagnosis of physiologic genu varum extensive experience has failed to provide any cases presenting for treatment at skeletal Blount’s disease maturity. Periodic follow-up and reassurance to Skeletal dysplasias ameliorate parental anxiety appears to be all Nutritional rickets that is necessary. Vit D resistant rickets Growth plate insult Infection Metatarsus adductus Neoplasm Metatarsus adductus is the least common cause of in-toeing seen in infants and children. It has occasionally been termed “monkey-toeing” due to the peculiar deviation of the great toe medially resembling that seen in arboreal apes, while the lateral four toes tend to be pointing in a straight position. The condition is most commonly seen from birth to 18 months and may persist until three years of age. It is characterized by a flexible medial deviation of the great toe, not unlike that seen in primates with a prehensile first digit. It is most Lower extremity developmental attitudes 14 commonly believed to be due to persistence of activity of the abductor hallucis muscle (Figure 2. The natural propensity for metatarsus adductus is to resolve spontaneously, and this casts doubt on the wisdom of using any active treatment. Occasionally adaptive shoes and orthotics have been utilized, but they should be viewed as unnecessary. Metatarsus adductovarus Metatarsus adductovarus is nearly as common a cause of in-toeing as internal tibial torsion. It has been known in the past by a number of different terms, all of which seem to create more confusion that reason. It has been referred to as “one-third of a clubfoot,” congenital “hooked” forefoot, forefoot adductus, forefoot adductovarus, metatarsus Figure 2. The activity of the abductor hallucis muscle tendon unit in internus, metatarsus varus, and metatarsus producing metatarsus adductus. The typical clinical deformity in metatarsus adductovarus, between metatarsus adductovarus and including the deep medial and plantar crease. Put more simply, it is a “stiff” supination deformity or varus deformity of the forefoot on the hindfoot. It is further characterized by a medial and plantar crease, beginning just distal to the navicular and medial cuneiform region, and extending roughly halfway across the plantar aspect of the foot (Figures 2. The etiology of this condition is unknown, but it is believed to occur antenatally and is likely related to intrauterine factors, particularly inadequate intrauterine space. This finding lends 15 Internal tibial torsion credence to the suggestion that intrauterine molding factors play a major part in etiology. Normally, gentle two-finger pressure across the forefoot, while holding the hindfoot in a stable position, will easily overcorrect the “deformity” in the type of metatarsus adductovarus that will spontaneously resolve (Figure 2. In children who have not resolved the deformity by three months of age, and in whom it is not possible to reverse the position of the forefoot on the hindfoot beyond the normal longitudinal axis of the foot, treatment is usually instituted. A wide variety of treatment modalities have been utilized, consisting primarily of adaptive shoe wear alone, or in combination with various orthotics. Serial plaster casting is also one of the most common forms of treatment used. Success in treating this condition has routinely been obtained by the use of serial casting, bar and shoes in Figure 2. The position of the hands in relationship to the foot in testing the degree of flexibility of metatarsus adductovarus. The residuals of this condition result in a cosmetic deformity that has never been shown to be functionally impairing. However, occasionally the forefoot deformation is sufficient to interfere with purchasing “over-the-counter” non-prescription shoes, which generates a great deal of parental concern, leading them to pressure for surgical correction.

Adding the Concept of ‘Personal Value’ to the Assessment of Disability Verbrugge stated that the omission of a broader spectrum of activities in disability assessment reflects assumptions by researchers that the ADLs cheap dipyridamole 100mg free shipping prehypertension vegetarian, IADLs buy generic dipyridamole 25mg on line heart attack grill death, and employment are more important and that difficulty performing them was more significant. The meaning, or ‘value’ attached to activities is person-specific, but may affect the impact of dis- ability. In other words, some activities are more important or more meaningful to individuals than others. However, many of the activities identified as most important to persons with RA, and perhaps most closely tied to quality of life, are not measured in conventional functional assessments [4, 22]. Studies have shown that a large proportion of activities that are deemed important to Disability and Psychological Well-Being 45 individuals are outside the realm of ADLs, IADLs, and employment [5, 23, 24]. Conversely, many items on the conventional measures were not important to their patients. In two other studies, when persons with RA were asked what activities were affected by RA that most bothered them or what activities they most wanted to improve, only about half of the functions or activities men- tioned were covered by the HAQ [23, 24]. The additional activities mentioned included a wide variety of leisure and recreational activities, childcare and other family roles, and work. Adding the concept of personal value to the assessment of disability is critical to determining the impact of functional problems on individuals’ quality of life, but adds complexity to the assessment. Katz found that over a 5-year period, persons with RA lost over 10% of the activities that they had valued at the beginning of the period. Losses were seen in each of 13 domains of activity assessed, with the greatest losses in work-related (loss of 26. Compared to controls without RA matched for age, gender, and area of residence, persons with RA performed significantly fewer VLAs at the initial assessment (81. Half of the RA sample lost 10% of the activities they had valued at baseline, while only one third of the control group lost a similar proportion. At the end of the 5-year period, the difference between the RA group and the con- trols in the proportion of valued activities performed had widened – persons with RA were performing 70. Another examination of the proportion of individuals with RA whose valued activities were affected by the disease is shown in table 1. It is readily apparent that individuals reported dis- ability in all activity domains, although there is wide variability across domains in 1These data, as well as the data in the previous paragraph, are from the annual telephone interviews of the University of California, San Francisco Rheumatoid Arthritis (UCSF RA) panel. The previous paragraph’s data are from interviews conducted from 1989 to 1993 (n 512). The second set of data is from interviews conducted in 1998 and 1999 (n 438). Detailed information on the UCSF RA panel is presented in references 29, 30, 46 and 47. VLA, disability prevalence and incidence VLA domains % whose % whose activities activities in in domain domain were were affected newly affected Visiting with friends or family members in your home 11 6 Participating in religious activities or services 28 11 Leisure activities, such as going to movies, the theater, or restaurants 30 10 Going to social events, such as birthday parties, holiday parties, 33 10 or family reunions, or visiting with friends or family members in their homes Traveling or getting around your community by car or by public transportation 36 14 Taking care of family members, such as grandchildren, children, parents, 38 10 or a sick spouse Taking care of yourself, that is, activities such as bathing, washing, 39 14 or getting dressed Cooking, including food preparation 39 8 Walking, just to get around 49 9 Shopping or doing errands 49 11 Hobbies or crafts, such as sewing or woodworking 57 15 Working, that is paid employment 68 11 Other housework, such as vacuuming or dusting 69 8 Recreational activities, such as taking walks, gardening, or bicycling 74 16 Home maintenance, such as painting or heavy yard work 85 5 Total n 438; denominator for percentages is number who rated domain as important to them. Table 1 also presents the proportion of individuals whose activities were ‘newly affected’in the second year of assessment, i. The proportion of individuals with newly affected activities is much smaller, although considering that many of these individuals have had RA for over 20 years, the incidence of new disability is remarkable. Rates of depression and depressive symptoms2 appear to be higher among individuals with RA than among the general population, with estimates ranging 2For the sake of simplicity, I will refer to both clinical diagnoses of depression and high levels of depressive symptoms suggestive of depression as ‘depression’. Disability and Psychological Well-Being 47 from 15 to 42% [30–33], depending on the sample and how depression was defined and assessed. For example, in a 3-year study, Katz and Yelin found that 15–17% of subjects with RA were depressed in each of the 4 years studied, 5% were consistently depressed in every year, and over 29% were depressed in at least 1 year. The presence of depression in 1 year greatly increased the probability of depression in future years. For example, an individual who was depressed at the first assessment was over 6 times more likely to be depressed 2 and 3 years later, and was over 5 times more likely to be depressed 4 years later. Among individuals with RA, many studies have demonstrated cross- sectional associations between depression and impaired functioning, primarily using measures of functional limitations or disability in ADL/IADL activities [30, 34–39]. For example, in the study just described, subjects who were depressed had poorer function as measured by the HAQ and were less likely to be working.

Trunk shifts over the hip quickly discount dipyridamole 100 mg on line pulse pressure product, and stance phase generic dipyridamole 100 mg with mastercard pulse pressure fluid responsiveness, in contrast with a muscle then shifts back to the opposite side. A painful knee limp with the trunk shifting away from the prolonged stance phase, and a lengthy period involved extremity at midstance. The history relative to the limp is quite important, as limping may have diurnal variations, may be persistent or intermittent in nature, may have been in close association with a recent illness, may have a peculiar type of appearance, and may be significantly affected by ascending and descending stairs. It is useful to do a very thorough clinical evaluation, particularly with “laying on of hands. Standing on one leg or both legs, walking fore and aft, and attempts at running will all be useful. Placing joints through a range of motion is essential in evaluating subtle degrees of stiffness and joint effusion. Adjunctive studies are of the essence, and include appropriate laboratory tests, conventional radiography, and radionuclide imaging. A quick review of a pathology “checklist” will help orient the various conditions seen in the various age groups, and 117 Limping child will incorporate the categories of trauma, infection, inflammation, circulatory disorders, congenital disorders, paralytic disorders, metabolic disorders and neoplastic disorders. Without question in all of the age groups encountered in children and adolescents, trauma is the number one etiologic factor. One of the more common causes of pain in children is juvenile myalgia or “growing pains. Between the ages of one and three years, the most common cause of a painful limp in a child is trauma, most notably fractures of the base of the first metatarsal, and of the necks of the second through the fifth metatarsals. Fractures of the tibia of the “toddler type” are seen in this age group and are usually a spiral fracture of the shaft, or a compression fracture of the distal tibia. Limping secondary to abuse must always be a part of the differential diagnosis, particularly in this age group. Conditions such as toxic synovitis of the hip or knee, and juvenile rheumatoid arthritis are seen, but are far less common. Limping from a neuromuscular origin occurs not uncommonly in this age group, particularly in Figure 6. A painful foot limp with trunk shifting away from the involved the form of spastic hemiplegia. Between the ages of 3–10 years, trauma is still the most common cause for limp. Antalgic limps of hip origin are most often seen with “toxic” or “transient” synovitis of the hip and Legg–Calve–Perthes disease, which is far less´ common than “toxic” synovitis of the hip. Juvenile rheumatoid arthritis is seen in this age group, as well as osteomyelitis and occasionally septic arthritis. Between the ages of 10 years and skeletal maturity, trauma is still the number one etiology for antalgic limps. In this age group the pain syndromes of adolescence, which are adequately addressed elsewhere in the text, occupy a large proportion of the causes of limp. Slipped capital femoral epiphysis should always be primarily considered in an antalgic limp in this age group. Although other conditions are somewhat uncommon, back Miscellaneous disorders 118 pain may radiate into the lower extremities Pearl 6. Differential diagnosis of limp (pathologic with accompanying limp (Pearls 6. A very careful history and physical examination, including direct palpation of Trauma the affected limb, will usually disclose the Infection diagnosis in at least 90 percent of all cases of Inflammation limp. Adjunctive studies such as radiography, Circulatory laboratory studies, radionuclide imaging, Congenital computed tomography (CT), and magnetic Paralytic resonance imaging (MRI) will generally provide Metabolic the answer in more complex cases. Neoplasia Leg length discrepancy The assessment and management of leg length discrepancy has been improved by tremendous Pearl 6. Most common causes of limp at age 1–3 years recent advances in technology relative to evaluation and treatment. Computed Trauma tomography, MRI imaging, and the enormous Inflammation capacity of modern external fixation devices Infection to achieve limb lengthening have made a Paralytic previously simplistic problem into a much more complex issue but with a favorable overall impact. The simplest technique of evaluating disparity in lower limb length is obtained by Pearl 6.

Popliteal cysts (ganglions) Popliteal cysts are soft tissue masses that appear in the posterior aspect of the knee purchase dipyridamole 25 mg free shipping heart attack billy, usually in the area of the medial popliteal space cheap dipyridamole 25 mg free shipping heart attack calculator. The cysts are seen most commonly in boys, and are most commonly unilateral. The vast majority of the cysts seem to arise from a space between the medial head of the gastrocnemius and the semitendinosis tendon (Figure 4. The cysts are clearly benign and have a histologic constitution resembling that of a ganglion cyst. Baker described the lesions in 1887, giving rise to the eponym of Baker’s cyst. Differential diagnosis includes subcutaneous lipomas, popliteal aneurysms, and benign and malignant tumors. All of these should be readily differentiated by radiographic texture, abnormal pulsation, computed tomography (CT) scanning or MRI if the cyst lies in an unusual location. After many years of surgical extirpation, with very frequent recurrences, sanity has begun to prevail, and recognition of the natural history of the disease is now being well appreciated. The vast majority of cysts will either recede in size or disappear within a two- to three-year period after clinical presentation or almost always by puberty. It is to be remembered that ganglions most commonly occur on the dorsal or volar aspects of the wrist and often communicate with the joint. In the absence of clinical symptoms, all cysts should be observed periodically and surgery should be avoided. Operations are generally reserved for those rare children who are suffering from significant pain and whose cysts persist until puberty. Anteroposterior radiograph of the thoracolumbar spine showing Spastic torticollis a thoracolumbar scoliosis. In addition to the far more common congenital muscular torticollis, there is a type of torticollis or “wryneck” that appears in the toddler to adolescent age group that is associated with either inflammatory conditions in the cervical region, traumatic lesions, tumors or neurogenic disorders. The obvious implication is that the source of the “wryneck” is secondary to some other medical condition apart from the sternocleidomastoid muscle. One of the more common reasons for a spastic torticollis is atlantoaxial rotary From toddler to adolescence 72 “subluxation. Typically the children “splint” and resist any attempts to rotate the head or the neck. The term rotary displacement is probably more appropriate inasmuch as it is uncommon to document any true radiographic subluxation of the atlantoaxial joint. Fortunately the condition resolves almost invariably and spontaneously, with or without treatment (physical therapy, traction, heat). Spastic torticollis is also occasionally seen following upper respiratory infections, in association with cervical adenitis. Presumably the inflamed lymph nodes irritate the sternocleidomastoid and the anterior cervical “strap” muscles, producing the torticollis. Diagnosis is established by identifying the primary infection and treatment by the primary care physician generally results in resolution of the torticollis. Spinal cord tumors and cerebellar tumors occasionally can produce a spastic torticollis. An adequate neurologic evaluation is mandatory and a part of evaluating all acquired cases of torticollis. Symptomatic treatment is generally used for spastic torticollis in the form of heat, massage, and intermittent cervical traction, providing there is no evidence of true cervical vertebral instability. Resolution is generally abrupt in inflammatory and atlantoaxial rotary displacements. Subluxation of the radialhead “Pulled elbow” is most commonly seen in children between one and five years of age. It occurs following an injury sustained in which the child’s forearm or hand is being held and the child attempts to fall away, or is lifted from 73 Muscular dystrophies the ground by the hands. The children tend to carry the forearm in a “lame” position of forearm pronation, and elbow flexion supported by the other hand (Figure 4. Supination of the forearm or pressure over the radial head increases the discomfort. True subluxation or dislocation of the radial head from its position against the capitellum has never been demonstrated radiographically or pathologically. The condition occurs when longitudinal traction is applied to the forearm with the arm extended and the forearm pronated.

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