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By J. Tjalf. Andrews University.

Hullin MG 250mg depakote with amex, Robb JE generic depakote 250 mg with amex, Loudon IR (1992) Ankle-foot orthosis function an arthrodesis performed to compensate for the lack of in low-level myelomeningocele depakote 250mg with visa. Mossberg KA discount depakote 500 mg without a prescription, Linton KA purchase depakote 250mg with amex, Friske K (1990) Ankle-foot orthoses: ef- the stabilizing function of the triceps surae. Polak F, Morton R, Ward C, Wallace WA, Doderlein L, Siebel A (2002) cot Marie Tooth disease. As loss of muscle strength is Double-blind comparison study of two doses of botulinum toxin progressive, transfers are not indicated. Clinically a short A injected into calf muscles in children with hemiplegic cerebral plantar fascia and tibialis posterior are found. Dev Med Child Neurol 44: 551–5 be helpful to ameliorate the position and mobility of 9. Romkes J, Brunner R (2002) Comparison of dynamic and hinged the foot to release the plantar fascia (Steindler) and to ankle-foot orthosis by gait analysis in patients with hemiplegic cerebral palsy. Steinwender G, Saraph V, Zwick EB, Uitz C, Linhart W (2001) Fixed and dynamic equinus in cerebral palsy: evaluation of ankle func- Other deformities tion after multilevel surgery. Sutherland DH, Kaufman KR, Wyatt MP, Chambers HG, Mubarak SJ The development of a ball-and-socket joint in the up- (1999) Double-blind study of botulinum A toxin injections into the per ankle in patients with myelomeningocele has been gastrocnemius muscle in patients with cerebral palsy. Hasler tures; see below), a CT scan with 3D-reconstruction can be helpful for surgical planning. Fracture types Extra-articular fractures (metaphyseal) 3 ▬ Compression fractures frequently show slight recurva- tion, but no deviation in the frontal plane. The lower ankle can functionally compensate for slight valgus deformities by inversion, but has only a lim- ited potential for compensation of varus deformities (⊡ Fig. The fracture patterns for the distal tibia and ankle ▬ Medial malleolar fractures usually involve the epiph- show typical age peaks: ysis (Salter-Harris type III, chapter 4. Transitional fractures occur as a result of external rota- Epiphysiolyses and epiphyseal fractures of the distal tibia tion trauma during physiological physeal closure, i. The ossification front spreads out from the center in a posteromedial, Diagnosis followed by an anterolateral direction. Its asymmetrical Clinical features advance determines the fracture pattern: the earlier the Localized pain, often accompanied by pronounced peri- fracture, the greater the anterolateral fragment, whose malleolar swelling. Deformities are readily apparent on horizontal wall runs through the still open physeal sec- clinical examination because of the thin perimalleolar tions and whose vertical, epiphyseal projections mark the soft tissue covering. If the x-ray shows an undisplaced but boundary between open and ossifying sections. The latter lead to the so-called juvenile Tillaux Imaging investigations fracture, similar to the bony, anterior syndesmotic dis- Standard AP and lateral x-rays, including the adjacent ruptions seen in adults. Views of the upper ankle in internal and external aforementioned basic morphology and are restricted rotation increase the sensitivity in cases of suspected to the epiphysis. The projection in internal rotation a metaphyseal fracture plane that runs obliquely, with provides a view of the distal tibiofibular joint space and a variable ascent, in a ventral-distal to dorsal-proxi- enables the examiner to assess the congruence of the mal direction. Metaphyseal fractures, distal tibia: Extra-articular frac- flexion fractures (b) and epiphyseal separations without (Salter I; c) tures include metaphyseal compression fractures (a), metaphyseal and with metaphyseal wedge (Salter II; d) a b c ⊡ Fig. Epiphyseal fractures, distal tibia: Intra-articular frac- with metaphyseal wedge (Salter IV; b) and transitional fractures tures include medial malleolar fractures without (Salter III, a) and (c; see also Fig. Greenstick fractures that are pushed in on the ventral If the metaphyseal plane continues into the joint at side of the cortical bone and split open on the dorsal the front, a posterior Volkmann fragment forms, as side must be fixed in plantar flexion in a below-knee cast with malleolar fractures in adults: This rarest and in order to achieve dorsal compression and thus timely most difficult type of transitional fracture is known consolidation. So-called complex transitional fractures are combined with ipsilateral tibial shaft Surgical treatment fractures. Reducible epiphysiolyses that are not closed in the desired position usually involve the interposition in the Treatment plate of a periosteal flap, or even the medial neurovascular Spontaneous corrections of varus, valgus and recurvation bundle, which then has to be released surgically. If a very large metaphyseal wedge is pres- of up to 10° are immobilized in a plaster slab, which is ent, the internal fixation can also be performed using only replaced by an encircling cast after the swelling has sub- percutaneously inserted metaphyseal lag screws. Bottom row: In the lateral or oblique view, two different distinction is made in transitional fractures between twoplane and tri- types of triplane fracture can be distinguished: In a type I triplane frac- plane fractures: In the twoplane fractures one of the fracture planes is ture, the metaphyseal fracture ends – as with an epiphyseal separation in the epiphysis, the other in the epiphyseal plate. In a type II triplane fracture, the metaphyseal fracture tures, an additional metaphyseal fracture forms the 3rd fracture plane. Both in the epiphyseal separations with a ally, even involving the medial malleolus, or very laterally. The more metaphyseal wedge and triplane fractures, the metaphyseal end of physiological physeal closure has already progressed, the more lateral the fracture can be seen on the AP view as a »Gothic arch« a b c ⊡ Fig. Treatment of metaphyseal fractures of the distal tibia: fractures requiring primary or secondary reduction due to an unac- The metaphyseal fractures are treated conservatively in a below-knee ceptable axial deviation the final position should be secured with cast (a). Any primary or secondary axial deviations are corrected crossed percutaneous Kirschner wires (c) around the 8th day with cast wedging (b).

Chapter 1 Basic considerations in grow ing bones and joints A mind that can comprehend the principles trusted 250 mg depakote, will devise its own methods generic depakote 250mg overnight delivery. The growth plate Although there are clear and distinct structural differences between very young and mature bones cheap 500mg depakote with amex, the structure that most clearly separates them is the physis or growth plate effective 500mg depakote. Anatomically situated beneath the epiphysis and above the metaphysis and diaphysis purchase depakote 500 mg on line, its role in our maturing process is a noble work of nature. Not only does it afford us eventual height and body mass, it contributes to our Figure 1. The upper cellular layer(s) of the growth plate are in a resting (germinal) stage, waiting to be converted into actively reproducing cells (chondrocytes) that will add to our eventual height by replicating in a longitudinal fashion (Figure 1. These cells also are responsible for producing the matrix in which they are embedded, most particularly the collagen that binds to the protein polysaccharide produced by these cells. This zone of proliferation is best conceived as an anabolic zone, where positive events are happening, both to elongate our bones and to build strength for the growth plate apparatus. Its tightly bound cells and matrix allow for considerable resistance to stress. The Basic considerations in growing bones and joints 2 next zone closer to the metaphysis is the zone of hypertrophy. This zone is much more catabolic in nature, where preparations for the eventual conversion of growth plate cartilage into bone are occurring. The tightly packed linear oriented cells seen in the proliferative zone have now become swollen, and are surrounded by abundant matrix in which the collagen bundles are much more loosely and irregularly arranged. Catabolic enzyme activity predominates and the growth plate strength is weakest in this area. An intrinsic mechanism that has not been fully clarified, operates within the zone of hypertrophy that controls the programmed cellular “life to death” cycle of the chondroblast (apoptosis). Clinically this is the zone through which epiphyseal separations (fractures and slipped epiphyses) occur. The lowest part of the zone of hypertrophy and the encroaching metaphyseal level is termed the zone of provisional ossification. The lower levels of the zone of hypertrophy are maturing and being converted into newly forming bone (osteoid). The most predominant anatomic structural difference in this region is the ingress of blood vessels carrying a high oxygen “front”, which creates an environment in which cartilage cannot survive. By a process of cartilage removal and subsequent conversion into newly formed osteoid, the region begins to assume the characteristics seen in the upper layer of the metaphyseal region. Two other commonly discussed structures have a profound bearing on growth plate integrity. The zone of Ranvier consists of cells lying laterally and circumferential around the upper zones of the physis whose responsibility it is to provide latitudinal growth of the physis and thereby provide for a wider bone at the level of the growth plate. The perichondrial ring of Lacroix is the continuation of the periosteum of the metaphysis as it reaches the growth plate to become the perichondrium of the epiphysis. This fibrocartilaginous osseous ring surrounds the growth plate, much like the 3 Epiphysis, metaphysis, and diaphysis bark of a tree, and is believed to provide up to 50 percent of the resistance of the epiphysis to displacement. The epiphysis, metaphysis, and diaphysis The growth plate in newborns is not constituted as an effective structure between the metaphysis and the epiphysis, and this transformation generally does not occur until between 12 and 24 months of age (Figure 1. Injury or disease affecting the metaphysis or epiphysis in the very young child (i. Once the growth plate is constituted, an effective barrier then develops between the epiphysis and metaphysis. The cartilage epiphysis prior to developing a primary center of ossification is termed a chondroepiphysis and is, as would be expected, less resistant to injury and disease. Its primary function is to evolve into an appropriate shape to provide a joint surface for motion and to be sturdy enough to absorb and transmit the loading stresses imposed on that joint. The configuration of the chondroepiphysis and its union with the active area in growing bone, with the richest greater trochanterin the neonate. This is contrasted with the presence of a vascularity and the highest turnover of bone. In a child, the large volume of cancellous bone compared with cortical bone in this region makes it obviously weaker than the cortical bone so prevalent in the diaphysis. For these accumulative reasons, bone pathology is most commonly reflected in the metaphysis (i. The diaphysis is composed for the most part of cortical bone surrounding the medullary canal. Therefore, this region is much stronger, less elastic, and more protective in nature to Basic considerations in growing bones and joints 4 provide resistance to the tremendous daily forces applied, and to keep us from “shattering.

This is characterized by intense ing kyphosing at the thoracolumbar junction (⊡ Fig discount depakote 500mg with visa. The frequently occurring femoral head necrosis can warmth generic depakote 250mg visa, redness and occasionally fever as well discount 500 mg depakote with amex. During result in premature osteoarthritis of the hip and the need the crisis buy cheap depakote 250 mg on-line, an increased uptake is apparent on the techne- for a total hip replacement generic depakote 500 mg without prescription. AP x-ray of the pelvis in a 7-year old girl with Gaucher disease and an intertrochanteric fracture of the right femur 699 4 4. The proliferating cells are derived either from the Schwann cells or accompanying cells. Viewed macroscopically the neurofibromas are bright, relatively compact nod- ules that are connected to the peripheral nerves. Neurofibromas also occur in the central nervous system (brain, spinal cord). Occurrence After Down syndrome, neurofibromatosis is the most common hereditary disease. In Israel, prevalence figures of 104/1,000,000 males and 119/1,000,000 females have been reported. Type II neurofibromatosis is much less common (1/1,000,000 inhabitants). Neurofibromatosis type I Clinical features, diagnosis At least two of the following clinical characteristics are required before a diagnosis of neurofibromatosis can be made: ⊡ Fig. X-ray of the spine of a 9-year old boy with Gaucher disease ▬ Café-au-lait spots: Light brown, regular pigmented le- and a low thoracic kyphosis sions that can cover large areas. Dystrophic scoliosis sues associated with the central and peripheral nervous is short-curved and has a kyphotic component. Typical or- vertebral bodies show a curved indentation, the ribs thopaedic problems include leg lengthening, congenital are thinned on the concave side facing the spine and tibial pseudarthroses and short-curved progressive sco- markedly rotated (⊡ Fig. In 1918 Gould mentioned nection with substantial accumulations of subcutane- the occurrence of scolioses in connection with neurofibromatosis. Such lengthening man with a grotesquely deformed skull who was the subject of a play occurs in approx. However, more recent investigations of his Neurological lesions: Discrete neurological changes, skull have revealed that John Merrick had suffered not from neurofi- particularly sensory abnormalities, occur in 15% of bromatosis, but rather from Proteus syndrome. In addition to the neurofibromatosis solitary at least two must be present, the following additional neurofibromas are also present in Proteus syndrome, al- changes can occur: though these do not usually affect children and adoles- ▬ Elephantiasis (pachydermatocele): hypertrophy of the cents, but patients aged between 20 and 40 years. Within the population of neuro- Patients with neurofibromatosis have a largely normal life fibromatosis patients, however, tibial pseudarthrosis expectancy. A detailed description A very important prognostic indicator is the malig- of congenital tibial pseudarthrosis can be found in nant degeneration of the neurofibromas. We have observed three such ▬ Paravertebral soft tissue tumors: These are usually as- cases. Isolated reports of degeneration into malignant sociated with scoliosis. They are readily viewed on the schwannomas or rhabdomyosarcomas are also described MRI scan and must be differentiated from ganglio- in the literature. The spinal changes must The diagnosis of neurofibromatosis is confirmed clini- be diagnosed as soon as possible and then monitored very cally. The scolioses are usually strongly progressive and history is present in only a minority of patients and most corset treatments are not very effective. X-rays are needed for diag- surgical treatment is often indicated ( Chapter 3. The MRI scan can reveal severe – cutaneous changes, and also with sensory ab- paravertebral, intraspinal and intracerebral tumors. The thickened, flabby skin on the Differential diagnosis sole of the foot can lead to pronounced trophic problems Neurofibromatosis can be confused with the very rare Pro- and pressure sores. Removal of the excess skin by the teus syndrome (see above: »Historical background«). From the orthopaedic standpoint, can also occur in this condition, and the patients may as soon as a discrepancy exceeds 2 cm, leg length equal- also show macrodactyly.

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