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INTRODUCTION
Deformity is the malformation of any component of the body. The malformation my be the result of bony distortion or alteration in the topography of soft tissues. The deformity could lead to an impairment or even functional loss along with cosmetic disfigurement.
TYPES OF DEFORMITY
There are two types of deformity: 1. Congenital. 2. Acquired.
Congenital Deformity
Incorrect position in the uterus, abnormal development due to a combination of genetic and acquired factors are the principal causes of congenital deformity. The congenital deformity may or may not be hereditary.
Acquired Deformity
The acquired deformity is that which was not present at birth, and has developed after birth. It can be produced as a result of following causes: 1. Bone disease 2. Joint diseases
3. Muscular causes: They are of following types:
Congenital Deformities
Shoulder Joint 1.Sprangels shoulder: Also called high scapula.
It is characterized by an abnormally raised scapula, on one or both sides. The eliology is unknown. The scapular muscles are poorly developed and may be represented by fibrous bands. It may be accompanied by scoliosis(thoracic curve) with convexity on the involved side. The movement of scapula is markedly limited due to fibrous bands or a bony bar resulting in the limitation of shoulder abduction and elevation.
Elbow Joint
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Wrist Joint
1. Carpal fusions: Coalition of one or more carpal bones
is one of the commonest congenital wrist abnormalities; it is usually inherited or an autosomal dominant trait and may be bilateral. Often it is associated with other abnormalities. It seldom causes problem and no treatment is necessary.
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3. Radial Longitudinal Deficiency(Radial Club Hand): The infant is born with the wrist in marked radial deviationhence the name club hand. Bilateral deformity is more common than unilateral. There is absence of the whole or part of the radius; often the thumb,scaphoid and trapezium fail to develop normally. It usually occurs as an isolated abnormality but is occasionally associated with other conditions such as thrombocytopaenia and absent radius(TAR),Fanconi anaemia, atrial septal defect(Holt-Oram syndrome) or the VATER syndrome(Vertebral defects, anal atresia , Tracheal-Esophageal fistula, renal and Radial dysplasia). Treatment in the neonate consists of gentle manipulation and splintage.
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Congenital Variations
The hand and foot are much the commonest sites of congenital variations in the musculoskeletal system; the incidence is at least one in 1000 live births. The cause may be an inherited genetic defect, a chromosome disorder or an embryonal insult due to viral infection, nuclear radiation or harmful drug administration during the first 2 months of pregnancy. The clinical disorders are conventionally divided into 7 groups.
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EXAMPLE
Transverse absence Longitudinal absence- radial (radial club hand) Longitudinal absence-ulnar (ulnar club hand)
Failure of differentiation
Syndactyly
Symphalangism
Camptodactyly Flexed Thumb
Arthrogrypois
Thumb duplication
Macrodactyly Thumb hypoplasia Simple rings Marfans, Turners, Downs etc.
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Failure of Formation
The upper limb can fail to develop either transversely or longitudinally.
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ulnar or central. 1. Radial longitudinal deficiency(Radial club hand): There is partial or complete absence of the thumb and/or radius; the typical deformity is one of marked radial deviation of the wrist and hand. In some cases the humerus is fused with ulna.
3. Central longitudinal deficiency(Cleft hand): This is usually present as a familiar disorder. Typically, the second, third and fourth rays are affected. The condition is bilateral and the feet are often involved. The appearance ranges from a simple cleft, with only the middle ray missing, to absence of all three central rays(unkindly described as a lobster claw).
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Failure of differentiation
1. Syndactyly(congenital webbing): It is the most
common congenital variation in the hand. It may be simple(skin only) or complex(skin and bone). With acrosyndactyly, only the tips are joined.
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3. Kirners deformity: It is not congenital but is mentioned here as it could otherwise be mistaken for camptodactyly or clinodactyly. Presenting in adolescence, the distal phalanx(yet again the little finger) becomes swollen and curved. Treatment is with splintage and occasionally osteotomy. 4. Hereditary symphalangism: It describes cognitive stiffness of the proximal interphalangeal joint. The whole finger is small, shiny and stiff. Motion can not be restored with surgery.
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Duplication
1.Polydactyly(extra digits): It is nearly as common as syndactyly. An extra little finger is usually inherited and other variations may be present. By contrast, an extra thumb is usually sporadic. An extra central digit, the rarest of the duplication, is often associated with syndactyly and disorganization of the skeleton. Extra skin tags can be simply excised.
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Overgrowth
1.Macrodactyly: It has a neurogenic cause. The giant finger is
stiff and unsightly, but attempts at operative reduction are fraught with complications. The finger can not be made normal; several attempts may be made to reduce the size, each leaving the finger increasingly stiff and scarred.
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Undergrowth
The thumb is most commonly affected, the defect ranging from a slightly small digit to complete aplasia. The most severe forms need a pollicization to provide a post to oppose against the fingers; less severer forms may need a web space release, stabilization of the MCP joint, correction of abnormal tendons and a muscle transfer to provide opposition.
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Constriction Bands
These may occur in any part of the limb. The consequences range from complete amputation to an obvious circumferential constriction with a viable distal part. The latter is treated by multiple Z-pasties.
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Neck Region
1.Torticollis(wry neck): This is description rather
than a diagnosis. The chin is twisted upwards towards one side. There are many causes. The condition may be either congenital or acquired.
common. The sternomastoid muscle on one side is fibrous and fails to elongate as the child grows; consequently, progressive deformity develops. The cause is unknown; the muscle may have suffered ischaemia from a distorted position in utero(the association with breech presentation and hip dysplasia is supporting evidence), or it may have been injured at birth. A history of difficult labour or breech birth is common. Deformity does not become apparent until the child is 1-2 years old. The head is tilted on one side, so that the ear approaches shoulder; the sternomastoid on that side may feel tight and hard. There may also be asymmetrical development of the face(plagiocephaly). These features become increasingly obvious as the child grows.
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synostosis):
This developmental disorder represents a failure of segmentation of the cervical somites; it is often associated with abnormalities in the genitourinary, nervous or cardiovascular system. Some children have a hearing impediment. Children with synostosis have a characteristic appearance: the neck is short or non-existent and there may be webbing; the hairline is low; and neck movements are limited. About one in three children with Klippel-Feil syndrome also has Sprengels deformity of the scapula. Scoliosis is present in about 60% and rib anomalies in about 30%. Hand deformities such as syndactyly, thumb hypoplasia and extra digits are also present. X-rays reveal fusion of two or more cervical vertebrae.
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2. Basilar Impression: In this condition the floor of the skull is indented by the upper cervical spine. The odontoid can impinge upon the brain stem. The cause is either a primary bone abnormality(associated with other bone defects such as odontoid abnormalities, Morquio syndrome and Klippel-Feil syndrome) or secondary to softening of the bones(osteomalacia, rickets rheumatoid arthritis, neurofibromatosis etc). The patients may present-often in the second or third decade-with symptoms of raised intracranial pressure(because the aqueduct of Sylvius becomes blocked), weakness and paraesthesia of the limbs(because of direct compression or ischaemia of the cord). Treatment involves surgical decompression and stabilization.
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3. Odontoid Anomalies: The odontoid may be absent or hypoplastic, or there may be a separate ossicle(the os odontoideum). The anomaly should be suspected(and looked for even if the child does not complain) in skeletal dysplasias which involve the spine. This is especially important in patients undergoing operation; the atlantoaxial joint may subluxate under anaesthesia. In the majority of cases the anomaly is discovered by chance in a routine cervical spine X-rays following trauma. Open-mouth radiographs show the abnormality; lateral flexion/extension views may show instability of the C1-C2 articulation.
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Back Region
Spinal Deformities: Variations and abnormalities of segmentation are common. The most serious type of congenital defect is spina bifida. Spinal deformity(as opposed to deformities of individual vertebrae) affects the entire shape of the back and manifests as abnormal curvature, in either the coronal plane(scoliosis) or the sagittal plane(hyperkyphosis and hyperlordosis).
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the incomplete closure of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to stick out through the opening in the bones. There may or may not be a fluid filled sac surrounding the spinal cord. Other neural tube defects include anencephaly, a condition in which the portion of the neural tube which will become the cerebrum does not close, and enecphalocele, which results when other parts of the brain remain unfused. Spina bifida malformations fall into four categories: spina bifida occulta, spina bifida cystica (myelomeningocele), meningocele and lipomeningocele. The most common location of the malformations is the lumbar and sacral areas . Myelomeningocele is the most significant form and it is this that leads to disability in most affected individuals. The terms spina bifida and myelomeningocele are usually used interchangeably. Spina bifida can be surgically closed after birth, but this does not restore normal function to the affected part of the spinal cord. Intrauterine surgery for spina bifida has also been performed and the safety and efficacy of this procedure is currently being investigated. The incidence of spina bifida can be decreased by up to 75% when daily folic acid supplements are taken prior to conception.
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Scoliosis cont.
b. Structural or Fixed Scoliosis: In structural scoliosis
there is non-correctible deformity of the affected spinal segment, an essential component of which is vertebral rotation. The spinous processes swing round towards the concavity of the curve and the transverse processes on the convexity rotate posteriorly; in the thoracic region the ribs on the convex side stand out prominently, producing the rib hump which is a characteristic part of the overall deformity. Dickson et al (1984) pointed out this is really a lordoscoliosis associated with rotational buckling of the spine. Most cases have no obvious cause(idiopathic scoliosis); other varieties are congenital or osteopathic(due to bony anomalies), neuropathic, myopathic(associated with some muscle dystrophies) and a miscellaneous group of connective-tissue disorders.
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Scoliosis Images:
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Scoliosis cont
Idiopathic scoliosis: This group constitutes about 80% of
all cases of scoliosis. The deformity is often familial, and the population incidence of serious curves(over 30 and therefore needing treatment) is three per 1000; trivial curves are very much more common. The age at onset has been used to define three groups: adolescence, juvenile and infantile. A simpler division is early onset(before puberty) and late onset(after puberty) scoliosis.
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Scoliosis cont
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Scoliosis cont
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Scoliosis cont
This variety is becoming uncommon, perhaps because most babies now a days are allowed to sleep prone. Boys predominate and most curves are thoracic with convexity to the left. Although 90% of the infantile curves resolve spontaneously, progressive curves can become very severe; those in which the rib-vertebra angle at the apex of the curve differs on the two sides by more than 20 are likely to deteriorate (Mehta, 1972). And because this also influences the development of the lungs, there is a high incidence of cardiopulmonary dysfunction. If the deformity continues to deteriorate, surgical correction may be required.
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Kyphosis cont
a. Postural kyphosis: It is usually associated with other
postural defects such as flat feet. It is voluntarily correctable. If treatment I needed, this consists of posture training and exercises. Compensatory kyphosis is secondary to some other deformity; usually increased lumbosacral lordosis. This deformity too, is correctable.
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Kyphosis cont
b. Structural Kyphosis: It is fixed and is associated with
changes in the shape of the vertebrae. In children this may be due to congenital vertebral defects; it is also seen in skeletal dysplasia such as achondroplasia and in osteogenesis imperfecta. Older children may develop severe deformity secondary to tuberculous spondylitis. In adolescence the commonest cause is Scheuermanndisease. In adults kyphosis could be due to an old childhood disorder, tuberculous spondylitis, ankylosing spondylitis or spinal trauma. In elderly people, osteoporosis may result in vertebral compression and an increase in a previously mild, asymptomatic deformity.
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Kyphosis cont
c. Congenital Kyphosis: Vertebral anomalies leading to kyphosis
may be due to failure of formation(type I), failure of segmentation(type II) or a combination of these. Type I (failure of formation) is the commonest(and the worst). If the anterior part of the vertebral body fails to develop, progressive kyphosis and posterior displacement of the hemivertebra may lead to cord compression. In children under 6 years with curves of less than 40 , posterior spinal fusion alone may prevent further progression. Older children or more severe curves may need combined anterior and posterior fusion; and those with neurological complications will require cord depression as well as fusion. Type II (failure of segmentation) usually takes the form of an anterior intervertebral bar; as the posterior elements continue to grow, that segment of the spine gradually becomes kyphotic. The risk of neurological compression is much less, but if the curve is progressive a posterior fusion will be needed.
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Kyphosis cont
d. Adolescent Kyphosis (Scheuermanns Disease):
Scheuermann, in 1920, described a condition which he called Juvenile dorsal kyphosis, distinguishing it from the more common postural(correctable) kyphosis. The characteristic feature was a fixed round-back deformity associated with wedging of several thoracic vertebrae. The term vertebral osteochondritis was adopted because the primary defect appeared to be in the ossification of the epiphyseal ring which define the peripheral rims on the upper and lower surfaces of each vertebral body. The true nature of the disorder is still unknown; the cartilaginous end-plates may be weaker than normal (perhaps due to a collagen defect) and are then damaged by pressure of the adjacent intervertebral discs during strenuous activity.
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Kyphosis cont
e. Osteoporotic Kiphosis(Elderly Kiphosis):
Postmenopausal osteoporosis may result in one or more compression fractures of the thoracic spine. Patients are usually in their 60s or 70s and may complain of pain. Kyphosis is seldom marked. Often the main complaint is of lumbosacral pain, which results from the compensatory lumbar lordosis in an ageing, osteoarthritic spine. Senile osteoporosis affects both men and women. Patients are usually over 75 years of age, often incapacitated by some other illness, and lacking exercise. They complain of back pain, and spinal deformity may be marked. It is important to exclude other conditions such as metastatic disease or myelomatosis.
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Hip Joint
condition was formerly known as congenital dislocation of the hip (CDH), and now called developmental dysplasia of the hip (DDH), comprises a spectrum of disorders: acetabular dysplasia without displacement; instability (subluxation or dislocation); and teratological forms of malarticulation. Whether the instability comes first and then affects acetabular development because of imperfect seating of the femoral head, or is a result of a primary acetabular dysplasia, is still unknown for sure. Both mechanisms might be important. The reported incidence of neonatal hip instability is 5-20 per 1000 live births; however, most of these hips stabilize spontaneously, and on reexamination 3 weeks after birth the incidence of instability in only 1 or 2 per 1000 infants. Girls are much more commonly affected than boys, the ratio being about 7:1. The left hip is more often affected than the right; in 1 in 5 cases the condition is bilateral.
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Leg Region
1. Congenital absence of the fibula(fibular hemimelia):
Congenital absence of the fibula, also known as fibular hemimelia, encompasses a spectrum of anomalies involving abnormal growth and development of the fibula. It is the most common long bone deficiency, followed by aplasia of the radius. According to Coventry and Johnson, the condition was first described in 1698. Manifestations of this condition range from mild degrees of limb shortening to its most severe form, which includes complete absence of the fibula with accompanying defects in the femur, tibia, and foot. The severity of foot abnormalities appears to correlate with the severity of the fibular deficiency. Only a few reports of prenatally diagnosed fibular hemimelia have been published, and to our knowledge there are no prior reports of isolated fibular hemimelia diagnosed antenatally on the basis of sonography. We report a case of the antenatal sonographic diagnosis of complete bilateral fibular hemimelia without the presence of other congenital anomalies.
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Tibial hemimelia is a rare anomaly characterized by deficiency of the tibia with relatively intact fibula. Jones et al. (1978) classified the anomaly into 4 types according to radiologic criteria. It may present as an isolated anomaly or be associated with a variety of skeletal and extraskeletal malformations. Tibial hemimelia may also constitute a part of a more complicated malformation complex or syndrome, such as the Gollop-Wolfgang complex and triphalangeal thumb-polysyndactyly syndrome (Matsuyama et al., 2003). Emami-Ahari and Mahloudji (1974) described bilateral absence of the tibia in 3 children, 2 males and 1 female, of phenotypically normal but related parents. No other anomalies were present and intelligence was normal. Jones et al. (1978) reported affected brother and sister. McKay et al. (1984) reported affected sisters. McKay et al. (1984) reviewed syndromes of congenital defects in which tibial hemimelia is a feature. Richieri-Costa et al. (1987) reported on 37 patients belonging to different families who had the tibial hemimelia/split-hand/split-foot syndrome. Quoting others, they suggested that the maximum risk to the offspring of an affected person married to an unaffected person is 8.6% and the maximum risk to a sib of an isolated patient is 12.5%. They suggested that there are 4 well-established and 2 other possible autosomal dominant tibial hemimelia syndromes in addition to 2 types with autosomal recessive inheritance. Richieri-Costa (1987) reported a Brazilian child, born to consanguineous but healthy parents, who had cleft lip/palate in addition to tibial hemimelia. Stevens and Moore (1999) described a girl with Langer-Giedion syndrome (LGS), a contiguous gene syndrome caused by deletion in the 8q24.1 region. The patient also showed bilateral tibial hemimelia and unilateral absence of the ulna. Turleau et al. (1982) had described an 8-year-old boy with LGS and bilateral tibial hemimelia. Although no genes involving limb development in the human had been identified in the 8q24.1 region, 2 mouse syndromes with limb abnormalities mapped to the homologous region of 9A1-A4: 'luxoid' (absent toes, radial and tibial hemimelia, preaxial polydactyly, bent tail, and oligospermia) and 'aft' (abnormal feet and tail). Stevens and Moore (1999) suggested that a gene involved in limb development is contiguous with the gene(s) for LGS and that deletion of this gene causes tibial hemimelia.
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Foot Region
1. Congenital Talipes Equinovarus(CTEV): (Idiopathic Club Foot)
The term talipes is derived from talus(Latin=ankle bone) and pes (Latin=foot). The elements of this congenital deformity are: Adduction and Inversion of the Forefoot. Inversion of the heel (hind foot) Cavus and equinus with clawing of the toes. The abnormality is relatively common, the incidence ranging from 1-2 per thousand births; boys are affected twice as often as girls and the condition is bilateral in onethird of the cases. The exact cause is unknown; it could be a genetic defect or a form of arrested development. Its occurrence in neurological disorders and neural tube defects(e.g. myelomeningocele and spinal dysraphism) points to a neuromuscular disorder.
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deformity which presents in the newborn as an acutely dorsiflexed foot. There is a deep crease (or several wrinkles) on the front of the ankle, and the calcaneum just out posteriorly. It is usually bilateral. There is an association with hip dysplasia, especially if it presents on one side only. This is a postural deformity, probably due to abnormal intrauterine positioning, and it often corrects spontaneously in the neonatal period.
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arch is higher than the normal, and often there is also clawing of the toes. The close resemblance to deformities seen in the neurological disorders where the intrinsic muscles are weak or paralyzed suggests that all types of pes cavus are due to some type of muscle imbalance. There are rare congenital causes such as arthrogryposis, but in the majority of cases pes cavus results from an acquired neuromuscular disorder. Hereditary motor and sensory neuropathies and spinal cord abnormalities(tethered cord syndrome, diastematomyelia) are the commonest, but poliomyelitis is the most commonest cause worldwide. Occasionally the deformity follows trauma-burns or a compartment syndrome resulting in Volkmanns contracture of the sole.
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Acquired Deformities
Shoulder Joint
the medial border (the side nearest the spine) of a person's scapula is abnormally positioned outward and backward. The resulting appearance of the upper back is said to be wing-like because the inferior angle of the shoulder blade protrudes backward rather than lying mostly flat like in people without the condition.
Causes
Although there are many causes of the condition, the most common is when the serratus anterior muscle are weakened (for various reasons) or when they are weakened and/or paralyzed by impingement of the long thoracic nerve. Treatment Surgery is sometimes used to treat the condition. Symptoms can also be alleviated through rehabilitation by using different strengthening and endurance exercises. Stretching is used with some precautions under supervision of a Certified Athletic Trainer or licensed PT.
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adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, and grows together with abnormal bands of tissue, called adhesions, greatly restricting motion and causing chronic pain. Adhesive capsulitis is a painful and disabling condition that often causes great frustration for patients and caregivers due to slow recovery. Movement of the shoulder is severely restricted. Pain is usually constant, worse at night, when the weather is colder, and along with the restricted movement can make even small tasks impossible. Certain movements can cause sudden onset of tremendous pain and cramping that can last several minutes. This condition, for which an exact cause is unknown, can last from five months to three years or more and is thought in some cases to be caused by injury or trauma to the area. It is believed that it may have an autoimmune component, with the body attacking healthy tissue in the shoulder. The condition may also cause chronic inflammation. Adhesions grow between the joints and tissue, greatly restricting motion and causing a number of painful complications. There is also a lack of fluid in the joint, further restricting movement.
2. Adhesive
capsulitis of
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3. Rotator
tears of one, or more, of the four tendons of the rotator cuff muscles. A rotator cuff injury can include any type of irritation or damage to your rotator cuff muscles or tendons. Rotator cuff tears are among the most common conditions affecting the shoulder. The tendons of the rotator cuff, not the muscles, are most commonly torn. Of the four tendons, the supraspinatus is most frequently torn; the tear usually occurs at its point of insertion onto the humeral head at the greater tuberosity.
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bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the suprasinatus tendon (one of the four tendons of the rotator cuff) from the overlying coraco-acromial ligament, acromion, coracoid ( the acromial arch) and from the deep surface of the deltoid muscle . The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work. Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. According to the American Academy of Orthopedic Surgeons (AAOS) visits to orthopedic specialists for shoulder pain has been rising since 1998 and in 2005 over 13 million patients sought medical care for shoulder pain, of which only 34% were related to injury. Primary inflammation of the subacromial bursa is relatively rare and may arise from autoimmune inflammatory conditions (rheumatoid arthritis), crystal deposition (Gout or Pseudo gout), calcific loose bodies (rheumatoid arthritis) and infection. More commonly, subacromial bursitis arises as a result of complex factors, thought to cause shoulder impingement symptoms. These factors are broadly classified as intrinsic (intratendinous) or extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury (Bigliani and Levine, Journal Bone Joint Surgery 1997).
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4. Subacromial
bursitis: Subacromial
Elbow Joint
1. Cubitus valgus: Cubitus valgus is a medical deformity
in which the elbows are turned in. A small degree of cubitus valgus (known as the carrying angle) is acceptable and occurs in the general population. When present at birth, it can be an indication of Noonan syndrome or Turner syndrome. It can also be acquired through fracture or other trauma.The physiological cubitus valgus varies from 3 to 29. Women usually have a more pronounced Cubitus valgus than men. The commonest cause is a malunion of a supra-condylar fracture and the deformity is obvious only when the elbow is extended The hand brushes against the side during normal walking Deformity can be corrected by a wedge osteotomy of the distal humerus.
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Cubitus
varus (varus means a deformity of a limb in which part of it is deviated towards the midline of the body) is a common deformity in which the extended forearm is deviated towards midline of the body . Cubitus varus is often referred to as 'Gunstock deformity', due to the crooked nature of the healing. The commonest cause is a malunion or non-union of a number of the lateral condyle of the humerus. The medial epicondyle becomes prominent on the medial side of the joint and there is a tendency for the development of a delayed ulnar nerve palsy (weakness of the hand and tingling of the ulnar fingers) The deformity itself may need no treatment but the delayed ulnar nerve palsy may require ulnar nerve transposition
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3.Subluxation of Radial Head: This is commonly associated with bony dysplasias in which the ulna is disproportionately shortened (e.g. hereditary multiple exostosis). It causes little disability, but if it becomes troublesome the radial head can be excised after all growth has ceased.
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Isolated radial head dislocations are rare; only 20 cases have been reported in 30 years. Radial head dislocations are usually complicated by complete elbow dislocations or fractures, as in the Monteggia complex.
Monteggia described the combination of radial head dislocation and proximal ulnar fracture in 1814. More than a century later, Bado further classified the Monteggia injury into 4 types based on the angulation of the fracture and direction of dislocation (see Table). The Bado classification is useful descriptively but not prognostically. Radial head dislocation is often associated with significant trauma (eg, motor vehicle accidents, pedestrianmotor vehicle accidents, significant falls).
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Wrist Joint
most of these injuries are either Salter I or II fractures; fractures separations of proximal humeral epiphysis occur most often between ages of 11 and 15 years; 80% of longitudinal growth of humerus occurs in proximal physis;large percentage of growth allows significant remodeling following injuries of proximal humeral physis; associated injuries: brachial plexus injuries: look for decrease sensation to pain. classification: type I epiphyseal injury: in newborns, fractures are usually Salter Harris type I injuries; type II epiphyseal fractures: in older children, they are most always Salter Harris type II; type III, IV, and V fractures: rare because of greater mobility of the glenohumeral joint; diff dx of proximal humeral injuries: tumor of proximal humerus little league shoulder clavicle fractures normal varient (accentuated w/ humerus externally rotated)
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palsy, is a condition where a person can not extend their wrist and it hangs flaccidly. To demonstrate wrist drop, hold your arm out in front of you with your forearm parallel to the floor. With the back of your hand facing the ceiling (i.e. pronated), let your hand hang limply so that your fingers point downward. A person with wrist drop would be unable to move from this position to one in which the fingers are pointing up towards the ceiling.
Wrist drop: Wrist drop, also known as radial nerve palsy, or Saturday night
Causes: Stab wounds to the chest at or below the clavicle may result in wrist drop. The radial nerve is the terminal branch of the posterior cord of the brachial plexus. A stab wound may damage the posterior cord and result in neurological deficits including an inability to abduct the shoulder beyond 15 degrees, an inability to extend the forearm, reduced ability to supinate the hand, reduced ability to abduct the thumb and sensory loss to the posterior surface of the arm and hand. The radial nerve can be damaged if the humerus (the bone of the arm) is broken, because it runs through the radial groove on the lateral border of this bone. Wrist drop is also associated with lead poisoning because of the effect of lead on the radial nerve. Persistent injury to the nerve is also a common cause through either repetitive motion or by applying pressure externally along the route of the radial nerve as in the prolonged use of crutches or extended leaning on the elbows.
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Hand
1.Boutonniere deformity:
Boutonniere deformity is a deformed position of the finger, in which the joint nearest the knuckle (PIP) is permanently bent toward the palm while the furthest joint (DIP) is bent back away (PIP hyperflexion with DIP hyperextension). It is commonly caused by injury or by an inflammatory conditions like rheumatoid arthritis. Stages Mild extension lag, passively correctable Moderate extension lag, passively correctable Mild flexion contracture Advanced flexion contracture
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5.Swan-Neck Deformity:
Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. The most common cause is rheumatoid arthritis. Other causes include untreated mallet finger, looseness (laxity) of the fibrous plate inside the hand at the base of the fingers or of the finger ligaments, muscle spasm affecting the hands, and misalignment in the healing of a fracture of the middle bone of the finger. Normal bending of the finger may become impossible. The deformity can therefore result in considerable disability. True swan-neck deformity does not affect the thumb, which has one less joint than the other fingers. However, in a variant of swan-neck deformity, called duck-bill deformity, the top joint of the thumb is severely over straightened with a bending in of the joint at the base of the thumb to form a 90 angle. If duck-bill deformity and swan-neck deformity of one or more fingers occur together, the ability to pinch can be seriously reduced.
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6.Trigger
Finger:
In trigger finger (flexor digital tenosynovitis), a finger becomes locked in a bent position. The finger locks when one of the tendons that flex the finger becomes inflamed and swollen. Normally, the tendon moves smoothly in and out of its surrounding sheath as the finger straightens and bends. In trigger finger, the inflamed tendon can move out of the sheath as the finger bends. However, when the tendon is very swollen, it cannot easily move back in as the finger straightens, and therefore the finger locks. Trigger finger can result from repetitive use of the hands (as may occur from using heavy gardening shears) or from inflammation (as occurs in rheumatoid arthritis). To straighten the finger, a person must force the swollen area into the sheathcausing a popping sensation similar to that felt when pulling a trigger. Splinting, moist heat, and nonsteroidal anti-inflammatory drugs (NSAIDs) can help in mild cases. Sometimes a corticosteroid and a local anesthetic are injected into the tendon sheath. Surgery is commonly needed to treat chronic trigger finger.
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manifested by flattening of the transverse metacarpal arch and longitudinal arches, with hyperextension of MCP joints and flexion of the PIP and DIP joints; deformity is produced by imbalance of the intrinsic & extrinsics; intrinsic muscles must be markedly weakened or paralyzed to produce claw deformity; long extensor muscles hyperextend the MCP joint, & long flexor muscles flex the PIP and DIP joints; weakness of the long flexors (as in high palsy) actually decreases claw fingers; PIP joint loses the ability to extend thru the lateral bands and must rely on the central slip; due to the anatomy of the saggital band, MP joint hyperextension blocks the the central slip from extending the PIP; hence, main force of contracted extensor mechanism is focused on saggital band, leading to further MCP hyperextension; tenodesis effect of extending the fingers with wrist flexion is lost; smooth flexion pattern is lost: normally, MP flexion initiates finger flexion, and all joint achieve full flexion nearly simultaneously; distal joint flexion is completed prior to initiation of MP joint flexion; hence, the fingers immediately come into contact with the palm with flexion; causes: combined low median and ulnar nerve lesions (may result in significant decreases in grip strength); brachial plexus injuries; spinal cord injuries; Charcot-Marie-Tooth-Disease;
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1.Coxa valga:
It is a deformity of the hip where the angle formed between the head and neck of the femur and its shaft is increased, usually above 135 degrees. It is caused by a slipped epiphysis of the femoral head.
Hip Joint
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whereby the angle between the ball and the shaft of the femur is reduced to less than 120 degrees which is 160 at birth and 125 in adults. This results in the leg being shortened, and therefore a limp occurs. It is commonly caused by injury, such as a fracture. It can also occur when the bone tissue in the neck of the femur is softer than normal, meaning it bends under the weight of the body. This may either be congenital, also known as Mau-Nilsonne Syndrome, or the result of a bone disorder. The most common cause of coxa vara is either congenital or developmental. Other common causes include metabolic bone diseases (e.g. Paget's disease of bone), post Perthes deformity, osteomyelitis, and post traumatic (due to improper healing of a fracture between the greater and lesser trochanter). Shepherds Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequellae of osteogenesis imperfecta, Pagets disease, osteomyelitis, tumour and tumour-like conditions (e.g. fibrous dysplasia). Treatment: Treatment depends on the cause of the condition. Most cases do not require any treatment. If treatment is required, it is usually a valgus osteotomy of the femur fixed by an angled blade plate device or even a dynamic hip screw.
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acetabuli is an uncommon defect of the acetabulum. The acetabulum is the socket that receives the femoral head to make the hip joint. The hip bone of the pelvic bone/girdle is composed of three bones, the ilium, the ischium and the pubis. The socket is too deep and may protrude into the pelvis. Classification Protrusio acetabuli is divided into two types, primary and secondary. Primary protrusio acetabuli Characterized by progressive protrusio in middle aged women. May be associated with OA. May be familial Secondary protrusio acetabuli Causes include: may be present bilaterally in Paget's disease, Marfan syndrome, RA, AS, & osteomalacia; Femoral head prosthesis, Cup arthroplasty,Septic arthritis, Central fracture dislocation, Total hip replacement surgery Treatment Joint replacement surgery is indicated for severe pain or substantial joint restriction. Prominent trabeculae. * Normal sacro-iliac joints and symphysis pubis.
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anteversion in children is usually congenital, meaning that the child is born with this condition. Up to ten percent of children are born with femur anteversion, and girls are twice as likely as boys to be affected. This condition does not increase the childs risk of developing conditions such as arthritis, or any other muscle or bone diseases. The exact cause of anteversion of the femur is unknown. It is thought to relate to the position of the child within the uterus, as certain positions may cause the hip muscles and femur bones to become abnormally situated. The condition may also be partially genetically inherited, as there is a tendency for the pigeon-toed gait and appearance to run in families. At birth, femur bones are normally anteverted approximately 40 degrees. By adolescence, this has reduced to between 10 and 15 degrees. In a child with femoral anteversion, the femurs are anteverted by more than 40 degrees, and in some cases, more than 50. When the anteversion is between 40 and 50 degrees, treatment is often not required, because the anteversion will have reduced significantly by the time the child enters adolescence.
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Unequal leg
length or leg length inequality (LLI) refers to a medical condition where the legs are of different lengths. One form is "leg length alignment asymmetry" (LLAA) which is a condition in physiology where one leg (the 'short leg', or unloaded leg) is unequal in length while in a supine or prone position (i.e., lying down). LLAA can be either anatomical in nature (short bones due to growth or an accident) or neuromuscular (hypertonicity in the musculature of the pelvis or leg). The most common treatment for discrepancies in leg length is the use of a simple heel lift, which can be placed within the shoe. Although prone "functional leg length" is a widely used chiropractic tool in their Activator technique, it is not a recognized anthropometric technique, since legs are usually of unequal length, and measurements in the prone position are not entirely valid estimates of standing X-ray differences. Measurements in the standing position are far more reliable. Another confounding factor is that simply moving the two legs held together and leaning them imperceptibly to one side or the other produces different results
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Chest
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Neck
of the spine to one side. In those who have the condition, the spine bends either to the left or to the right. The bend can occur at any point along the spine, from the top to the bottom. The curvature can also vary from a slight to severe. However, the chest area (thoracic scoliosis) and the lower part of the back (lumbar scoliosis) are the most common regions to be affected. Scoliosis affects 3-4 children out of every 1,000. In 90% of cases of scoliosis, treatment is not required because the condition corrects itself as the child grows. Most of the remaining 10% of cases can be successfully treated by using a back brace to prevent further curvature. Three out of every 1,000 children with scoliosis will need surgical treatment. Scoliosis can develop at any time during childhood and adolescence. It is more common in girls than boys, most commonly occurring at the start of adolescence. In approximately 80% of scoliosis cases, the causes are unknown (idiopathic). Scoliosis is normally not a serious condition, but treatment is essential. Left untreated, the curve of the spine can worsen, and cause damage to the spine, chest, pelvis, heart and lungs. In approximately 80% of cases, the cause of scoliosis is unknown (idiopathic). However, it is thought that idiopathic scoliosis runs in families, and researchers have recently discovered a gene that may make people more susceptible to idiopathic scoliosis.
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the head is tilted toward one side (cervical Lateral flexion), and the chin is elevated and turned toward the opposite side (cervical extension). Acquired torticollis occurs because of another problem and usually presents in previously normal children and adults. Trauma to the neck can cause atlantoaxial rotatory subluxation, in which the two vertebrae closest to the skull slide with respect to each other, tearing stabilizing ligaments; this condition is treated with traction to reduce the subluxation, followed by bracing or casting until the ligamentous injury heals. Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically. Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridement in intractable cases. Ear infections and surgical removal of the adenoids can cause an entity known as Grisel's syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge must either be broken through manipulation of the neck, or surgically resected. The use of certain drugs, such as antipsychotics, can cause torticollis. There are many other rare causes of torticollis.
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bandiness), is a deformity marked by medial angulation of the leg in relation to the thigh, an outward bowing of the legs, giving the appearance of a bow. It is also known as bandy-leg, bowleg, bow-leg, and tibia vara. Usually there is an outward curvature of both femur and tibia. "Genu varum" is distinguished from Blount's disease because it involves both the femur and the tibia, while Blount's disease affects only the tibia with no femur involvement. Causes If a child is sickly, either with rickets or suffering from any ailment that prevents the due ossification of the bones, or is improperly fed, the bowed condition may remain persistent. Thus the chief cause of this deformity is rickets. Skeletal problems, infection, and tumors can also affect the growth of the leg, sometimes giving rise to a one-sided bow-leggedness. The remaining causes are occupational, especially among jockeys, and from physical trauma, the condition being very likely to supervene after accidents involving the condyles of the femur. Adults with rickets are thought to be bowlegged due to horse back riding.
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"knock-knees", is a condition where the knees angle in and touch one another when the legs are straightened. Females have a wider pelvis than men and a relatively shorter length of the thigh bone, and as a result, have a greater static genu valgum than men. Individuals with severe valgus deformities are typically unable to touch their feet together while simultaneously straightening the legs. The term originates from the Latin genu, "knee", and valgus, "bent inward". For a discussion of the etymology of valgus, see the entry under varus. Mild genu valgum can be seen in children from ages 2 to 5, and is often corrected naturally as children grow. However, the condition may continue or worsen with age, particularly when it is the result of a disease, such as rickets or obesity. Idiopathic is the term used to describe genu valgum that is congenital or has no known cause.
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bend back: A deformity in which the lower leg is hyperextended at the knee joint. Also called back knee. Genu recurvatum denotes hyperextension of the tibiofemoral joint. It can be subdivided into constitutional physiological and acquired pathological variants. Constitutional genu recurvatum is generally bilateral, symmetric, < 15, and asymptomatic. Acquired genu recurvatum usually is unilateral, > 15, and often symptomatic. Acquired genu recurvatum is known to have multiple causative factors including physeal trauma, osteomyelitis, poliomyelitis, tibial wire traction, and soft-tissue trauma. To emphasize the pathoanatomical changes responsible for genu recurvatum, Moroni et al qualified the deformity into three subtypes: bony, soft tissue, and combined bony and soft tissue. Signs and symptoms of pathological genu recurvatum include weakness, pain, and instability. The degree of deformity differed between them, but deformities began at the same age in both (17 years) and progressed over a short period.
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Foot
1.Flat feet: Flat feet (also called pes planus
or fallen arches) is an informal reference to a medical condition in which the arch of the foot collapses, with the entire sole of the foot coming into complete or near-complete contact with the ground. In some individuals (an estimated 2030% of the general population) the arch simply never develops in one foot (unilaterally) or both feet (bilaterally).
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partly due to "baby fat" which masks the developing arch and partly because the arch has not yet fully developed. The human arch develops in infancy and early childhood as part of normal muscle, tendon, ligament and bone growth. Training of the feet, especially by foot gymnastics and going barefoot on varying terrain, can facilitate the formation of arches during childhood, with a developed arch occurring for most by the age of four to six years. Flat arches in children usually become proper arches and high arches while the child progresses through adolescence and into adulthood. Because young children are unlikely to suspect or identify flat feet on their own, it is a good idea for parents or other adult caregivers to check on this themselves. Besides visual inspection, parents should notice whether a child begins to walk oddly, for example on the outer edges of the feet, or to limp, during long walks, and to ask the child whether he or she feels foot pain or fatigue during such walks. Flat feet of a child are usually expected to develop into high or proper arches, as shown by feet of the mother. Children who complain about calf muscle pains or any other pains around the foot area, may be developing or have flat feet. Pain or discomfort may also develop in the knee joints. A recent randomized controlled trial found no evidence for the treatment of flat feet in children either for expensive prescribed orthoses (shoe inserts) or less expensive over-the-counter orthoses.
Flat feet in children: The appearance of flat feet is normal and common in infants,
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remain flat permanently. Flatfoot in a 55 years old female with ankle and knee arthritis. If a youth or adult appears flatfooted while standing in a full weight bearing position, but an arch appears when the person dorsiflexes (stands on heel or pulls the toes back with the rest of the foot flat on the floor), this condition is called flexible flatfoot. This is not a true collapsed arch, as the medial longitudinal arch is still present and the Windlass mechanism still operates; this presentation is actually due to excessive pronation of the foot (rolling inwards), although the term 'flat foot' is still applicable as it is a somewhat generic term. Muscular training of the feet, while generally helpful, will usually not result in increased arch height in adults, because the muscles in the human foot are so short that exercise will generally not make much difference, regardless of the variety or amount of exercise. However, as long as the foot is still growing, it may be possible that a lasting arch can be created.
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dorsiflexion of the hallux ("big toe"). Symptoms Pain in the big toe when walking, standing, running or even during rest Inflammation around the toe Cure During the early stages, one can place the foot in warm water for few minutes which may relieve the pain and ointment can be applied after drying the foot completely Taking enough rest Removing the dead skin with pumice stone Foot massage releaves pain
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6.Bunion(hellux velgus):
A bunion is a structural deformity of the bones and the joint between the foot and big toe, and may be painful. A bunion is an enlargement of bone or tissue around the joint at the base of the big toe (metatarsophalangeal joint).The big toe may turn in toward the second toe (angulation), and the tissues surrounding the joint may be swollen and tender. Today the term usually is used to refer to the pathological bump on the side of the great toe joint. The bump is the swollen bursal sac and/or an osseous (bony) deformity that has grown on the mesophalangeal joint (where the first metatarsal bone and hallux meet). Symptoms The symptoms of bunions include irritated skin around the bunion, pain when walking, joint redness and pain, and possible shift of the big toe toward the other toes. Treatment Bunions may be treated conservatively with changes in shoe gear, different orthotics (accommodative padding and shielding), rest, ice, and medications. These sorts of treatments address symptoms more than they correct the actual deformity. Surgery, by a podiatrist or an orthopeadist, may be necessary if discomfort is severe enough or when correction of the deformity is desired
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Bunion cont.
Hallux Valgus (Bunion Deformity): The big toe of
the foot is called the hallux. If the big toe starts to deviate inward in the direction of the baby toe the condition is called hallux valgus. As the big toe drifts over into valgus, a bump starts to develop on the inside of the big toe over the metatarsal bone. This bone prominence on the inner edge for the metatarsal is referred to as a bunion.
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Patella
subluxation of patella, or floating patella), is a condition in which the patella, or kneecap, dislocates or moves out of its normal location. Patellar luxation is a common condition in dogs, particularly small and miniature breeds. The condition usually becomes evident between the ages of 4 to 6 months. It can occur in cats as well, especially the Domestic Shorthair. Causes: Rarely, it can be caused by some form of blunt trauma, but most frequently, it is a developmental congenital defect. In congenital cases, it is frequently bilateral. The condition can also be inherited through genetics.
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2.Chondromalacia patellae:
Chondromalacia patellae (also known as CMP) is a term that goes back eighty years. It originally meant "soft cartilage under the knee cap," a presumed cause of pain at the front of the knee. It has gradually come to mean pain at the front of the knee from just about any cause. It is therefore no longer a diagnosis (see below). Pain at the front of the knee is common in young adults, especially soccer players, cyclists, rowers, tennis players, ballet dancers, horseback riders, volleyball players, and runners. Snowboarders and skateboarders are especially prone to this injury, particularly those specializing in jumps where the knees are under great stress (skateboarders most commonly receive this injury in their non-dominant foot due to the constant kicking and twisting that is required of it during skateboarding). The condition may result from acute injury to the patella or from chronic friction between the patella and the groove in the femur through which it passes during motion of the knee. When pain at the front of the knee is due to overuse it can be addressed with a basic program consisting of RICE method (an acronym for rest, ice, compression, elevation), antiinflammatory medications, physiotherapy. Possible causes include a tight iliotibial band, neuromas, bursitis, overuse, malalignment, core instability, patellar maltracking, to name but a few. The term chondromalacia can also be used to describe abnormal appearing cartilage (anywhere in the body). A radiologist might, for example, note chondromalacia on an MRI of an ankle. There is no one "cause" of chondromalacia. There are as many causes as there are conditions lumped under the term "chondromalacia".
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an extremely rare condition affecting mobility and leg strength. It is so rare that it does not show up in an orthopedic literature search on PubMed. It is characterized by an unusually small knee cap (patella) that develops out of and above the joint. Normally, as the knee cap sits in the joint, it is stimulated to growth by abrasion from the opposing bones. When not situated properly in the joint, the knee cap does not experience such stimulation and remains small and undeveloped. Note that the cartilage under and around the kneecap is eight times smoother than ice, so "abrasion" may not be the best term. A similar condition, patella alta, can occur as the result of a sports injury, though the large majority of the time it is a congenital/developmental condition that is unrelated to trauma. A kneecap in an "alta" position sits above the "trochlear groove" and therefore is less stable. The "patellar tendon" that connects the kneecap to the tibia (shinbone)is elongated (longer than normal). This cannot happen by way of trauma, unless there has been a rupture of the tendon and a less-than-optimal surgical repair.
Insall Ratio: This ratio is calculated with the knee flexed to 30 degrees. It is the ratio of the length of the patella to the length of the patellar tendon. Normally this ratio is 1:1 but 20% variation represents patella alta or patella baja. Actually, the Insall-Salvati ratio can be measured at any degree of flexion, which is one reason for its popularity.
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