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By: Aamir Rauf Memon 1st Year DPT Student

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.

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:

Acquired Deformities cont.

a)Muscle Paralysis b)Muscle spasticity c)Muscular disease d)Shortening of musculo-tendinous complex 4. Trauma 5. Postural causes 6. Nerve lesions

Classification of the Degree of Deformity

A deformity is classified into the following three grades: 1. First degree: The deformity is mild and can be corrected by passive stretching. 2. Second degree: Shortening in the soft tissues prevents full passive correction of the deformity. Attempted passive correction results in pain. Slight degree of bony changes may be present. 3. Third degree: The deformity is rigid and cant be corrected by passive manoeuvres. It may be associated with bony changes.

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

1.Congenital Dislocation: This may be

anterior or posterior and is usually bilateral. The patient may notice the lump, which is easily palpable and can be felt to move when the forearm is rotated. Xrays show that the dislocated radial head is domeshaped(due to abnormal modeling). Function is usually surprisingly good and pain is unusual. Surgery is therefore rarely required; however, if the lump limits elbow flexion it can be excised.

2. Congenital Synostosis: Congenital

deficiencies of the forearm bones are occasionally associated with fusion of the humerus to the radius or ulna. This disabling condition is fortunately very rare. A more useful angle can be achieved by osteotomy. Proximal radio-ulnar synostosis causes loss of rotation, but elbow flexion is retained and the inconvenience is often only moderate.


3. Dislocation of the Radial Head: Rare (familial) and

often associated with other abnormalities. Associated with congenital below elbow amputation (hemimelia),arthrogryposis, Ehlers-Danlos syndrome. May be anterior or posterior and is usually bilateral The patients usually notice a lump which moves on rotation of the forearm X-Rays show the dislocated radial head is dome shaped. Treatment: If the lump limits elbow flexion it can be excised Congenital subluxation of the radial head is usually lateral and commonly associated with a wide variety of bone dysplasias


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.


2. Transverse Absence: The commonest

site of transverse absence in the upper limb is at the junction of the middle and the upper one third of the forearm. A static prosthesis is fitted at 6 months. If facilities are available, it is replaced at 18 months by a split hook operated by a cord from the outer shoulder, and at about 3 years by a myoelectric prosthesis.


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.


4. Ulnar Longitudinal Deficiency: In this

rare deformity ulnar deviation is present at birth and is due to partial or complete absence of ulna; in addition the ulnar rays of the hand may be missing. As the child grows the radial head may dislocate. Treatment consists of stretching and splintage during the first few months.


5. Distal Ulnar Dysplasia: In older children with

hereditary multiple exostoses there is often disproportionate shortening of the ulna ; its distal end becomes carrot-shaped and the radius is bowed. The same deformity is sometimes seen in dyschondroplasia, and occasionally without any obvious bone disease. Treatment is seldom necessary. If deformity is marked, ulnar lengthening with or without osteotomy of the radius) may be advisable.


6.Madelungs Deformity: In this deformity the

lower radius curves forwards, carrying with it the carpus and the hand but leaving the lower ulna sticking out as a lump on the back of the wrist. It may be congenital or post-traumatic. The congenital disorder may appear as an isolated entity or as part of a generalized dysplasia; although the abnormality is present at birth, the deformity is rarely seen before the age of 10 years, after which it increases until growth is complete. Function is usually excellent. Treatment: If deformity is severe the lower end of the ulna may be excised(Darrachs procedure), this is sometimes combined with osteotomy of the radius.


7. Arthrogryposis Multiplex Congenita: Multiple, non-progressive joint contractures are

noted at birth. The cause is unknown; there is an underlying neuropathy or myopathy. The limbs appear atrophic, with waxy skin lacking normal joint creases. The elbows are extended, the wrists flexed and ulnar deviated, the thumb adducted and clasped, and the fingers flexed. Treatment is difficult. Serial splintage is started soon after birth; however, correction is often inadequate.


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.


TYPE Failure of formation

Transverse absence Longitudinal absence- radial (radial club hand) Longitudinal absence-ulnar (ulnar club hand)

Longitudinal absence-central (typical cleft hand)

Failure of differentiation


Camptodactyly Flexed Thumb


Duplication Overgrowth Undergrowth Constriction ring syndrome Generalized skeletal abnormalities

Thumb duplication
Macrodactyly Thumb hypoplasia Simple rings Marfans, Turners, Downs etc.

Failure of Formation
The upper limb can fail to develop either transversely or longitudinally.

Transverse Failure: It may occur at any level,

the commonest being the proximal third of the fore arm. Absence of parts of the fingers(symbrachydactyly) can be managed by nonvascularized bone transfer or microvascular transfer of a toe, or by simply fitting a prosthesis.


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.

Longitudinal Failure: The deficiency can be radial,

2. Ulnar longitudinal deficiency(Ulnar club hand):

This is much rarer than radial club hand. Digits are absent from the ulnar side of the hand and the remaining digits are often syndactylized. The elbow is frequently unstable or stiff. The condition is associated with skeletal defects such as fibular hemimelia rather than the visceral defects which frequently accompany a radial longitudinal deficiency. treatment includes syndactyly release, excision of soft tissue tether(anlage) and stabilization of the elbow.

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).


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.

2. Camptodactyly: It is a flexion deformity of the proximal

interphalangeal joint(usually of the little finger). It is hereditary and often bilateral, but deformity is rarely obvious before the age of 10 years. A normal distal interphalangeal joint distinguishes it from a boutonniere deformity.


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.


5. Arthrogryposis: It is a condition in which there is severe

muscle weakness caused by an intrinsic abnormality of the motor nerves and muscle. The joint are stiff and contracted. The overlying skin is smooth, without flexion creases. There may be a single abnormality, such as pronated forearm, flexed wrist and clasped thumb, or the whole limb may be involved. Treatment includes splintage, tendon transfers and arthidesis. 6. Congenital clasped thumb: It is due to weak or absent extensor tendons(and contractures of the MCP and CMC joints in severe cases). Simple extensor tendon weakness may respond to splintage in extension for a few months; if this fails; an extensor tendon transfer is needed. The condition must be distinguished from a congenital trigger thumb, which is due to stenosing tenovaginitis of the flexor pollicis longus.

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.


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.


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.


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.


Generalized Skeletal Abnormalities

Generalized skeletal disorders often involve the hand, e.g. Marfans syndrome(spider hand), achondroplasia(trident hand) and Downs syndrome(short little finger, often curved).


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.

Infantile(congenital) torticollis: This condition is

Secondary Torticollis: Childhood torticollis may be

secondary to congenital bone anomalies, atlantoaxial rotatory displacement, infection(lymphadentitis, retropharyngeal abscess, tonsillitis, discitis, tuberculosis), trauma, juvenile rheumatoid arthritis, posterior fossa tumours, dystonia(benign paroxysmal torticollis) or ocular dysfunction. Atlantoaxial Rotatory Displacement: The aetiology of this condition is unclear, but it is thought to be due to muscle spasm resulting from inflammation of the atlantoaxial region. There may be a history of trauma of upper RTI. The child presents with a painful wry neck.


Vertebral Anomalies: There are many anomalies and

most are very rare. Three are described here: 1. Klippel-Feil syndrome(cervical-vertebral


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.


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.

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.

4.Bifid rib: A bifid rib or bifurcated rib or

sternum bifidum is a congenital deformity occurring in about 1.2% of the population. Bifid ribs occur in up to 8.4% of Samoans (McKinley & O'Loughlin, p. 214). The sternal end of the rib is cleaved into two. It is usually unilateral. Bifid ribs are usually asymptomatic, and are often discovered incidentally by chest x-ray. Effects of this neuroskeletal anomaly can include respiratory difficulties, neurological difficulties, limitations, and limited energy from the stress of needing to compensate for the neurophysiological difficulties


5.Cervical rib: A cervical rib is a

supernumerary (or extra) rib which arises from the seventh cervical vertebra. It is a congenital abnormality located above the normal first rib. A cervical rib is present in only about 1 in 500 (0.2%) of people; in even rarer cases, an individual may have two cervical ribs.


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).


1.Spina Bifida:(Latin: "split spine") is a developmental birth defect caused by

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.


2. Scoliosis: (from Greek: skoliosis meaning "crooked condition,"

from skolios, "crooked"). Scoliosis is an apparent lateral(sideways) curvature of the spine. Apparent because, although lateral curvature does occur, the commonest form of scoliosis is actually a triplanar deformity with lateral, anteroposterior and rotational components[Dickson et al, 1984). Two broad types of deformity are defined: postural and structural.

a. Postural Scoliosis: In postural scoliosis the deformity is

secondary or compensatory to some condition outside the spine, such as a short leg, or pelvic tilt due to the contracture of the hip; when the patient sits(thereby cancelling leg asymmetry) the curves disappear. Local muscle spasm associated with a prolapsed lumber disc may cause a skew back; although sometimes called sciatic scoliosis this, too, is a spurious deformity.


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.

Scoliosis Images:


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.


Scoliosis cont

Adolescent Idiopathic Scoliosis: (Presenting at aged 10 years or over)

This, the commonest type, occurs mostly(99%) in girls. Primary thoracic curves are usually convex to the right, lumber curves to the left; intermediate(thoracolumber) and combined(double primary) curves also occur. Progression is inevitable; indeed, most curves under 20 either remain spontaneously or remain unchanged. However, once a curve starts to progress, its usually goes on doing so throughout the remaining growth period(and, to a much lesser degree, beyond that). Reliable predictors of progression are (1) a very young age, (2) marked curvature and (3) and incomplete Risser sign at presentation (Lonstein and Carlson, 1984).


Scoliosis cont

Juvenile Idiopathic Scoliosis: (presenting at age 4-9 years)

This is uncommon. The characteristics of this group are similar to those of adolescent group, but the prognosis is worse and surgical correction may be necessary before puberty. However, if the child is very young, a brace may hold the curve stationary until he or she is about 10 years old, when fusion is more likely to succeed.


Scoliosis cont

Infantile Idiopathic Scoliosis: (presenting age 3 years and under)

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.


3. Kyphosis: (Greek - kyphos, a hump), also called hunchback,

is a common condition of a curvature of the upper (thoracic) spine. Rather confusingly, the term kyphosis is used to describe both the normal(the gentle rounding of the thoracic spine) and the abnormal(excessive thoracic curvature or straightening out of the cervical or lumbar lordotic curves). Excessive thoracic curvature might be better described as hyperkyphosis. Kyphos, or gibbus, is a sharp posterior angulation due to localized collapse or wedging of one or more vertebrae. This may be the result of the congenital defect, a fracture(sometimes pathological) or spinal tuberculosis.

Two broad types of deformity are defined: postural and structural.


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.


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.


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.

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.


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.

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.

1.Developmental Dysplasia of the Hip: This


Hip Joint cont

2. Acetbular Dysplasia and Subluxation:
Acetabular dysplasia may be genetically determined or may follow incomplete reduction of a congenital dislocation, damage to the lateral acetabular epiphysis or maldevelopment of the femoral head (either congenital or, for example, after Parthes disease). The socket is unusually shallow, the roof is sloping and there is deficient coverage of the femoral head superolaterally and anteriorly; in some cases the hip subluxates. Faulty load transmission in the lateral part of the joint may lead to secondary osteoarthritis.


Hip Joint cont

3. Congenital Coxa vara: This is a rare developmental disorder
of infancy and early childhood and may be associated with Developmental Dysplasia of the Hip(DDH). It is due to a defect of endochondral ossification in the medial part of the femoral neck. There is marked decrease in the angle between the neck and the shaft of the femur (90 or less) along with subluxation of the head and the distortion of the neck(bending backwards), the greater trochanter is raised. Adductor muscle group weakens and tends to short and contracted. When the child starts to crawl or stand, the femoral neck bends or develops a stress fracture, and with continued weight bearing it collapses increasingly into varus and retroversion. Sometimes there is shortening or bowing of the femoral shaft. The condition is bilateral and is about one-third of cases.


Hip Joint cont

4. Congenital Short Femur: The proximal femur is
usually short and rudimentary resulting in marked shortening of the leg. The limb length disparity gives rise to difficulty in standing and walking, besides putting extra strain on the normal limb. Treatment: It depends on the degree of the limb length disparity. Compensatory shoe raise is the accepted method of management. Surgery can be performed either on the affected limb or the normal limb.


Hip Joint cont

5.Congenital Limb Reduction:
Thalilomide was the most celebrated limb reducing insult (teratogen) in humans which also produced a range of other deformities depending on developmental time and concentration of the drug exposure. Agents - Many substances have been found capable of producing limb reduction defects in experimental animals but few have been related to humans. Mechanisms - Limb reduction defects may also be indirect, for example with loss of blood supply to part of the limb or to defects in innervation at the spinal or cerebral level. Also there are a number of as yet undefined mechanisms involved. Limb reduction defects may be apical (congenital amputation) or pre- or post-axial (absence of radius and lateral digits; ulnar and medial digits).


Hip Joint cont

6. Proximal Femoral Focal Deficiency(PFFD):
This is a rare non-genetic(possibly teratogenic) anomaly in which part of all the proximal femur is missing. The most useful classification is that of Aitken. In type A there appears to be a gap in the femoral neck or subtrochanteric region, which is infact a segment of unossified cartilage. This does eventually ossify, but by then the proximal femur has developed a varus deformity and shortening. In type B the gap persists, the femoral head and acetabulum are dysplastic and there is significant shortening. In type C the femoral head is missing and the acetabulum is undeveloped. In type D there is agenesis of the entire proximal femur and acetabulum. Both hips may be affected and in half the cases there are also distal anomalies.


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.


2. Congenital absence of the tibia(tibial hemimelia):

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.

3.Congenital Pseudarthrosis of Tibia:

Congenital pseudoarthrosis of the tibia, which has been known to be one of the diseases of the orthopaedic surgery, the treatment of which is the most difficult, since it was first described by Hatzoecher 1708, is an ossification defect, which is localized at the junction the middie third and lower third of the tibial shaft. It may be associated with fibrous dysplasia or neurofibromatosis. In order not to cause any errors as regards to therapy, one should identify congenital tibial angulatlons adequately, which should especiaily be carefully evaluated in diferential diagnosis. A great variety of procedures have been suggested in its treatment. But, with the establishment of the effects of electromagnetic currents and the advances realized in microsurgery and the application of free voscularized bone grafts have increased the chance of curability of this disease, the treatment of which in extremely difficult. Attempts have been made to present congenital pseudoarthrosis of the tibia and its angulations treated by surgery as well as treatment methods applied and results obtained. It is rare, occurring equally in girls and boys; disease is almost always unilateral; acute fractures occur during first 2 yrs of life, usually shortly after birth. It is associated with anterolateral bowing and neurofibromatosis; neurofibromatosis is present in approx 40-50% of patients with pseudarthrosis, while about 10% of patients with neurofibromatosis will have pseudarthrosis of tibia; dysplastic type is characterized by narrowing, sclerosis, and obliteration of the medullary canal.


4.Blount's disease(Blount-Barber disease):

(nonrachitic bowlegs in children)
Blount's Disease is one which affects the bone development of toddlers and older children. Most often, it starts as bow-leggedness which does not improve in a child between two and four years of age. Seeking appropriate treatment in a timely matter can help your child develop normally. Bow-leggedness in toddlers is particularly common most especially in those who walk at an early age and those who are slightly overweight for their age and height. But legs that are bowed and which do not correct by age two are cause for concern and investigation to see if Blount's Disease is a possibility. What happens with Blount's Disease is that as the child grows and the legs are bowed, some children have the tendency, for unknown reasons, to develop bones which continue to bow. It is a vicious circle. The bow-leggedness causes further bow-leggedness which perpetuates the problem. So as the legs continue to grow abnormally the child is forced to walk with knees that bulge outward and continue to get worse. What often accompanies this is a condition called internal tibial torsion. What this is, is toes which turn inward below the knee. The toes point obviously inward and some children even have a tendency to fall down more often with this infliction. When bow-leggedness and tibial torsion occur together it is a red flag g that it is probably Blount's Disease. Radiographic Appearance: Physiologic bowing typically show flaring and bowing of tibia and femur in a symmetric fashion and is normal in children < 2 years of age (maximal at about 18 mo); physiologic genu valgum, or knock knees, develops next, with maximal deformity occurring at 3 years of age; gradual correction to ultimate alignment of slight genu valgum occurs by 9 years of age in the great majority of patients.


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.


2. Telipes Calcaneo-valgus: It is a common

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.


3. Metatarsus Addutus ( Metatarsus varus):

Here the foot is adducted at the TMT joint but the foot is plantigrade. It varies from a slightly curved forefoot to something resembling a mild club foot. The majority (99%) either improve spontaneously or can be managed non-operatively using serial corrective casts followed by straight-last shoes. Variations of the Dilwyn Evans procedure(which aims to balance the lengths of the medial and lateral columns of the foot), often in combination with basal metatarsal osteotomies, are suitable for the small percentage of children who require surgical treatment.


4.Congenital Convex Pes Valgus(Congenital Flat Foot): (Congenital Vertical Talus)

This rare condition is seen in infants, usually affecting both feet. Superficially it resembles other types of valgus foot, but the deformity is more severe; the medial arch is not only flat , it is the most prominent part of the sole, producing the appearance of a rocker-bottom foot. The hind foot is equinus and valgus and the talus points almost vertically towards the sole; the forefoot is abducted,pronated and dorsiflexed, with subluxation of the talonavicular joint. Passive correction is impossible; by the time child is seen, the tendons and ligaments on the dorsolateral side of the foot are usually shortened.


5. High-Arched Feet(Pes Cavus): In pes cavus the

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.


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.

1. Winged scapula: Winged scapula (scapula alata) is a condition in which

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.


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.

shoulder: Frozen shoulder, medically referred to as

2. Adhesive

capsulitis of


3. Rotator

cuff tear: Rotator cuff tears are

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.


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).

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.


2. Cubitus varus(Gun-stock deformity)


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


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.


4.Unreduced Dislocation of the head of Radius:

Dislocation of the radial head occurs most frequently in men who are subject to highforce injury. In children, the radial head is much more commonly subluxed than dislocated.

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).


5.Pulled Elbow: Nursemaid's elbow or

Babysitter's elbow is a dislocation of the elbow joint caused by a sudden pull on the extended pronated arm, such as by an adult tugging on an uncooperative child. The technical term for the injury is radial head subluxation. A pulled elbow, also known as nursemaid's elbow or a partially dislocated elbow joint, commonly occurs to toddlers and preschoolers(under 6 years of age). Nursemaid's elbow happens when kids are picked up or swung around by their hands. The ligament of the elbow may stretch and slip out of place causing severe pain.


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)

1.Proximal Humeral Physeal Injuries:


2. Wrist drop: Wrist drop, also known as radial nerve palsy, or

Saturday night 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. Symptoms of wrist drop include wrist weakness, resulting in the inability to raise the hand at the wrist. Additional symptoms may include wrist pain, wrist tenderness, or wrist swelling, wrist deformity, hand numbness (unilateral), and hand weakness (unilateral). Initial management includes splinting of the wrist for support along with occupational or physical therapy. In some cases surgical removal of bone spurs or other anatomical defects that may be impinging on the nerve might be warranted.


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.



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


Boutonnire Deformity cont

(Buttonhole Deformity) : Boutonnire deformity (buttonhole deformity) is a deformity in which the middle finger joint is bent in a fixed position inward (toward the palm) and the outermost finger joint is bent excessively outward (away from the palm). This disorder most often results from rheumatoid arthritis but can also occur from injury (such as deep cuts, joint dislocation, or fractures) or osteoarthritis . People with rheumatoid arthritis can develop the disorder because they have long-standing inflammation of the middle joint of a finger. If the deformity is caused by an injury, the injury usually occurs at the base of a tendon (called the middle phalanx extensor tendon). As a result, the middle joint (called the proximal interphalangeal joint) becomes buttonholed between the outer bands of the tendon that runs to the end of the finger. The deformity can, but need not, interfere with hand function. The doctor makes the diagnosis by examining the finger.

2.Dupuytrens Contracture: Dupuytren's

contracture (also known as "Morbus Dupuytren," "Dupuytren's disease," or "Palmar fibromatosis", and sometimes misspelled as Dupuytren's constricture) is a fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended (straightened). It is named after Baron Guillaume Dupuytren, the surgeon who described an operation to correct the affliction. Dupuytren's contracture is caused by underlying contractures of the palmar fascia. The ring finger and little finger are the fingers most commonly affected. The middle finger may be affected in advanced cases, but the index finger and the thumb are nearly always spared. Dupuytren's contracture progresses slowly and is usually painless. In patients with this condition, the tissues under the skin on the palm of the hand thicken and shorten so that the tendons connected to the fingers cannot move freely. The palmar aponeurosis becomes hyperplastic and undergoes contracture. Incidence increases after the age of 40; at this age men are affected more often than women. After the age of 80 the distribution is about even.


3.Volkmann's Ischaemic Contracture: Volkmann's

contracture, also known as Volkmann's ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers.
Volkmann's contracture is a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm.
Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the forearm. This usually occurs when there is increased pressure due to swelling, a condition called compartment syndrome. Trauma to the arm, including a crush injury or fracture, can lead to swelling that compresses blood vessels and can decrease blood flow to the arm. A prolonged decrease in blood flow will injure the nerves and muscles, causing them to shorten and become stiff (scarred). When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it were normally contracted, but because it is stiff the joint remains bent and cannot straighten. This condition is called a contracture. In Volkmann's contracture, the muscles of the forearm are severely injured, resulting in contracture deformities of the fingers, hand, and wrist.


4.Mallet finger: In medicine, mallet finger, also

baseball finger, dropped finger and (more generally) extensor tendon injury, is an injury of the extensor digitorum tendon of the fingers at the distal interphalangeal joint(DIP). It results from hyperflexion of the extensor digitorum tendon, and usually occurs when a ball (such as a softball, basketball, or volleyball), while being caught, hits an outstretched finger and jams it. Management options include putting the finger in a Mallet splint for 6 to 8 weeks or extension block k-wire for 4 weeks. This allows the tendon to reattach, if the finger is bent during these weeks the healing process must start all over again.


Mallet Finger cont

Mallet finger is a deformity in which the fingertip is curled in and cannot straighten itself. This deformity usually results from injury, which either damages the tendon or tears the tendon from the bone. It can affect one or more fingers. A doctor can make the diagnosis by examining the finger. An xray is usually taken to be sure that there is no fracture. The usual treatment is placing a splint on the finger with the finger straightened. The tendon may take 6 to 10 weeks to heal. Mallet finger rarely requires surgery, unless a large fragment of bone has broken off or the joint is partially dislocated. Mallet finger has also been referred to as drop, hammer, or baseball finger (although baseball accounts for only a small percentage of such injuries).


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.




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.


7.Erosive (Inflammatory) Osteoarthritis:

Erosive (inflammatory) osteoarthritis is a form of osteoarthritis that, in the hand, causes swelling, pain, and sometimes formation of cysts on the finger joints (particularly the outermost ones). Osteoarthritis of the hand is apparent by enlargement of bones over the outermost joints of the fingers (Heberden's nodes) and overgrowth of bones over the middle joints of the fingers (Bouchard's nodules). With erosive osteoarthritis, there is also swelling of surrounding tissues. The joints between the fingers and hand and the wrists are usually not affected. The involved joints can become misaligned.

8.Intrinsic Plus Hand: results from intrinsic stiffness

(contracture). specific causes: They may be truama,posttraumatic intrinsic contractures may occur after severe injuries to hand that have resulted in considerable edema or hematoma; ischemia, rheumatoid arthritis, Still's disease, mycobacterium leprae,CNS lesions, Parkinson's disease, cerebral palsy. Treatment: corrected with therapy, or if that fails, sometimes by intrinsic release/transfer (Little - distal) or (Zancolli - proximal), late deformity, distal intrinsic release of those oblique fibers contributing to lateral bands, preserving more proximal transverse contribution of interosseous aponeurotic expansion.


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;

9.Intrinsic Minus and Claw Hand: claw hand deformity is

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


2.Coxa vara:Coxa vara is a deformity of the hip,

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.


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.

3.Protrusio acetabuli(Otto pelvis): Protrusio


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.

4. Femoral Anteversion(in-toe gait): Femoral


5.Unequal leg length:

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


1.Pectus excavatum: Pectus excavatum (a Latin

term meaning hollowed chest) is the most common congenital deformity of the anterior wall of the chest , in which several ribs and the sternum grow abnormally. This produces a caved-in or sunken appearance of the chest. It can either be present at birth or not develop until puberty. Pectus excavatum is sometimes considered to be cosmetic; however, depending on the severity, it can impair cardiac and respiratory function and cause pain in the chest and back. People with the abnormality may experience negative psychosocial effects, and avoid activities that expose the chest. Pectus excavatum is sometimes referred to as cobbler's chest, sunken chest, funnel chest or simply a dent in the chest.



2.Pectus carinatum: Pectus carinatum, (L carntus, equiv.

to carn(a) keel), also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. It is the opposite of pectus excavatum. Causes: Pectus carinatum is an overgrowth of cartilage causing the sternum to protrude forward. It occurs in 3 different ways. The least common way is post surgically after open heart surgery. Sometimes the sternum does not heal flat and there is a protrusion of the sternum. The second most common is from birth. It is evident in new borns are a rounded chest and as they reach 2 or 3 years old the sternum begins to grow outwardly even more. The most common occurrence for pectus carinatum seems to be in the 11-14 year old pubertal male undergoing a growth spurt. Some parents report that their child's pectus seemingly popped up 'overnight'. It may occur as a solitary congenital abnormality or in association with other genetic disorders or syndromes : Marfan syndrome, Morquio syndrome, Noonan syndrome, Trisomy 18, Trisomy 21, homocystinuria, osteogenesis imperfecta, multiple lentigines syndrome, and Sly syndrome. In about 25% of cases of pectus carinatum, the patient has a family member with the condition.



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.

1.Acquired Scoliosis: Scoliosis is an abnormal curvature


2.Acquired torticollis: Torticollis, or wry neck, is a condition in which

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.


Knee Joint 1.Genu varum:

Genu varum (also called bow-leggedness or

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.


2.Genu valgum: Genu valgum, commonly called

"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.


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.

3.Genu Recurvatum: Etymology: L, genu, knee, recurvare, to


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).


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,


Flat feet in adults:

Flat feet can also develop as an adult ("adult acquired flatfoot") due to injury, illness, unusual or prolonged stress to the foot, faulty biomechanics, or as part of the normal aging process. Flat feet can also occur in pregnant women as a result of temporary changes, due to increased elastin (elasticity) during pregnancy. However, if developed by adulthood, flat feet generally

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.


2.Foot drop: Foot drop is a deficit in turning the ankle and

toes upward, known as dorsiflexion. Therefore, the foot will hang inferiorly. The deep fibular/peroneal nerve innervates the anterior compartment of the leg. Damage to this nerve will lead to the inability for the leg to dorsiflex the foot, therefore causing foot drop. Conditions leading to foot drop may be neurologic, muscular or anatomic in origin, often with significant overlap. The result is an abnormal gait. Features Foot drop is characterized by steppage gait. When the person with foot drop walks, the foot slaps down onto the floor. To accommodate the toe drop, the patient may use a characteristic tiptoe walk on the opposite leg, raising the thigh excessively, as if walking upstairs, while letting the toe drop.


3.Hammer toe: A hammer toe is a deformity of the

proximal interphalangeal joint of the second, third, or fourth toe causing it to be permanently bent, resembling a hammer. Mallet toe is a similar condition affecting the upper joint. Causes Hammer toe most frequently results from wearing poorly-fit shoes that can force the toe into a bent position, such as excessively high heels or shoes that are too short or narrow for the foot. Having the toes bent for long periods of time can cause the muscles in them to shorten, resulting in the hammer toe deformity. This is often found in conjunction with bunions or other foot problems. It can also be caused by muscle, nerve, or joint damage resulting from conditions such as osteoarthritis, rheumatoid arthritis, stroke, Charcot-Marie-Tooth disease or diabetes. Treatment In many cases, conservative treatment consisting of physical therapy and new shoes with soft, spacious toe boxes is enough to resolve the condition, while in more severe or longstanding cases orthopedic surgery may be necessary to correct the deformity.


4.Hallux rigidus: Hallux rigidus is a condition restricting

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


5.Hallux varus: Hallux varus is a deformity

of the great toe joint where the hallux is deviated medially (towards the midline of the body) away from the first metatarsal bone. The hallux usually moves in the transverse plane.


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


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.


6.Metatarsalgia: Metatarsalgia (literally metatarsal pain, colloquially

known as stone bruise) is a general term used to refer to any painful foot condition affecting the metatarsal region of the foot. This is a common problem that can affect the joints and bones of the metatarsals. Metatarsalgia is most often localized to the first metatarsal head (the ball of the foot just behind the big toe). There are two small sesamoid bones under the first metatarsal head. The next most frequent site of metatarsal head pain is under the second metatarsal. This can be due to either too short a first metatarsal bone or to "hypermobility of the first ray" (metatarsal bone + medial cuneiform bone behind it), both of which result in excess pressure being transmitted into the second metatarsal head. Common causes of metatarsalgia include interdigital neuroma (also known as Morton neuroma), metatarsophalangeal synovitis, avascular necrosis, sesamoiditis, and inflammatory arthritis; however, these causes are often diagnosed separately.


7.Cock-up deformity: Cockup of the great toe is

characterized by persistent extension of the first metatarsophalangeal joint; the interphalangeal joint also may be involved. The syndrome has many causes, all easily diagnosed. Surgery is indicated in nearly every instance and will produce a corrected or improved result. The type of surgery--whether reefing, lengthening, or transposition of tendons, implant arthroplasty, or arthrodesis--is tailored to the underlying cause.



1.Luxating patella: Luxating patella (or trick knee,

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.


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".

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.

3.Attenuated patella alta: Attenuated patella alta is