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Pediatric Deformities
Class of Medical Program 7th Semester Lecture
Dr. Komang Agung I S, dr.,Sp.OT (K)
Suchong Softworks
Lecture Topics
Congenital torticollis (IIIA)
Congenital Talipes Equino Varus (IIIA)
Developmental Dysplasia of the Hip (IIIA)
Scoliosis (IIIA)
Text Book
Appley System of orthopaedic and fractures
Lovell Pediatric orthopedi
The Art and Practice of Childrens Orthopaedics
Congenital Muscular Torticalis
Congenital torticollis
Congenital Muscular
TORTICOLLIS (CMT)
is :
unilateral contracture
of sterno.cleido-
mastoid muscle (s.c.m.)
the head tilted toward
the contracture side
the chin rotated toward
the opposite side
head and face :
asymmetric deformity
Etiology
Fibrosis s.c.m. contracture, shortens
fail to elongate as the child grows
progressive deformity
Cause of fibrosis?
local ischaemia : distorted position in utero
birth history : breech, forcipal delivery
note : sectio caesaria : CMT (+)
compartment syndrome of s.c.m.
75% R-side
CMT with DDH = 1 in 5 CMT (Hummer & Mc Ewen)
20% with lump (tumor)
Congenital torticollis
Pathophysiology
The sternocleidomastoid muscle on one side is
fibrous and fails to elongate as the child grows.
As a result, a progressive deformity develops.
1. Congenital Anomalies :
postural toricollis
hemivertebrae, cervical-superior dorsal spine
unilateral atlanto-occipital fusion
Klippel-Feil syndrome
unilateral cong.absence of s.c.m.
Pterygium colli
2. Trauma : mainly C1,C2, rotatory subluxation, fracture
3. Inflammatory conditions-unilateral
Cervical lymphadenitis
Cervical spine infection = tb, pyogenic
Rheumatoid arthritis (Juvenile)
Spontaneous hyperaemic subluxation of the atlas
Congenital torticollis
Treatment
Early diagnosis during infancy is proven to be
beneficial as daily stretching by the parents may
prevent incipient deformity.
If the condition persists beyond a year, operative
correction is required.
The contracted muscle is divided and head is
manipulated into a neutral position.
After operation, correction must be maintained
with a temporary rigid orthosis followed by
stretching exercises
Solomon, Louis et al., 2010
Treatment
Conservative :
manipulation
passive stretching
each stretching halted for 10 seconds (15-20) x
a day (4-6) x
by physiotherapist or by parents
result (85-90)% success
Operative
+ 10% fail by stretching
Age > 1 year
recurrent
Technic :
unipolar
bipolar
1874 : William Cheseldon : tenotomy s.c.m.
Treatment
Complications :
lesion of spinal accessory nerve
recurrent :
incomplete release
post op tx : indiscipline
operation at late age
cosmetics :
scar
no s.c.m. (band)
Note : Avoid injury of carotid vessels
n.accessorius
n. phrenicus
n.hypoglossus
Operative technic :
1 case monopolar (Z plasty)
14 cases : bipolar
Postoperative :
Glisson traction
Sand pillows lateral of the head
Diazepam
2 days after surgery : stretching [7 days after
surgery : stitches off]
Collar, 1 cm elevated on the affected side. To be
used for 3 months
Continue stretching programme
Thank you
Early Diagnosis
Early Management
Minimize possibility to do
surgery
Congenital Talipes Equinovarus
What is the definition of Talipes Equinovarus?
Talipes => Talus (Latin = Ankle Bone) and Pes
(Foot)
CTEV
Talipes = talus + pes
ankle + foot
Equinus = horse like
= heel in plantar
flexion
Varus = inverted + adducted
Phatoanatomy
Bone, joint, soft tissue
Talus
Talonaviculare joint
Talocalcaneal
Calcaneocuboid joint
Muscle contracture
36
Pucking syndrome
Pucking Syndrome
44
Sacral Agenesis
Agenesis Tibia
Failure of formation
Congenital Talipes Equinovarus
Diagnosis
Clinical Diagnosis
X-Ray AP, Lateral
View After 3 months
Surgical
Teratological forms of
malarticulation leading to
dislocation are also included.
Etiology
Genetic Factors
Hormonal Factors
Intrauterine Malposition
Postnatal Factors
PHYSICA
L
EXAM
Exam
Galeazzi test: dislocated hip may
be displaced posteriorly so the
knee appears lower/shorter
Look for asymmetry in skin
folds
Gait asymmetry
Bilateral DDH can be a
challenge- look for widening of
the perineum, symmetric
limited abduction, and short
thigh segments relative to the
child's size. Once the child
begins to walk, hyperlordosis
and a waddling Trendelenburg
gait can be seen
Exam
Bilateral DDH:
widening of the perineum
symmetric limited abduction
short thigh segments relative to the child's size.
Once walking, hyperlordosis and a waddling
Trendelenburg gait
By 3 months: hip often stabilizes and tests for
instability are no longer very helpful
Imaging
Ultrasound
Plain radiographs- limited value early on due to
femoral heads cartilaginous and not ossified
Radiographs should be with hips flexed 20 to 30
degrees, or neutral if the child is older
Management
If abnormal exam:
Referral to orthopedic surgeon
Imaging:
Ultrasound if less than 5 months
Radiograph if >4 months
Breech females: screening is recommended-
ultrasound at 6 weeks or radiograph at 4 months.
This is optional for lower risk groups.
Treatment
Based on age
Abduction splints in younger kids (usually <6
months)
Closed reduction- goal is to reduce the hip, then
keep it stabilized in spica cast
Open reduction
If closed reduction is unsuccessful
Often needed in kids >18 months
Risks vs benefits
Follow up is important; complications, failure
Pavlik Harness
Look
Gallaezis sign
x ray
Developmental Dysplasia of The Hip
Diagnosis
Ideally, best to be diagnosed at birth (ask if
theres a family history of congenital dysplasia)
Ortolanis test
Barlows test
USG
Plain X-Ray (more useful after 6 months)
Treatment/Management
First 3-6 months: Splintage
Persistent 6-18 months: Closed reduction,
splintage, operation
Persistent 18 months 4 years: Traction,
Arthrography, Operation, Splintage