Abnormal posture

Abnormal posture

talipes equinovarus (clubfoot)
1. positional talipes
  1. from intrauterine compression
  2. common
  3. normal-sized foot
  4. mild deformity
    1. corrected to neutral position w/ passive manipulation
  5. if marked, physio can show parents passive exercises
2. abnormalities
  1. entire foot inverted & supinated
  2. forefoot adducted
  3. heel internally rotated and in plantar flexion
  4. affected foot shorter than normal
  5. calf mm thinner than normal
3. position of foot is fixed
  1. can't be completely corrected
  2. often bilateral
4. epidemiology
  1. birth prevalence 1 per 1000 live births
  2. mostly males affected M:F= 2:1
  3. causes
    1. idiopathic
    2. familial
    3. 2ndary to oligohydramnios during pregnancy
    4. malformation syn or neuromuscular disorder
      1. spina bifida
      2. spinal lesion
  4. assoc w/ developmental dysplasia of hip (DDH)
5. Rx
  1. Ponsetti method
    1. plaster casting & bracing
    2. may be needed for many months
    3. usually successful
  2. if severe, corrective surgery
vertical talus
1. stiff foot
2. rocker-bottom shape
3. need to differentiate this from talipes equinovarus
4. other malformations common
5. X-ray
  1. confirm diag
6. usually needs surgery
flat feet
1. rigid flat foot pathological in older kids & teens
  1. suggested by absence of normal arch on tip toeing
2. causes
  1. tendo-Achilles contracture (ankle)
  2. tarsal coalition
  3. inflammatory arthropathy (JIA)
tarsal coalition
1. due to lack of segmentation btw 1 or more bones of foot
2. coalitions that were fibrous or cartilaginous get symptomatic as they start to ossify
  1. progressively get more rigid & limit normal foot motion
  2. get symptomatic during pre-teen years
3. normal radiographs if bars haven't yet ossified
4. corrective surgery
pes cavus
1. high arched foot
2. presentation in older kids assoc w/ neuromuscular disorders
  1. Friedrich ataxia
  2. type I hereditary motor sensory neuropathy (peroneal muscular atrophy)
3. Rx needed if foot stiff or painful
developmental dysplasia of hip (DDH)
1. spectrum of disorders
  1. ranging from dysplasia to frank dislocation of hip
2. early detection important
  1. cos DDH responds to conservative Rx
  2. neonatal screening as part of routine examination of newborn
    1. Barlow manoeuvre
      1. checks if hip can be dislocated posteriorly out of acetabulum
      2. repeat @ 8 weeks old
    2. Ortolani manoeuvre
      1. checks if hip can be relocated back into acetabulum
      2. repeat @ 8 weeks old
    3. hip abnormality detected on neontal screening
      1. 6-10 per 1000 live births
    4. some cases missed
      1. examiner inexperience
      2. sometimes not possible to detect dislocation @ this stage e.g. if only mildly shallow acetabulum
        can use ultrasound screening to overcome this
        highly specific in detecting DDH
        expensive
        high false + rate
        not recommended in UK
3. late diagnosis usually assoc w/ hip dysplasia
  1. needs complex Rx incl surgery
4. presentation after neonatal period
  1. usually as limp or abnormal gait
  2. IDed from
    1. asymmetry of skinfolds around hip
    2. limited abduction of hip
    3. shortening of affected leg
5. true birth prevalence= 1.3 1000 live births
6. diag
  1. if ?DDH refer to orthopaed specialist
  2. ultrasound
    1. detailed assessment of hip
      1. quantify degree of dysplasia
      2. subluxation or dislocation present?
    2. if initial US abnormal
      1. place infant in splint or harness
        keep hip flexed & abducted for several months
        expert to do splinting
        potential complication of splinting
        necrosis of femoral head
7. Mx
  1. splinting
  2. harness
  3. US or X-ray
    1. monitor progress
  4. surgery
    1. if conservative measures
torticollis (wry neck)
1. sternocleidomastoid tumour (congenital muscular torticollis)
  1. commonest cause in infants
  2. occur in 1st few weeks of life
  3. presentation
    1. mobile, non-tender nodule
      1. palpable within body of SCM
    2. restriction of head turning
    3. tilting of head
  4. usually resolves in 2-6 months
  5. passive stretching advised
    1. but unproven efficacy
2. cause of presentation in childhood (i.e. after infancy)
  1. muscular spasm
  2. secondary to
    1. ENT infection
    2. spinal tumour
      1. osteoid osteoma
    3. cervical spine malformation or malformation
    4. posterior fossa tumour
scoliiosis
1. = lateral curvature in the frontal plane of spine
2. structural scoliosis
  1. rotation of vertebral bodies
    1. causes prominence in back from rib asymmetry
  2. changes often mild, pain-free and mainly cosmetic prob
  3. severe cases
    1. spinal curvature ->chest distortion
      1. -> cardiorespiratory failure
3. causes
  1. idiopathic
    1. commonest cause
    2. early onset (< 5 years old)
    3. late onset
      1. most often
      2. mainly girls 10-14 years old
        during pubertal growth spurt
  2. congenital
    1. from congenital structural defect of spine
      1. hemivertebra
      2. spina bifida
      3. syndromes
        e.g. VACTERL assocn- vertebral, anorectal, cardiac, tracheo-oesophageal, renal & limb anomalies)
  3. secondary to
    1. disorders of neuromuscular imbalance
      1. cerebral palsy
      2. muscular dystrophy
    2. disorders of bone
      1. neurofibromatosis
    3. connective tissue disorders
      1. Marfan's syn
    4. leg length discrepancy
      1. e.g arthritis of 1 knee in JIA
4. examination
  1. start w/ inspection of child's back while standing up straight
    1. irregular skin creases
    2. differences in shoulder height
  2. examine child's back when bent forward
    1. to ID scoliosis
      1. rib rotation seen (caused by vertebral rotation)
    2. if scoliosis disappears
      1. = postural scoliosis
        but check leg lengths too
5. Mx
  1. mild scoliosis will resolve spontaneously or progresses minimally
  2. mod-severe
    1. X-ray
      1. to assess severity & progression of spine curvature
  3. severe cases
    1. specialist spinal centres
      1. bracing
      2. surgery
        if severe
        if coexisting pathology e.g.
        neuromuscular disease
        respiratory disease

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	Created by v.djabatey almost 11 years ago