Clinics in podiatry最新文献

Dancers are an interesting and exciting group of patients. An understanding of the pathomechanics of their injuries coupled with their genuine interest in a prompt recovery teaches much about the diagnosis, treatment, and prognosis of similar lower extremity disorders occurring in the population at large. The majority of dance injuries occur in the lower extremity, commonly in the foot and ankle. Conservative therapy is usually successful; surgical intervention is only rarely indicated. Rehabilitation following all injuries is important as well as attention to proper alignment and technique.

This article attempts to provide a complete and systematic approach to conducting a thorough lower extremity biomechanical examination for the child. It is hoped that the material presented here will allow you, the practitioner, to conduct a thorough and relevant series of examination techniques. Once these techniques are perfected and performed efficiently, you will be capable of providing effective and appropriate care for your pediatric patients.

Age is often a determining factor in establishing a treatment program for these axial and angular problems. As can be seen, the deformities of torsion are noticeable from early life. Any tibial torsion should be treated early, but an excessive medial range of motion in the infant leg with a corresponding adequate lateral range of motion of the limb may be cautiously observed. Medial femoral torsion is a normal early finding in the infant thigh. The problem becomes evident as the child matures without the corresponding reduction in femoral torsion, leading to a persistence of fetal or infantile alignment. The gait consequences are usually noticed at 4 to 8 years of age. The angular changes generally are a delayed finding noticed in stance. The bowleg may be associated with marked tibial torsion and picked up early but the Blount's patient has been traditionally definable at 2 years of age. Levin and Drennan may hasten the time of diagnosis with their radiographic criteria. Knock-knee is an alignment disturbance noticed during the early to mid-childhood years, age 4 to 8 years. The diagnosis is important, differentiating physiologic from torsion-related deformities, and treatment, if warranted, should not be delayed. Generally the earlier these problems are discovered, the more optimistic the prognosis. Since the pediatric limb is in a constant state of transition, there will be a perpetual argument as to the need or efficacy of various approaches to the problems of knock-knee and bowleg. If observation is the treatment of choice, the percentage of cases which go on to osteotomies and epiphyseal stapling will continue. For those with axial or angular deformities, degenerative arthritis of the knee may be forthcoming. Swanson, Greene, and Allis warned of problems becoming "unphysiologic." If we consider the epiphyseal malleability, not only to deformity but to correction, we can appreciate Lenoir's comment of "every day the problem goes untreated is a golden opportunity lost forever." Early, gentle conservative therapy, using splints and casting, is an approach which should be considered in appropriate early problems.

There are a multitude of congenital deformities that can occur in the feet. Some are very common and others are more remote. They can frequently be corrected with conservative care, such as splinting, casting, and various exercises over a period of time. Those that are not resolved by conservative measures can generally be surgically improved or corrected. A few conditions should be left for surgical resolution after maturity occurs.

An overview of the clinical entity referred to as developmental flatfoot has been discussed. Specific reference has been made to its occurrence, etiology, identification, pathomechanics, clinical significance, and management rationale. This often overlooked, inconspicuous condition is the most common musculoskeletal abnormality affecting the foot of the child under 6 years of age. Recognition of the fact that the developmental flatfoot is the logical precursor of foot dysfunction, deformity, and resultant disability later in life will allow the practitioner to design a management program for today that will meet the foot health needs of tomorrow.

In the cases presented in this article only the broad aspects were considered. Special references were made to those signs and symptoms which are usually apparent on physical examination. The purpose of these discussions is to alert the podiatric clinician to the possibility of underlying associated systemic disease for further follow-up. The major diagnostic considerations concern involvement of the lower extremities and possible treatment of these disorders.

Muscle balance involves increasing or decreasing the relative strength of a muscle. It also includes redirection of muscle tendons to change their mechanical retrograde pull. Tendoachilles lengthening, gastrocnemius lengthening, anterior tendon teno-suspension, and the Kidner procedure exemplify this method. Muscle balancing is necessary whenever an imbalance exists. However, muscle balancing is usually only able to mildly effect joint position. It is important to eliminate a deforming muscle force and restore the balance of muscle power. Osteotomy to change internal bone shape is effective in pediatric foot surgery since malshape of the osseous structures is a major problem. The osteotomy is becoming a more important part of surgical treatment as a better understanding and recognition of the biomechanics of the foot and leg develops. The arthroerisis procedure for subtalar joint balance using implants is rapidly advancing. The concept that the subtalar joint can be balanced satisfactorily has been demonstrated. However, the lifetime implications are still unexplored. Joint stabilization with some motion still available at the subtalar is a leading concept in treating the foot. Fusion procedures are meant to realign malaligned joints and prevent further motion. They are applicable to pediatric foot surgery only in extreme conditions and in the growing foot at adolescence.

The functional and behavioral aspects of children require age-dependent orthotic therapy. For excessive pronation, these age groups have been discussed: 7 to 18 months, 18 months to 3 years, 3 to 6 years, 6 to 10 years, and over 10 years. Intoeing, out-toeing, pes cavus, peroneal spastic flatfoot, calcaneal apophysitis, and os vesalianum therapies with orthotics have also been outlined.

A general approach to the management of the cerebral palsied child has been described. Because the podiatric practitioner is often the recipient of parental inquiries concerning the possible therapy and lower limb management for their child with cerebral palsy, it is desirable to have a general awareness of how neurologically impaired children may be managed with regard to the lower extremity. Understanding the rationale for such therapeutic programs is helpful in outlining a specific course to follow when treating the foot posture of the dyslocomotive child.

Short-leg syndrome, or asymmetry of length in the lower extremities, is a common orthopedic problem in children. It is vital to recognize normal bone function, bone growth, and potential growth when evaluating this syndrome. Classification of this problem is either structural or functional. Structural (real) short legs usually have trauma or congenital growth inequality as their etiology. Functional (apparent) short legs usually result from soft tissue contractures or foot function aberrations. The child's age determines the extent of our examination. The lower extremity should be segmented during examination to help determine the location of pathology. Measuring the deformity requires precise scientific procedures. The level of compensation must be determined. Foot, pelvic, and spinal compensations should be evaluated. Scanograms or orthoroentgenograms are useful in diagnosing, quantifying, and prognosing short-leg syndrome. Prediction of the projected discrepancy is accomplished by the Anderson et al. remaining growth charts. Common etiologic considerations include congenital, neuromuscular, infection, trauma-induced, and tumor-caused disorders. Treatment of short-leg syndrome is determined by classification. Structural problems may need heel elevation or a combination of heel elevation and orthotic control on a conservative basis. Functional problems may require neutral position control of the feet with orthotics and correction of soft tissue contractures. Resin foam or orthopedic shoe adjustment may be used in moderate discrepancies. Structural leg inequalities may be corrected by surgical epiphysiodesis. This bone growth retardation procedure is normally performed on the long limb in pediatric patients. Therapy is directed at correcting pelvic obliquity, gait and postural aberration. The end result should be a child with cosmetically acceptable and normal functioning lower extremities.