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Surgery 057 Locomotor System Malformations
Surgery, mainly includes congenital deformities, developmental hip dislocation, congenital clubfoot, etc. Hope it helps everyone.
Edited at 2024-03-29 03:47:09
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Surgery 057 Locomotor System Malformations
- Valentine's Day marketing campaign
This Valentine's Day brand marketing handbook provides businesses with five practical models, covering everything from creating offline experiences to driving online engagement. Whether you're a shopping mall, restaurant, or online brand, you'll find a suitable strategy: each model includes clear objectives and industry-specific guidelines, helping brands transform traffic into real sales and lasting emotional connections during this romantic season.
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- Milano Cortina 2026 Ice Hockey Schedule
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Surgery 057 Locomotor System Malformations
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familiar
Causes and pathological changes of congenital torticollis and developmental hip dislocation
Differential diagnosis of congenital torticollis
Clinical manifestations and diagnosis of developmental hip dislocation
Treatment of congenital torticollis and developmental hip dislocation
learn
Clinical manifestations and treatment of congenital clubfoot
Clinical manifestations and treatment of flatfoot
Clinical manifestations and treatment of hallux valgus
Clinical manifestations and treatment of scoliosis
Section 1 Congenital malformations
1. Congenital muscular torticollis
Congenital muscular torticollis refers to the fibrous contracture of the sternocleidomastoid muscle on one side, causing the neck and head and face to deviate toward the affected side.
(1) Cause of disease
The cause is still not entirely clear. Birth trauma or dystocia during childbirth may be the cause of sternocleidomastoid muscle ischemia, bleeding, hematoma organization, and muscle fiber degeneration. Some babies with normal fetal position and normal delivery also develop muscular torticollis. Therefore, some scholars believe that sternocleidomastoid muscle fibrosis has already formed in the mother and is caused by congenital or genetic factors. In addition, there are also theories of myonecrosis caused by intrauterine and external infections, genetics, and arteriovenous embolism.
(2) Clinical manifestations
Usually after the baby is born, there will be a mass on one side of the sternocleidomastoid muscle, which is hard, oval or round, and moves left and right with the passive movement of the sternocleidomastoid muscle.
The surface of the mass is not red, the temperature is normal, and there is no tenderness. The head tilts toward the affected side, the mandible turns toward the healthy side, and the active or passive rotation of the mandible toward the affected side is limited to varying degrees. Then the mass gradually shrank until it disappeared, and fibrous contracture cords formed about half a year later.
As the disease continues to progress, various secondary deformities may occur. The face on the affected side is short and flat, the healthy side is long and round, and the eyes and ears are not in the same plane. In severe cases, cervical scoliosis may occur.
(3) Diagnosis and differential diagnosis
According to the clinical manifestations, the diagnosis can be confirmed if the sternocleidomastoid muscle on the affected side shows a cord-like contracture and the head and face are tilted. However, it should be distinguished from torticollis caused by other causes:
1. Bony torticollis
Congenital cervical spine developmental abnormalities such as atlantoaxial subluxation, cervical hemivertebra, odontoid deformity, and cervical fusion can all manifest as torticollis in varying degrees. X-ray examination can confirm the diagnosis. The sternocleidomastoid muscle is not contracted.
2. Torticollis caused by infection
For example, when inflammation of the throat, tonsillitis, purulent or tuberculous infection of cervical lymph nodes occurs, due to inflammatory stimulation, local soft tissue is congested and edematous, and the cervical ligaments become more relaxed, resulting in rotational displacement of the atlas and axis and the occurrence of torticollis, sternocleidomastoid muscle No contracture.
3. Ophthalmogenic, otogenic, neurogenic, habitual torticollis
The primary tumor can be found in the first three. Ophthalmogenic torticollis is also called visual torticollis due to visual impairment, such as refractive error, ophthalmic nerve paralysis, drooping of the eyes and face, and torticollis posture when viewing objects, but there is no sternocleidomastoid muscle contracture and no restriction of neck movement.
4. Benign paroxysmal torticollis in infants
It is a self-limiting disease that occurs in infancy. She presented with cyclic torticollis, and the sternocleidomastoid muscle on physical examination was normal, without any other organic disease.
(4) Treatment
Early detection, early treatment, and significant results are the key to preventing secondary deformities of the head, face, and cervical spine. Although advanced torticollis can be corrected surgically, other associated tissue abnormalities (such as facial deformity and cervical scoliosis) are difficult to return to normal.
1.Non-surgical treatment
Suitable for babies under 1 year old. Including local hot compress, massage, manual correction and orthopedic cap external fixation. At night, after the child goes to bed, use a sandbag to keep the head in a corrected position, perform manual stretching of the sternocleidomastoid muscle, and perform daily treatment with persistence. Most of the patients can achieve satisfactory results.
Orthopedic cap external fixation
2. Surgical therapy
It is suitable for children over 1 year old, and the ideal age for surgery is 1 to 4 years old.
(1) For mild cases, only the clavicular head or sternal head of the sternocleidomastoid muscle is cut off, and a neck collar is used to maintain it in a slightly over-corrected position after surgery.
(2) For severe torticollis, 2cm of the clavicle and sternal head of the muscle should be removed.
(3) For patients with soft tissue contracture, an incision must be made from the mastoid along the sternocleidomastoid muscle to remove all tense soft tissues until the muscle is completely relaxed. After surgery, the head was placed in an overcorrected position and immobilized with a head and neck plaster cast for 4 weeks. After canceling the cast immobilization, manual stretching training of the cervical muscles should be started immediately to avoid recurrence of adhesion contracture.
(4) For those over 12 years old, although facial and neck deformities are difficult to correct, surgical treatment can still improve the deformities. Be careful not to damage the facial nerve, accessory nerve and subclavian blood vessels.
Schematic diagram of sternocleidomastoid myotomy Cut off the muscles of the clavicle and sternum
Developmental dislocation of hip joint 2
Developmental dislocation of the hip (DDH), formerly known as congenital dislocation of the hip, is also called congenital displasia of the hip. Mainly, there are developmental defects in the acetabulum, proximal femur and joint capsule, which lead to joint instability until the development of hip joint dislocation. The incidence rate ranges from 0.1% to 0.4%, and the incidence varies greatly among different races and regions. There are more females than males, about 6:1. The left side is more common than the right side, and bilateral cases are not uncommon.
(1) Cause of disease
The cause of the disease remains unclear so far. It may be related to factors such as endocrine, genetics, intrauterine fetal position, and living habits. About 20% of sick children have a family history, indicating that there are certain genetic factors. The incidence is related to fetal position, and clinical statistics show that breech birth has the highest incidence rate. There are also other factors such as living habits and environmental factors. For example, the incidence rate is significantly higher in areas where the habit of using lower limbs to tie up swaddled babies in cold climates. In addition, primary acetabular dysplasia and joint ligament laxity are important causes of hip dislocation.
Primary pathological changes include:
① Acetabulum: The front, upper and rear edges of the acetabulum are underdeveloped, and the acetabulum is shallow and flat;
② Femoral head: The epiphysis of the femoral head appears slow and small in growth. The femoral head gradually loses its spherical shape and becomes irregular;
③Femoral neck: becomes thicker and shorter, and the anteversion angle increases significantly;
④Joint capsule: loose, joint unstable, elongated as the femoral head moves upward, and thickened into a gourd shape;
⑤ Round ligament: changes vary, elongated, thickened or disappeared;
⑥Labrum: inversion, involution.
Secondary pathological changes:
①Pelvis: tilt;
②Spine: It can cause lumbar scoliosis or excessive lordosis, lumbar muscle strain and spinal osteoarthrosis over time;
③Muscles and fascia: As the femoral head moves upward, the adductors and iliopsoas muscles become tense, and the gluteal muscles and tensor fascia lata contract to varying degrees.
(2) Classification
Hip dislocations can be divided into two main types. One type is the simplex type, which is the most common type and is the content introduced in this section.
This type can also be divided into:
(1) Acetabular dysplasia
(2) Hip subluxation
(3) Hip dislocation
The other type is deformed hip dislocation.
Developmental dislocation of the hip (DDH) classification
(3) Clinical manifestations and diagnosis
The clinical manifestations of congenital hip dislocation vary greatly depending on the age of the child. The clinical symptoms of newborns and infants are not obvious in the early stage of standing. If the following symptoms appear, it indicates the possibility of hip dislocation:
①The skin folds on the inner thighs on both sides are asymmetrical, and the skin folds on the affected side are deepened and increased.
②The perineum of the child is widened, which is more obvious when bilateral dislocation occurs.
③The affected hip joint has less and limited movement. The pedaling strength is weaker than that of the healthy side. Often in a flexed position and unable to straighten.
④The affected limb is shortened.
⑤ There is a popping sound or snapping sensation when the affected lower limb is stretched, and sometimes the child will cry.
The following tests can help with diagnosis:
1. Allis sign or Galeazzi sign: The sick child lies on his back, knees bent 90°, and both feet flat on the examination table. When the two ankles are close together, the height of the knees is different.
2. Barlow test (pop-up test): The patient is in the supine position. The examiner faces the patient's buttocks, bends both hips and knees at 90°, places the thumb on the inner thigh, applies pressure to the lesser trochanter, and pushes the femoral head outward and upward. , feel the popping sound of the femoral head sliding out of the acetabulum. When the pressure of the thumb is removed, the femoral head will naturally bounce back into the acetabulum. This is positive.
3. Ortolani sign (bounce test): The sick child lies on his back, bending the knees and hips 90 each. When abducted to a certain angle and then suddenly bounces, it is positive.
4. Hip abduction test:
If the knee flexion, hip flexion and abduction are limited (normal 7-9 month old babies can flex both hips and knees 90, and hip abduction can reach 70～80), it is positive.
(1) The length of both lower limbs is unequal, the wrinkles on the inner side of the left thigh are increased, and the left hip is sunken.
(2) The left side of the knee flexion and hip flexion abduction test was positive, and the right side was normal.
Allis sign: The left knee joint is lower than the healthy side (right)
In addition, you need to check the following items:
① Lame gait: limp when unilateral dislocation occurs, and bilateral dislocation manifests as a "duck walk" with obvious protrusion of the buttocks;
②Nelaton's line: The line connecting the anterior superior iliac spine and the ischial tuberosity is called the Nelaton's line. Normally, this line passes through the apex of the greater trochanter. In dislocation, the greater trochanter is above this line;
③Trendelenburg test: Instruct the child to stand on one leg and bend the hip and knee of the other leg as much as possible to keep the foot off the ground. Normally, the contralateral pelvis rises. After dislocation, the femoral head cannot support the acetabulum. The gluteus medius muscle is weak, causing the contralateral pelvis to descend. This is especially clear when viewed from behind. This is called a positive Trendelenburg sign, which is a sign of hip joint instability.
Trendelenburg sign (one-legged stance test)
5.B-ultrasound examination
Congenital hip dislocation is diagnosed when the femoral head is found outside the acetabulum. This method is most convenient and effective when conducting a census.
6.X-ray examination
For children with suspected congenital hip dislocation, anteroposterior pelvic radiographs of both hip joints should be taken more than 3 months after birth (before then, most of the acetabulum is still cartilage). Acetabular dysplasia, subluxation or dislocation can be found on X-rays. When taking X-rays, attention should be paid to protecting the gonads. Generally, drawing several connecting lines on the anteroposterior X-ray of the pelvis is helpful for diagnosis.
1) Perkin Quadrant
When ossification of the epiphyseal nucleus of the femoral head occurs, the Perkin quadrant can be used, that is, a straight line connecting the centers of the acetabulum on both sides is called the Y line, and then a perpendicular line (P) is drawn from the outer edge of the acetabulum to the Y line to divide the hip joint into Of the four quadrants, the normal femoral head epiphysis is located in the inner and lower quadrants. If it is subluxation in the lower outer quadrant, it is total dislocation in the upper outer quadrant.
2) Acetabular index
The development of the hip joint is commonly measured by the acetabular index or acetabular angle. A straight line is connected through the center points of the bilateral acetabular cartilage (also called Y-shaped cartilage) and extended, which is called the Y line. A line drawn from the center point of the Y-shaped cartilage to the outer upper edge of the acetabulum is called line C. The angle between line C and line Y is the acetabular index or acetabular angle.
Normal newborns are 30° to 40°, 1 year old are 23° to 28°, and 3 years old are 20° to 25°. Anything greater than this range indicates acetabular hypoplasia. This ratio decreases year by year after the child walks, and is basically constant at around 15 until the age of 12 years.
3) CE corner
It is also called the center edge angle, which is the angle formed by the vertical line connecting the center point of the femoral head and the line connecting the outer edge of the acetabulum and the center point of the femur. Its significance is to detect the relative position of the acetabulum and the femoral head, which is valuable for acetabular dysplasia and subluxation. Normally it is above 20
4) Shenton Line
That is, the continuous line between the inner edge of the femoral neck and the upper edge of the obturator foramen. Under normal circumstances, it is a smooth parabola. In case of dislocation, this line is interrupted.
Schematic diagram of Perkin quadrant, acetabular index and Shenton line
(4) Differential diagnosis
1. Congenital coxa varum deformity: There is also lameness, shortening of the affected limb, free hip flexion, and limited abduction. X-ray films show a small neck-shaft angle, Allis sign ( ), Trendelenburg sign ( ), and triangular bone fragments can be seen in the inner lower part of the femoral head near the neck.
2. Pathological hip dislocation: There is often a history of hip infection in the neonatal period. X-ray films: the femoral head epiphysis is absent but the acetabular index is normal.
3. Paralysis or spastic dislocation: The former is mostly the sequelae of infantile paralysis, with partial limb paralysis, obvious muscle atrophy, low muscle strength, and "subluxation" in X-ray films, which is generally easy to identify. The latter are mostly premature infants or those with postnatal asphyxia and those with a history of encephalopathy, who show symptoms of upper neuron damage such as hemiplegia or paraplegia.
(5) Treatment
The key to the prognosis of this disease lies in early diagnosis and early treatment. The earlier treatment is given, the better the results. As age increases, the pathological changes become more severe and the treatment effect becomes worse.
Under 1 year old, use the pedal sling method. If dislocation or subluxation of the hip joint is found, a pedal sling can be used for 6 to 9 months. Only hip extension is limited, and no other activities are restricted. Except for factors that hinder reduction in individual hip joints, the vast majority of children can achieve reduction without aseptic necrosis of the femoral head. Also useful are the method of wearing stockings and swaddling in the abduction position, which can be maintained for more than 4 months.
Over 3 years old: At this time, the degree of dislocation has worsened, and the secondary changes in bone and soft tissue have become more serious. It is difficult to achieve successful manual correction, and surgical treatment should be used. The main purpose of the surgery is to change the direction of the abnormal acetabulum to the physiological direction, increase the acetabulum's tolerance of the femoral head, and make the center of the femoral head coincide with the center of the acetabulum, which is called the hip joint rotation center. Common surgical methods include the following:
(1) Salter pelvic osteotomy: suitable for patients under 6 years old, with acetabular index below 45, and acetabular dysplasia dominated by the front edge.
(2) Chiair pelvic medial translation osteotomy: suitable for older children with an acetabular index greater than 45. This surgery mainly involves making an osteotomy of the pelvis from the upper edge of the acetabulum, the anterior inferior iliac spine, to the top of the joint capsule, which is high in the inside and low in the outside, and then moves the distal end inward by about 1 to 1.5 cm to increase the tolerance. The disadvantage is that it can lead to narrowing of the female birth canal, and the increased containment part is not covered by cartilage.
Pelvic osteotomy treatment
(1) Salter pelvic osteotomy;
(2) Chiari pelvic medial translation osteotomy
Schematic diagram of Pavlik sling in the treatment of congenital hip dislocation
6. Treatment
Early treatment methods are simple, easy to correct deformities, and have good long-term results.
1.Non-surgical treatment
(1) Ponseti orthopedic method
(2) Methods to correct
2. Surgical therapy
If the effect of non-surgical treatment is unsatisfactory or the deformity recurs, surgical treatment can be considered.
Generally, it is not advisable to perform bone surgery before the age of 10 to avoid damaging the epiphysis and affecting development.
Section 3 Congenital clubfoot
1. Cause
The cause of this disease has not yet been determined, and there are many theories. It is caused by developmental abnormalities caused by internal and external factors in the early embryonic stage. It may also be related to the abnormal position of the fetus' feet in the womb. However, there are also reports in the literature that this malformation is familial and is autosomal dominant inheritance with incomplete penetrance.
2. Pathology
Congenital clubfoot deformity in newborns consists of four factors:
(1) Adduction of the intertarsal joint;
(2) Ankle joint plantar flexion;
(3) Inversion of foot;
(4) Internal rotation of the tibia and posterior tibial muscle contracture may occur at older ages.
3. Clinical manifestations
After birth, one or both feet have equinus deformity, that is, pointed feet, small heels, calcaneus inversion, and forefoot adduction, that is, each toe is deflected inward, and the tibia is combined with internal rotation. From the analysis of treatment effect, it is divided into two categories: soft type and stiff type.
4. Diagnosis
It is not difficult to diagnose those with obvious malformations after birth. The main basis includes:
(1) Forefoot adduction
(2) Calcaneus varus
(3) Horseshoe shape of ankle joint
(4) Combined tibial internal rotation
5. Differential diagnosis
1. Arthrogryposis multiplex congenita affects many joints of the limbs. The deformity is relatively fixed and difficult to correct. There are bone changes in the early stage.
2. Cerebral palsy is spastic paralysis with increased muscle tone, hyperreflexia, pathological reflexes, and other manifestations of brain involvement.
3. Poliomyelitis causes muscle paralysis and atrophy.