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By M. Ayitos. University of North Carolina at Charlotte.

Extension treatments are most commonly required in arthrogrypo- contractures also occur but are extremely rare discount cefixime 100 mg free shipping. Differential diagnosis of acquired knee contractures History Clinical features Affected structured Additional Differential diagnosis investigations Locking Recent Effusion buy 200mg cefixime with mastercard, instability Capsular ligamentous poss discount cefixime 200 mg free shipping. Various surgical treatments have been proposed [2 purchase cefixime 200mg with visa, 9, 10]: lengthening of the hamstring muscles, division of the shortened, dorsal soft tissue structures, epiphysiodesis of the anterior part of the distal femoral epiphyseal plate and a femoral or tibial extension osteotomy. While soft tissue operations cannot achieve any lasting effect in cases of severe contractures (particularly in arthrogryposis), ex- tending osteotomies are effective, albeit at the expense of a permanent alteration in joint anatomy. Since 1989 we have therefore used the Ilizarov ap- paratus to correct severe knee contractures. At that time, this apparatus was already being used successfully for the correction of complex foot deformities [4, 6, 7]. The method involves the fitting of 2 circular rings to both the upper and lower leg, the linking of these ring systems with 2 lateral hinged joints and a dorsal distraction rod and a ventral compression rod (⊡ Fig. Fifty percent of the patients were suffering from arthrogryposis (⊡ Fig. The flexion contracture was improved, on average, from 40° preoperatively to 6° postoperatively, ⊡ Fig. Legs of a 16-year old girl with arthrogryposis and fitted although a subsequent deterioration to 18° was noted at Ilizarov apparatus on both sides for the correction of knee contrac- the follow-up control after 3 years. Specific problems associated with the treatment of con- tractures in spastic cerebral palsies and flaccid paralyses are discussed in chapter 3. More recently we have started using the Tailor Spatial Frame for the correction of severe flexion contractures of the knee. This apparatus allows a more precise definition of the axis of rotation. Brunner R, Hefti F, Tgetgel JD (1997) Arthrogrypotic joint contrac- severe knee pterygium. Microsurgery 9: 246–8 ture at the knee and the foot – Correction with a circular frame. Grill F, Franke J (1987) The Ilizarov distractor for the correction of Pediatr Orthop B 6 (3): 192–7 relapsed or neglected clubfoot. Grill F (1989) Corrections of complicated extremity deformities by mity of the knee in children and adolescents using the Ilizarov external fixation. DelBello DA, Watts HG (1996) Distal femoral extension osteotomy aspects. Clin Orthop 194: 104–14 3 for knee flexion contracture in patients with arthrogryposis. Sodergard J, Ryoppy S (1990) The knee in arthrogryposis multi- Pediatr Orthop 16: 22–6 plex congenita. Thomas B, Schopler S, Wood W, Oppenheim WL (1985) The knee in relapse using Ilizarov’s apparatus in children 8–15 years old. Differential diagnosis of knee pain History Clinical features Affected structured Additional investigations Differential diagnosis Joint effusion present Trauma present Swelling, instability Capsular ligamen- Depending on the individual Ligament lesion tous apparatus situation: aspiration, radio- graphy Giving way Menisci Meniscal lesion Locking Bone Inability to walk No trauma Effusion Synovial membrane CRP, ESR, blood count Rheumatoid arthritis With/without fever Bone/cartilage Serology, bacteriology Infectious arthritis Joint aspiration Osteomyelitis near the joint Radiography No joint effusion After exercise Possibly circumscribed Prepatellar or – Bursitis swelling anserine bursa After exercise Pain on external rotation Femoral condyles Radiography (tunnel view) Osteochondrosis dissecans After exercise Tenderness of tip of patella Tip of patella Knee x-rays: AP and lateral Sinding-Larsen, jumper‘s knee After exercise Tenderness Tibial tuberosity Possibly lateral x-ray Osgood-Schlatter disease Tibial tuberosity After exercise Tenderness patella Patella Possibly radiography Patellofemoral syndrome (particularly downhill) After exercise Tenderness of medial Synovial membrane – Mediopatellar plica (medial femoral condyle shelf) After exercise in Bulging in popliteal fossa Connective tissue – Popliteal cyst popliteal fossa Giving way during ex- Hypermobility of the Patella Knee x-rays: AP and lateral, Habitual or recurrent ercise, pseudolocking patella axial view of patella, poss. CT dislocations of the patella Giving way during Instability (Lachman Ligamentous Possibly x-ray with knee held Ligament lesion exercise (poss. Indications for imaging procedures for the knee Tentative clinical Circumstances/Indication Imaging procedures diagnosis Fracture Trauma Knee: AP and lateral (poss. CT in extension with and without tensing of the quadriceps Tumor Pain, swelling Knee: AP and lateral, possibly bone scan, possibly MRI Inflammation Pain, fever, positive laboratory result Knee: AP and lateral, possibly bone scan Growing pains If atypical (e. Indications for physiotherapy in knee disorders Disorder Indication Goal/type of treatment Duration Additional measures Osgood-Schlatter Pain Alleviate pain 12 sessions Swimming, knee protection, disease warmth Strengthen the muscles Warmth (Electrostimulation, quadriceps Knee support, poss. Pes calcaneus: The back of the foot can strike the ante- Inspection rior edge of the tibia Abnormalities of the foot that can be diagnosed at birth are usually also apparent on visual inspection. Thus, polydactyly, syndactyly and split foot are readily visible externally, as are abnormalities of the great toes ( Chap- ter 3. Clubfoot also shows a very characteristic picture, with adduction of the forefoot, marked varus of the hind- foot, an elevated calcaneus and an equinus foot position ( Chapter 3. Diagnosis by visual inspection is not always so easy for congenital flatfoot (vertical talus ).

After the knee has been aspirated buy cefixime 200 mg with visa, we do not ligament and/or a meniscal lesion will be found generic cefixime 100 mg without prescription, depend- perform any more diagnostic procedures cefixime 100mg with mastercard, but apply a dor- ing on the age group generic 100mg cefixime, in 30–40% of cases (children) or sal plaster cast in approx. The surgical If a hemarthrosis is present, an x-ray should always be treatment of intraligamentous ruptures of the anterior recorded to rule out a fracture. Intra-articular fractures cruciate ligament while the epiphyseal plates are still open most commonly appear as bony avulsions of the anterior has become a routine treatment in specialist centers over cruciate ligament at the intercondylar eminence and, the past 15 years [3, 8, 19]. In our hospital we have ob- rarely, of the proximal attachment in the intercondylar served and treated around 45 such cases over the past 15 notch. On the x-ray, the effusion is usually visible as an enlarged soft tissue shadow, oth- Diagnosis erwise the x-ray does not reveal any specific signs of a Recently traumatized knee lesion of the internal structures of the knee. Meniscal History lesions and ligament ruptures cannot be diagnosed on a The possibility of a lesion ofthe internal structures of the plain x-ray. The Everything usually happens very quickly and children are following conclusions can be drawn on the basis of the often unable to recall the precise circumstances. Typical aspirate: mechanisms are injuries in a flexion/external rotation/ Serous effusion: Not a consequence of a recent internal valgus position or with a hyperextended knee. The most likely fracture is a bony avulsion of the anterior cruciate ligament at the Stability testing intercondylar eminence, although other intra-articu- Lachman test, i. Another Testing for the meniscus signs possibility is a recent, traumatic dislocation of the test whether pain is elicited during internal and exter- patella with tearing of the retinacula. Knee traumatized 2 weeks or more in the past Other imaging procedures History The prospect of being able to diagnose internal knee le- If the trauma occurred slightly further back in the past, sions by ultrasound raised great hopes, particularly since it the following questions are relevant: is a cheap, painless and non-invasive investigation meth- ▬ Does genuine locking occur (the knee can neither be od. Periarticular structures (collateral ligaments, tendons, flexed nor extended from a particular position)? Greater difficulties ▬ Does pseudolocking occur (in a particular position the are posed, however, by the internal structures (particu- knee has to overcome an occasionally painful snap- larly the anterior cruciate ligament), although certain ping )? Even though certain After 2 weeks, the acute pain has subsided and the ef- authors have reported a close correlation between MRI fusion has also usually regressed. The knee can now be and arthroscopic findings, the sensitivity of the MRI examined thoroughly. We proceed according to the fol- scan is generally poor, particularly in children under 12 lowing examination protocol (the examination technique years of age, and the MRI is no more reliable in terms of is described in detail in chapter 3. Furthermore, it is difficult to assess the need for treat- Inspection ment on the basis of MRI findings. The MRI scan frequently shows structural changes mal axis, valgus / varus axis with intermalleolar / within the menisci that are of no clinical signifi- intercondylar distance), cance and yet are readily overrated. Arthroscopy is much better than MRI for checking the diagnosis and establishing whether surgical treatment Palpation is indicated, particularly since any treatment can be ad- ▬ palpate the effusion by pressing the suprapatellar ministered during the same anesthetic session – whether pouch and checking for »dancing« of the patella as an arthroscopic or open procedure. Only the inner part of the meniscus should be removed, leaving the outer part in place. The lateral meniscus has a very important stabilizing function, and a particularly problematic situation in this context is widening of the popliteal hiatus during resection of the posterior horn. Severe instability can result if this occurs in connection with a lesion of the anterior cruciate liga- ment, posing one of the most difficult therapeutic prob- lems for the knee. Medial collateral ligament lesions Lesions of the medial collateral ligament are likewise not especially rare in children. In many cases, avulsion occurs at the cartilaginous proximal attachment. This cartilaginous portion subsequently ossifies and is vis- ible on the x-ray as a »Stieda-Pellegrini shadow«. Arthroscopic photograph of a bucket-handle lesion of the isolated lesions of the medial collateral ligament have a medial meniscus in a 14-year old boy with still open epiphyseal plates good prognosis, the treatment should be conservative. It should be noted, however, that a medial opening of more than + (= 5 mm) indicates that the central pillar must also be damaged, i. Only then can two lesions occur in combination with a medial meniscal the condition of the posterior horns of the menisci and a lesion this produces the classical »unhappy triad«, which partially ruptured anterior cruciate ligament be properly occurs during external rotation-flexion-valgus trauma. Since the same mechanism can also lead to dislocation of the patella, the possibility of this concomitant injury Treatment should also be considered ( Chapter 3. If a combi- The treatment of internal lesions of the knee in children nation of such injuries has been diagnosed, the cruciate and adolescents with open epiphyseal plates differs to ligament and possibly the meniscal lesion and dislocation some extent from that for adults. Certain therapeutic of the patella will require surgical correction, but not the methods are unsuitable for children because of the open medial collateral ligament rupture.

Conservative treatment with rest loid deposits cause swelling of the involved tendon and antiinflammatory drugs is sufficient in most and a more heterogeneous appearance of the fibrillar patients 100mg cefixime otc. Occasionally cefixime 100mg low price, a hyperaemic pattern can tendon cheap cefixime 100 mg online, surgical lengthening of the tendon may be be found at colour and power Doppler examination purchase 100mg cefixime visa. Differing from traumatic and degenerative lesions, the inflammatory involvement of tendons invested by synovial sheath is commonly encoun- 3. Degenerative and Inflammatory Conditions The US appearance of the affected tendons varies depending on the stage of synovial involvement Degenerative disorders of tendons are rare in children (acute vs chronic). In the early stages, the tendon has and usually follow mechanical stress related to foot a normal size and echotexture and is surrounded by disorders, including clubfoot and flat foot (Fig. In chronic renal failure treated by haemodialysis, In more advanced disease, synovial hypertrophy Fig. When the hip is flexed (a), the iliotibial band is present as a hyperechoic stripe (arrows) posterior to the trochanter (asterisk) and superficial to the gluteus medius tendon (Gm). During extension of the hip (b), an abrupt displacement (dotted arrow) of the iliotibial band occurs as it gets closer to the trochanter, coinciding with the snapping sensation 48 M. Degenerative changes in the Achilles tendon of a 10-year-old boy who was previously operated upon for flat foot. Longitudinal (a) and transverse (b) grey-scale 12-5 MHz US images obtained over the Achilles tendon demonstrate diffuse fusiform hypoechoic swelling (asterisks) of the tendon extending from its insertion to approximately 3 cm above the calcaneus due to microtears and mucoid degeneration. The colour Doppler image (c) shows an increased depiction of intratendinous flow signals. The pattern distribution of flow is characterized by vessel pedicles that enter the tendon from its anterior surface can be seen as hypoechoic folds projecting inside plete tears a gap is observed between hypoechoic and filling the synovial sheath (Fig. Although the diagnosis of synovitis, colour and power Doppler imaging and complete tears is usually straightforward on clinical gadolinium-enhanced MR sequences can aid dif- examination, high-resolution US can help the sur- ferentiation between pannus and effusion by show- geon assess the amount of retraction of the proximal ing flow signals inside the synovium (Fig. However, one should always In specific clinical settings, US can provide an accu- keep in mind that the fibrous pannus does not show rate and confident guidance to direct the needle for hypervascular changes. A definite advantage of US synovial biopsy procedures and for the injection of is the ability to differentiate tendon involvement corticosteroids inside the tendon sheath. The differential diagnosis of inflammatory teno- These conditions require different treatments synovitis includes infection. If a synovial sheath and may be difficult to discriminate on physical tendon is involved in isolation, the possibility of an examination. In longstanding disease, the involved infectious tenosynovitis should be considered, espe- tendons may become swollen and hypoechoic. Most of these patients are being tial tendon tears, US demonstrates focal swelling or treated with corticosteroids which may mask the thinning of the involved tendon, whereas in com- signs of infection (fever, pain, limitation of move- Ultrasonography of Tendons and Ligaments 49 Fig. Tenosynovitis of the long head of the biceps tendon in a 5-year- old child with juvenile idiopathic arthritis. Longitudinal (a) and transverse (b) 12-5 MHz US images over the anterior aspect of the shoulder demonstrate thickening of synovial tissue (arrowheads) around the long head of the biceps tendon (arrows) related to synovial hypertrophy. The patient had also disten- sion of the anterior recess of the glenohumeral joint. Colour Doppler imaging (c) shows hypervascularity of the synovial sheath as a sign of active synovial pannus; H humerus Fig. Flexor tenosynovitis of the wrist in an 8- year-old female with juvenile rheumatoid arthritis. Axial gadolinium DTPA-enhanced T1-weighted MR image of the carpal tunnel demonstrates contrast uptake of the synovial pannus (asterisks) surround- ing the flexor tendons (T) 50 M. Longitudinal 12-5 MHz US images obtained over the dorsal aspect of the wrist in two different patients affected by juvenile idiopathic arthritis. Deep to these tendons, the dorsal recesses of the radiocarpal (RC) and mediocar- pal (MC) joints appear normal. Instead, a definite effusion is detected within radiocarpal (small asterisk) and mediocarpal (large aster- isk) joints indicating joint synovitis ment). In full-thickness tears, the ligament is entiation between these conditions, but it can guide interrupted and its ends are separated by either the needle aspiration of the sheath fluid for Gram hypoechoic blood collection (acute) or hyperechoic staining and culture. At the medial aspect of the elbow, the anterior band of the medial collateral ligament complex may be injured in adolescents who practice baseball pitching or throwing sports. They are show either a gap or focal hypoechoic areas in the almost exclusively observed in adolescents involved proximal and distal aspects of the ligament.

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