Essential Orthopedics-Maheshwari

Tuberculosis of Bones and Joints | 183 A tubercular osteomyelitis in the vicinity of a joint Usual presenting complaints are pain, swelling, may result in the involvement of the joint. deformity and inability to use that part. Sometimes, Joint involvement is usually in the form of a the presentation is atypical. The following general low-grade synovitis, with thickening of the principles will help in making a diagnosis: synovial membrane. Unlike pyogenic arthritis where proteolytic enzymes cause severe early a) High index of suspicion: Tuberculosis should destruction of the articular cartilage, tubercular be included in the differential diagnosis infection causes slow destruction. Once the of any slow onset disease of the musculo- synovium is inflamed, it starts destroying the skeletal system, particularly in countries where cartilage from the periphery. This inflammatory tuberculosis is still prevalent. Because of its synovium at the periphery of the cartilage is slow onset and progress, the symptoms and called Pannus. Eventually, the articular cartilage signs are often minimal and non-specific. A high is completely destroyed. The joint gets distended index of suspicion and a close watch over such with the pus. Joint capsule and ligaments become symptoms in susceptible individuals, is the key lax, and the joint may get subluxated. us and to early diagnosis. tubercular debris burst out of the joint capsule to form a cold abscess, and subsequently a chronic b) Fallacious history of trauma: Very often the discharging sinus. patient assigns all his symptoms to an episode Healing: It occurs by fibrosis, which results in of injury. One should not get carried away significant limitation or near complete loss of joint by such information, as the injury may be movement (fibrous ankylosis). If considerable coincidental. A detailed inquiry in such cases destruction of the articular cartilage has occurred, will reveal a symptom-free period between the joint space is completely lost, and is traversed the episode of trauma and the beginning of by bony trabeculae between the bones forming symptoms, thus establishing the non-traumatic the joint (bony an ylosis) as shown in Fig-23.1. nature of the disease. Fibrous ankylosis is a common outcome of healed tuberculosis of the joints, except in the spine where c) Lack of constitutional symptoms: Symptoms bony ankylosis follows more often. like fever, loss of appetite, weight loss etc. are present in only about 20 per cent cases. An 23.1 T e a l active primary focus is detected only in about 15 per cent of cases at the time of diagnosis; in CLINICAL FEATURES the rest it has already healed by the time the Clinical features depend upon the site affected. patient presents. atients of all ages and both sexes are affected Specific signs and symptoms in patients with frequently. The onset is gradual in most cases. tuberculosis at major sites will be discussed in respective sections. INVESTIGATIONS Radiological examination: X-ray examination of the affected part, antero-posterior and lateral views, is the single most important investigation. Findings in the early stages may be minimal and are likely to be missed. A comparison with an identical X-ray of the opposite limb or with an X-ray repeated after some period, may be helpful. Following are some of the general radiological features of tuberculosis of the bones and joints: TB osteomyelitis: A tubercular osteomyelitis presents as a well-defined area of bone destruction, typically with minimal reactive new bone formation. This is unlike a pyogenic infection, where reactive periosteal new bone formation is an important feature. https://kat.cr/user/Blink99/

184 | Essential Orthopaedics Control of infection: It is brought about by potent anti-tubercular drugs, rest to the affected part and TB arthritis: In tubercular arthritis there is reduction the building up of patient s resistance. of the joint space, erosion of the articular surfaces a) Anti-tubercular drugs: Table–23.2 shows com- and marked peri-articular rarefaction. This is unlike many other causes of joint space reduction such as mon anti-tubercular drugs, their dosage, route osteoarthritis, septic arthritis, etc., where there is of administration and common side-effects. subchondral sclerosis instead. It is usual practice to start the treatment with 4 drugs — ifampicin, H, yrazinamide, X-ray features specific to different sites will be discussed in their respective sections. A chest thambutol for 3 months. n selected cases with X-ray should be done routinely to detect any multifocal tuberculosis, 5 drugs — F, H, tubercular lesion in the lungs. , TH and Streptomycin, may be required Other investigations: Some of the following for the initial period. The patient is monitored* investigations may be helpful in diagnosis: to detect any failure to respond or for any side- effects of the drugs. • Blood examination: Lymphocytic leukocytosis, b) Rest: The affected part should be rested during high S . the period of pain. In the upper extremities this can be done with a plaster slab; in the lower • Mantoux test: useful in children. extremities traction can be applied. In most • Serum ELISA test for detecting anti-myco bacte- cases of spinal tuberculosis bed rest for a short period is sufficient; in others, support with a rium antibodies. brace may be necessary. • yno ial fluid aspiration (see Table–22.3, page 177). c) Building up the patient's resistance: The patient • Aspiration of cold abscess and examination of should be given a high protein diet and exposed to fresh air and sunlight to build up his general pus for AFB. resistance. • Histopathological examination of the granulation Care of the affected part: This consists of protection tissue obtained by biopsy or curettage of a of the affected part from further damage, correction lesion. of any deformities and prevention of joint contractures. Once the disease is brought under TREATMENT control, exercises to regain functions of the joint are carried out. Care consists of the following: Principles of treatment: Treatment of tuberculosis a) Proper positioning of the joint: The joints should of bones and joints consists of control of the infec- tion and care of the diseased part. In most cases, be kept in proper position so that contractures conservative treatment suffices; sometimes opera- do not develop. tive intervention is required. b) Mobilisation: As the disease comes under con- trol and the pain reduces, joint mobilisation is Table–23.2: Common anti-tubercular drugs and their begun. This prevents contractures and helps regain movement. In cases with extreme dam- dosages age to the joint, it is best to expect ankylosis of the joint in the position of most useful func- Name/ Side effects tion. Daily dose (max.) c) Exercises: As the joint regains movement, muscle strength building exercises are taught. Bactericidal –Hepatotoxicity, pin coloured d) Weight bearing: It is started gradually as • ifampicin ( F) urine osteoporosis secondary to the disease is –Hepatotoxicity, eripheral reversed. 10 mg/kg (600 mg) neuritis • soniazide ( H) – estibular damage, ephrotoxicity * Multi-drug resistance is a serious upcoming problem. Anti- Circumoral paraesthesia tubercular drugs, in proper combination, in proper dosages and 5-10 mg/ g (300) –Hepatotoxicity under close supervision is the key to its prevention. • Streptomycin (SM) –Optic neuritis, Colour blindness 30 mg/ g (1 gm) • yrazinamide ( ) –C S toxicity -Headache, Tremor, Dysarthria 25 mg/ g (1.5 gm) –Anorexia, ausea, omiting Bacteriostatic –Anorexia, ausea, omiting • thambutol ( TH) 25 mg/ g for 4 w s (1000 mg), thereafter 15 mg/kg (800 mg) • Cycloserine 10 mg/kg (500 mg) • thionamide 25 mg/ g (750 mg) • ara-amino salicilate ( AS) 200-400 mg/ g (12 g)

Tuberculosis of Bones and Joints | 185 Operative intervention may be required in some 23.2 l l e eb ae cases. Following are some procedures commonly used: (diagrammatic, simplified) a) Biopsy: For cases where the diagnosis is in doubt, ‘embryological’ section, as in the commoner a fine needle aspiration cytology (FNAC) may paradiscal tuberculosis of the spine. be performed from an enlarged lymph node or from a soft tissue swelling. An open biopsy Surface anatomy of the vertebral column: The may be necessary from a bony lesion, or in case only part of the vertebra which is accessible FNAC fails to confirm the diagnosis. to palpation is its spinous process, hence this is used for localising the level of the vertebral b) Treatment of cold abscess: A small stationary segment. Table–23.3 shows the relationship abscess may be left alone as it will regress with between the vertebral spinous processes to the healing of the disease. A bigger cold abscess that of some of the easily palpable anatomical may need aspiration or evacuation (discussed landmarks. Once the affected vertebra is known, in detail on page 191). the corresponding cord-segment can be found as discussed subsequently. c) Curettage of the lesion: If the lesion is in the vicinity of a joint, infection is likely to spread to Cord-segment localisation: Because of the the joint. An early curettage of the lesion may disproportionate growth of the vertebral column prevent this complication. Table–23.3: Vertebral level – landmarks T1 d) Joint debridement: In cases with moderate joint destruction, surgical removal of infected and • Most prominent spinous process at the D3 necrotic material from the joint may be required. base of the neck D7 This helps in the early healing of the disease, D12 and thus promotes recovery of the joint. • At the level of the spine of the scapula • At the level of lower angle of the scapula 4 e) Synovectomy: In cases of synovial tuberculosis, a • Floating rib synovectomy may be required to promote early • At the level of the iliac crests S2 recovery. • At the level of the post. sup. iliac spine f) Salvage operations: These are procedures Table–23. : Relationship between spinal and cord performed for markedly destroyed joints in segments order to salvage whatever useful functions are possible e.g., Girdlestone arthroplasty of the hip Spinal segment Cord segment (page 198). • Cervical vertebrae Add 1 to vertebral level g) Decompression: In cases with paraplegia • pper dorsal vertebrae Add 2 to vertebral level secondary to spinal TB, surgical decomp-ression • ower dorsal vertebrae Add 3 to vertebral level may be necessary. • At D10 All dorsal segments over • At D12 All lumbar segments L I OF THE SPINE over ( ott's disease) • At 1 All sacral segments over • Below 1 Cauda equina The spine is the commonest site of bone and joint tuberculosis; the dorso-lumbar region being the one affected most frequently. RELEVANT ANATOMY Development of a vertebra (Fig-23.2): A vertebra develops from the sclerotomes which lie on either side of the notochord. The lower-half of one vertebra and upper-half of the one below it, along with the intervening disc develop from each pair of sclerotomes and have a common blood supply. Therefore, infections via the arteries involve the https://kat.cr/user/Blink99/

186 | Essential Orthopaedics 23.3 T e e eb al be l and spinal cord, the cord ends at the lower border d) Posterior: In this type, the posterior complex of of first lumbar vertebra. Beyond this, up to S2 there the vertebra i.e., the pedicle, lamina, spinous is only the dural sac containing a bunch of nerve process and transverse process are affected. roots (cauda equina). The segment of the cord which corresponds to a given vertebra is therefore Pathology: Basic pathology is the same as that in above the level of that vertebra. elationship other bone and joint tuberculosis. In the commoner between the spinal segment and cord segment in paradiscal type, bacteria lodge in the contiguous different regions of the spinal column is as shown areas of two adjacent vertebrae. Granulomatous in Table–23.4, page 1 5. inflammation results in erosion of the margins of these vertebrae. Nutrition of the intervening PATHOLOGY disc, which comes from the end-plates of the adjacent vertebrae is compromised. This results Like tuberculosis of the bones and joints elsewhere in disc degeneration, and as the process continues, in the body, TB of the spine is always secondary. complete destruction. The bacteria reach the spine via the haematogenous Weakening of the trabeculae of the vertebral body route, from the lungs or lymph nodes. It spreads results in collapse of the vertebra. Type of collapse is via the para-vertebral plexus of veins i.e., Batson s generally a wedging, occurs early, and is severe plexus, which has free communication with the in lesions of the dorsal spine. This is because, in visceral plexus of the abdomen, a common site of the dorsal spine the line of weight bearing passes tuberculosis. anterior to the vertebra, so that the anterior part of the weakened vertebra is more compressed than the Types of vertebral tuberculosis: Lesions in the posterior, resulting in wedging. In the cervical and vertebrae may be of the following types (Fig-23.3): 23. Types of collapse of vertebrae a) Paradiscal: This is the commonest type. In this, the contiguous areas of two adjacent vertebrae along with the intervening disc are affected. b) Central: In this type, the body of a single vertebra is affected. This leads to early collapse of the weakened vertebra. The nearby disc may be normal. The collapse may be a ‘wedging’ or ‘concertina’ collapse (Fig-23.4); wedging being commoner. c) Anterior: In this type, infection is localised to the anterior part of the vertebral body. The infection spreads up and down under the anterior longitudinal ligament.

lumbar spines, because of their lordotic curvature Tuberculosis of Bones and Joints | 187 (round forwards), wedging is less. Destruction occurs early, and is severe in children. may be a ‘radicular’ pain i.e., a pain radiating Cold abscess: This is a collection of pus and along a nerve root. Depending upon the nerve tubercular debris from a diseased vertebra. It is root affected, it may present as pain in the arm called a cold abscess because it is not associated (cervical roots), girdle pain (dorsal roots), pain with the usual signs of inflammation – heat, abdomen (dorso-lumbar roots), groin pain redness etc., found with a pyogenic abscess. (lumbar roots) or ‘sciatic’ pain (lumbo-sacral The tubercular pus can track in any direction roots). from the affected vertebra (Fig-23.5). f it travels • Stiffness: It is a very early symptom in TB of backwards, it may press upon the important the spine. It is a protective mechanism of the neural structures in the spinal canal. us may body, wherein the para-vertebral muscles go come out anteriorly (pre-vertebral abscess) or on into spasm to prevent movement at the affected the sides of the vertebral body (para-vertebral vertebra. abscess). Once outside the vertebra the pus may • Cold abscess: The patient may present the first travel along the musculo-fascial planes or neuro- time with a swelling (cold abscess) or problems vascular bundles to appear superficially at places secondary to its compression effects on the far away from the site of lesion. nearby visceral structures, such as dysphagia in TB of the cervical spine. A detailed examination 23. e a be la in such cases reveals underlying TB of the pus from a vertebral focus spine. • Paraplegia: If neglected, which is often the case Healing: As healing occurs, the lytic areas in the in developing countries, a case of TB of the bone are replaced by new bone. The adjacent spine presents with this serious complication. vertebrae undergo fusion by bony-bridges. For details see ott s paraplegia, page 1 1. Whatever changes have occurred in the shape of • Deformity: Attention to TB of the spine may the vertebral body are, however, permanent. be attracted, especially in children, by a CLINICAL FEATURES gradually increasing prominence of the Presenting complaints: Clinical presentations of spine – a gibbus. a case of TB of the spine is very variable – from a • Constitutional symptoms: Symptoms li e fever, seemingly non-specific pain in the back to complete weight loss etc., are rarely the only presenting paraplegia. Following are some of the common symptoms. presenting complaints: • Pain: Back pain is the commonest presenting EXAMINATION symptom. It may be diffuse; no more than a The aim of examination is: (i) to pick up findings dull ache in the early stages, but later becomes suggestive of tuberculosis of the spine; (ii) to localised to the affected diseased segment. It localise the site of lesion; (iii) find skip lesions; and (iv) to detect any associated complications like cold abscesses or paraplegia. Following is the systematic way in which one should proceed to examine a case of suspected TB of the spine. • Gait: A patient with TB of the spine walks with short steps in order to avoid jerking the spine. He may take time and may be very cautious while attempting to lie on the examination couch. In TB of the cervical spine, the patient often supports his head with both hands under the chin and twists his whole body in order to look sideways. • Attitude and deformity: A patient with TB of the cervical spine has a stiff, straight neck. In dorsal spine TB, part of the spine becomes prominent (gibbus or kyphus*). Significant https://kat.cr/user/Blink99/

188 | Essential Orthopaedics Table–23. : Presentation of cold abscesses from different regions of the spine Region Anteriorly Presentation Along musculo-facial plane Along of spine On the sides neurovascular plane To axilla, to arm along neuro- At the posterior border of vascular bundle of the arm Cervical etro-pharyngeal ara-vertebral sterno-cleidomastoid muscle, spine abscess abscess in the posterior triangle of neck Along thoracic spinal nerves to Tric les downward and enters present at Thoracic Mediastinal ara-vertebral either of the two lumbo costal • Anterior chest wall spine abscess abscess arches: • Mid-axillary line • ateral lumbo-costal arch • osterior chest wall umbar re-vertebral ara-vertebral spine abscess abscess –to present as lumbar abscess Along neurovascular bundle of • Medial lumbo-costal arch the leg to present in groin or down in the leg –to present as psoas abscess umbar abscess or psoas abscess lower deformity is generally absent in lumbar spine • Tenderness: It can be elicited by pressing upon tuberculosis; there may just be loss of lumbar the side of the spinous process in an attempt to lordosis. rotate the vertebra. • Para-vertebral swelling: A superficial cold abscess may present as fullness or swelling on • Movement: There is no necessity to examine for the back, along the chest wall or anteriorly. It is spinal movement in a patient with obviously easy to diagnose because of its fluctuant nature. painful spine. Spinal movement are limited Sometimes, an abscess may be tense and it may in a case of TB of the spine, and can be tested, not be possible to elicit fluctuation. A needle wherever considered suitable. aspiration may be performed in such cases, to confirm the diagnosis. It is important to look • Neurological examination: A thorough neuro- for cold abscesses in not so obvious locations, logical examination of the limbs, upper or lower, depending upon the region of the spine affected depending on the site of tuberculosis should be (Table–23.5). performed. In addition to motor, sensory and reflexes examination, an assessment should * There are three types of kyphotic deformities: be made of urinary or bowel functions. Aim of (i) Knuckle – prominence of one spinous process neurological examination is to find: (i) whether (ii) Gibbus – prominence of two or three spinous processes or not there is any neurological compression; (iii) Kyphus – diffuse rounding of the vertebral column (ii) level of neurological compression; and (iii) severity of neurological compression. (a) (b) (c) (d) 23. a T e e. a a l a e al l la e b le e l la e Destruction of vertebral bodies with loss of disc prolapse, (d) Advance destruction and wedging of vertebrae

Tuberculosis of Bones and Joints | 189 • General examination: A general physical Table 23. : Number of affected vertebrae examination should be performed to detect any active or healed primary lesion. The patient may Type No. of vertebrae involved have some other systemic illness like diabetes, hypertension, jaundice etc., which may have a Knuc le 1 bearing on further treatment. ibbus 2-3 3-4 RADIOLOGICAL INVESTIGATIONS Angular kyphosis a e a a : One must specify the level of ounded yphosis 4 the suspected damage, when requisitioning an • Evidence of cold abscess: adiological evidence -ray of the spine. Minimum of two views, A and of a cold abscess is a very useful finding in diagnosing a case of suspected spinal TB. lateral, are necessary. A chest X-ray for primary Following abscesses may be seen on X-rays: focus or an -ray of the abdomen – K B, if a psoas abscess is suspected, may also be taken. Following • Para-vertebral abscess: A para-vertebral are some of the important radiological features. soft tissue shadow corresponding to the site of the affected vertebra in A view indicates • Reduction of disc space: This is the earliest sign in a para-vertebral abscess. It may be of the the commoner, paradiscal type of tuberculosis following types: (i) a fusiform para-vertebral (Fig-23. a). n early stages, reduction in disc space abscess (bird nest abscess – an abscess whose may be minimal, and may be detectable only on length is greater than its width (Fig-23.7a); comparing the height of the suspected disc with those and (ii) globular or tense abscess – an abscess above and below it. In advanced stages, disc space whose width is greater than the length may be completely lost (Fig-23. b). A lateral -ray (Fig-23.7b). The latter indicates pus under is better for evaluation of disc space. eduction of pressure and is commonly associated with disc space is an important sign because in other paraplegia. diseases of the spine e.g. secondaries in the spine, the disc space is well preserved. • Widened mediastinum: An abscess from the dorsal spine may present as widened • Destruction of the vertebral body: In early stages, mediastinum on A -ray. the contiguous margins of the affected vertebrae may be eroded. The diseased, weakened • Retro-pharyngeal abscess: In cervical spine vertebra may undergo wedging. In late stages, TB, a retro-pharyngeal abscess may be seen on a significant part or whole of the vertebral a lateral X-ray. Normally, soft tissue shadow body may be destroyed (Fig-23. c), leading in front of the C3vertebral body is 4 mm thick; to angular yphotic deformity. Severity of the an increase in its thickness indicates a retro- deformity depends upon the extent of wedging pharyngeal abscess (Fig-23.7c). and number of affected vertebrae (Table–23. ). (a) (b) (c) Fusiform abscess Tense abscess Retro-pharyngeal abscess 23. T e a a e eb al ab e e https://kat.cr/user/Blink99/

190 | Essential Orthopaedics 23. e e T1 & T2 images), showing TB spine • Psoas abscess: In dorso-lumbar and lumbar tuberculosis, psoas shadow on an X-ray of the (Note the compression on the cord and abdomen may show a bulge. huge pre-vertebral abscess) • Rarefaction: There is diffuse rarefaction of the the clinical level of neurological deficit does not vertebrae above and below the lesion. correspond to the radiological level of the lesion. • Unusual signs: In tuberculosis involving the Biopsy: CT guided needle biopsy, or an open posterior complex, there may be erosion of the biopsy may be required in a case with doubtful posterior elements of pedicle, lamina etc. These diagnosis. are better visible on oblique X-rays of the spine. Anterior type of vertebral tuberculosis may Other general investigations: Investigations like show erosion of the anterior part of the body, S , Mantoux test, SA test for detecting anti- much the same as that possibly seen sometimes in cases with aneurysm of aorta, thus termed tubercular antibodies, chest X-ray, etc., to support aneurysmal sign. There may be lytic lesions in the diagnosis of tuberculosis, may be carried out the ribs in the vicinity of the affected vertebra. whenever required. • Signs of healing: Once the disease starts healing, DIFFERENTIAL DIAGNOSIS the density of the affected bones gradually Cases with TB of the spine report fairly late in improves. Areas surrounding the lytic lesion developing countries, so they present mostly show sclerosis, and over a period of time these with classic signs, symptoms and radiological lesions are replaced by sclerotic bone. The features. In the early stages, and sometimes adjacent vertebrae undergo bony fusion. in some atypical presentations, diagnosis may be difficult. Some of the common differential CT scan: It may detect a small para-vertebral diagnosis and their differentiating features are abscess, not otherwise seen on plain X-ray; may given in Table–23.7. indicate precisely the extent of destruction of the vertebral body and posterior elements; and may TREATMENT show a sequestrum or a bony ridge pressing on the Principles of treatment: Aim of treatment is: cord (Fig-23. ). This is a very useful investigation (i) to achieve healing of the disease; and (ii) to in cases presenting as ‘spinal tumour syndrome’, prevent, detect early, and treat promptly any where there may be no signs on plain X-rays. complication like paraplegia etc. Treatment consists of anti-tubercular chemotherapy (page 184), 23. T a a a e T e general care (page 184), care of the spine, and treatment of the cold abscess. Only the latter two (Note bony fragments in the canal) will be discussed here. is the investigation of choice to evaluate the Care of the spine: This consists of providing rest type and extent of compression of the cord (Fig- to the spine during the acute phase, followed by 23. ). t also shows condition of the underlying guarded mobilisation. neural tissues, and thus helps in predicting the prognosis in a particular case. Myelography: This may be indicated in cases presenting with ‘spinal tumour syndrome’, or when

Tuberculosis of Bones and Joints | 191 Table–23. : TB of the spine – Differential diagnosis Symptoms Clinical features Investigations Back pain History of trauma present -ray – disc height normal. • Traumatic No fever or abscess Wedging of vertebrae present No para-vertebral shadow seen • Secondaries/Myeloma History of ‘primary’ elsewhere Disc space normal or myeloma edicles may be involved • rolapsed disc adiating pain in secondaries S T – positive Lesions in other bones present • An . spondylitis Localised nerve root deficit Chronic bac pain, starts in lower bac ormal -rays Neurological deficit Diffuse morning stiffness • Spinal tumour Chest expansion reduced ‘Bamboo spine’ appearance on -rays S joints affected – hazy, fused • Traumatic resent with gradually increasing • Secondaries in the neurological deficit -ray – interpedicle space increased No back pain, or other edicle erosion present spine findings on spine examination CT myelogram confirms History of definite trauma present Weakness is sudden onset -ray suggestive of Fracture-dislocation o history of trauma -ray shows erosion of vertebrae Back pain present History of ‘primary’ elsewhere Rest: Ashort period of bed rest for pain relief may of a pyogenic abscess, where a post-operative be sufficient during early stages of treatment. drain is always left. A psoas abscess can be In cases with significant vertebral destruction, a drained extra-peritoneally using a kidney longer period of bed rest is desirable to prevent incision. further collapse and pathological dislocation of the diseased vertebrae. In children, a body cast Medical esearch Council of reat Britain is sometimes given, basically to force them to conducted controlled trials to study various rest. Minerva jacket or a collar may be given for aspects of TB spine and published findings immobilising the cervical spine. in four reports (1 73-74). Their conclusions were that (i) bed rest is not necessary; (ii) Mobilisation: As the patient improves, he is Streptomycin is not necessary; (iii) o jac et allowed to sit and walk while the spine is offers no benefit; and (iv) debridement is not a supported in a collar for the cervical spine, good operation. or an ASH brace for the dorso-lumbar spine. The patient is weaned off the brace once bony COMPLICATIONS fusion occurs. He is advised to avoid sports for 2 years. 1. Cold abscess: This is the commonest complication of TB of the spine. Treatment is as discussed above. Treatment of cold abscess: A small cold abscess 2. Neurological compression: At times the patient may subside with anti-tubercular treatment. presents as a case of spinal tumour syndrome; the Abscesses presenting superficially need treatment first clinical symptom being a neurological deficit as discussed below; (discussed subsequently). • Aspiration: A thick needle is required because ' PARAPLEGIA often there is thick caseous material. It should ( pine ith eurological In ol ement) be an anti-gravity insertion with the needle entering through a zig-zag tract. The incidence of neurological deficit has been reported to be 20 per cent. t occurs most commonly • Evacuation: In this procedure, the cold abscess in tuberculosis of the dorsal spine because the is drained, its walls curetted, and the wound spinal canal is narrowest in this part, and even closed without a drain. This is unlike drainage https://kat.cr/user/Blink99/

192 | Essential Orthopaedics a small compromise can lead to a neurological pes of ott's paraplegia It can be divided into two deficit. types: PATHOLOGY a) a l onset paraplegia i.e., paraplegia occurring during the active phase of the disease, usually This consists of pressure on the neural tissues within two years of onset of the disease. within the canal by products from the diseased vertebrae. It could occur in the following ways: b) Late onset paraplegia i.e., paraplegia occurring several years after the disease has become • la a e e a: The neural tissues quiescent, usually at least two years after the onset of disease. become oedematous because of vascular stasis in the adjacent diseased area. athology of the two types is different, as also is the prognosis. Table–23. gives the causes of • a al a a la e: This is neurological deficit in early and late onset paraplegia. the commonest cause of compression on neural structures. The abscess formed around the diseased vertebrae may compress the neural CLINICAL FEATURES structures from the front, much the same way Neurological complications can occur in a known case of tuberculosis of the spine; or the case may as an extradural tumour. present for the first time with a neurological deficit. In the latter, tuberculosis as the cause of paraplegia • Sequestra: Devascularised bone and extruded is detected only on examination and further disc material may be displaced into the canal. investigation. Onset of paraplegia is gradual in most cases, but in some it is sudden. Tubercular • e al bb : Angulation of the diseased paraplegia is usually spastic to start with. Clonus spine may lead to formation of the bony (ankle or patellar) is the most prominent early sign. ridge on the anterior wall of the spinal canal (Fig-23.10). This is called the internal aralysis may pass with varying rapidity, through gibbus. the following stages: 23.1 e al bb • Muscle weakness, spasticity and in-coordination due to pressure on the corticospinal tracts • a on of the spinal cord: This is an unusual which are placed anteriorly in the cord and are but important cause of paralysis. It results from probably more sensitive to pressure. blockage of the anterior spinal artery, caused by the inflammatory reaction. • Paraplegia in extension: Tone of the muscles is increased due to absence of normal cortico- • a al a l a: Very rarely, an extradural spinal inhibition, resulting in paraplegia in granuloma may form without any damage to extension. the osseous structures. Such a patient presents with a clinical picture of a spinal tumour – the • Paraplegia in flexion: Absence of paraspinal so-called ‘Spinal tumour syndrome’. tract functions in addition to the corticospinal functions leads to paraplegia in flexion. • Complete flaccid paraplegia: araplegia becomes completely flaccid once all transmission across the cord stops. rades of ott's paraplegia otts paraplegia has been graded on the basis of degree of motor involvement, into four grades ( oel, 1 7): ae: atient is unaware of the neural deficit; the physician detects Babinski positive and ankle or patellar clonus on clinical examination.

Table–23. : Causes* of paraplegia in TB of the spine Tuberculosis of Bones and Joints | 193 a l e a a le a a) To promote recovery of the affected neural nfla atory causes tissues, by reversing the cause responsible for • Abscess – commonest compression, either by drugs or by operation. • ranulation tissue • Circumscribed tuberculous focus b) To achieve healing of the vertebral lesion, and • osterior spinal disease to support the spine till the diseased segment • nfective thrombosis of the spinal becomes stable. blood supply c) To undertake rehabilitative measures to prevent Mechanical causes contractures, and to regain strength in the • Sequestrum in the canal affected part. • nfected degenerated disc in the canal • athological dislocation – a ridge of bone Treatment of ott s paraplegia has been the topic of considerable study and discussion. Following pressing on the cord is the treatment considered most acceptable in author s opinion. Treatment may be divided into Late onset paraplegia conservative and operative. All cases of ott s • ecurrence of the disease paraplegia must be treated under supervision, after • rominent anterior wall of the spinal canal in admission to a hospital. case of severe kyphosis (Internal gibbus) Conservative treatment: Anti-tubercular • Fibrous septae following healing chemotherapy forms the mainstay of treatment. All patients are started on 4-drugs anti-tubercular * Although these several mechanisms have been described chemotherapy as soon as the diagnosis is made. as acting separately to produce paraplegia, more than one The spine is put to absolute rest by a sling traction cause may be responsible in a particular patient. for the cervical spine, and bed rest for the dorso- lumbar spine. The paralysed limbs are taken a e : atient presents with complaints care of, as discussed in the Chapter 32. During of clumsiness, in-coordination or treatment, repeated neurological examination of spasticity while walking, but manages the limbs is carried out to detect any deterioration to walk with or without support. or improvement in the neurological status. a e : atient is not able to wal because of If paraplegia improves, conservative treatment severe weakness. On examination, he is continued. atient is allowed to sit in the bed has paraplegia in extension. There may with the help of a brace as soon as the spine has be partial loss of sensation. gained sufficient strength. Bracing is continued for a period of about to 12 months. a e : atient is unable to wal , and has paraplegia in flexion with severe Operative treatment: If paraplegia does not improve muscle spasm. There is near complete at a satisfactory rate, or if it actually deteriorates; loss of sensation with sphincter surgical intervention is indicated. Following are disturbances. the indications for surgery considered suitable in most centres. INVESTIGATIONS Absolute indications It is usually possible to diagnose vertebral 1. araplegia occurring during usual conservative tuberculosis as a cause of paraplegia by typical radiological signs. n some cases, a M scan may treatment. be done to see: (i) type of vertebral destruction; 2. araplegia getting worse or remaining stationary (ii) presence of para-vertebral soft tissue abscess; and (iii) cause of paraplegia i.e., whether it is pus, despite adequate conservative treatment. sequestra etc. CT scan may be required in some 3. Severe paraplegia with rapid onset may indicate cases to better evaluate the vertebral canal. M is the investigation of choice, wherever available. severe pressure from a mechanical accident or abscess. TREATMENT 4. Any severe paraplegia such as paraplegia in flexion, motor or sensory loss for more than Principles of treatment: Aims of treatment are as six months, complete loss of motor power follows: for one month despite adequate conservative treatment. https://kat.cr/user/Blink99/

194 | Essential Orthopaedics In this operation, the spine is opened from its lateral side and access is made to the front 5. araplegia accompanied by uncontrolled spasticity and side of the cord, thus it is called antero- of such severity that reasonable rest and lateral decompression. The cord is laid free of immobilisation are not possible. any granulation tissue, caseous material, bony spur or sequestrum pressing on it. Structures Relative indications removed in order to achieve adequate exposure 1. ecurrent paraplegia, even with paralysis that of the cord are; the rib, transverse process, pedicle and part of the body of the vertebra (Fig- would cause no concern in the first attack. 23.11b). amina or facet joints are not removed, 2. araplegia with onset in old age: Indications for otherwise stability of the spine will be seriously jeopardized. surgery are stronger because of the hazards of recumbency. c) Radical debridement and arthrodesis 3. Painful paraplegia, pain resulting from spasm or (Hongkong operation): Wherever facilities are root compression. available, a radical debridement is performed 4. Complications such as urinary tract infection and by exposing the spine from front using trans- stones. thoracic or trans-peritoneal approaches. All the dead and diseased vertebrae are excised Rare indications and replaced by rib grafts. Advantage of this 1. araplegia due to posterior spinal disease. operation is early healing of the disease and no 2. Spinal tumour syndrome. progress of the kyphosis. 3. Severe paralysis secondary to the cervical d) a e . It is indicated in cases of disease. 4. Severe cauda equina paralysis. spinal tumour syndrome, and those where perati e procedures for ott's paraplegia The operative paraplegia has resulted from posterior spinal method aims at removal of the agents causing disease. compression on the neural structures. The following operations are commonly performed: Surgery for the cervical spine tuberculosis requires a separate technique; anterior decompression is a) Costo-transversectomy (Fig-23.11a): As preferable in this area. the name suggests, this operation consists of the removal of a section of rib (about 2 PROGNOSIS inches), and transverse process. As this is done, sometimes liquid pus comes out under rognosis of ott s paraplegia depends upon the pressure. This is considered by some as a following factors: tense abscess relieved, and thus enough to decompress the neural tissues. It is indicated 1. Age: Children respond to treatment better than in a child with paraplegia, and when a tense adults. abscess is visible on X-ray. In all other cases, it may not produce adequate decompression 2. Onset: Acute onset paraplegia has a better and an antero-lateral decompression may be prognosis. necessary. 3. Duration: Long standing paraplegia has a worse b) Antero-lateral decompression (ALD): This prognosis. is the most commonly performed operation. 4. Severity: Motor paralysis alone has a good prognosis. Sphincter involvement i.e., urinary or bowel incontinence are bad prognostic indicators. 5. Progress: Sudden progress of the paraplegia has a bad prognosis. 23.11 e be e e L I OF THE HIP After spine, the hip is affected, most commonly. It usually occurs in children and adolescents, but patients at any age can be affected.

PATHOLOGY Tuberculosis of Bones and Joints | 195 The basic pathology is the same as that discussed 23.13 a e a e ab l on page 1 2. The usual initial lesion is in the bone adjacent to the joint i.e., either the acetabulum or the region of the greater trochanter. us may the head of the femur (osseous tuberculosis). In perforate the acetabulum and appear as a pelvic some cases, the lesion may begin in the synovium abscess. (synovial tuberculosis), but quickly the articular Healing: If left untreated, healing may take place cartilage and the bones are affected. A purely by fibrosis, leading to ankylosis of the hip usually synovial tuberculosis, as seen in the knee joint, is in a deformed position (fibrous ankylosis). uncommon in the hip. Common sites of initial bone focus in TB of the hip are as shown in Fig-23.12. CLINICAL FEATURES Presenting complaints: The disease is insidious 23.12 T – e in onset and runs a chronic course. The child may be apathetic and pale with loss of appetite before Natural history: The infected granulation tissue definite symptoms pertaining to the hip appear. harbouring the bacilli, from the initial bony One of the first symptoms is stiffness of the hip, focus erodes the overlying cartilage or bone and and it produces a limp. Initially, stiffness may occur reaches the joint. In early stage, this results in only after rest, but later it persists all the time. synovial hypertrophy and effusion. The pannus of hypertrophied synovium around the articular ain may be absent in early stages, or if present, cartilage gradually extends over and under it. may be referred to the knee. The child may Cartilage is thus destroyed and the joint becomes complain of ‘night cries’, the so called ‘starting full of pus and granulation tissue. Synovium pain’, caused by the rubbing of the two diseased gets thickened, oedematous, grey and ulcerated. surfaces, when movement occurs as a result of the Denuded of their protective cartilage, the bone muscle relaxation during sleep. Later, there may be ends become raw. cold abscesses around the hip or these may burst, resulting in discharging sinuses. Multiple cavitation is typical of tuberculosis. Such cavities are formed in the femoral head EXAMINATION and the acetabulum. Eventually, the head or It should be carried out with the patient undressed. the acetabulum gets partially absorbed. By the Following physical findings may be present: constant pull of the muscles acting on the hip, • Gait: Lameness is one of the first signs. In the remaining head of the femur may dislocate from the acetabulum onto the ilium, giving rise the early stage, it is because of stiffness and to the so-called wandering acetabulum (Fig-23.13). deformity of the hip. Because of the flexion In later stages, pus bursts through the capsule deformity at the hip, the child stands with and spreads in the line of least resistance. It compensatory exaggerated lumbar lordosis. may present as cold abscess in the groin or in While wal ing the hip is ept stiff. Forward– backward movement at the lumbar spine is used for propulsion of the lower limb. This is called the ‘stiff-hip gait’. ater the limp is exaggerated by pain so the child hastens to take the weight off the affected side. This is called the ‘painful or antalgic gait’. https://kat.cr/user/Blink99/

196 | Essential Orthopaedics Table–23. : Hip deformities, ASIS and limb length • Muscle wasting: The thigh muscles and gluteal Deformity ASIS level Limb length muscles are wasted. Adduction higher Abduction lower apparent < true • Swelling: There may be swelling around the hip No add. abd. same (apparent shortening) because of a cold abscess. apparent true (apparent lengthening) • Discharging sinuses: There may be discharging apparent = true sinuses in the groin or around the greater trochanter. There may be puckered scars from There may be severe limitation of movements, both healed sinuses. active and passive, in all directions in late cases of tuberculosis. This is called ankylosis of the hip. If • Deformity: Gross deformities may be obvious on there is no movement at all, it is bony ankylosis. inspection. Minimal deformities are compensated for by pelvic tilt and can be made obvious by • Abnormal position of the head: In a dislocated tests. Commonly it is flexion, adduction and hip, the head can be felt in the gluteal region. internal rotation deformity of the hip. Method of measuring deformities is as discussed in • Telescopy: This test assesses the instability of Annexure-III. the head if it is out of the acetabulum (details in Annexure-III). • Shortening: There is generally a true shortening in TB of the hip, except in Stage , in which A F F I an apparent lengthening occurs (Annexure III). Limb length discrepancy can occur at this TB of the hip has been arbitrarily divided into three joint not only because of actual shortening of stages in its clinical course (Fig-23.14). the bones (true length) but also because of the adduction-abduction deformity, which results in ae ae : There is effusion pelvic tilt and thus affects the length of the limb (apparent length). The method of measuring into the joint which demands the hip to be in a true and apparent lengths is as discussed in Annexure-III. True and apparent length, and their position of maximum capacity. This is a position relation to different deformities of the hip are given in Table–23. . of flexion, abduction and external rotation. Since • Movements: Both, active and passive move– flexion and abduction deformities are only slight ments are limited in all directions. An attempted movement is associated with muscle spasm. and are compensated for by tilting of the pelvis, these do not become obvious. The limb remains in external rotation. As the pelvis tilts downwards to compensate for the abduction deformity, 23.1 a e T

the affected limb appears longer (apparent Tuberculosis of Bones and Joints | 197 lengthening), though on measuring true limb INVESTIGATIONS lengths, the two limbs are found to be equal. This Radiological examination: An X-ray examination stage is also called the stage of apparent lengthening. of the pelvis with both hips, A and lateral views It lasts for a very short period. Very rarely does of the affected hip are essential. Inclusion of the normal hip in the same film on the A view helps a patient present to the hospital in such an early in comparing the joint spaces on the two sides. M stage of the disease. scan and bone scan may be useful in early diagno- sis. Some of the radiological signs in an established a e a e ea : In this stage, the case of TB of the hip are as follows: articular cartilage is involved. This leads to spasm • Haziness: Haziness of the bones around the hip is the earliest sign. To appreciate it best, the affected of the powerful muscles around the hip. Since the hip is compared with the normal hip. flexors and adductors are stronger muscle groups • Lytic lesion: There may be lytic lesions in the regions specified in Fig-23.12, on page 1 5). than the extensors and abductors, the hip takes the • Reduction of joint space: This occurs because of attitude of flexion, adduction and internal rotation. destruction of the cartilage. It may be uniformly or irregularly diminished, better appreciated Flexion and adduction may be concealed by in the early stages on comparing it with the opposite side (Fig-23.15a). compensatory tilt of the pelvis but internal rotation • Irregular outline: The outline of the articular of the leg is obvious. As the pelvis tilts upwards ends of the bone becomes irregular because of destruction by the disease process. In severe to compensate for the adduction, the affected limb cases, a significant part of the head or acetabulum may be destroyed (Figs-23.15b and c). appears shorter (apparent shortening), although on • Acetabular changes: The head may be lying out comparing the limb lengths in similar positions, the of the acetabulum in a ‘pseudo’ acetabulum on two limbs are equal. This is also called the stage of the ilium – the wandering acetabulum. In some apparent shortening. cases, the acetabulum simply gets enlarged and deepened with the deformed head shifted ae ae e : In this stage, the medially, giving the appearance of the ‘pestle and mortar’. cartilage is destroyed and the head and/or the • Signs of healing: If the disease starts healing, there acetabulum is eroded. There may be a pathological may be sclerosis around the hip. dislocation or subluxation of the hip. Attitude of the limb is the same as that in Stage i.e., flexion, adduction and internal rotation except for the fact that the deformities are exaggerated. There is true shortening of the limb because of the actual destruction of the bone. In addition, apparent length of the limb is further reduced because of the adduction deformity. (a) (b) (c) 23.1 a l al ea e T e https://kat.cr/user/Blink99/

198 | Essential Orthopaedics Other investigations: The investigations that that of abduction and internal rotation. Little can be carried out to confirm the diagnosis are as or no shortening is present. Typically, X-ray discussed on page 169. changes are out of proportion to the physical findings. The joint space, unlike in TB of Biopsy: It may be needed in some doubtful cases. the hip, may even be widened (for details see This is done by exposing the hip by the posterior page 31 ). approach and taking a piece of the synovium for histopathological examination. It is possible to do d) Osteoarthritis: This occurs in older individuals. an arthroscopic biopsy. Hip movements are limited in all directions but only terminally. There is associated pain DIFFERENTIAL DIAGNOSIS and crepitus. Most cases are of osteoarthritis secondary to some other pathology (see TB of the hip is the commonest cause of pain in Chapter 35). the hip in children in countries where TB is still prevalent. Following differential diagnosis should TREATMENT be considered: Principles of treatment: It is to control the disease a) Other causes of monoarthritis of the hip: activity, and to preserve joint movement. In early Subacute low grade monoarthritis due to low stages (Stages and ), it is possible to achieve this grade septic infection or rheumatoid arthritis by conservative treatment. n later stages (Stage also presents with pain and stiffness of the hip. and after), significant limitation of joint functions Lack of supportive evidence for TB (like positive occur despite best treatment. Treatment may be family history, past history) and destruction conservative or operative. and sclerosis on X-ray, favour a diagnosis of septic arthritis. It may sometimes be difficult to Conservative treatment: It consists of anti- differentiate the two. In rheumatoid arthritis, tubercular chemotherapy (page 184) and care of joint space is uniformly reduced. the hip. b) al l a e a a ab e : • Care of the hip: The affected hip is put to rest by immobilisation using below-knee skin traction. atients with these extra-articular diseases In addition to providing pain relief, this also corrects any deformity by counteracting the often present with a flexion deformity of the muscle spasm. hip because of spasm of the iliopsoas. An • General care - Same as on page 1 4. examination reveals that all movements of the Operative treatment: The following operative hip except extension are pain free. procedures may be indicated in TB of the hip (see plan of treatment on page 200). c) Other diseases of the hip presenting at that age: In a child presenting with a limp without • Joint debridement: The joint is opened using much pain the following conditions should be posterior approach. us, necrotic tissue, inflamed synovium and dead cartilage are removed from considered: the joint. Any cavities in the head of the femur or acetabulum are curetted. The joint is washed • Congenital dislocation of the hip: The limp is thoroughly with saline and the wound closed. painless. It can generally be detected at birth, ost-operatively the joint surfaces are ept apart but is often noticed only when the child starts by traction to the leg. After the wound heals, the walking. An abnormal femoral head can be joint is mobilised. felt in the gluteal region. Telescopy test is positive. X-rays are decisive. • Girdlestone arthroplasty: The hip joint is exposed using the posterior approach. Head and neck of • Congenital coxa vara: The limp is painless. the femur are excised (Fig-23.1 ). Dead necrotic The movements limited are abduction and tissues and granulation tissues are excised. ost- internal rotation. In fact, adduction and operatively, bilateral skeletal traction is given for external rotation may be increased. X-ray 4 weeks, followed by mobilisation of the hip. It examination usually confirms the diagnosis. is possible to regain reasonable movement of the • Perthes' disease: This occurs in children in the age group of 5-10 years. The main complaint is a limp, which is generally painful. There is minimal limitation of movement, mainly

23.1 le e a la Tuberculosis of Bones and Joints | 199 (shaded portion excised) suggests significant joint damage or subluxation, hip by this procedure even in severely damaged one expects that normal joint functions cannot be joints. regained. In such a situation, the options before the surgeon are essentially these: • Arthrodesis: In selected cases, where a stiff hip in a functional position is more suitable a) To provide a painless, mobile but unstable joint considering day-to-day activities of the patient, by an excision arthroplasty (Girdlestone it is produced surgically by knocking the joint arthroplasty). Though the hip becomes unstable out. and the limb short, one can expect that patient will be able to squat on the floor. • Corrective osteotomy: Cases where bony ankylosis of the hip has occurred in an unacceptable b) To provide a painless sta le ut fixed oint by position from the functional viewpoint, a sub- surgically fusing the joint (arthrodesis) or by trochanteric corrective osteotomy of the femur conservative means. Though the hip is stable, may be required. lack of movement, and thus an inability to squat is the major problem. • Total hip replacement: There is enough evidence now, that a total hip replacement is a useful In countries, where for most of day-to-day activities operation in some patients with quiescent squatting is required, Girdlestone arthroplasty is tuberculosis. But as of now in most Afro-Asian still considered a suitable operation. In addition to countries, where most cannot afford a total hip providing a mobile hip, this operation enhances replacement, and where most patients want to healing of the disease as physical removal of the be able to squat even at the cost of instability, an infected bone, synovium etc. is done. In selected excision arthroplasty is a preferred option. patients, joint debridement has resulted in a stable hip with reasonable mobility of the hip. A total Deciding the plan of treatment: In early stages, hip replacement has also been advocated in some ATT and skin traction is given. As the disease cases of healed TB. comes under control, as is evident from the relief of symptoms; joint mobilisation is begun. By Flow chart-23.1 shows a general plan of treatment physiotherapy good joint functions can be regained for TB of the hip. in most cases. In cases presenting in late stages, initial treatment is by ATT and below-knee skin L I OF THE KNEE traction. The traction keeps the hip in a functional position with the joint surfaces apart while healing The knee is a common site of tuberculosis. Being a occurs. As the disease activity comes under control superficial joint, early diagnosis is usually possible. and symptoms (pain etc.) subside, a decision has A delay in diagnosis can severely compromise joint to be made whether useful hip functions can be functions. regained, depending upon the X-ray appearance of the hip. In a case, where there is no or minimal PATHOLOGY destruction of the hip joint mobilisation is begun with the hope of regaining as much movement The basic pathology is same as that described as possible. In a case where the X-ray picture on page 1 2. The disease may begin in the bone (osseous tuberculosis), usually in the femoral or tibial condyles, or more rarely in the patella. More commonly, the disease begins in the synovial membrane (synovial tuberculosis), leading to hypertrophy of the synovium. In early stages, the disease may be confined to the synovium without significant damage to the joint. Natural history: In later stages, the articular cartilage and bone are destroyed irrespective of the site of origin. In all types, there occurs synovial hypertrophy, synovial effusion and pus formation in the joint. The hypertrophied synovium spreads https://kat.cr/user/Blink99/

200 | Essential Orthopaedics l a 23.1 T ea e la T under and over the cartilage and destroys it. The CLINICAL FEATURES cartilage may become detached, leaving the bone Presenting complaints: The patient, usually in the exposed. Long standing distension of the joint and age group of 10-25 years, presents with complaints destruction of the ligaments produces subluxation of pain and swelling in the knee. It is gradual in of the tibia. The tibia flexes, slips backwards and onset without any preceding history of trauma. rotates externally on the femoral condyles (triple Subsequently, pain increases and the nee ta es subluxation). us may burst out of the capsule to an attitude of flexion. The patient starts limping. present as a cold abscess, and subsequently a sinus. There is severe stiffness of the knee. Healing: f untreated, nature s attempt at healing EXAMINATION may result in fibrosis, and thereby stiffness of the Following findings may be present on examination: joint in a deformed position. Healing is by fibrosis (fibrous ankylosis).

Tuberculosis of Bones and Joints | 201 • Swelling: The joint is swollen, which may be osseous tuberculosis, one may see juxta-articular due to synovial hypertrophy or effusion. The lytic lesions. The joint surfaces may be eroded. same can be detected by tests, as discussed on In later stages, joint space may be diminished pages 189 and 190. or completely lost. In advanced stages, triple subluxation with cavitatory bone lesions may be • Muscle atrophy: Atrophy of the thigh muscles is present. more than what can be accounted for by disuse alone. This is an unexplained feature of joint Other investigations along the lines already tuberculosis. discussed on page 1 3 may be carried out. A biopsy is sometimes required. • Coldabscess:There may be swelling due to a cold abscess, either around the knee or in the calf. DIFFERENTIAL DIAGNOSIS Diagnosis is not difficult in a late case, but • Sinus: There may be discharging or healed when the patient presents with synovitis, other sinuses. causes of synovitis should be excluded before arriving at a diagnosis of TB of the knee. These • Deformity: In early stages, there is a mild include subacute pyogenic infection, mono- flexion deformity of the knee because of effusion articular rheumatoid arthritis, chronic traumatic in the knee, and muscle spasm. Later, triple synovitis, rheumatic arthritis and haemophilic displacement (flexion, posterior subluxation and arthritis. external rotation) occurs due to ligament laxity. TREATMENT • Movements: The movements at the joint are limited. There is pain and muscle spasm on Principles of treatment: Aim of treatment is to attempting movement. achieve, wherever possible, a painless mobile joint. This is possible if a patient has come early INVESTIGATIONS for treatment. In later stages, some amount of pain Radiological examination (Fig-23.17): X-ray and stiffness persist in spite of treatment. is essentially normal in a case of synovial tuberculosis, except for a soft tissue shadow Conservative treatment: This consists of corresponding to the distended knee. The antitubercular chemotherapy, general care and joint space may be widened. There is diffuse local care of the part affected. It is started an all osteoporosis of the bones around the joint. In cases and decision for surgery taken if indicated, as discussed later. 23.1 a e ee a a e al e • Care of the knee: The knee is rested by applying showing changes in tuberculosis of the knee below- nee s in traction or an above- nee o slab. This helps in the healing process, and also (Note, reduction in joint space and takes care of the associated muscle spasm which marginal erosions - arrow) keeps the knee in a deformed position. Operative treatment: Following operative procedures may be required in suitable cases: • Synovectomy: It may be required in cases of purely synovial tuberculosis. Very often one finds ‘melon seed’ bodies within the joint. • Joint debridement: This may be required in cases where the articular cartilage is essentially preserved. The pus is drained, the synovium excised, and all the cavities curetted. • Arthrodesis: In advanced stages of the disease with triple subluxation and complete cartilage destruction, the knee is arthrodesed in https://kat.cr/user/Blink99/

202 | Essential Orthopaedics L I F J I functional position, i.e., about 5-10o of flexion Other joints uncommonly affected by tuberculosis and neutral rotation. One popular method of are the elbow, shoulder and ankle joints. Clinical features are similar to tuberculosis of other nee arthrodesis is Charnley s compression joints. Diagnosis is generally possible by X-ray arthrodesis. examination. Occasionally a biopsy may be required. With the current state of development of surgery, all these operations can be performed by minimally Shoulder joint tuberculosis, at times, may not invasive arthroscopic surgery. produce any pus etc., and hence is called ‘caries sicca’ and should always be considered in Plan of treatment: A plan of treatment for a case of TB of the knee is similar to that of the hip and is shown in Flow chart-23.2. l a 23.2 T ea e la T ee

23.1 a e al a e la e al e Tuberculosis of Bones and Joints | 203 tubercular cavity in the calcaneum subacute osteomyelitis of the shaft. Very often these are multifocal lesions. An important radiological differential diagnosis of much commoner shoulder feature is that the bone lysis is out of proportion problem – ‘frozen shoulder’. to the new bone formation, unlike in pyogenic osteomyelitis. A biopsy may be necessary in some OSTEOMYELITIS cases. uberculosis of long bones Tuberculosis rarely affect uberculosis of short bones Tuberculosis of the small the shafts of long bones. It is usually a low grade bones of the feet and hands is a rather common entity. These may occur as isolated lesions or as multiple ones. Diagnosis is easy with X-ray. Calcaneum is a common site (Fig-23.1 ). Treatment is by rest and ATT. In cases where diagnosis is in doubt, curettage of the lesion and histopathological examination of the curetted material may be required. Spina ventosa: This is a name given to tuberculosis of the phalanges of hand. The affected phalanx swells up like a balloon. An X-ray typically shows a lytic lesion distending the phalanx, and a lot of new bone formation. Further Reading • Martini M ( d.): Tuberculosis of the Bones and Joints. Berlin: Springer erlag, 1 . • Tuli SM: Tuberculosis of Bone and Joint: Jaypee Brothers Medical ublishers, Delhi, 1 . What have we learnt? • one and joint tuberculosis constitute - percent of total number of cases of tuberculosis. • ystemic features of infection, such as fever, do not occur commonly in bone and joint tuberculosis. • pine is the commonest site of bone and joint tuberculosis. • Dorsolumbar spine is the commonest region to get affected aradiscal being the commonest type. • eduction of disc space is the earliest radiological sign of T spine. • It is the neurological complications associated ith spine T , hich are of serious concern. • T hip is common cause of monoarthritis in children. arly diagnosis can save the joint from developing ankylosis. • T knee is of t o types ynovial and articular. • oints gets affected early, if there is a juxta-articular tubercular osteomyelitis. • Treatment is focussed on (a) control of the disease, (b) functional recovery. • ealing of tuberculous arthritis occurs by brous ankylosis. • T osteomyelitis is common in small bones. https://kat.cr/user/Blink99/

204 | Essential Orthopaedics Additional information: From the entrance exams point of view • Tuberculosis most commonly affects the dorsolumbar region of the spine, mainly T junction. • The earliest feature of tuberculosis is pain. • Tuberculosis of the spine affects the vertebral body rst. • Tuberculosis ith polyarthritis is called oncet s disease. • ong ong operation is done in T . • oor prognostic factors in ott s paraplegia are acute onset, sudden progression and long standing paraplegia. • ost common se uelae of T spondylitis is bony ankylosis. • irst sign of T spin is loss of curvature of the spine follo ed by reduction in intervertebral space radiologically. • ost common cause of early onset paraplegia is cold abscess. • Triple deformity is seen in T knee and is characteri ed by posterior subluxation of the knee, external or lateral rotation of the tibia and exion of the knee. It is treated by anti- tubercular drugs ith replacement or arthrodesis.

2C H A P T E R Infections of the and TOPICS • iddle olar space infection • ro imal olar space infection • lassification • eb space infection • Aetiopatholog • eep palmar abscess • Acute paron chium • Acute suppurati e tenos no itis • Apical subungual infection • erminal pulp space infection CLASSIFICATION AETIOPATHOLOGY Infections of the hand can be classified into two Hand infections are common in manual workers broad categories; spreading infections and localised and housewives who frequently suffer small infections. Spreading infections are the ones which pricks or abrasions in the course of their work. spread to involve a large area of the hand e.g., Staphylococcus aureus is the causative organism lymphangitis, cellulitis etc. Localised infections are in 80 per cent of cases; in others Streptococcus and those which are localised to an area of the hand other gram-negative bacteria are responsible. because of certain anatomical factors. Infections The organisms reach the tissue planes by direct of the hand are classified as given in Table–24.1. implantation from outside or via the blood. They set up an acute inflammatory reaction, which in Table–2 .1: Hand infections many cases progresses to suppuration. Without ea e effective treatment, the infection may spread to • Cellulitis adjacent tissue planes. • ymphangitis ACUTE PARONYCHIUM al e e aronychium is an infection of the nail fold. t is On the dorsum of the hand the commonest infection of the hand, and usually • Subcutaneous infection results from careless nail paring or use of unsterile • nfection deep to the aponeurosis manicure instruments. On the palmar aspect of the hand Clinical features: There is pain, tenderness, redness • Superficial aponeurotic infection • Deep aponeurotic infection and swelling at one or both sides of the nail • Thenar space infection fold, and at the base of the nail if suppuration • Mid-palmar space infection has extended deep to the nail. There is a mar ed tenderness on pressing the nail. Others • Apical space of finger infection • Terminal pulp space infection • Middle volar space infection • roximal volar space infection • Web space infection • Tenosynovitis • Space of arona s infection 2 .1 a a e a https://kat.cr/user/Blink99/

206 | Essential Orthopaedics reatment In its early stage, when no suppuration has occurred, conservative treatment may abort the infection. Once suppuration has occurred, the pus must be let out. For a mild infection, it is sufficient to raise the cuticle alone without incising, but better drainage is secured by vertical incision through the cuticle on one or both sides (Fig-24.1). When the pus extends beneath the nail, it is necessary to remove the proximal one-third of the nail for adequate drainage. omplications These are: (i) extension of the infection to the pulp space; and (ii) chronic 2 .3 Te al l a e paronychium. APICAL SUBUNGUAL INFECTION (Fig-24.3). At its proximal end, this space is closed by a septum of deep fascia connecting the distal GThis is an infection of the tissues between the nail flexor crease of the finger to the periosteum just distal to the insertion of the profundus flexor plate and the periosteum of the terminal phalanx. tendon. The digital artery, before it enters the space gives a branch to the epiphysis at the base of the Rt results from a pin-pric or splinter beneath the distal phalanx. On entering the space it divides into terminal branches. nail. The lesion is excruciatingly painful with little Clinical features: This is the second most common Vswelling. Tenderness is maximum just beneath the infection of the hand, commonly resulting from free edge of the nail. The pus comes to the surface a pin-pric . The index finger and the thumb are affected most often. The pulp is swollen, tense and dat the free edge of the nail. tender. A severe throbbing pain and excruciating itereatment In the early stage, the infection can tenderness suggest suppuration. be aborted by conservative treatment, but once reatment In its early stage, conservative treatment nsuppuration occurs, drainage is required. For may abort the infection. In the later stage, when suppuration has occurred, drainage is required. drainage, a small -shaped piece is removed This is achieved either by incising directly over the centre of the abscess where it is pointing, or Ufrom the centre of the free edge of the nail along by a lateral incision just in front of the plane of the terminal phalanx. with a little wedge of the full thickness of the skin omplications These are: (i) osteomyelitis of tahir99 -overlying the abscess (Fig-24.2). the terminal phalanx, often with necrosis and sequestration of its distal half. Thrombo-arteritis of the terminal branches of the digital vessels accounts 2 .2 al b al e for this. The basal plate of the epiphysis is rarely involved; (ii) pyogenic arthritis of the distal inter- omplications us may spread under the nail, and phalangeal joint; and (iii) very rarely, infection may lead to a chronic sinus. Occasionally, the tip spreads to the flexor tendon sheath (suppurative of the phalanx becomes infected. tenosynovitis). TERMINAL PULP SPACE INFECTION I L LA A I F I ( hitlo or Felon) urgical anatom The middle volar space extends urgical anatom The terminal pulp space is the volar from the proximal to the distal volar creases of the finger. t is filled with loosely pac ed fibro-fatty space of the distal digit. It is filled with compact tissue. fat, feebly partitioned by multiple fibrous septae

Clinical features: It commonly results from a Infections of the Hand | 207 pin-pric . ain, swelling, and tenderness are first one being between the thumb and the index maximally localised to this space. The finger is finger. ept in semi flexion. Frequently a purulent blister Clinical features: The infection arises: (i) from a s in appears in the distal flexor crease. n early cases, it may be difficult to distinguish this infection crac ; (ii) from a purulent blister on the forepart from infection of the underlying flexor tendon of the hand; or (iii) from a proximal volar space sheath. However, in the former, tenderness over infection which communicates with the web the proximal end of tendon sheath – at the base of space through the lumbrical canal (the canal that the finger, is lacking. carries the lumbrical tendon from the hand into the finger). n the early stage, before localisation reatment In the early stage, conservative treatment of infection occurs, there is oedema over back of the hand. Although, the condition is strongly is enough. In late stage, drainage of pus via suspected by the location of the tenderness, a a longitudinal incision on the lateral side is precise diagnosis is often difficult at this stage. performed. Once localisation has occurred, signs of web space infection manifest themselves. The swelling at omplications Infection may spread to the distal or the base of the finger becomes obvious. In severe cases, the finger immediately adjacent to the space the proximal volar spaces, into the inter-phalangeal is ‘separated’ because of the mechanical effect of joints, or into the synovial sheath of the flexor the abscess. Maximum tenderness is found in the tendons. web and on the volar surface of the base of the finger. I AL LA A I F I reatment In the early stage, conservative treatment urgical anatom This space is well partitioned from may abort the infection. In late stage, drainage of the middle volar space, but it communicates freely the pus is required. The web space abscess is with the corresponding web space. drained by a transverse incision on the palmar surface over the affected web space. Care needs Clinical features: t is usually a consequence of a pin- to be taken to deepen the incision cautiously until the subcutaneous fat is reached. Only a few pric . ain, swelling and tenderness are localised strands of palmar fascia need to be divided, and to the space. Often the swelling is asymmetrical if pus does not flow, it is sought with a probe or because of the concomitant involvement of the a dissector. The edges of the wound are cut away web space. so as to leave a diamond-shaped opening. When the abscess communicates with a dorsal pocket, reatment The abscess is drained by an incision a counter-incision is advisable on the dorsum of the hand. on the lateral side or at the point of maximum tenderness. A I F I urgical anatom The web space is the triangular space between the bases of adjacent fingers; the 2 . ee al a a e https://kat.cr/user/Blink99/

208 | Essential Orthopaedics omplications Spread of the infection to the the lac of fluctuation. A strong suspicion and a throbbing pain are indications of deep seated pus nearby spaces and tendon sheaths is a common requiring drainage. A needle aspiration may be complication. helpful in confirming the presence of pus. AL A A A central transverse incision is made in the line of An abscess beneath the palmar fascia is a serious the flexor crease, passing across the middle of the but rare infection of the hand. It may be an infection palm at the site of maximum tenderness. f pus is in the thenar* or mid-palmar space. encountered beneath the aponeurosis, the floor of urgical anatom The deep palmar spaces of the hand the abscess must be probed systematically for a sinus leading to a deeper plane. In order to ensure lie in the hollow of the palm, deep to the flexor free drainage of the pus, the skin edges as well as tendons and their synovial sheaths. The space is those of the palmar fascia are trimmed. divided into two halves – a medial half (the mid- palmar space), and a lateral half (the thenar space). omplications Spread of infection to nearby spaces The posterior relation of the space is formed by the fascia covering the interossei and metacarpal and tendon sheaths may occur. A chronic infection may result in a discharging sinus and stiffness of Gbones on the medial side, and the adductor pollicis the hand. muscle on the lateral side. On the two sides of A AI II Rthe space are the thenar and hypothenar muscles This is a rare but important infection because prompt treatment is essential if the function of the (Fig-24.4). finger is to be preserved. VClinical features: The infection can arise from a urgical anatom The flexor tendons of the hand dpenetrating wound, via the blood stream, or as a itecomplication of suppurative tenosynovitis. At an are covered with fibrous and synovial flexor sheaths (Fig-24.5). The fibrous sheaths exist only early stage, there is an intense throbbing pain, and up to the bases of the digits. A synovial sheath deep tenderness in the palm. There is only little lines the fibrous sheaths. In the thumb and little finger, the synovial lining extends proximally nswelling on the volar aspect of the palm; rather it through the palm and ends 2–3 cms above the wrist. The synovial sheaths of the index, middle is severe on the dorsum of the hand, sometimes Uso great as to give rise to what is called ‘frog -hand’. The fingers are ept flexed. xtension at the metacarpo-phalangeal joints is very painful, but painless at the inter-phalangeal joints. This 9distinguishes this condition from suppurative ir9tenosynovitis where there is pain on extending the metacarpo-phalangeal as well as inter-phalangeal joints. Regional lymphadenopathy is commonly hpresent. taAs tension within the space mounts, the normal concavity of the palm becomes flattened. Subsequently, the pus erodes through the palmar fascia and the intense pain eases off. The palm now becomes slightly convex, and it may be possible to elicit fluctuation only at this stage of the infection. reatment It is often difficult to diagnose deep 2 . le e ea palmar space infection in its early stages because and ring fingers end proximally at the level of the of its deep location. In some cases, treatment by conservative methods may abort the infection, but transverse palmar s in crease. The proximal part more often suppuration follows. The pus, being in a deeper plane, is difficult to detect because of of the sheath of the flexor tendon of the thumb is known as the radial bursa. The sheath of the little * Thenar space is not same as the space containing thenar muscles See finger tendons open proximally into the ulnar Fig. 26.4 bursa, which encloses the grouped tendons of the

flexor digitorum superficialis and flexor digitorum Infections of the Hand | 209 profundus. It should be noted that there is normal but great t is held semi-flexed, and active or passive anatomical variation in the arrangement of the extension at the inter-phalangeal joint is very synovial tendon sheaths. The ulnar and radial painful. In tenosynovitis of the little finger, the bursae may communicate. The tendon sheaths ulnar bursa also becomes involved, giving rise of the index, middle and ring fingers may to swelling of the palm and sometimes fullness communicate with the ulnar bursa. immediately above the flexor retinaculum. The area of maximum tenderness in an ulnar bursa Clinical features: The bacteria enter the tendon sheath infection can be elicited over that part of the bursa lying between the transverse palmar creases. with the point of a needle or other sharp objects This is Kanavel's sign (Fig-24. ). n infections of penetrating the tendon sheath. Exceptionally, the the radial bursa, there is more swelling over the sheath is infected by extension from the terminal thenar eminence and thumb. The other findings pulp space infection. are similar to other tendon sheath infections. The finger is swollen throughout its length, and is acutely tender over the flexor tendon sheath. reatment An aggressive conservative treatment is 2 . a a el started at an early stage. Clinical re-examinations are carried out every hours to assess improvement. Conservative treatment is continued only so long as there is good local and general response. Any delay in decompression leads to a spread of the infection proximally into the forearm. omplications These are: (i) permanent stiffness of the finger in semi-flexion because of necrosis of the tendons and adhesions between the tendon and the sheath; and (ii) spread of the infection to nearby structures such as the ulnar and radial bursae. e ea • reen D ( d.): Operative Hand Surgery, 2nd ed. Churchill ivingstone, 1 . What have we learnt? • and infections are of t o types uper cial and Deep. • arly surgical intervention is preferred. • tiffness is a common complication. Additional information: From the entrance exams point of view • elon most commonly affects the thumb. • anavel s sign is seen in tenosynovitis, it consists of eliciting tenderness on percussion over the exor tendon sheath of the nger, exion posture of ngers ith pain on hyprextension and uniform s elling involving the entire nger. https://kat.cr/user/Blink99/

25C H A P T E R ongenital alipes uino arus (CTEV) TOPICS • ele ant anatom • athoanatom • omenclature • linical features • Aetiolog • reatment RG‘Clubfoot’ is a rather vague term which has been Vused to describe a number of different abnormalitiesThe ligaments related to the aetiology of clubfoot din the shape of the foot, but over the years it hasare as follows (Fig-25.2): come to be synonymous with the commonest itecongenital foot deformity i.e., Congenital Talipes quino arus (CT ). t occurs once in every 1000 live births. nRELEVANT ANATOMY UThe joints of the foot relevant to understanding -of this chapter are: (i) the an le joint between the tibia and the talus; (ii) the subtalar joint between 9the talus and the calcaneum; (iii) the talo-navicular joint; and (iv) the calcaneo-cuboid joint (Fig-25.1). hir9 Fig-25.2 Ligaments of the foot ta • Deltoid ligament: This is the medial collateral ligament of the an le. t has a superficial and a deep component. • Spring ligament: This is a ligament which joins the anterior end of the calcaneum to the navicular. Fig-25.1 Joints of the foot • Interosseous ligament: This ligament is between the talus and calcaneum, joining their apposing For the purpose of description, the foot is often divided into hindfoot, midfoot and forefoot. The surfaces. hindfoot is the part comprising of talo-calcaneal • Capsular ligaments: The thic ened portions of (subtalar) and calcaneo-cuboid joints. Midfoot comprises of talo-navicular and naviculo-cuneiform the capsule of the talo-navicular, naviculo- joints. The forefoot is cuneiform-metatarsal and other joints beyond it. cuneiform, and cuneiform-metatarsal joints, termed as the capsular ligaments, are important structures in pathology of CT .

Congenital Talipes Equino Varus (CTEV) | 211 used to describe foot deformities (Fig-25.4). The following are some such terms: • Equinus: (derived from ‘equine’ i.e., a horse who wal s on toes). This is a deformity where the foot is fixed in plantar-flexion. • Calcaneus (reverse of equinus): This is a deformity where the foot is fixed in dorsiflexion. • Varus: The foot is inverted and adducted at the mid-tarsal joints so that the sole ‘faces’ inwards. Fig-25.3 Tendons on medial side of foot • Valgus: The foot is everted and abducted at the mid-tarsal joints so that the sole ‘faces’ outwards. • Plantar ligaments: These are ligaments extending from the plantar surface of the calcaneum to the • Cavus: The logitudinal arch of the foot is foot, giving rise to the longitudinal arch of the exaggerated. foot. • Planus: The longitudinal arch is flattened. Tendons related to the pathology of clubfoot are • Splay: The transverse arch is flattened. those on the medial side of the foot (Fig-25.3). The tendon immediately behind the medial malleolus nvariably, the foot has a combination of above is that of the tibialis posterior. More posteriorly mentioned deformities; the commonest being are the flexor digitorum longus tendon, posterior equino-varus. The next most common congenital tibial artery and nerve, and flexor hallucis longus foot deformity is calcaneo-valgus. tendon. The tibialis posterior tendon has its main insertion on the navicular. This is the most important AETIOLOGY muscle related to pathology of clubfoot. n the vast majority of cases, aetiology is not NOMENCLATURE nown, hence it is termed idiopathic. n others, the so called secondary clubfoot, some underlying Before discussing this topic further, it is wise to cause such as arthrogryposis multiplex congenita understand the meaning of the various terms (AMC) can be found. Idiopathic clubfoot Following are some of the theories proposed for the aetiology of idiopathic clubfoot: a) Mechanical theory: The raised intrauterine pressure forces the foot against the wall of the uterus in the position of the deformity. b) Ischaemic theory: schaemia of the calf muscles during intrauterine life, due to some un nown factor, results in contractures, leading to foot deformities. c) Genetic theory: Some genetically related disturbances in the development of the foot have been held responsible for the deformity. Fig-25.4 Types of foot deformities econdar clubfoot Following are some of the causes of secondary clubfoot: a) Paralytic disorders: n a case where there is a muscle imbalance i.e., the invertors and plantar flexors are stronger than the evertors and dorsiflexors, an equino-varus deformity will develop. This occurs in paralytic disorders such as polio, spina bifida, myelodysplasia and Freidreich’s ataxia. https://kat.cr/user/Blink99/

212 | Essential Orthopaedics b) Arthrogryposis multiplex congenita (AMC): the medial side. There are dimples on the lateral This is a disorder of defective development of aspect of the an le and midfoot. the muscles. The muscles are fibrotic and result in econdar changes These changes occur in the foot deformities, and deformities at other joints. foot if the child starts wal ing on the deformed PATHOANATOMY feet. Weight bearing exaggerates the deformity. Callosities and bursae develop over the bony All the tissues of the foot i.e., the bones, joints, prominences on the lateral side of the foot. ligaments and muscles have developmental abnormality. CLINICAL FEATURES ones Bones of the foot are smaller than normal. resenting complaints Though, the history dates bac ec of the talus is angulated so that the head of the to birth, a child with CT may present some time talus faces downwards and medially. Calcaneum after birth, often as late as adulthood. Following is small, and concave medially. Joints Deformities occur from the malpositioning are some of the common presentations: Gof different joints: a) Detected at birth: At places where delivery is conducted by trained medical personnel, CT • Equinus deformity occurs primarily at the an le is detected at the time of routine screening of newborns for congenital mal-formations. At Rjoint. Other tarsal joints also contribute to it. times, the deformity is very mild, the so-called postural equino-varus. • Inversion deformity occurs primarily at the b) Brought during early infancy: At places where Vsubtalar joint. The inverted calcaneum ta es the delivery is conducted at primary health centres, dwhole foot with it so that the sole faces medially. the child is generally brought to the hospital around the age of 3- wee s. • Forefoot adduction deformity occurs at the mid- c) Brought during late infancy and early itetarsal joints, mainly at talo-navicular joint. childhood: n these cases, the child has received treatment elsewhere, or the deformity • Forefoot cavus deformity is the result of excessive has recurred, or it has never been corrected. nfortunately, in developing countries, a large narching of the foot at the mid-tarsal joints. number of cases report to the hospital late. uscles and tendons Muscles of the calf are underde- d) Brought during late childhood: t is not Uveloped. As a result, the following muscles–tendon uncommon in developing countries to have a -units are contracted: grown up child, or sometimes an adult with • Posteriorly clubfoot, reporting to the hospital for the first time. gnorance, poverty and illiteracy are 9• Medially generally the reasons for such late presentations. ir9(3 muscles) - Tendoachilles - Tibialis posterior - Flexor digitorum longus - Flexor hallucis longus apsule and ligaments All the ligamentous structures on the postero-medial side of the foot are shortened. hFollowing are some of these structures: ta• Posterior osterior capsule of the (3 structures) an le joint EXAMINATION osterior capsule of the subtalar n addition to foot examination, a general joint osterior talo-fibular and examination should be carried out to detect associated malformations in other parts of the body. calcaneo-fibular ligaments • Medial Talo-navicular ligament Foot examination: ormally, the foot of a newborn (3 ligaments) Spring ligament child can be dorsiflexed until the dorsum touches Deltoid ligament the anterior aspect of the shin of the tibia (Fig- • Plantar 25.5). This is a good screening test for detecting lantar fascia the milder variety of clubfoot. The more classic one • Others lantar ligaments will have the following findings: nterosseous ligament between the talus and calcaneum kin The s in develops adaptive shortening on the • Bilateral foot deformity in 0 per cent cases. • Size of the foot smaller (in unilateral cases). medial side of the sole. There are deep creases on

Congenital Talipes Equino Varus (CTEV) | 213 Table 25-1: Terminology to describe clubfoot Type Description Supple Foot can be brought to normal position igid Foot deformities not correctable esistant Foot deformities not responding to manipulation and O casting eglected elapsed ot treated for 1 year ot corrected but recurred Fig-25.5 Foot of a newborn. It is possible to touch the dor- page 210. A patient of residual polio may present sum of the foot to the shin with equino-varus deformity, which may mimic clubfoot, but there will be paralysis of some other • Foot is in equinus, varus and adduction. This can part of the limb. resence of sensory deficit points be judged by the inability to bring the foot in to an underlying neurological cause. The presence the opposite direction. n late cases, in addition, of deformities at other joints indicate possible cavus of the foot may also be present. arthrogryposis multiplex congenita (AMC). • Heel is small in size; the calcaneum may be felt DIAGNOSIS with great difficulty. This is easy in cases presenting soon after birth. n those presenting late, secondary causes of • Deep skin creases on the bac of the heel and on talipes equino-varus deformity must be excluded the medial side of the sole. (Table–25.2). X-rays of the foot are done (antero- posterior and lateral) with the foot in whatever • Bony prominences felt on the lateral side of the corrected position possible. The talo-calcaneal foot, the head of the talus and lateral malleolus. angles*, in both, A and lateral views, in a normal foot are more than 35o, but in CT these are • Outer side of the foot is gently convex. There are reduced (Fig-25. ). -rays are used by some dimples on the outer aspect of the an le. Fig-25.6 X-rays showing reduced talo- On attempted correction, one can feel the tight calcaneal angles in clubfoot (normal 35o) structures posteriorly (tendoachilles) and plantar- wards (plantar fascia). * This is an angle between long axis of talus and calcaneum – also called as Kite's angle. Achild presenting late may have callosities over the lateral aspect of the foot. The calf muscles are wasted. Terminology to describe clubfoot in different presentations is as shown in Table-25.1. General examination: t is aimed at finding an underlying cause of the deformity as discussed on Table-25.2: Differences between primary and secondary club feet Differentiating features Primary clubfoot Secondary clubfoot resent since birth es Sometimes Side affected Bilateral common ( 0 ) nilateral common Foot size Much smaller ormal or small Heel size Small with fat ormal with fat S in Chubby, creases present Atrophic, creases absent eurological examination ssentially normal Motor and sensory loss present rognosis ood oor https://kat.cr/user/Blink99/

214 | Essential Orthopaedics as a method of baseline documentation of the by manipulation and o , beginning at the deformities and a method for assessment of age of 1 month. The deformities are corrected correction after treatment. sequentially. Adduction deformity is corrected fir t followed by inversion deformity and then TREATMENT equinus deformity. A below- nee plaster cast Principles of treatment: n principle, treatment is usually sufficient. The casts are changed consists of correction of the deformity, and its every 2 wee s, and are continued until it is maintenance. Correction can be achieved by non- possible to ‘overcorrect’ all the deformities. operative or operative methods. Maintenance is Once this happens, the foot is ept in a suitable continued until the foot (and its bones) grows to maintenance device (discussed subsequently). a reasonable size, so that the deformity does not By this method, correction is achieved in 30 recur. of cases, over a period of - months. The rest need surgical correction. METHODS OF CORRECTION OF DEFORMITY A deformity can be corrected by non-operative or • onsetti s philosophy: This philosophy is based on better understanding of the pathoanatomy Goperative methods. of the deformed foot. According to onsetti, the calcaneo-cuboid-navicular complex is internally Non-operative methods: Following are the non- rotated (adducted) under the plantarflexed ta- lus, Hence, the deformity can be corrected by Roperative methods of correcting deformities: bringing the complex bac under the talus by Va) Manipulation alone: n a newborn, the mother is gradually stretching the tight structures. This is done by putting thumb pressure over the talus taught to manipulate the foot after every feed. head (and not over calcaneo-cuboid joint as in Kite s method). By doing this, the calcaneo- dThe foot is dorsiflexed and everted as shown cuboid-navicular complex is externally ro- itein Fig-25.7. While manipulating, sufficient tated under the talar head. Treatment is started within 1st week of life. The cavus aspect of the pressure should be applied by the person so as deformity is corrected first, followed by the to blanch her own fingers. This pressure should adduction, then varus and lastly equinus. After every manipulation, an above- nee o cast nbe maintained for about 5 seconds, and this is is applied, which is changed every 5-7 days. t is usually possible to correct all components repeated several times, over a period of roughly of the deformity within wee s. The equinus deformity often remains undercorrected, and U5 minutes. Minor deformities are usually can be treated by percutaneous tenotomy of -corrected by this method alone. For major tendoachilles. The cut tendoachilles regener- ates spontaneously. deformities, further treatment by corrective 9plaster casts is required. b) Manipulation and PoP: n this method, the ir9surgeon manipulates the foot after sedating the child. The foot is then held in the corrected position with plaster casts. There are two hphilosophies of treatment of clubfoot: Kite s taand onsetti s. • Kite s philosophy: This has been a popular method for over 40 years. The foot is treated Operative methods: n more severe deformities, which are not corrected by conservative methods, or in those that recur, operative treatment is required. Soft tissue release operations may be sufficient in younger children (younger than 3 years), but bony operations are required in older children. The following operations are performed: Fig-25.7 Manipulation of a clubfoot a) Postero-medial soft tissue release (PMSTR): This operation consists of releasing the tight soft tissue structures (tendons, ligaments, capsule etc.) on the posterior and medial side of

Congenital Talipes Equino Varus (CTEV) | 215 Fig-25.8 Z-plasty of tendoachilles • For cavus alone a plantar release. c) Tendon transfers: n some cases, the tibialis the foot. This can be performed in younger children. n older children, an additional anterior and tibialis posterior (both invertors bony procedure is required. The following of the foot) may exert a deforming force against structures are generally released: the wea peronei (evertors). This muscle imbalance may be corrected by transfering the On The Posterior Side: tibialis anterior to the outer side of the foot, • engthening of the tendoachilles by where it acts as an everter. Minimum age for tendon transfers is 5 years. -plasty (Fig-25. ). d) Dwyer's osteotomy: This is an open-wedge • elease of posterior capsules of the an le osteotomy of the calcaneum, performed in and subtalar joints. Fig-25.9 Dwyer's osteotomy (open wedge) • elease of posterior talo-fibular and calcaneo- order to correct varus of the heel (Fig-25. ). fibular ligaments. Minimum age at which this operation can be performed is 3 years, as prior to this the On The Medial Side: calcaneum is mainly cartilaginous. Some prefer • engthening of 3 tendons* i.e., tibialis a closed-wedge osteotomy on the lateral side. e) Dilwyn Evan's procedure: This consists of a posterior, flexor digitorum longus and flexor thorough soft tissue release ( MST ) with hallucis longus. n addition, their contracted thic ened sheaths are excised. Fig-25.10 Dilwyn Evan's operation • elease of 3 ligaments i.e., talo-navicular calcaneo-cuboid fusion (Fig-25.10). t is used ligament, superficial part of the deltoid for a neglected or recurred clubfoot in children ligament and the spring ligament. between 4- years. With fusion of the calcaneo- cuboid joint, the lateral side of the foot does not • elease of 3 more structures is needed in severe cases. These are the interosseous talo- calcaneal ligament, capsules of the naviculo- cuneiform and cuneiform-first metatarsal joints. On The Plantar Side: • lantar fascia release. • elease of the short flexors of the toes (flexor digitorum brevis) and abductor hallucis from their origin on the calcaneum. b) Limited soft tissue release: n some cases, the foot remains partially corrected after conservative treatment, and only limited soft tissue release may be sufficient as shown below: • For equinus alone a posterior release • For adduction alone a medial release * For ease of remembering, a ‘rule of 3’makes it simple – 3 tendons, 3 ligaments and 3 more structures are released. https://kat.cr/user/Blink99/

216 | Essential Orthopaedics recurred after previous operation. A simpler technique based on above principles has been Fig-25.11 Wedge tarsectomy (Dorsolateral wedge) popularized by Dr. B.B. oshi from Bombay ( SS fixation). grow as much as the medial side, thus resulting in gradual correction of the deformity. METHODS OF MAINTENANCE OF THE CORRECTION f) Wedge tarsectomy: This consists of removing Correction once achieved, is maintained by the a wedge of bones from the mid-tarsal area following methods: (Fig-25.11). The wedge is cut with its base on the a) CTEV splints: These are splints made of plastic, dorso-lateral side. Once the wedge is removed the foot can be brought to normal (plantigrade) moulded in such a way that when tied with position. This operation is performed for straps, it eeps the foot in corrected position. neglected clubfeet between the age of -11 years. b) Denis-Brown splint (DB splint): This is a g) Triple arthrodesis: This consists of the fusion of three joints of the foot (subtalar, calcaneo- Fig-25.13 Denis Brown splint splint to hold the foot in the corrected position (Fig-25.13). t is used throughout the day before the child starts wal ing. Once he starts wal ing, a DB splint is used at night and CT shoes during the day. c) CTEV shoes: These are modified shoes, used once a child starts wal ing. The following modifications are made in the shoe (Fig-25.14): Fig-25.12 Triple arthrodesis Fig-25.14 CTEV shoes cuboid and talo-navicular), after ta ing suitable wedges to correct the deformity (Fig-25.12). t is performed after the age of 12 years, because before this the bones are cartilaginous and it is difficult to achieve fusion. Of the three, talo- navicular joint fusion is most difficult to achieve. h) Ilizarov's technique: sing the principles of lizarov s technique, different components of the deformity are corrected by gradual stretching, using an external fixator. Once correction is achieved, it is maintained by plaster casts. lizarov s technique is indicated in neglected clubfeet, and in those in which it has

Congenital Talipes Equino Varus (CTEV) | 217 Flow chart-25.1 Treatment plan for CTEV https://kat.cr/user/Blink99/

218 | Essential Orthopaedics b) A child whose deformities have recurred (recurrent clubfeet): This usually happens if • Straight inner border to prevent forefoot correction is not maintained. The fir t deformity adduction. to recur is the equinus. • Outer shoe raise to prevent foot inversion. c) A child who has presented late or has not been adequately treated (neglected clubfeet). • o heel to prevent equinus. Once corrected a clubfoot has to be maintained in These shoes are used until the child is 5 years the corrected position by the methods described old. earlier. A comprehensive plan of treatment for CT is shown in Flow chart-25.1. PLAN OF TREATMENT Most cases which are treated early, respond well to Further Reading non-operative methods. Operative methods may be indicated in the following cases: • Sharrard W W: Paediatric Orthopaedics and Fractures, 3rd edn. Oxford: Blac well, 1 3. a) A child who does not respond to non-operative treatment (resistant clubfeet): These feet are generally severely deformed, ‘chubby’ or associated with underlying arthrogryposis multiplex congenita (AMC). What have we learnt? • Idiopathic clubfoot is to be differentiated from secondary clubfoot, as the prognosis of the t o is different. • Treatment consists of manipulation and o , follo ed by maintenance in splints. onservative treatment is successful in most cases. • Different surgical procedures are indicated at different stages.

26C H A P T E R ongenital islocation of the ip and ther alformations TOPICS ) • ongenital dislocation of the hip ( • ther congenital malformations CONGENITAL DISLOCATION OF THE HIP (CDH) AETIOLOGY This is a spontaneous dislocation of the hip Aetiology is not well understood, but the following occurring before, during or shortly after birth. factors appear to be important: In western countries, it is one of the commonest congenital disorder. It is uncommon in India and a) Hereditary predisposition to joint laxity: some other Asian countries, probably because of Heredity related lax joints are predisposed to the culture of mother carrying the child on the side hip dislocation in some positions. of her waist with the hips of the child abducted (Fig-26.1). This position helps in reduction of b) Hormone induced joint laxity: CDH is 3-5 an unstable hip, which otherwise would have times more common in females. This may dislocated. The general term dysplastic hip is be due to the fact that the maternal relaxin sometimes used for these congenital malformations (a ligament relaxing hormone in the mother of the hip. during pregnancy) crosses the placental barrier to enter the foetus. If the hormonal Fig-26.1 Mother carrying a child by her side environment of the foetus is a female, relaxin acts on the foetus's joints in the same way as it does on those of the mother. This produces joint laxity, and thus dislocation. c) Breech malposition: The incidence of an unstable hip is about 10 times more in newborns with breech presentation than those with vertex presentation. It is possible that in breech presentation the foetal legs are pressed inside the uterus in such a way that if the hip ligaments are lax, dislocation may occur. PATHOLOGY Present evidence suggests that there are two distinct types of dysplastic hips; (i) those dislocated at birth (classic CDH); and (ii) those dislocatable after birth. The first are primarily due to a hereditary faulty development of the acetabulum, and are difficult to treat. The second are due to underlying joint laxity, https://kat.cr/user/Blink99/

220 | Essential Orthopaedics of the affected hip, or a clic everytime the hip is moved. with a precipitating factor causing the dislocation. • Older child: CDH may become apparent once Following changes are seen in a dislocated joint the child starts wal ing. arents notice that the (Fig-26.2): child wal s with a ‘peculiar gait’ though there is no pain. On examination a CDH may be found Fig-26.2 Pathology of CDH to be the underlying cause. • Femoral head is dislocated upwards and laterally; A I AI its epiphysis is small and ossifies late. A meticulous examination is the ey to the early diagnosis of CDH. There may be limitation of • Femoral nec is excessively anteverted. hip abduction, asymmetry of groin creases or an • Acetabulum is shallow, with a steep sloping roof. audible clic . hysical findings in a younger child • igamentum teres is hypertrophied. may be little, and diagnosis may only be possible • Fibro-cartilaginous labrum of the acetabulum by special tests designed to elicit instability. These are as follows: (limbus) may be folded into the cavity of the Barlow's test: The test has two parts. In the first acetabulum (inverted limbus). part, the surgeon faces the child's perineum. He • Capsule of the hip joint is stretched. grasps the upper part of each thigh, with his • Muscles around the hip, especially the adductors, fingers behind on the greater trochanter and undergo adaptive shortening. thumb in front. The child s nees are fully flexed and the hips flexed to a right angle (Fig-26.3). The DIAGNOSIS hip is now gently adducted. As this is being done, Diagnosis is easy in an older child; but may be gentle pressure is exerted by the examining hand very difficult in younger children, especially in a proximal direction while the thumb tries during infancy. This is because of subtle clinical to ‘push out’ the hip. As the femoral head rolls findings and difficulties in interpreting X-rays of over the posterior lip of the acetabulum, it may, these children. if dislocatable (but not, if dislocated) slip out of CLINICAL FEATURES the acetabulum. One feels an abnormal posterior CDH is more common in first born babies, more on the left, more common in females (M:F=1:5), Fig-26.3 Barlow's test bilateral in 20% cases. CDH may be detected at birth or soon after; sometimes not noticed until the child movement, appreciated by the fingers behind the starts walking. Following are the salient clinical greater trochanter. There may be a distinct ‘clun ’. features at different ages: If nothing happens, the hip may be normal or may • At birth: Routine screening of all newborns is already be dislocated; in the latter, second part of the test would be more relevant. necessary. The examining paediatrician may notice signs suggestive of a dislocated or a dis- locatable hip, as discussed subsequently. • Early childhood: Sometimes, the child is brought because the parents have noticed an asymmetry of creases of the groin, limitation of movements

Congenital Dislocation of the Hip and Other Malformations | 221 In the second part of the test, with the hips in 90o Fig-26.5 Galeazzi sign flexion and fully adducted, held as described above, thighs are gently abducted. The examiner's hand • The limb is short and slightly externally rotated. tries to pull the hips while the fingers on the greater There is lordosis of the lumbar spine. trochanter exert pressure in a forward direction, as if one is trying to put bac a dislocated hip. f the • Telescopy positive: In a case of a dislocated hip, hip is dislocated, either because of the first part of it will be possible to produce an up and down the test or if it was dislocated to start with, a ‘clun ’ piston-li e movement at the hip. This can be will be heard and felt, indicating reduction of the appreciated by feeling the movement of the dislocated hip. If nothing happens, the hip may greater trochanter under the fingers (details in be normal or it is an irreducible dislocation. In the Annexure-III). latter case, there will be limitation of hip abduction. In a normal hip, it is possible to abduct the hips till • A child with unilateral dislocation exhibits a the nee touches the couch. typical gait in which the body lurches to the affected side as the child bears weight on it Ortolani's test: This test is similar to the second part (Trendelenburg's gait). In a child with bilateral of Barlow s test. The hips and nees are held in a dislocation, there is alternate lurching on both flexed position and gradually abducted. A ‘clic of sides (waddling gait). entrance’ will be felt as the femoral head slips into the acetabulum from the position of dislocation. • Some hip pathologies mimic ing CDH are: Coxa vara, posterior hip dislocation and In an older child, the following findings may be paralytic hip dislocation and paralytic hip present: dislocation. • imitation of abduction of the hip. RADIOLOGICAL FEATURES • Asymmetrical thigh folds (Fig-2 .4). In a child below the age of 1 year, since the epiphysis of the femoral head is not ossified, it is difficult to diagnose a dislocated hip on plain X-rays (Fig- 26.6). Von Rosen's view may help. Ultrasound Fig-26.4 Asymmetrical thigh folds • Higher buttoc fold on the affected side. Fig-26.6 X-ray of the pelvis of an infant with • Galeazzi's sign: The level of the nees are CDH on the left. compared in a child lying with hip flexed to 70o (Note that the epiphysis on the affected side has not appeared yet) and nees flexed. There is a lowering of the nee on the affected side (Fig-26.5). • Ortolani's test may be positive. • Trendelenburg's test is positive: This test is performed in an older child. The child is as ed to stand on the affected side. The opposite ASIS (that of the normal side) dips down (details in Annexure-III). https://kat.cr/user/Blink99/

222 | Essential Orthopaedics great deal of force or if it fails, the hip is ept in traction for some time, and is progressively examination is useful in early diagnosis at birth. abducted. As this is done, it may be possible to In an older child, the following are the important reduce the femoral head easily under general X-ray findings: anaesthesia. An adductor tenotomy is often • Delayed appearance* of the ossification centre necessary in some cases to allow the hip to be fully abducted. of the head of the femur. d) Open reduction: This is indicated if closed • etarded development of the ossification centre reduction fails. Reasons of failure of closed reduction could be the presence of fibro-fatty of the head of the femur. tissue in the acetabulum or a fold of capsule and • Sloping acetabulum. acetabular labrum (inverted limbus) between • ateral and upward displacement of the the femoral head and the superior part of the acetabulum. In such situations, the hip is ossification centre of the femoral head. exposed, the soft tissues obstructing the head • A brea in Shenton's line (Fig-26.7). excised or released, and the head repositioned in the acetabulum. Fig-26.7 Diagrammatic representation of the X-ray, show- Maintenance of reduction: Once the hip has been ing break in Shenton's line reduced by closed or open methods, following methods may be used for maintaining the head A inside the acetabulum. Principles of treatment: Aim is to achieve reduction a) Plaster cast: A frog leg or Bachelor's cast of the head into the acetabulum, and maintain it (Fig-26.8). until the hip becomes clinically stable and a 'round' acetabulum covers the head. In most cases, it is Fig-26.8 Casts for CDH possible to reduce the hip by closed means; in some an open reduction is required. Once the head is b) Splint: Some form of splint such as Von Rosen's inside the acetabulum, in younger children, under splint (Fig-26.9). the mould-li e effect of the head, it develops into a round acetabulum. If reduction has been delayed Fig-26.9 e splint for more than 2 years, acetabular remodelling may not occur even after the head is reduced for a long time. Hence, in such cases, surgical reconstruction of the acetabulum may be required. Methods of reduction: Following methods of reduction may be used: a) Closed manipulation: It is sometimes possible in younger children to reduce the hip by gentle closed manipulation under general anaesthesia. b) In unilateral cases, reduction can be attempted till 10 years of age and till 8 years in bilateral cases c) Traction followed by closed manipulation: In cases where the manipulative reduction requires a * Normally, epiphysis of the head of the femur appears at 1 year of age.

Congenital Dislocation of the Hip and Other Malformations | 223 External splints can be removed once the is done at the sub-trochanteric region. The distal acetabulum develops to a round shape. The hip is fragment is realigned and the osteotomy fixed now mobilised, and ept under observation for a with a plate. period of 2-3 years for any recurrence. Acetabular reconstruction procedures: The Treatment plan: Treatment varies according to the available procedures are: age at which the patient presents. For convenience a) Salter's osteotomy: This is an osteotomy of the of discussion, this has been divided into four groups on the basis of age of the patient: iliac bone, above the acetabulum. The roof of the acetabulum is rotated with the fulcrum at • Birth to 6 months: The femoral head is reduced the pubic symphysis, so that the acetabulum into the acetabulum by closed manipulation, and becomes more horizontal, and thus covers the maintained with plaster cast or splint. head (Fig-26.10a). • 6 months to 6 years: It may be possible up to 2 Fig-26.10 Acetabular reconstruction procedures years to reduce the head into the acetabulum by closed methods. After 2 years, it is difficult b) Chiari's pelvic displacement osteotomy: The and also unwise to attempt closed reduction. iliac bone is divided almost transversely This is because, when the head has been out immediately above the acetabulum, and the for some time, the soft tissues around the hip lower fragment (bearing the acetabulum) is become tight. Such a hip, if reduced forcibly displaced medially. The margin of the upper into the acetabulum, develops avascular fragment provides additional depth to the necrosis of the femoral head. In these cases, acetabulum (Fig-26.10b). reduction is achieved by open methods, and an additional femoral shortening may be c) Pemberton's pericapsular osteotomy: A curved required. In older children, an acetabular osteotomy as shown in the (Fig-26.10c) is reconstruction may be performed at the same made. The roof of the acetabulum is deflected time or later. Salter's osteotomy is preferred downwards over the femoral head, with by most surgeons. the fulcrum at the triradiate cartilage of the acetabulum. • 6-10 years: The first point to be decided in children at this age is whether or not to treat the In some cases, reduction of the hip may be possible dislocation at all. No treatment may be indicated only in extreme abduction or internal rotation of for children with bilateral dislocations because the thigh. In such cases a varus derotation osteotomy of the following reasons: • The limp is less noticeable. • Although having some posture and gait abnormalities, these patients tend to live normal lives until their 40 s or 50 s. • esults of treatment are unpredictable and a series of operations may be required. • n unilateral cases, an attempt at open reduction with reconstruction of the acetabulum may be made. A derotation osteotomy is needed in most cases. • 11 years onwards: Indication for treatment in these patients is pain. If only one hip is affected, a total hip replacement may be practical once adulthood is reached. Sometimes, arthrodesis of the hip may be a reasonable choice. A general plan of treatment of a child with CDH is as shown in Flow chart-26.1. https://kat.cr/user/Blink99/

224 | Essential Orthopaedics Flow chart-26.1 Treatment plan for congenital dislocation of hip (CDH) I AL ALF A I 3. Hemivertebra: Growth of only one half of a vertebra resulting in congenital scoliosis. This TRUNK AND SPINE is common in the dorsal spine. 1. Klippel-Feil syndrome: Congenital short and 4. Block vertebra: The bodies of two vertebrae are stiff nec due to fused or deformed cervical joined together with no intervening disc space. vertebrae. This is common in the cervical spine. 2. Sprengel's shoulder: Failure of descent of the 5. Spondylolysis: A brea in the pars inter- scapula, which is developmentally a cervical articularis of one of the lumbar vertebra, appendage, i.e. congenital high scapula. commonly 5 (see page 285).

Congenital Dislocation of the Hip and Other Malformations | 225 6. Spondylolisthesis: Displacement of one 13. Polydactyly: More than five fingers; commonly vertebra over the one below it, because of an extra thumb. defective development, commonly 5 over S1 (see page 285). L LI 14. Congenital dislocation of the hip. 7. Diastematomyelia: A longitudinal fibrous or bony septum dividing the spinal canal. 15. Congenital coxa vara: educed femoral nec - shaft angle due to a developmental defect in the LI growth of the proximal femur (see page 323). 8. Phocomelia: ac of development of proximal 16. Congenital short femur: Failure of development part of the limb, the distal part being present of the proximal half of the femur resulting in (seal limb). severe shortening. 9. Absence of radius: The hand deviates to lateral side because of lac of normal support by the 17. Congenital pseudarthrosis of the tibia: A birth radius (radial club hand or manus valgus). 10. Congenital radio-ulnar synostosis: The forearm defect in the lower third of the tibia in children, bones are joined together at the proximal end, thus preventing forearm rotation. whereby a fracture in this region fails to unite. 11. Madelung's deformity: Defective growth of the distal radial epiphysis resulting in deformity of 18. T l b : Congenital deformed foot the distal end of the radius, and dislocation of the head of the ulna, dorsally. (see page 210). 12. Syndactyly: Webbing of two or more digits; the commonest being middle and ring fingers. 19. e al e al al eb : A vertically placed talus due to defective development (see page 326). Further Reading • Sharrard WJW: Paediatric Orthopaedics and Fractures, 3rd edn. Oxford: Blac well, 1 3. What have we learnt? • ongenital dilocation of the hip is uncommon in developing countries. • arly diagnosis by ultrasound at birth, is useful. • Aim of treatment is to put the dislocated head back in place, as soon as possible. • ate cases need surgery, hich essentially consists of reducing the head into acetabulum, and doing something to keep it there by reconstructing the acetabulum and or femur. Additional information: From the entrance exams point of view • The best diagnostic modality for DD is I. • creening for DD done by ultrasound. • ltrasound-guided aspiration is the best ay of differentiating septic arthritis and transient synovitis. • Investigation of choice to diagnose early erthe s disease is I. https://kat.cr/user/Blink99/

27C H A P T E R oliom elitis and ther euromuscular isorders TOPICS • isorders of the muscles • eripheral neuropathies • oliom elitis • erebral pals • pina bifida POLIOMYELITIS lead to permanent paralysis; while the others Poliomyelitis, commonly called polio, is an acute may regenerate, so that partial recovery of the infectious disease caused by the poliovirus. In the majority of cases, the infection may manifest paralysis may occur. It is this residual paralysis merely as an episode of diarrhoea; in others the virus may affect the anterior horn cells of the (called post-polio residual paralysis – ) which spinal cord and lead to extensive paralysis of the muscles. In extreme forms, the paralysis may is responsible for the host of problems associated involve the respiratory muscles, and may lead to death. with a paralytic limb (deformities, weakness etc.). AETIOPATHOLOGY CLINICAL FEATURES Presenting complaints: Often, the patient is a child The poliovirus enters the body either through around the age of 9 months. The mother gives the faeco-oral route or by inhalation of droplets. a history that the child developed mild pyrexia The infection occurs commonly in summer. associated with diarrhoea, followed by inability Paralysis may be precipitated after strenuous to move a part or whole of the limb. The lower physical activity, by an intramuscular injection or limbs are affected most commonly. Paralysis is of in a child on cortisone therapy. A tonsillectomy, varying severity and asymmetrical in distribution. adenoidectomy or tooth extraction predisposes to In extreme cases, the respiratory muscles may also paralysis during polio epidemics. be paralysed. Pathogenesis: The virus multiplies in the intestine. Often, the child is seen by a paediatrician in the From here it travels to the regional lymph nodes early stages. When he is referred to an orthopaedic and reticulo-endothelial structures, from where surgeon, the paralysis may already be on its it enters the blood circulation. If the defense mechanism of the body is poor, the virus reaches Fig-27.1 Stages of poliomyelitis. (a) Incubation period the nervous system (mainly the anterior horn (b) Pre-paralysis stage (c) Stage of maximum paralysis cells) via the blood or peripheral nerves. The (d) Stage of recovery (e) Post-polio residual paralysis neurons undergo varying degree of damage – some may permanently die, others may be only temporarily damaged, still others may undergo only functional impairment due to tissue oedema. The neurons, which are permanently damaged,

Poliomyelitis and Other Neuromuscular Disorders | 227 way to recovery. ecovery of power, if it occurs, of the hand are usually spared. The limb may may continue for a period of 2 years. Most of the become short. With time, the deformities recovery occurs within the first 6 months. Any become permanent due to contracture of the residual weakness persisting after 2 years is soft tissues and mal-development of the bones permanent, and will not recover. For descriptive in the deformed position. purposes, the disease is conveniently divided into five stages (Fig-27.1, page 226). IA I EXAMINATION A diagnosis of poliomyelitis should be considered in an endemic area if a child presents with pyrexia A patient of the paralytic polio may have the and acutely tender muscles. At this stage, the following features, on examination: poliomyelitis is usually confused with influenza, a) In the early stage, the child is febrile, often osteomyelitis, septic arthritis, scurvy etc. Once the paralysis sets in, other common conditions with rigidity of the neck and tender muscles. producing flaccid paralysis must be excluded. This may be associated with diffuse muscle Some of these are as follows: paralysis. The following are some of the typical features of a paralysis resulting from polio: • yogenic meningitis: A lumbar puncture may • t is asymmetric i.e., the involvement of the reveal the diagnosis. affected muscles is haphazard. • ost-diphtheritic paralysis. • t occurs commonly in the lower limbs • uillain Barre syndrome: This is to be consid- because the anterior horn cells of the lumbar ered if flaccid paralysis occurs later in life. In enlargement of the spinal cord are affected this syndrome, paralysis is symmetrical, and most often. facial nerve involvement occurs early. Complete • The muscle affected most commonly is the recovery usually occurs within 6 months. quadriceps, although in most cases it is only partially paralysed. In a patient presenting in the stage of residual • The muscle which most often undergoes paralysis, polio should be differentiated from complete paralysis is the tibialis anterior. other causes of flaccid paralysis. Some of these • The muscle in the hand affected most are myopathy, spina bifida, other spinal disorders commonly is the opponens pollicis. producing paralysis, and peripheral neuropathy • The motor paralysis is not associated with (Table–27.1). any sensory loss. • Bulbar or bulbo-spinal polio: This is a rare Table–2 .1: Differential diagnosis of post-polio but life threatening polio, where the motor paralysis neurons of the medulla are affected. This results in involvement of respiratory and • Poliomyelitis - Asymmetrical cardiovascular centres, and may cause death. - Lower motor neurone type • Myopathy - No sensory loss b) In late stage (PPRP), the paralysis may result - Improves with time, or is static in wasting, weakness, and deformities of the • pina ifida and limbs. The deformities result from imbalance other spinal - sually symmetrical, between muscles of opposite groups at a disorders follows a pattern joint, or due to the action of the gravity on the paralysed limb. The common deformity at • Neuropathy - Lower motor neurone type the hip is flexion-abduction-external rotation. - No sensory loss At the knee, flexion deformity is common; - Deteriorates with time in severe cases triple deformity comprising of flexion, posterior subluxation and external - sually symmetrical rotation occurs. At the foot, equino-varus - Motor+sensory loss deformity is the commonest; others being - Deteriorates with growth equino-valgus, calcaneo-valgus and calcaneo- carus, in that order. In the upper limbs, polio - sually bilateral, affects shoulder and elbow muscles. Muscles ‘ love and stoc ing’ pattern - Motor+sensory loss - May improve with treatment PROGNOSIS Of the total number of cases infected with the poliovirus, 50 per cent do not develop paralysis https://kat.cr/user/Blink99/

228 | Essential Orthopaedics • Prevention of deformity by proper splintage, and joint mobilising exercises. at all (non-paralytic polio). 40 per cent develop paralysis of a varying degree (mild, moderate, • Correction of the deformity that may have or severe). 10 per cent patients die because of already occurred (discussed in Chapter 11). respiratory muscle paralysis. Of the patients with paralytic polio, 33 per cent recover fully, 33 per • Retraining of muscles that are recovering by cent continue to have moderate paralysis, while exercises. Progress is judged by repeated another 33 per cent remain with severe paralysis. examination of the motor power of the paralysed limb (muscle charting). TREATMENT • Encourage walking with the help of appliances, Principles of treatment: Polio can be prevented wherever possible (Fig-27.2). by immunisation. It is important to immunise patients even after an attack of acute poliomyelitis. Fig-27.2 A caliper This is because there are three strains of the virus, and the patient could still get paralytic polio by d) Stage of residual paralysis: It is the stage where another strain. Once polio infection occurs, there more active orthopaedic treatment is required. is no specific treatment for it, and there is no way It consists of the following: of preventing the paralysis or limiting its severity. • Detailed evaluation of the patient: Most Whatever recovery from paralysis occurs is patients with residual polio ( ) wal spontaneous, and there is very little a doctor can with a limp, with or without calipers. An do to enhance the recovery. The role of a doctor assessment is made whether functional is: (i) to provide supportive treatment during the status of the patient can be improved. stage of paralysis or recovery; (ii) to prevent the For this, an evaluation of the deformities development of deformities during this period; and muscle wea ness is made. ait can and (iii) to use, in a more efficient way, whatever be improved by the use of a caliper or by muscles are functioning. The treatment appropriate operations. to each stage of the disease is best considered stage • Prevention or correction of deformities: The by stage. main emphasis is on prevention of defor- mity. This is done by splinting the paralysed a) Stage of onset: It is generally not possible to part in such a way that the effect of muscle diagnose polio at this stage. In an endemic imbalance and gravity is negated (details in area, if a child is suspected of having polio, Chapter-11). An operation may sometimes intramuscular injections and excessive physical be required to prevent the deformity. For activity should be avoided. example, in a foot with severe muscle imbalance between opposite group of b) Stage of maximum paralysis: In this stage, muscles, a tendon transfer operation is done. the child needs mainly supportive treatment. This produces a more ‘balanced’ foot, hence A close watch is kept for signs suggestive less possibility of deformity. Commonly of bulbar polio. These are signs of paralysis of the vagus nerve, causing weakness of the soft palate, pharynx and the vocal cords – hence problem in deglutition, and speech. A respirator may be necessary to save life if the respiratory muscles are paralysed. Paralytic limbs may have to be supported by splints to prevent the development of contractures. All the joints should be moved through the full range of motion several times a day. Muscle pain may be eased by applying hot packs. c) Stage of recovery: The patient should be kept under close supervision of a skilled physio- therapist. The principles of treatment during this stage are as follows:

performed operation for correction of Poliomyelitis and Other Neuromuscular Disorders | 229 deformities are as follows: clinical disorders, mostly arising in childhood. The • For hip deformity (flexion-abduction- essential features of all these disorders is a varying external rotation): Soutters’ release. degree of upper motor neurone type of limb paralysis (spasticity), together with difficulty in • For nee flexion deformity: Wilson’s coordination (ataxia) and purposeless movements release. (athetosis). • For equinus deformity of the an le: AETIOPATHOLOGY Tendoachilles lengthening. Birth anoxia and injuries are the commonest cause of CP in developing countries. Causes can • For cavus deformity of the foot: Steindler’s be divided into prenatal, natal and postnatal release. (Table–27.2). • Tendon transfers: The available muscle Table–2 .2: Causes of cerebral palsy power is redistributed either to equalise an unbalanced paralysis, or to use the motor • Prenatal causes Defective development power for a more useful function (see page • Natal causes Kernicterus 86). It is not done before 5 years of age, as • Postnatal causes the child has to be manageable enough to Birth anoxia* be taught proper exercises. More commonly Birth injury performed tendon transfers are as follows: ncephalitis • Transfer of extensor hallucis longus ( H ) Meningitis from the distal phalanx of great toe to Head injury the neck of the first metatarsal (modified Jone's operation). This is done to correct * The commonest first metatarsal drop in case of tibialis anterior muscle weakness. Pathology: The pathology of this disorder is the degeneration of the cerebral cortex or • Transfer of peronius tertious and brevis basal ganglion, either because of their faulty muscles (evertors of the foot) to the development or because of damage caused by the dorsum of the foot. The transfer is various factors given in Table–27.2. required in a foot with dorsiflexor weak- ness. vertors can be spared for more CLINICAL FEATURES useful function of dorsiflexion of the foot. Presenting complaints: The clinical features vary according to the severity of the lesion, the site of • Hamstring ( nee flexors) transfer to the the neurological deficit and the associated defects. quadriceps muscle to support a weak knee extensor. • Severity of lesion: The lesion may be mild in 20 per cent of cases, in which case the child may remain • Stabilisation of flail joints: Joints with such ambulatory without any help and may never severe muscle paralysis that the body loses require consultation. In the majority (almost 50 control over them are called flail joints. per cent of cases), the child requires help with Stabilisation of these joints is necessary for ambulation. The usual presentation is a child walking. This can be achieved by operative less than one year old, in whom the parents have or non-operative methods. Non-operative noticed a lack of control on the affected limb. methods consist of calipers, shoes etc. There is a delay in the deve-lopmental milestones Operative methods consist of fusion of the such as sitting up, standing or walking. In about joints (e.g., triple arthrodesis for stabilisation 30 per cent of cases, the involvement is severe, of the foot). and the child is bed-ridden. • Leg length equalisation: In cases where a leg is • Pattern of involvement: The pyramidal tracts are short by more than 4 cm, a leg lengthening involved in 65 per cent of cases, and they present procedure may be required. with spasticity, exaggerated reflexes etc. One or all the limbs may be involved. The commonest CEREBRAL PALSY (CP) pattern is a symmetrical spastic paresis of the This is defined as a non-progressive neuro-muscular disorder of cerebral origin. It includes a number of https://kat.cr/user/Blink99/

230 | Essential Orthopaedics adductors of the thigh. A number of other opera- tive procedures may be necessary for improving lower limbs, resulting in a tendency to flex and selective functions. adduct the hips (scissoring), to keep the knees Speech therapy and occupational therapy constitutes flexed and the feet in equinus. Less commonly, an important adjunct to the overall treatment of it may present as monoplegia, hemiplegia or the child. Mild cases can be looked after at home, quadriplegia. In the upper limb, there is typical but specialised residential schools are required for flexion of the wrist and fingers with adduction severely handicapped children. of the thumb and pronation of the forearm. In 35 per cent of cases, extra-pyramidal symptoms PROGNOSIS such as ataxia, athetoid movements, dystonia Complete cure is impossible since an essential part predominate. of the brain is destroyed and cannot be repaired or replaced. All that can be hoped for is improvement. • Associated defects: These consist of speech defect, Depending upon the severity of the underlying sensory defect, epilepsy, occular defects and damage, a child can be made independent enough mental retardation. About 50 per cent of the to earn his own living in due course. A child for- patients are severely mentally retarded, 25 per merly dependent on others for many daily activi- cent have moderate mental retardation and 25 ties may often become independent. This needs a per cent have borderline mental retardation. great amount of patience and perseverance on the part of the parents and attendants of the child. In EXAMINATION spite of all the treatment, there are a few in whom On examination, there may be weakness of worthwhile improvement cannot be gained. muscles, the distribution of which is variable. This leads to marked muscle imbalance, resulting I A IFI A in deformities. The joints are stiff because of spasticity; hence when a steady pressure is RELEVANT ANATOMY applied, the muscle relaxes and the deformity is The vertebral bodies develop from the mesoderm partially corrected. As the pressure is released, the around the notochord. From the centre of each spasm returns immediately. The tendon reflexes body extend two projections which grow around are exaggerated, and clonus may be present. the neural canal to form the vertebral arch (Fig- 27.3). The two halves of the arch fuse in the The patient exhibits a lack of voluntary control thoracic region, from where the fusion extends when asked to hold an object. As the patient tries up and down. Failure of fusion of these arches to move a single group of muscles, other groups gives rise to spina bifida. It is often associated contract at the same time (athetoid movements). with maldevelopment of the spinal cord and the Mental deficiency may be present. There may also membranes. be defective vision and impaired hearing. Fig-27.3 Development of vertebral column TREATMENT TYPES Principles of treatment: The aim of treatment is The defect varies in severity from a mere failure of to maintain and develop whatever physical and fusion of the spinous processes, to a bony defect mental capabilities the child has. It consists of: (i) orthopaedic treatment; and (ii) speech and occupational therapy. Orthopaedic treatment consists of the prevention and correction of deformities, and keeping the spasticity under check. Methods of controlling the spasticity are: (i) drugs – e.g., Diazepam, Beclofen; (ii) phenol nerve block; and (iii) neurectomy. Neu- rectomy may be required to control severe muscle spasm interfering with optimal rehabilitation. Obturator neurectomy is performed for spasm of

with a major aberration in the development of the Poliomyelitis and Other Neuromuscular Disorders | 231 neural elements. Accordingly, there are two main types of spina bifida: (i) spina bifida occulta; and Fig-27.4 Types of spina bifida (ii) spina bifida aperta. Commonest site: The dorso-lumbar spine is affected Spina bifida occulta: This is the mildest and the most commonly. There is a variable structural commonest. In this, the failure of the vertebral defect of closure of the embryonal neural tube arches to fuse results in bifid spinous processes of giving rise to the following (Fig-27.4): vertebrae. The following are some of the important a) Meningocele i.e., protrusion of meninges features: through a defect in the neural arch. This • Commonest site: This is common in the lumbo- contains only CSF. sacral spine; S1 being the commonest site. b) Meningomyelocele i.e., the protrusion of the meninges along with some neural elements • Externally, the skin may be normal or there may (normally developed spinal cord or cauda be tell tale signs in the form of a dimple in the equina). skin, a lipomatous mass, a dermal sinus or a tuft c) Syringomyelocele i.e., the central canal of the of hair. cord is dilated (syringomyelia), and the cord lies within the protruded meningeal sac • Neurological impairment is not related to the together with the nerves arising from it. severity of the bone defect. The commonest d) Myelocele: This results from an arrest in the manifestation of neurological involvement is development at the time of closure of the neural a muscle imbalance in the lower limbs with groove. An elliptical raw surface, representing selective muscle wasting. This leads to foot the ununited groove is seen. At the upper end deformities because of muscle imbalance; of this surface opens the central canal through common ones being equinovarus or cavus. The which CSF may be seen leaking. cause of neural impairment may be: (i) tethering With the exception of spina bifida occulta, myelocele of the cord to the undersurface of the skin by is the commonest type of spina bifida; though many a fibrous membrane (membrana reuniens); (ii) of these cases are stillborn. If the child is born alive, tethering of the cord to the filum terminale; (iii) death ensues within a few days from infection of bifid cord, transfixed with an antero-posterior the cord and meninges. The other types of spina bone bar (diastematomyelia); or (iv) defective neural development (myelodysplasia). Treatment: A symptomless patient, where the lesion is detected on an X-ray taken for some other problem, needs no treatment. Cases presenting with backache respond to physiotherapy. Cases presenting with a neurological deficit need to be evaluated regarding the cause and likelihood of worsening of the neurological deficit. M is the imaging modality of choice. Surgical treatment may be required in some cases. Orthopaedic treatment is the same as for a paralytic limb, i.e., (i) prevention and correction of deformities; (ii) using residual muscle power for more useful functions by tendon transfers and joint stabilisation; (iii) giving support for walking. Spina bifida aperta: This developmental defect involves not only the vertebral arches but also the overlying soft tissues, skin, and often the meninges. In severe cases, the nerve tube itself may be exposed. The following are some of the important features: https://kat.cr/user/Blink99/

232 | Essential Orthopaedics FI I I Myopathy is a generic term for somatic motor bifida with neural development defects where dysfunctions due to diseases of the skeletal muscles the patient often survives is meningocele and i.e., dysfunctions not otherwise attri–butable to meningomyelocele. There may be mild to severe lesions of the central nervous system, the lower paralysis of the lower limbs. These children are motor neurone (LMN) or the neuro-muscular often born with deformities, particularly flexion- junction (NMJ). adduction contracture of the hip, and deformities of the foot. These deformities are the direct result Myopathy may be inherited or acquired. The of muscle imbalance due to paralysis. There may underlying pathological process may be restricted be urinary and bowel incontinence. to the muscles or may affect other organ systems as well. In an inherited myopathy, the defect may be: (i) Treatment: Treatment of this condition consists of: abnormal cellular enzymes; (ii) abnormal structural (i) treatment of the basic defect i.e., spina bifida; (ii) proteins; or (iii) both. It is the inherited myopathy orthopaedic treatment to prevent and correct the with structural protein as its underlying defect, which deformities, and to use the residual motor power in is designated muscular dystrophy (Flow chart-27.1). It the best possible way; and (iii) urological treatment comprises of a group of heterogenous disorders that for bladder incontinence. share in common: (i) bilateral, usually symmetrical, topographically patterned loss of strength and I F L muscle wasting; (ii) progression over several years; and (iii) largely non-specific laboratory and These diseases are still incurable. Accurate histologic evidence of myofibril necrosis. One type diagnosis is important: (i) to rule out other of dystrophy is distinguishable from another type treatable disorders; (ii) to act as a guide to optimal by the following criteria: rehabilitation efforts; and (iii) to permit genetic counselling. Flow chart-27.1 Approach to a patient with motor dysfunction