By R. Pyran. Olivet College.

The The knee is less frequently affected than the hip in con- rheumatoid factors have greater prognostic rather than nection with juvenile rheumatoid arthritis discount prinivil 10mg overnight delivery, which is dis- diagnostic value prinivil 10mg fast delivery. The hip is involved in The most important differential diagnosis is an effu- around 9% of cases, but precise figures are not avail- sion or hematoma after trauma. Spontane- Juvenile rheumatoid arthritis of the knee is relatively easy ous effusions (hematomas) also occur (without relevant to diagnose. If a chronic effusion occurs without a his- trauma) in: tory of trauma and persists for more than a month, this osteochondrosis dissecans ( Chapter 3. If a knee effusion without a traumatic cause is diag- nosed, the other large joints must always be examined as The first four conditions on this list can be diagnosed by well. Around half of the cases of juvenile arthritis occur- careful history-taking, clinical examination, an x-ray and ring in the knee are mono- or pauciarticular, while the possibly routine laboratory tests. No long-term effect, however, is achievable for the progressive form of the condition. Correction of the flexion contracture (with the ring fixator Ilizarov apparatus or Taylor Spatial Frame) The principle of this treatment is discussed in chap- ter 3. This treatment can be successfully employed even for severe flexion contractures and very advanced arthroses [1, 2]. The permanent flexion position of the knee hinders walking so much that the actual ability to walk at all is jeopardized even if the hips and ankles are only slightly affected. While the Ilizarov apparatus can produce permanent extension, one should not expect the ⊡ Fig. AP x-rays of both knees of 14-year old female patient full range of movement to be restored by this treatment.

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The facial asymmetry is not just present as a primary sign discount 5mg prinivil, but can also develop secondarily or become Clinical features order 10mg prinivil with mastercard, diagnosis exacerbated if the torticollis persists for a prolonged Congenital muscular torticollis can be diagnosed on the period. Furthermore, the patient’s brain becomes basis of purely clinical criteria. On palpation of the con- accustomed to the oblique position, which is even- tracted sternocleidomastoid muscle, the doctor can fre- tually sensed as »straight« by the child itself. In such quently feel a lump or a kind of tumor, generally in the cases, the corrected, objectively straight, position is distal part of this muscle. The infant’s head is inclined towards the side of the contracted muscle, turned towards the opposite side and almost in- Differential diagnosis variably shows asymmetry of varying degree, otherwise The most important differential diagnosis is the Klippel- known as plagiocephaly. Contracture of the sternocleidomastoid muscle in an 8-year old girl (a), particularly affecting the clavicular part. This tenses a especially during rotation to the opposite side (b) 119 3 3. Therapeutic measures in- clude chiropractic manipulations, heat treatments, muscle relaxants and physiotherapy. Associated conditions As mentioned above, congenital muscular torticollis is as- sociated with a hip dysplasia or clubfoot in almost a third of cases. Congenital muscular torticollis is also part of the prune belly syndrome, which is characterized by a defi- cient abdominal wall, cryptorchism, renal malformations, congenital torticollis and frequently associated with hip ⊡ Fig. Secondary asymmetry of the atlas in congenital muscular dysplasia, clubfoot or vertical talus. An os odontoideum is also present as a secondary finding Treatment, prognosis The following options are available for the treatment of congenital muscular torticollis: ▬ physical therapy, of the cervical spine, which can be relatively discreet, as orthoses (cervical collar), found for example in the form of a unilateral dysplasia plaster fixation, of the joint surfaces of the axis. Another di- Conservative treatment agnosis to be differentiated is paroxysmal torticollis (also Conservative treatment for the neonate consists of phys- known as Grisel syndrome) [6, 10]. This rare condition iotherapy, the aim of which is to stretch the shortened particularly affects small children and manifests itself in sternocleidomastoid muscle.

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Physical abuse Physical abuse victims are commonly young children with 80% of reported inci- 7 dences involving children under the age of 2 years 5mg prinivil free shipping. The sex of the child does not appear to affect the likelihood of physical abuse but other risk factors have been identified and these are summarised in Box 9 prinivil 2.5 mg without prescription. Role of imaging Non-accidental injury (NAI) frequently presents via the Accident and Emergency department as either an occult injury or as a raised clinical suspicion due to unclear and inappropriate history or other suspicious signs7 (see Box 9. Physical injury: The actual or likely physical injury to a child, or failure to prevent physical injury (or suffering) to a child including deliberate poisoning, suffocation and Munchausen’s syndrome by proxy. Sexual abuse: The actual or likely sexual exploitation of a child or adolescent. Emotional abuse: The actual or likely adverse effect on the emotional and behav- ioural development of a child caused by persistent or severe emotional ill treat- ment or rejection. Neglect: The persistent or severe neglect of a child, or the failure to protect a child from exposure to any kind of danger, including cold and starvation, or extreme failure to carry out important aspects of care, resulting in the significant impairment of the child’s health or development, including non-organic failure to thrive. Parental pressure Premature baby/serious neonatal illness Handicapped child Failure to bond with baby/child Fretful/crying baby – difficult to console Environmental factors Young, immature/inexperienced parents Social deprivation/drug and alcohol abuse Lack of good parenting models (persistent cycle of abuse) Box 9. The role of imaging in the examination of NAI is: To demonstrate and date clinically suspected fractures To demonstrate and date clinically occult fractures8 194 Paediatric Radiography The skeletal survey is the main plain film examination undertaken when NAI is suspected but it is only appropriate for the examination of children under 2 years of age. Above this age, the use of alternative imaging strategies (MRI or scintigraphy) combined with confirmatory radiographic examination or selec- tive radiography of clinically suspicious regions is more appropriate8,9. Imaging requests for NAI skeletal surveys should only be accepted from a paediatric con- sultant, preferably following discussion with a radiologist10 as there is a large amount of inter-reliance between clinical and radiological evidence in the diag- nosis of NAI5. The skeletal survey examination should be performed during normal working hours when the appropriate radiological expertise is available as this will prevent any unnecessary delay in the reporting of the examination or the recall of patients for additional projections. Each clinical department should have a skeletal survey protocol for use in cases of suspected physical abuse and, although the purpose of the skeletal survey is always to identify suggestive and occult skeletal injuries in order to confirm a suspected NAI diagnosis, the number and type of radi- ographic projections undertaken as part of the survey are not consistent between hospitals within the UK. This local variation may be as a result of radiologist preference, research evidence or traditional practice, but whatever the reason for the inclusion or exclusion of projections, it is important to ensure that the benefit to the patient from the examination outweighs the detriment/harm of exposure to radiation.