K. Diego. Olivet College.
If these children are 8 years of age or older and have a dislocated hip with very severe acetabular defi- ciency generic 50mg amitriptyline visa, it may still be difficult to determine whether this is a missed DDH or a spastic hip disease generic 75mg amitriptyline mastercard. The principles outlined previously for the treatment of spastic hip disease do not work for DDH because the hip dislocation oc- curred much earlier and there is generally much less acetabulum present to reconstruct. It may be very difficult to tell the difference between DDH and spastic hip disease when the spastic hip dislocation occurs between the ages of 2 and 3 years and the children are seen at age 10 years. In this scenario, the spastic hip dislocation may mimic the DDH more closely. However, this condition should seldom happen because it would indicate children who really have not been receiving appropriate medical care. No child with spasticity should ever present with a dislocated hip at age 6, 7, or 8 years without having previous radiographs to verify when that hip dislocation oc- curred. Children should also seldom present at this age with a dislocated hip. It is much less common to have children with CP present with a dislocated hip than normal children with DDH because the ease of determining a spas- tic hip dislocation is much more clear, as it is always empirically obvious that these children have CP. Hip 635 Slipped Capital Femoral Epiphysis Slipped capital femoral epiphysis has never been reported in a spastic hip and we have never seen a slipped epiphysis in a spastic hip. We have seen one child who developed a slipped capital femoral epiphysis on the normal side. This boy had hemiplegia, was severely obese, and started complaining of pain on his normal side. The presence of coxa valga is probably protective of the slipped capital femoral epiphysis in the spastic hip, although even hips that have had a varus osteotomy have not had a slipped epiphysis. Perthes Disease in Children with Spasticity Perthes disease also has not been reported in children with spastic hips and we have seen only one case.
This position is the most functional position in ambulators and provides for consistency of the evalu- ation amitriptyline 25mg. Assessment of hip flexion should have the contralateral hip in relative extension to avoid having apparent hip flexion through the lumbar spine (Figure 3 discount amitriptyline 25 mg free shipping. Hip extension is measured in the prone position with the con- tralateral hip flexed over the end of the table, or in the supine position with the contralateral hip flexed to prevent pelvic motion (Figure 3. At the knee, the primary measure is the popliteal angle (Figure 3. The amount of fixed knee flexion contracture also needs to be measured and recorded. Ankle dorsiflexion with knee extension and with knee flexion are key measures in determining the source of equinus (Figure 3. The rotational alignment of the lower leg is best assessed in the prone position where the transmalleolar axis and the thigh–foot axis are measured (Figure 3. In the upper extremity, specific routine angle measurements have less direct impact on treatment decisions; therefore, the focus is on the functional problems encountered. Except for the basic measures of the hip, knee, and ankle, a large aspect of the physical examination of a child is directed at the spe- Figure 3. The child should be relaxed in cific functional impairments caused by the individual’s pattern of neurologic the supine position with the hips and knees involvement. The hip abduction is performed without much force, and the amount of each side is measured by palpating the iliac crest A to make sure that the pelvis is not rotating. Care is taken to measure each side hip ab- duction independent of the other side because tilting of the pelvis can mask significant sym- metry.
The ingrown nail usually occurs on the medial side of the hallux nail bed cheap amitriptyline 25mg mastercard, but it may involve either or both sides discount amitriptyline 75 mg mastercard. Also, there is a fa- milial tendency, as many parents also have had problems with ingrown toe- nails. Another cause of the symptomatic nails are trimming of the nails too far proximally at the borders, especially on the medial side. Some parents reason that the cause of the soreness is due to the nail corner causing an inflammation and, therefore, they try to trim the nail back even further. All this trimming does is cause more irritation, as the sharp nail corner only irritates the skin further and causes granulation tissue hypertrophy. Treatment When the nail has an acute infection and inflammation, the foot should be soaked in salt water or Betadine solution for 20 minutes daily, then well dried. If cellulitis is present, broad-spectrum oral antibiotics for 5 days are indicated. If this acute inflammation does not respond in 2 weeks, an acute lateral nail bed and nail matrix resection is required. It is usually best not to do the re- section when acute inflammation with purulent drainage is present; however, in a few situations, it is very difficult to clear these inflammatory symptoms, and the operative procedure can be safely done in the acute phase. If children have several bouts of acute inflammation of the nail bed, the lateral nail, nail bed, and nail matrix should be resected as a wedge to the depth of the distal phalanx. One or two loose sutures are used to close the area of the wedge resection. Both the medial and lateral border of the nail should be done at the same time if indicated by the presence of a history of inflam- matory changes or nail deformity. A very common problem in children with CP is decreased control of blood Blue Feet: Sympathetic Vascular Dysfunction flow, which is seen when the limb becomes very cold and cyanotic appearing (A). Some A very common problem in children and adolescents with CP, especially in feet may be very mottled in appearance (B).
