1. By: Aamir Rauf Memon
1st Year DPT Student
1

2. INTRODUCTION
―Deformity is the malformation of any component of
the body‖.
 The malformation my be the result of bony distortion
or alteration in the topography of soft tissues.
 The deformity could lead to an impairment or even
functional loss along with cosmetic disfigurement.
2

3. TYPES OF DEFORMITY
There are two types of deformity:
1. Congenital.
2. Acquired.
3

4. Congenital Deformity
Incorrect position in the uterus, abnormal
development due to a combination of genetic and
acquired factors are the principal causes of
congenital deformity.
The congenital deformity may or may not be
hereditary.
4

5. Acquired Deformity
The acquired deformity is that which was not
present at birth, and has developed after birth.
It can be produced as a result of following causes:
1. Bone disease
2. Joint diseases
3. Muscular causes: They are of following types:
5

6. Acquired Deformities cont….
a)Muscle Paralysis
b)Muscle spasticity
c)Muscular disease
d)Shortening of musculo-tendinous complex
4. Trauma
5. Postural causes
6. Nerve lesions
6

7. Classification of the Degree of Deformity
A deformity is classified into the following three
grades:
1. First degree: The deformity is mild and can be
corrected by passive stretching.
2. Second degree: Shortening in the soft tissues
prevents full passive correction of the
deformity. Attempted passive correction results
in pain. Slight degree of bony changes may be
present.
3. Third degree: The deformity is rigid and can‘t
be corrected by passive manoeuvres. It may be
associated with bony changes.
7

8. Congenital Deformities
Shoulder Joint
1.Sprangel’s shoulder: Also called ―high scapula‖.
It is characterized by an abnormally raised scapula, on one or both
sides. The eliology is unknown. The scapular muscles are poorly
developed and may be represented by fibrous bands. It may be
accompanied by scoliosis(thoracic curve) with convexity on the
involved side. The movement of scapula is markedly limited due to
fibrous bands or a bony bar resulting in the limitation of shoulder
abduction and elevation.
8

9. Elbow Joint
1.Congenital Dislocation: This may be
anterior or posterior and is usually bilateral. The
patient may notice the lump, which is easily palpable
and can be felt to move when the forearm is rotated. X-
rays show that the dislocated radial head is dome-
shaped(due to abnormal modeling).
Function is usually surprisingly good and pain is
unusual. Surgery is therefore rarely required;
however, if the lump limits elbow flexion it can be
excised.
9

10. 2. Congenital Synostosis: Congenital
deficiencies of the forearm bones are occasionally
associated with fusion of the humerus to the radius
or ulna. This disabling condition is fortunately very
rare. A more useful angle can be achieved by
osteotomy.
Proximal radio-ulnar synostosis causes loss of
rotation, but elbow flexion is retained and the
inconvenience is often only moderate.
10

11. 3. Dislocation of the Radial Head: Rare (familial) and
often associated with other abnormalities. Associated with congenital
below elbow amputation (hemimelia),arthrogryposis, Ehlers-Danlos
syndrome.
May be anterior or posterior and is usually bilateral
The patients usually notice a lump which moves on rotation of the
forearm
X-Rays show the dislocated radial head is dome shaped.
Treatment:
If the lump limits elbow flexion it can be excised
Congenital subluxation of the radial head is usually lateral and
commonly associated with a wide variety of bone dysplasias
11

12. Wrist Joint
1. Carpal fusions: Coalition of one or more carpal bones
is one of the commonest congenital wrist abnormalities; it is usually
inherited or an autosomal dominant trait and may be bilateral. Often
it is associated with other abnormalities. It seldom causes problem
and no treatment is necessary.
12

13. 2. Transverse Absence: The commonest
site of transverse absence in the upper limb is at
the junction of the middle and the upper one
third of the forearm. A static prosthesis is fitted
at 6 months. If facilities are available, it is
replaced at 18 months by a split hook operated by
a cord from the outer shoulder, and at about 3
years by a myoelectric prosthesis.
13

14. 3. Radial Longitudinal Deficiency(Radial Club
Hand): The infant is born with the wrist in marked radial deviation-
hence the name ―club hand‖. Bilateral deformity is more common than
unilateral. There is absence of the whole or part of the radius; often the
thumb,scaphoid and trapezium fail to develop normally. It usually occurs as
an isolated abnormality but is occasionally associated with other conditions
such as thrombocytopaenia and absent radius(TAR),Fanconi anaemia, atrial
septal defect(Holt-Oram syndrome) or the VATER syndrome(Vertebral
defects, anal atresia , Tracheal-Esophageal fistula, renal and Radial
dysplasia).
Treatment in the neonate consists of gentle manipulation and splintage.
14

15. 4. Ulnar Longitudinal Deficiency: In this
rare deformity ulnar deviation is present at birth and
is due to partial or complete absence of ulna; in
addition the ulnar rays of the hand may be missing.
As the child grows the radial head may dislocate.
Treatment consists of stretching and splintage
during the first few months.
15

16. 5. Distal Ulnar Dysplasia: In older children with
hereditary multiple exostoses there is often disproportionate
shortening of the ulna ; its distal end becomes carrot-shaped and the
radius is bowed. The same deformity is sometimes seen in
dyschondroplasia, and occasionally without any obvious bone
disease.
Treatment is seldom necessary. If deformity is marked, ulnar
lengthening with or without osteotomy of the radius) may be
advisable.
16

17. 6.Madelung’s Deformity: In this deformity the
lower radius curves forwards, carrying with it the carpus and the hand but
leaving the lower ulna sticking out as a lump on the back of the wrist. It may
be congenital or post-traumatic. The congenital disorder may appear as an
isolated entity or as part of a generalized dysplasia; although the
abnormality is present at birth, the deformity is rarely seen before the age of
10 years, after which it increases until growth is complete. Function is
usually excellent.
Treatment: If deformity is severe the lower end of the ulna may be
excised(Darrach‘s procedure), this is sometimes combined with osteotomy of
the radius.
17

18. 7. Arthrogryposis Multiplex
Congenita: Multiple, non-progressive joint contractures are
noted at birth. The cause is unknown; there is an underlying
neuropathy or myopathy. The limbs appear atrophic, with waxy skin
lacking normal joint creases. The elbows are extended, the wrists
flexed and ulnar deviated, the thumb adducted and clasped, and the
fingers flexed.
Treatment is difficult. Serial splintage is started soon after birth;
however, correction is often inadequate.
18

19. Congenital Variations
The hand and foot are much the commonest sites of
congenital variations in the musculoskeletal system;
the incidence is at least one in 1000 live births. The
cause may be an inherited genetic defect, a
chromosome disorder or an embryonal insult due to
viral infection, nuclear radiation or harmful drug
administration during the first 2 months of
pregnancy.
The clinical disorders are conventionally divided into
7 groups.
19

20. TYPE EXAMPLE
Failure of formation Transverse absence
Longitudinal absence- radial
(radial club hand)
Longitudinal absence-ulnar
(ulnar club hand)
Longitudinal absence-central
(typical cleft hand)
Failure of differentiation Syndactyly
Symphalangism
Camptodactyly
Flexed Thumb
Arthrogrypois
Duplication Thumb duplication
Overgrowth Macrodactyly
Undergrowth Thumb hypoplasia
Constriction ring syndrome Simple rings
Generalized skeletal abnormalities Marfan‘s, Turner‘s, Down‘s etc.
20

21. Failure of Formation
The upper limb can fail to develop either
transversely or longitudinally.
Transverse Failure: It may occur at any
level, the commonest being the proximal third of the
fore arm. Absence of parts of the
fingers(symbrachydactyly) can be managed by non-
vascularized bone transfer or microvascular transfer
of a toe, or by simply fitting a prosthesis.
21

22. Longitudinal Failure: The deficiency can be
radial, ulnar or central.
1. Radial longitudinal deficiency(Radial club hand):
There is partial or complete absence of the thumb and/or
radius; the typical deformity is one of marked radial deviation
of the wrist and hand. In some cases the humerus is fused with
ulna.
2. Ulnar longitudinal deficiency(Ulnar club hand):
This is much rarer than radial club hand. Digits are absent
from the ulnar side of the hand and the remaining digits are
often syndactylized. The elbow is frequently unstable or stiff.
The condition is associated with skeletal defects such as fibular
hemimelia rather than the visceral defects which frequently
accompany a radial longitudinal deficiency.
treatment includes syndactyly release, excision of soft tissue
tether(anlage) and stabilization of the elbow.
22

23. 3. Central longitudinal deficiency(Cleft hand):
This is usually present as a familiar disorder.
Typically, the second, third and fourth rays are
affected. The condition is bilateral and the feet are
often involved. The appearance ranges from a simple
cleft, with only the middle ray missing, to absence of
all three central rays(unkindly described as a ‗lobster
claw‘).
23

24. Failure of differentiation
1. Syndactyly(congenital webbing): It is the most
common congenital variation in the hand. It may be simple(skin
only) or complex(skin and bone). With acrosyndactyly, only the tips
are joined.
2. Camptodactyly: It is a flexion deformity of the proximal
interphalangeal joint(usually of the little finger). It is hereditary and
often bilateral, but deformity is rarely obvious before the age of 10
years. A normal distal interphalangeal joint distinguishes it from a
boutonniere deformity.
24

25. 3. Kirner’s deformity: It is not congenital but is
mentioned here as it could otherwise be mistaken for
camptodactyly or clinodactyly. Presenting in
adolescence, the distal phalanx(yet again the little
finger) becomes swollen and curved. Treatment is
with splintage and occasionally osteotomy.
4. Hereditary symphalangism: It describes
cognitive stiffness of the proximal interphalangeal
joint. The whole finger is small, shiny and stiff.
Motion can not be restored with surgery.
25

26. 5. Arthrogryposis: It is a condition in which there is severe
muscle weakness caused by an intrinsic abnormality of the
motor nerves and muscle. The joint are stiff and contracted.
The overlying skin is smooth, without flexion creases. There
may be a single abnormality, such as pronated forearm, flexed
wrist and clasped thumb, or the whole limb may be involved.
Treatment includes splintage, tendon transfers and arthidesis.
6. Congenital clasped thumb: It is due to weak or absent
extensor tendons(and contractures of the MCP and CMC joints
in severe cases). Simple extensor tendon weakness may
respond to splintage in extension for a few months; if this fails;
an extensor tendon transfer is needed.
The condition must be distinguished from a ‘congenital’
trigger thumb, which is due to stenosing tenovaginitis of the
flexor pollicis longus.
26

27. Duplication
1.Polydactyly(extra digits): It is nearly as
common as syndactyly. An extra little finger is
usually inherited and other variations may be
present. By contrast, an extra thumb is usually
sporadic. An extra central digit, the rarest of the
duplication, is often associated with syndactyly and
disorganization of the skeleton.
Extra skin tags can be simply excised.
27

28. Overgrowth
1.Macrodactyly: It has a neurogenic cause. The giant finger is
stiff and unsightly, but attempts at operative reduction are fraught
with complications. The finger can not be made normal; several
attempts may be made to reduce the size, each leaving the finger
increasingly stiff and scarred.
28

29. Undergrowth
The thumb is most commonly affected, the defect
ranging from a slightly small digit to complete
aplasia. The most severe forms need a pollicization to
provide a post to oppose against the fingers; less
severer forms may need a web space release,
stabilization of the MCP joint, correction of
abnormal tendons and a muscle transfer to provide
opposition.
29

30. Constriction Bands
These may occur in any part of the limb. The
consequences range from complete amputation to an
obvious circumferential constriction with a viable
distal part. The latter is treated by multiple Z-pasties.
30

31. Generalized Skeletal
Abnormalities
Generalized skeletal disorders often involve the hand,
e.g. Marfan‘s syndrome(‗spider hand‘),
achondroplasia(‗trident hand‘) and Down‘s
syndrome(short little finger, often curved).
31

32. Neck Region
1.Torticollis(wry neck): This is description rather
than a diagnosis. The chin is twisted upwards towards one
side. There are many causes. The condition may be either
congenital or acquired.
Infantile(congenital) torticollis: This condition is
common. The sternomastoid muscle on one side is fibrous and fails to
elongate as the child grows; consequently, progressive deformity
develops. The cause is unknown; the muscle may have suffered
ischaemia from a distorted position in utero(the association with
breech presentation and hip dysplasia is supporting evidence), or it
may have been injured at birth.
A history of difficult labour or breech birth is common. Deformity
does not become apparent until the child is 1-2 years old. The head is
tilted on one side, so that the ear approaches shoulder; the
sternomastoid on that side may feel tight and hard. There may also be
asymmetrical development of the face(plagiocephaly). These features
become increasingly obvious as the child grows.
32

33. Secondary Torticollis: Childhood torticollis may be
secondary to congenital bone anomalies, atlantoaxial rotatory
displacement, infection(lymphadentitis, retropharyngeal
abscess, tonsillitis, discitis, tuberculosis), trauma, juvenile
rheumatoid arthritis, posterior fossa tumours, dystonia(benign
paroxysmal torticollis) or ocular dysfunction.
Atlantoaxial Rotatory Displacement: The aetiology of this condition
is unclear, but it is thought to be due to muscle spasm resulting from
inflammation of the atlantoaxial region. There may be a history of
trauma of upper RTI. The child presents with a painful wry neck.
33

34. Vertebral Anomalies: There are many anomalies and
most are very rare. Three are described here:
1. Klippel-Feil syndrome(cervical-vertebral
synostosis):
This developmental disorder represents a failure of segmentation of the
cervical somites; it is often associated with abnormalities in the genito-
urinary, nervous or cardiovascular system. Some children have a hearing
impediment.
Children with synostosis have a characteristic appearance: the neck is short
or non-existent and there may be webbing; the hairline is low; and neck
movements are limited. About one in three children with Klippel-Feil
syndrome also has Sprengel‘s deformity of the scapula. Scoliosis is present in
about 60% and rib anomalies in about 30%. Hand deformities such as
syndactyly, thumb hypoplasia and extra digits are also present. X-rays reveal
fusion of two or more cervical vertebrae.
34

35. 2. Basilar Impression: In this condition the floor of the
skull is indented by the upper cervical spine. The
odontoid can impinge upon the brain stem. The cause is
either a primary bone abnormality(associated with other
bone defects such as odontoid abnormalities, Morquio
syndrome and Klippel-Feil syndrome) or secondary to
softening of the bones(osteomalacia, rickets rheumatoid
arthritis, neurofibromatosis etc). The patients may
present-often in the second or third decade-with
symptoms of raised intracranial pressure(because the
aqueduct of Sylvius becomes blocked), weakness and
paraesthesia of the limbs(because of direct compression
or ischaemia of the cord).
Treatment involves surgical decompression and
stabilization.
35

36. 3. Odontoid Anomalies: The odontoid may be
absent or hypoplastic, or there may be a separate
ossicle(the os odontoideum). The anomaly should be
suspected(and looked for even if the child does not
complain) in skeletal dysplasias which involve the
spine. This is especially important in patients
undergoing operation; the atlantoaxial joint may
subluxate under anaesthesia. In the majority of cases
the anomaly is discovered by chance in a routine
cervical spine X-rays following trauma. Open-mouth
radiographs show the abnormality; lateral
flexion/extension views may show instability of the
C1-C2 articulation.
36

37. 4.Bifid rib: A bifid rib or bifurcated rib or
sternum bifidum is a congenital deformity occurring in
about 1.2% of the population. Bifid ribs occur in up to 8.4% of
Samoans (McKinley & O'Loughlin, p. 214). The sternal end of
the rib is cleaved into two. It is usually unilateral.
Bifid ribs are usually asymptomatic, and are often discovered
incidentally by chest x-ray. Effects of this neuroskeletal
anomaly can include respiratory difficulties, neurological
difficulties, limitations, and limited energy from the stress of
needing to compensate for the neurophysiological difficulties
37

38. 5.Cervical rib: A cervical rib is a
supernumerary (or extra) rib which arises from the
seventh cervical vertebra. It is a congenital
abnormality located above the normal first rib. A
cervical rib is present in only about 1 in 500 (0.2%)
of people; in even rarer cases, an individual may
have two cervical ribs.
38

39. Back Region
Spinal Deformities: Variations and
abnormalities of segmentation are common. The
most serious type of congenital defect is spina bifida.
‗Spinal deformity‘(as opposed to deformities of
individual vertebrae) affects the entire shape of the
back and manifests as abnormal curvature, in either
the coronal plane(scoliosis) or the sagittal
plane(hyperkyphosis and hyperlordosis).
39

40. 1.Spina Bifida:(Latin: "split spine") is a developmental birth defect caused by
the incomplete closure of the embryonic neural tube. Some vertebrae overlying the spinal
cord are not fully formed and remain unfused and open. If the opening is large
enough, this allows a portion of the spinal cord to stick out through the opening in the
bones. There may or may not be a fluid filled sac surrounding the spinal cord. Other
neural tube defects include anencephaly, a condition in which the portion of the neural
tube which will become the cerebrum does not close, and enecphalocele, which results
when other parts of the brain remain unfused.
Spina bifida malformations fall into four categories: spina bifida occulta, spina bifida
cystica (myelomeningocele), meningocele and lipomeningocele. The most common
location of the malformations is the lumbar and sacral areas . Myelomeningocele is the
most significant form and it is this that leads to disability in most affected individuals.
The terms spina bifida and myelomeningocele are usually used interchangeably.
Spina bifida can be surgically closed after birth, but this does not restore normal function
to the affected part of the spinal cord. Intrauterine surgery for spina bifida has also been
performed and the safety and efficacy of this procedure is currently being investigated.
The incidence of spina bifida can be decreased by up to 75% when daily folic acid
supplements are taken prior to conception.
40

41. 2. Scoliosis: (from Greek: skoliosis meaning "crooked condition,"
from skolios, "crooked"). Scoliosis is an apparent lateral(sideways)
curvature of the spine. ‗Apparent‘ because, although lateral curvature
does occur, the commonest form of scoliosis is actually a triplanar
deformity with lateral, anteroposterior and rotational
components[Dickson et al, 1984). Two broad types of deformity are
defined: postural and structural.
a. Postural Scoliosis: In postural scoliosis the deformity is
secondary or compensatory to some condition outside the spine, such
as a short leg, or pelvic tilt due to the contracture of the hip; when the
patient sits(thereby cancelling leg asymmetry) the curves disappear.
Local muscle spasm associated with a prolapsed lumber disc may
cause a skew back; although sometimes called ―sciatic scoliosis‖ this,
too, is a spurious deformity.
41

42. Scoliosis cont….
b. Structural or Fixed Scoliosis: In structural scoliosis
there is non-correctible deformity of the affected spinal
segment, an essential component of which is vertebral
rotation. The spinous processes swing round towards the
concavity of the curve and the transverse processes on the
convexity rotate posteriorly; in the thoracic region the ribs on
the convex side stand out prominently, producing the rib
hump which is a characteristic part of the overall deformity.
Dickson et al (1984) pointed out this is really a lordoscoliosis
associated with rotational buckling of the spine.
Most cases have no obvious cause(idiopathic scoliosis); other
varieties are congenital or osteopathic(due to bony anomalies),
neuropathic, myopathic(associated with some muscle
dystrophies) and a miscellaneous group of connective-tissue
disorders.
42

43. Scoliosis Images:
43

44. Scoliosis cont…
Idiopathic scoliosis: This group constitutes about 80% of
all cases of scoliosis. The deformity is often familial, and the
population incidence of serious curves(over 30° and therefore
needing treatment) is three per 1000; trivial curves are very
much more common. The age at onset has been used to define
three groups: adolescence, juvenile and infantile. A simpler
division is early onset(before puberty) and late onset(after
puberty) scoliosis.
44

45. Scoliosis cont…
Adolescent Idiopathic Scoliosis:
(Presenting at aged 10 years or over)
This, the commonest type, occurs mostly(99%) in girls. Primary thoracic curves
are usually convex to the right, lumber curves to the left;
intermediate(thoracolumber) and combined(double primary) curves also occur.
Progression is inevitable; indeed, most curves under 20° either remain
spontaneously or remain unchanged. However, once a curve starts to progress, its
usually goes on doing so throughout the remaining growth period(and, to a much
lesser degree, beyond that). Reliable predictors of progression are (1) a very young
age, (2) marked curvature and (3) and incomplete Risser sign at presentation
(Lonstein and Carlson, 1984).
45

46. Scoliosis cont…
Juvenile Idiopathic Scoliosis:
(presenting at age 4-9 years)
This is uncommon. The characteristics of this group are similar to
those of adolescent group, but the prognosis is worse and surgical
correction may be necessary before puberty. However, if the child is
very young, a brace may hold the curve stationary until he or she is
about 10 years old, when fusion is more likely to succeed.
46

47. Scoliosis cont…
Infantile Idiopathic Scoliosis:
(presenting age 3 years and under)
This variety is becoming uncommon, perhaps because most babies now a days are
allowed to sleep prone. Boys predominate and most curves are thoracic with
convexity to the left. Although 90% of the infantile curves resolve spontaneously,
progressive curves can become very severe; those in which the rib-vertebra angle
at the apex of the curve differs on the two sides by more than 20° are likely to
deteriorate (Mehta, 1972). And because this also influences the development of
the lungs, there is a high incidence of cardiopulmonary dysfunction.
If the deformity continues to deteriorate, surgical correction may be required.
47

48. 3. Kyphosis: (Greek - kyphos, a hump), also called hunchback,
is a common condition of a curvature of the upper (thoracic) spine.
Rather confusingly, the term ‗kyphosis‘ is used to describe both the
normal(the gentle rounding of the thoracic spine) and the
abnormal(excessive thoracic curvature or straightening out of the
cervical or lumbar lordotic curves). Excessive thoracic curvature might
be better described as ‗hyperkyphosis‘. Kyphos, or gibbus, is a sharp
posterior angulation due to localized collapse or wedging of one or more
vertebrae. This may be the result of the congenital defect, a
fracture(sometimes pathological) or spinal tuberculosis.
Two broad types of deformity are defined: postural and
structural.
48

49. Kyphosis cont…
a. Postural kyphosis: It is usually associated with other
postural defects such as flat feet. It is voluntarily correctable. If
treatment I needed, this consists of posture training and exercises.
Compensatory kyphosis is secondary to some other deformity; usually
increased lumbosacral lordosis. This deformity too, is correctable.
49

50. Kyphosis cont…
b. Structural Kyphosis: It is fixed and is associated with
changes in the shape of the vertebrae. In children this may be due
to congenital vertebral defects; it is also seen in skeletal dysplasia
such as achondroplasia and in osteogenesis imperfecta. Older
children may develop severe deformity secondary to tuberculous
spondylitis.
In adolescence the commonest cause is Scheuermann‘disease.
In adults kyphosis could be due to an old childhood
disorder, tuberculous spondylitis, ankylosing spondylitis or spinal
trauma.
In elderly people, osteoporosis may result in vertebral
compression and an increase in a previously mild, asymptomatic
deformity.
50

51. Kyphosis cont…
c. Congenital Kyphosis: Vertebral anomalies leading to kyphosis
may be due to failure of formation(type I), failure of
segmentation(type II) or a combination of these.
Type I (failure of formation) is the commonest(and the worst). If the
anterior part of the vertebral body fails to develop, progressive
kyphosis and posterior displacement of the hemivertebra may lead to
cord compression. In children under 6 years with curves of less than
40° , posterior spinal fusion alone may prevent further progression.
Older children or more severe curves may need combined anterior and
posterior fusion; and those with neurological complications will
require cord depression as well as fusion.
Type II (failure of segmentation) usually takes the form of an anterior
intervertebral bar; as the posterior elements continue to grow, that
segment of the spine gradually becomes kyphotic. The risk of
neurological compression is much less, but if the curve is progressive a
posterior fusion will be needed.
51

52. Kyphosis cont…
d. Adolescent Kyphosis (Scheuermann’s Disease):
Scheuermann, in 1920, described a condition which he called Juvenile dorsal
kyphosis, distinguishing it from the more common postural(correctable) kyphosis.
The characteristic feature was a fixed round-back deformity associated with wedging
of several thoracic vertebrae. The term ‗vertebral osteochondritis‘ was adopted
because the primary defect appeared to be in the ossification of the epiphyseal ring
which define the peripheral rims on the upper and lower surfaces of each vertebral
body. The true nature of the disorder is still unknown; the cartilaginous end-plates
may be weaker than normal (perhaps due to a collagen defect) and are then
damaged by pressure of the adjacent intervertebral discs during strenuous activity.
52

53. Kyphosis cont…
e. Osteoporotic Kiphosis(Elderly Kiphosis):
Postmenopausal osteoporosis may result in one or more
compression fractures of the thoracic spine. Patients are
usually in their 60s or 70s and may complain of pain.
Kyphosis is seldom marked. Often the main complaint is of
lumbosacral pain, which results from the compensatory
lumbar lordosis in an ageing, osteoarthritic spine.
Senile osteoporosis affects both men and women. Patients
are usually over 75 years of age, often incapacitated by
some other illness, and lacking exercise. They complain of
back pain, and spinal deformity may be marked. It is
important to exclude other conditions such as metastatic
disease or myelomatosis.
53

54. Hip Joint
1.Developmental Dysplasia of the Hip: This
condition was formerly known as ―congenital dislocation of the hip (CDH)‖,
and now called ―developmental dysplasia of the hip (DDH)‖, comprises a
spectrum of disorders: acetabular dysplasia without displacement;
instability (subluxation or dislocation); and teratological forms of
malarticulation. Whether the instability comes first and then affects
acetabular development because of imperfect seating of the femoral head,
or is a result of a primary acetabular dysplasia, is still unknown for sure.
Both mechanisms might be important.
The reported incidence of neonatal hip instability is 5-20 per 1000 live
births; however, most of these hips stabilize spontaneously, and on re-
examination 3 weeks after birth the incidence of instability in only 1 or 2 per
1000 infants. Girls are much more commonly affected than boys, the ratio
being about 7:1. The left hip is more often affected than the right; in 1 in 5
cases the condition is bilateral.
54

55. Hip Joint cont…
2. Acetbular Dysplasia and Subluxation:
Acetabular dysplasia may be genetically determined or may
follow incomplete reduction of a congenital dislocation, damage
to the lateral acetabular epiphysis or maldevelopment of the
femoral head (either congenital or, for example, after Parthes‘
disease). The socket is unusually shallow, the roof is sloping and
there is deficient coverage of the femoral head superolaterally
and anteriorly; in some cases the hip subluxates. Faulty load
transmission in the lateral part of the joint may lead to
secondary osteoarthritis.
55

56. Hip Joint cont…
3. Congenital Coxa vara: This is a rare developmental disorder
of infancy and early childhood and may be associated with Developmental
Dysplasia of the Hip(DDH). It is due to a defect of endochondral ossification
in the medial part of the femoral neck. There is marked decrease in the angle
between the neck and the shaft of the femur (90° or less) along with
subluxation of the head and the distortion of the neck(bending backwards),
the greater trochanter is raised. Adductor muscle group weakens and tends to
short and contracted. When the child starts to crawl or stand, the femoral
neck bends or develops a stress fracture, and with continued weight bearing it
collapses increasingly into varus and retroversion. Sometimes there is
shortening or bowing of the femoral shaft. The condition is bilateral and is
about one-third of cases.
56

57. Hip Joint cont…
4. Congenital Short Femur: The proximal femur is
usually short and rudimentary resulting in marked shortening
of the leg. The limb length disparity gives rise to difficulty in
standing and walking, besides putting extra strain on the
normal limb.
Treatment: It depends on the degree of the limb length
disparity. Compensatory shoe raise is the accepted method of
management. Surgery can be performed either on the affected
limb or the normal limb.
57

58. Hip Joint cont…
5.Congenital Limb Reduction:
Thalilomide was the most celebrated limb reducing insult
(teratogen) in humans which also produced a range of other
deformities depending on developmental time and
concentration of the drug exposure.
Agents - Many substances have been found capable of
producing limb reduction defects in experimental animals
but few have been related to humans.
Mechanisms - Limb reduction defects may also be
indirect, for example with loss of blood supply to part of the
limb or to defects in innervation at the spinal or cerebral
level. Also there are a number of as yet undefined
mechanisms involved.
Limb reduction defects may be apical (congenital
amputation) or pre- or post-axial (absence of radius and
lateral digits; ulnar and medial digits).
58

59. Hip Joint cont…
6. Proximal Femoral Focal Deficiency(PFFD):
This is a rare non-genetic(possibly teratogenic) anomaly in which part of all the
proximal femur is missing. The most useful classification is that of Aitken. In
type A there appears to be a gap in the femoral neck or subtrochanteric
region, which is infact a segment of unossified cartilage. This does eventually
ossify, but by then the proximal femur has developed a varus deformity and
shortening. In type B the ‗gap‘ persists, the femoral head and acetabulum are
dysplastic and there is significant shortening. In type C the femoral head is
missing and the acetabulum is undeveloped. In type D there is agenesis of the
entire proximal femur and acetabulum. Both hips may be affected and in half
the cases there are also distal anomalies.
59

60. Leg Region
1. Congenital absence of the fibula(fibular hemimelia):
Congenital absence of the fibula, also known as fibular hemimelia, encompasses a
spectrum of anomalies involving abnormal growth and development of the fibula. It
is the most common long bone deficiency, followed by aplasia of the radius.
According to Coventry and Johnson, the condition was first described in 1698.
Manifestations of this condition range from mild degrees of limb shortening to its
most severe form, which includes complete absence of the fibula with accompanying
defects in the femur, tibia, and foot. The severity of foot abnormalities appears to
correlate with the severity of the fibular deficiency.
Only a few reports of prenatally diagnosed fibular hemimelia have been published,
and to our knowledge there are no prior reports of isolated fibular hemimelia
diagnosed antenatally on the basis of sonography. We report a case of the antenatal
sonographic diagnosis of complete bilateral fibular hemimelia without the presence
of other congenital anomalies.
60

61. 2. Congenital absence of the tibia(tibial hemimelia):
 Tibial hemimelia is a rare anomaly characterized by deficiency of the tibia with relatively intact fibula.
Jones et al. (1978) classified the anomaly into 4 types according to radiologic criteria. It may present as an
isolated anomaly or be associated with a variety of skeletal and extraskeletal malformations. Tibial
hemimelia may also constitute a part of a more complicated malformation complex or syndrome, such as
the Gollop-Wolfgang complex and triphalangeal thumb-polysyndactyly syndrome (Matsuyama et al.,
2003).
 Emami-Ahari and Mahloudji (1974) described bilateral absence of the tibia in 3 children, 2 males and 1
female, of phenotypically normal but related parents. No other anomalies were present and intelligence
was normal. Jones et al. (1978) reported affected brother and sister. McKay et al. (1984) reported affected
sisters. McKay et al. (1984) reviewed syndromes of congenital defects in which tibial hemimelia is a
feature. Richieri-Costa et al. (1987) reported on 37 patients belonging to different families who had the
tibial hemimelia/split-hand/split-foot syndrome. Quoting others, they suggested that the maximum risk to
the offspring of an affected person married to an unaffected person is 8.6% and the maximum risk to a sib
of an isolated patient is 12.5%. They suggested that there are 4 well-established and 2 other possible
autosomal dominant tibial hemimelia syndromes in addition to 2 types with autosomal recessive
inheritance. Richieri-Costa (1987) reported a Brazilian child, born to consanguineous but healthy parents,
who had cleft lip/palate in addition to tibial hemimelia.
 Stevens and Moore (1999) described a girl with Langer-Giedion syndrome (LGS), a contiguous gene
syndrome caused by deletion in the 8q24.1 region. The patient also showed bilateral tibial hemimelia and
unilateral absence of the ulna. Turleau et al. (1982) had described an 8-year-old boy with LGS and bilateral
tibial hemimelia. Although no genes involving limb development in the human had been identified in the
8q24.1 region, 2 mouse syndromes with limb abnormalities mapped to the homologous region of 9A1-A4:
'luxoid' (absent toes, radial and tibial hemimelia, preaxial polydactyly, bent tail, and oligospermia) and 'aft'
(abnormal feet and tail). Stevens and Moore (1999) suggested that a gene involved in limb development is
contiguous with the gene(s) for LGS and that deletion of this gene causes tibial hemimelia.
61

62. 3.Congenital Pseudarthrosis of Tibia:
Congenital pseudoarthrosis of the tibia, which has been known to be one of the
diseases of the orthopaedic surgery, the treatment of which is the most difficult,
since it was first described by Hatzoecher 1708, is an ossification defect, which is
localized at the junction the middie third and lower third of the tibial shaft. It
may be associated with fibrous dysplasia or neurofibromatosis. In order not to
cause any errors as regards to therapy, one should identify congenital tibial
angulatlons adequately, which should especiaily be carefully evaluated in
diferential diagnosis. A great variety of procedures have been suggested in its
treatment. But, with the establishment of the effects of electromagnetic currents
and the advances realized in microsurgery and the application of free
voscularized bone grafts have increased the chance of curability of this disease,
the treatment of which in extremely difficult. Attempts have been made to
present congenital pseudoarthrosis of the tibia and its angulations treated by
surgery as well as treatment methods applied and results obtained.
It is rare, occurring equally in girls and boys; disease is almost always unilateral;
acute fractures occur during first 2 yrs of life, usually shortly after birth. It is
associated with anterolateral bowing and neurofibromatosis; neurofibromatosis
is present in approx 40-50% of patients with pseudarthrosis, while about 10% of
patients with neurofibromatosis will have pseudarthrosis of tibia; dysplastic type
is characterized by narrowing, sclerosis, and obliteration of the medullary canal.
62

63. 4.Blount's disease(Blount-Barber disease):
(nonrachitic bowlegs in children)
Blount's Disease is one which affects the bone development of toddlers and older children. Most often,
it starts as bow-leggedness which does not improve in a child between two and four years of age.
Seeking appropriate treatment in a timely matter can help your child develop normally.
Bow-leggedness in toddlers is particularly common most especially in those who walk at an early age
and those who are slightly overweight for their age and height. But legs that are bowed and which do
not correct by age two are cause for concern and investigation to see if Blount's Disease is a
possibility.
What happens with Blount's Disease is that as the child grows and the legs are bowed, some children
have the tendency, for unknown reasons, to develop bones which continue to bow. It is a vicious
circle. The bow-leggedness causes further bow-leggedness which perpetuates the problem.
So as the legs continue to grow abnormally the child is forced to walk with knees that bulge outward
and continue to get worse. What often accompanies this is a condition called internal tibial torsion.
What this is, is toes which turn inward below the knee. The toes point obviously inward and some
children even have a tendency to fall down more often with this infliction. When bow-leggedness and
tibial torsion occur together it is a red flag g that it is probably Blount's Disease.
Radiographic Appearance: Physiologic bowing typically show flaring and bowing of tibia and
femur in a symmetric fashion and is normal in children < 2 years of age (maximal at about 18 mo);
physiologic genu valgum, or knock knees, develops next, with maximal deformity occurring at 3
years of age; gradual correction to ultimate alignment of slight genu valgum occurs by 9 years of age
in the great majority of patients.
63

64. Foot Region
1. Congenital Talipes Equinovarus(CTEV):
(Idiopathic Club Foot)
The term ‗talipes‘ is derived from talus(Latin=ankle bone) and pes (Latin=foot).
The elements of this congenital deformity are:
 Adduction and Inversion of the Forefoot.
 Inversion of the heel (hind foot)
 Cavus and equinus with clawing of the toes.
The abnormality is relatively common, the incidence ranging from 1-2 per thousand
births; boys are affected twice as often as girls and the condition is bilateral in one-
third of the cases.
The exact cause is unknown; it could be a genetic defect or a form of arrested
development. Its occurrence in neurological disorders and neural tube defects(e.g.
myelomeningocele and spinal dysraphism) points to a neuromuscular disorder.
64

65. 2. Telipes Calcaneo-valgus: It is a common
deformity which presents in the newborn as an acutely
dorsiflexed foot. There is a deep crease (or several
wrinkles) on the front of the ankle, and the calcaneum
just out posteriorly. It is usually bilateral. There is an
association with hip dysplasia, especially if it presents on
one side only. This is a postural deformity, probably due
to abnormal intrauterine positioning, and it often
corrects spontaneously in the neonatal period.
65

66. 3. Metatarsus Addutus ( Metatarsus varus):
Here the foot is adducted at the TMT joint but the foot is plantigrade.
It varies from a slightly curved forefoot to something resembling a
mild club foot. The majority (99%) either improve spontaneously or
can be managed non-operatively using serial corrective casts
followed by straight-last shoes. Variations of the Dilwyn Evans
procedure(which aims to balance the lengths of the medial and
lateral columns of the foot), often in combination with basal
metatarsal osteotomies, are suitable for the small percentage of
children who require surgical treatment.
66

67. 4.Congenital Convex Pes Valgus(Congenital Flat
Foot):
(Congenital Vertical Talus)
This rare condition is seen in infants, usually affecting both feet.
Superficially it resembles other types of valgus foot, but the deformity is
more severe; the medial arch is not only flat , it is the most prominent
part of the sole, producing the appearance of a ‗rocker-bottom‘ foot. The
hind foot is equinus and valgus and the talus points almost vertically
towards the sole; the forefoot is abducted,pronated and dorsiflexed, with
subluxation of the talonavicular joint. Passive correction is impossible;
by the time child is seen, the tendons and ligaments on the dorsolateral
side of the foot are usually shortened.
67

68. 5. High-Arched Feet(Pes Cavus): In pes cavus the
arch is higher than the normal, and often there is also clawing of the
toes. The close resemblance to deformities seen in the neurological
disorders where the intrinsic muscles are weak or paralyzed suggests
that all types of pes cavus are due to some type of muscle imbalance.
There are rare congenital causes such as arthrogryposis, but in the
majority of cases pes cavus results from an acquired neuromuscular
disorder. Hereditary motor and sensory neuropathies and spinal
cord abnormalities(tethered cord syndrome, diastematomyelia) are
the commonest, but poliomyelitis is the most commonest cause
worldwide. Occasionally the deformity follows trauma-burns or a
compartment syndrome resulting in Volkmann‘s contracture of the
sole.
68

69. Acquired Deformities
Shoulder Joint
1. Winged scapula: Winged scapula (scapula alata) is a condition in which
the medial border (the side nearest the spine) of a person's scapula is abnormally
positioned outward and backward. The resulting appearance of the upper back is said
to be wing-like because the inferior angle of the shoulder blade protrudes backward
rather than lying mostly flat like in people without the condition.
Causes
Although there are many causes of the condition, the most common is when the
serratus anterior muscle are weakened (for various reasons) or when they are
weakened and/or paralyzed by impingement of the long thoracic nerve.
Treatment
Surgery is sometimes used to treat the condition.
Symptoms can also be alleviated through rehabilitation by using different
strengthening and endurance exercises. Stretching is used with some precautions
under supervision of a Certified Athletic Trainer or licensed PT.
69

70. 2. Adhesive capsulitis of
shoulder: Frozen shoulder, medically referred to as
adhesive capsulitis, is a disorder in which the shoulder capsule, the
connective tissue surrounding the glenohumeral joint of the
shoulder, becomes inflamed and stiff, and grows together with abnormal
bands of tissue, called adhesions, greatly restricting motion and causing
chronic pain.
 Adhesive capsulitis is a painful and disabling condition that often causes
great frustration for patients and caregivers due to slow recovery. Movement
of the shoulder is severely restricted. Pain is usually constant, worse at
night, when the weather is colder, and along with the restricted movement
can make even small tasks impossible. Certain movements can cause sudden
onset of tremendous pain and cramping that can last several minutes.
 This condition, for which an exact cause is unknown, can last from five
months to three years or more and is thought in some cases to be caused by
injury or trauma to the area. It is believed that it may have an autoimmune
component, with the body attacking healthy tissue in the shoulder. The
condition may also cause chronic inflammation. Adhesions grow between
the joints and tissue, greatly restricting motion and causing a number of
painful complications. There is also a lack of fluid in the joint, further
restricting movement.
70

71. 3. Rotator cuff tear: Rotator cuff tears are
tears of one, or more, of the four tendons of the rotator cuff muscles.
A rotator cuff injury can include any type of irritation or damage to
your rotator cuff muscles or tendons.
 Rotator cuff tears are among the most common conditions affecting
the shoulder.
 The tendons of the rotator cuff, not the muscles, are most commonly
torn. Of the four tendons, the supraspinatus is most frequently torn;
the tear usually occurs at its point of insertion onto the humeral head
at the greater tuberosity.
71

72. 4. Subacromial bursitis: Subacromial
bursitis is a condition caused by inflammation of the bursa that separates the
superior surface of the suprasinatus tendon (one of the four tendons of the
rotator cuff) from the overlying coraco-acromial ligament, acromion, coracoid
( the acromial arch) and from the deep surface of the deltoid muscle . The
subacromial bursa helps the motion of the supraspinatus tendon of the rotator
cuff in activities such as overhead work.
 Musculoskeletal complaints are one of the most common reasons for primary
care office visits, and rotator cuff disorders are the most common source of
shoulder pain. According to the American Academy of Orthopedic Surgeons
(AAOS) visits to orthopedic specialists for shoulder pain has been rising since
1998 and in 2005 over 13 million patients sought medical care for shoulder
pain, of which only 34% were related to injury.
 Primary inflammation of the subacromial bursa is relatively rare and may
arise from autoimmune inflammatory conditions (rheumatoid
arthritis), crystal deposition (Gout or Pseudo gout), calcific loose bodies
(rheumatoid arthritis) and infection. More commonly, subacromial bursitis
arises as a result of complex factors, thought to cause shoulder impingement
symptoms. These factors are broadly classified as intrinsic (intratendinous) or
extrinsic (extratendinous). They are further divided into primary or secondary
causes of impingement. Secondary causes are thought to be part of another
process such as shoulder instability or nerve injury (Bigliani and
Levine, Journal Bone Joint Surgery 1997).
72

73. Elbow Joint
1. Cubitus valgus: Cubitus valgus is a medical deformity
in which the elbows are turned in. A small degree of cubitus valgus (known as
the carrying angle) is acceptable and occurs in the general population.
 When present at birth, it can be an indication of Noonan syndrome or Turner
syndrome. It can also be acquired through fracture or other trauma.The
physiological cubitus valgus varies from 3° to 29°. Women usually have a
more pronounced Cubitus valgus than men.
 The commonest cause is a malunion of a supra-condylar fracture and the
deformity is obvious only when the elbow is extended
The hand brushes against the side during normal walking
Deformity can be corrected by a wedge osteotomy of the distal humerus.
73

74. 2. Cubitus varus(‘Gun-stock’ deformity) : Cubitus
varus (varus means a deformity of a limb in which part of it is deviated towards
the midline of the body) is a common deformity in which the extended forearm is
deviated towards midline of the body .
 Cubitus varus is often referred to as 'Gunstock deformity', due to the crooked
nature of the healing. The commonest cause is a malunion or non-union of a
number of the lateral condyle of the humerus.
The medial epicondyle becomes prominent on the medial side of the joint and
there is a tendency for the development of a delayed ulnar nerve palsy (weakness
of the hand and tingling of the ulnar fingers)
The deformity itself may need no treatment but the delayed ulnar nerve palsy
may require ulnar nerve transposition
74

75. 3.Subluxation of Radial Head: This is
commonly associated with bony dysplasias in
which the ulna is disproportionately shortened
(e.g. hereditary multiple exostosis). It causes little
disability, but if it becomes troublesome the radial
head can be excised after all growth has ceased.
75

76. 4.Unreduced Dislocation of the head of Radius:
Dislocation of the radial head occurs most frequently in men who are subject to high-
force injury. In children, the radial head is much more commonly subluxed than
dislocated.
Isolated radial head dislocations are rare; only 20 cases have been reported in 30
years. Radial head dislocations are usually complicated by complete elbow
dislocations or fractures, as in the Monteggia complex.
Monteggia described the combination of radial head dislocation and proximal ulnar
fracture in 1814. More than a century later, Bado further classified the Monteggia
injury into 4 types based on the angulation of the fracture and direction of dislocation
(see Table). The Bado classification is useful descriptively but not prognostically.
Radial head dislocation is often associated with significant trauma (eg, motor vehicle
accidents, pedestrian–motor vehicle accidents, significant falls).
76

77. 5.Pulled Elbow: Nursemaid's elbow or
Babysitter's elbow is a dislocation of the elbow joint
caused by a sudden pull on the extended pronated
arm, such as by an adult tugging on an uncooperative child.
The technical term for the injury is radial head
subluxation.
 A pulled elbow, also known as nursemaid's elbow or a
partially dislocated elbow joint, commonly occurs to
toddlers and preschoolers(under 6 years of age).
Nursemaid's elbow happens when kids are picked up or
swung around by their hands. The ligament of the elbow
may stretch and slip out of place causing severe pain.
77

78. Wrist Joint
1.Proximal Humeral Physeal Injuries: most of these
injuries are either Salter I or II fractures; fractures separations of proximal
humeral epiphysis occur most often between ages of 11 and 15 years; 80% of
longitudinal growth of humerus occurs in proximal physis;large percentage of
growth allows significant remodeling following injuries of proximal humeral
physis;
associated injuries:
brachial plexus injuries: look for decrease sensation to pain.
classification:
type I epiphyseal injury: in newborns, fractures are usually Salter Harris type I
injuries;
type II epiphyseal fractures: in older children, they are most always Salter Harris
type II;
type III, IV, and V fractures: rare because of greater mobility of the
glenohumeral joint;
diff dx of proximal humeral injuries:
tumor of proximal humerus
little league shoulder
clavicle fractures
normal varient (accentuated w/ humerus externally rotated)
78

79. 2. Wrist drop: Wrist drop, also known as radial nerve palsy, or
Saturday night palsy, is a condition where a person can not extend their wrist
and it hangs flaccidly. To demonstrate wrist drop, hold your arm out in front of
you with your forearm parallel to the floor. With the back of your hand facing the
ceiling (i.e. pronated), let your hand hang limply so that your fingers point
downward. A person with wrist drop would be unable to move from this position
to one in which the fingers are pointing up towards the ceiling.
Symptoms of wrist drop include wrist weakness, resulting in the inability to raise
the hand at the wrist. Additional symptoms may include wrist pain, wrist
tenderness, or wrist swelling, wrist deformity, hand numbness (unilateral), and
hand weakness (unilateral).
Initial management includes splinting of the wrist for support along with
occupational or physical therapy. In some cases surgical removal of bone spurs or
other anatomical defects that may be impinging on the nerve might be warranted.
79

80. Wrist drop: Wrist drop, also known as radial nerve palsy, or Saturday night
palsy, is a condition where a person can not extend their wrist and it hangs flaccidly. To
demonstrate wrist drop, hold your arm out in front of you with your forearm parallel to the
floor. With the back of your hand facing the ceiling (i.e. pronated), let your hand hang
limply so that your fingers point downward. A person with wrist drop would be unable to
move from this position to one in which the fingers are pointing up towards the ceiling.
Causes: Stab wounds to the chest at or below the clavicle may result in wrist
drop. The radial nerve is the terminal branch of the posterior cord of the brachial
plexus. A stab wound may damage the posterior cord and result in neurological
deficits including an inability to abduct the shoulder beyond 15 degrees, an
inability to extend the forearm, reduced ability to supinate the hand, reduced
ability to abduct the thumb and sensory loss to the posterior surface of the arm
and hand.
The radial nerve can be damaged if the humerus (the bone of the arm) is broken,
because it runs through the radial groove on the lateral border of this bone.
Wrist drop is also associated with lead poisoning because of the effect of lead on
the radial nerve.
Persistent injury to the nerve is also a common cause through either repetitive
motion or by applying pressure externally along the route of the radial nerve as in
the prolonged use of crutches or extended leaning on the elbows.
80

81. Hand
1.Boutonniere deformity:
Boutonniere deformity is a deformed position of the finger, in which
the joint nearest the knuckle (PIP) is permanently bent toward the palm
while the furthest joint (DIP) is bent back away (PIP hyperflexion with
DIP hyperextension). It is commonly caused by injury or by an
inflammatory conditions like rheumatoid arthritis.
Stages
 Mild extension lag, passively correctable
 Moderate extension lag, passively correctable
 Mild flexion contracture
 Advanced flexion contracture
81

82. Boutonnière Deformity cont…
(Buttonhole Deformity) :
Boutonnière deformity (buttonhole deformity) is a deformity in
which the middle finger joint is bent in a fixed position inward
(toward the palm) and the outermost finger joint is bent excessively
outward (away from the palm).
This disorder most often results from rheumatoid arthritis but can
also occur from injury (such as deep cuts, joint dislocation, or
fractures) or osteoarthritis . People with rheumatoid arthritis can
develop the disorder because they have long-standing inflammation
of the middle joint of a finger. If the deformity is caused by an injury,
the injury usually occurs at the base of a tendon (called the middle
phalanx extensor tendon). As a result, the middle joint (called the
proximal interphalangeal joint) becomes ―buttonholed‖ between the
outer bands of the tendon that runs to the end of the finger. The
deformity can, but need not, interfere with hand function. The doctor
makes the diagnosis by examining the finger.
82

83. 2.Dupuytren’s Contracture: Dupuytren's
contracture (also known as "Morbus Dupuytren," "Dupuytren's disease," or
"Palmar fibromatosis", and sometimes misspelled as Dupuytren's constricture) is a
fixed flexion contracture of the hand where the fingers bend towards the palm and
cannot be fully extended (straightened). It is named after Baron Guillaume
Dupuytren, the surgeon who described an operation to correct the affliction.
Dupuytren's contracture is caused by underlying contractures of the palmar fascia.
The ring finger and little finger are the fingers most commonly affected. The middle
finger may be affected in advanced cases, but the index finger and the thumb are
nearly always spared. Dupuytren's contracture progresses slowly and is usually
painless. In patients with this condition, the tissues under the skin on the palm of the
hand thicken and shorten so that the tendons connected to the fingers cannot move
freely. The palmar aponeurosis becomes hyperplastic and undergoes contracture.
Incidence increases after the age of 40; at this age men are affected more often than
women. After the age of 80 the distribution is about even.
83

84. 3.Volkmann's Ischaemic Contracture: Volkmann's
contracture, also known as Volkmann's ischaemic contracture, is
a permanent flexion contracture of the hand at the wrist, resulting in a
claw-like deformity of the hand and fingers.
Volkmann's contracture is a deformity of the hand, fingers, and wrist caused by
injury to the muscles of the forearm.
Volkmann's contracture occurs when there is a lack of blood flow (ischemia) to the
forearm. This usually occurs when there is increased pressure due to swelling, a condition
called compartment syndrome.
Trauma to the arm, including a crush injury or fracture, can lead to swelling that
compresses blood vessels and can decrease blood flow to the arm. A prolonged decrease in
blood flow will injure the nerves and muscles, causing them to shorten and become stiff
(scarred).
When the muscle shortens, it pulls on the joint at the end of the muscle just as it would if it
were normally contracted, but because it is stiff the joint remains bent and cannot
straighten. This condition is called a contracture.
In Volkmann's contracture, the muscles of the forearm are severely injured, resulting in
contracture deformities of the fingers, hand, and wrist.
84

85. 4.Mallet finger: In medicine, mallet finger, also
baseball finger, dropped finger and (more generally) extensor
tendon injury, is an injury of the extensor digitorum tendon of the
fingers at the distal interphalangeal joint(DIP). It results from
hyperflexion of the extensor digitorum tendon, and usually occurs
when a ball (such as a softball, basketball, or volleyball), while being
caught, hits an outstretched finger and jams it.
Management options include putting the finger in a Mallet splint for
6 to 8 weeks or extension block k-wire for 4 weeks. This allows the
tendon to reattach, if the finger is bent during these weeks the
healing process must start all over again.
85

86. Mallet Finger cont…
Mallet finger is a deformity in which the fingertip is curled in and
cannot straighten itself.
This deformity usually results from injury, which either damages the
tendon or tears the tendon from the bone. It can affect one or more
fingers. A doctor can make the diagnosis by examining the finger. An x-
ray is usually taken to be sure that there is no fracture. The usual
treatment is placing a splint on the finger with the finger straightened.
The tendon may take 6 to 10 weeks to heal. Mallet finger rarely
requires surgery, unless a large fragment of bone has broken off or the
joint is partially dislocated. Mallet finger has also been referred to as
drop, hammer, or baseball finger (although baseball accounts for only
a small percentage of such injuries).
86

87. 5.Swan-Neck Deformity:
Swan-neck deformity is a bending in (flexion) of the base of the finger, a
straightening out (extension) of the middle joint, and a bending in (flexion) of the
outermost joint.
The most common cause is rheumatoid arthritis. Other causes include untreated
mallet finger, looseness (laxity) of the fibrous plate inside the hand at the base of
the fingers or of the finger ligaments, muscle spasm affecting the hands, and
misalignment in the healing of a fracture of the middle bone of the finger.
Normal bending of the finger may become impossible. The deformity can
therefore result in considerable disability.
True swan-neck deformity does not affect the thumb, which has one less joint
than the other fingers. However, in a variant of swan-neck deformity, called
duck-bill deformity, the top joint of the thumb is severely over straightened with
a bending in of the joint at the base of the thumb to form a 90° angle. If duck-bill
deformity and swan-neck deformity of one or more fingers occur together, the
ability to pinch can be seriously reduced.
87

88. 6.Trigger Finger:
In trigger finger (flexor digital tenosynovitis), a finger becomes locked in a bent
position. The finger locks when one of the tendons that flex the finger becomes
inflamed and swollen. Normally, the tendon moves smoothly in and out of its
surrounding sheath as the finger straightens and bends. In trigger finger, the
inflamed tendon can move out of the sheath as the finger bends. However, when
the tendon is very swollen, it cannot easily move back in as the finger
straightens, and therefore the finger locks.
Trigger finger can result from repetitive use of the hands (as may occur from
using heavy gardening shears) or from inflammation (as occurs in rheumatoid
arthritis). To straighten the finger, a person must force the swollen area into the
sheath—causing a popping sensation similar to that felt when pulling a trigger.
Splinting, moist heat, and nonsteroidal anti-inflammatory drugs (NSAIDs) can
help in mild cases. Sometimes a corticosteroid and a local anesthetic are injected
into the tendon sheath. Surgery is commonly needed to treat chronic trigger
finger.
88

89. 7.Erosive (Inflammatory) Osteoarthritis:
Erosive (inflammatory) osteoarthritis is a form of
osteoarthritis that, in the hand, causes swelling, pain,
and sometimes formation of cysts on the finger joints
(particularly the outermost ones).
Osteoarthritis of the hand is apparent by
enlargement of bones over the outermost joints of
the fingers (Heberden's nodes) and overgrowth of
bones over the middle joints of the fingers
(Bouchard's nodules). With erosive osteoarthritis,
there is also swelling of surrounding tissues. The
joints between the fingers and hand and the wrists
are usually not affected. The involved joints can
become misaligned.
89

90. 8.Intrinsic Plus Hand: results from intrinsic stiffness
(contracture).
specific causes: They may be truama,posttraumatic intrinsic
contractures may occur after severe injuries to hand that have
resulted in considerable edema or hematoma; ischemia, rheumatoid
arthritis, Still's disease, mycobacterium leprae,CNS
lesions, Parkinson's disease, cerebral palsy.
Treatment: corrected with therapy, or if that fails, sometimes by
intrinsic release/transfer (Little - distal) or (Zancolli - proximal), late
deformity, distal intrinsic release of those oblique fibers contributing
to lateral bands, preserving more proximal transverse contribution of
interosseous aponeurotic expansion.
90

91. 9.Intrinsic Minus and Claw Hand: claw hand deformity is
manifested by flattening of the transverse metacarpal arch and
longitudinal arches, with hyperextension of MCP joints and flexion of
the PIP and DIP joints; deformity is produced by imbalance of the
intrinsic & extrinsics; intrinsic muscles must be markedly weakened or
paralyzed to produce claw deformity; long extensor muscles
hyperextend the MCP joint, & long flexor muscles flex the PIP and DIP
joints; weakness of the long flexors (as in high palsy) actually decreases
claw fingers; PIP joint loses the ability to extend thru the lateral bands
and must rely on the central slip; due to the anatomy of the saggital
band, MP joint hyperextension blocks the the central slip from
extending the PIP; hence, main force of contracted extensor mechanism
is focused on saggital band, leading to further MCP hyperextension;
tenodesis effect of extending the fingers with wrist flexion is lost;
smooth flexion pattern is lost: normally, MP flexion initiates finger
flexion, and all joint achieve full flexion nearly simultaneously; distal
joint flexion is completed prior to initiation of MP joint flexion;
hence, the fingers immediately come into contact with the palm with
flexion;
causes: combined low median and ulnar nerve lesions (may result in
significant decreases in grip strength); brachial plexus injuries; spinal
cord injuries; Charcot-Marie-Tooth-Disease;
91

92. Hip Joint
1.Coxa valga:
It is a deformity of the hip where the angle formed
between the head and neck of the femur and its shaft
is increased, usually above 135 degrees. It is caused by
a slipped epiphysis of the femoral head.
92

93. 2.Coxa vara:Coxa vara is a deformity of the hip,
whereby the angle between the ball and the shaft of the femur is reduced to
less than 120 degrees which is 160° at birth and 125° in adults. This results in
the leg being shortened, and therefore a limp occurs. It is commonly caused
by injury, such as a fracture. It can also occur when the bone tissue in the
neck of the femur is softer than normal, meaning it bends under the weight
of the body. This may either be congenital, also known as Mau-Nilsonne
Syndrome, or the result of a bone disorder. The most common cause of coxa
vara is either congenital or developmental. Other common causes include
metabolic bone diseases (e.g. Paget's disease of bone), post Perthes
deformity, osteomyelitis, and post traumatic (due to improper healing of a
fracture between the greater and lesser trochanter). Shepherds Crook
deformity is a severe form of coxa vara where the proximal femur is severely
deformed with a reduction in the neck shaft angle beyond 90 degrees. It is
most commonly a sequellae of osteogenesis imperfecta, Pagets disease,
osteomyelitis, tumour and tumour-like conditions (e.g. fibrous dysplasia).
Treatment: Treatment depends on the cause of the condition. Most cases
do not require any treatment. If treatment is required, it is usually a valgus
osteotomy of the femur fixed by an angled blade plate device or even a
dynamic hip screw.
93

94. 3.Protrusio acetabuli(Otto pelvis): Protrusio
acetabuli is an uncommon defect of the acetabulum. The acetabulum is the socket that
receives the femoral head to make the hip joint. The hip bone of the pelvic bone/girdle is
composed of three bones, the ilium, the ischium and the pubis. The socket is too deep and
may protrude into the pelvis.
Classification
Protrusio acetabuli is divided into two types, primary and secondary.
Primary protrusio acetabuli
Characterized by progressive protrusio in middle aged women. May be associated with OA.
May be familial
Secondary protrusio acetabuli
Causes include: may be present bilaterally in Paget's disease, Marfan syndrome, RA, AS, &
osteomalacia; Femoral head prosthesis, Cup arthroplasty,Septic arthritis, Central fracture
dislocation, Total hip replacement surgery
Treatment
Joint replacement surgery is indicated for severe pain or substantial joint restriction.
Prominent trabeculae. * Normal sacro-iliac joints and symphysis pubis.
94

95. 4. Femoral Anteversion(in-toe gait): Femoral
anteversion in children is usually congenital, meaning that the child is born with
this condition. Up to ten percent of children are born with femur anteversion,
and girls are twice as likely as boys to be affected. This condition does not
increase the child‘s risk of developing conditions such as arthritis, or any other
muscle or bone diseases.
The exact cause of anteversion of the femur is unknown. It is thought to relate to
the position of the child within the uterus, as certain positions may cause the hip
muscles and femur bones to become abnormally situated. The condition may
also be partially genetically inherited, as there is a tendency for the pigeon-toed
gait and appearance to run in families.
At birth, femur bones are normally anteverted approximately 40 degrees. By
adolescence, this has reduced to between 10 and 15 degrees. In a child with
femoral anteversion, the femurs are anteverted by more than 40 degrees, and in
some cases, more than 50. When the anteversion is between 40 and 50 degrees,
treatment is often not required, because the anteversion will have reduced
significantly by the time the child enters adolescence.
95

96. 5.Unequal leg length: Unequal leg
length or leg length inequality (LLI) refers to a medical condition where the legs are of
different lengths.
 One form is "leg length alignment asymmetry" (LLAA) which is a condition in physiology
where one leg (the 'short leg', or unloaded leg) is unequal in length while in a supine or
prone position (i.e., lying down).
 LLAA can be either anatomical in nature (short bones due to growth or an accident) or
neuromuscular (hypertonicity in the musculature of the pelvis or leg).
 The most common treatment for discrepancies in leg length is the use of a simple heel
lift, which can be placed within the shoe.
 Although prone "functional leg length" is a widely used chiropractic tool in their Activator
technique, it is not a recognized anthropometric technique, since legs are usually of unequal
length, and measurements in the prone position are not entirely valid estimates of standing
X-ray differences. Measurements in the standing position are far more reliable. Another
confounding factor is that simply moving the two legs held together and leaning them
imperceptibly to one side or the other produces different results
96

97. Chest
1.Pectus excavatum: Pectus excavatum (a Latin
term meaning hollowed chest) is the most common congenital deformity of the
anterior wall of the chest , in which several ribs and the sternum grow
abnormally. This produces a caved-in or sunken appearance of the chest. It can
either be present at birth or not develop until puberty.
Pectus excavatum is sometimes considered to be cosmetic; however, depending
on the severity, it can impair cardiac and respiratory function and cause pain in
the chest and back. People with the abnormality may experience negative
psychosocial effects, and avoid activities that expose the chest.
Pectus excavatum is sometimes referred to as cobbler's chest, sunken
chest, funnel chest or simply a dent in the chest.
97

98. 2.Pectus carinatum: Pectus carinatum, (L carīnātus, equiv.
to carīn(a) keel), also called pigeon chest, is a deformity of the chest characterized by a
protrusion of the sternum and ribs. It is the opposite of pectus excavatum.
Causes: Pectus carinatum is an overgrowth of cartilage causing the sternum to protrude
forward. It occurs in 3 different ways. The least common way is post surgically after open
heart surgery. Sometimes the sternum does not heal flat and there is a protrusion of the
sternum. The second most common is from birth. It is evident in new borns are a rounded
chest and as they reach 2 or 3 years old the sternum begins to grow outwardly even more.
The most common occurrence for pectus carinatum seems to be in the 11-14 year old
pubertal male undergoing a growth spurt. Some parents report that their child's pectus
seemingly popped up 'overnight'.
It may occur as a solitary congenital abnormality or in association with other genetic
disorders or syndromes : Marfan syndrome, Morquio syndrome, Noonan
syndrome, Trisomy 18, Trisomy 21, homocystinuria, osteogenesis imperfecta, multiple
lentigines syndrome, and Sly syndrome.
In about 25% of cases of pectus carinatum, the patient has a family member with the
condition.
98

99. Neck
1.Acquired Scoliosis: Scoliosis is an abnormal curvature
of the spine to one side. In those who have the condition, the spine bends either to the left or to
the right. The bend can occur at any point along the spine, from the top to the bottom. The
curvature can also vary from a slight to severe. However, the chest area (thoracic scoliosis) and
the lower part of the back (lumbar scoliosis) are the most common regions to be affected.
 Scoliosis affects 3-4 children out of every 1,000. In 90% of cases of scoliosis, treatment is not
required because the condition corrects itself as the child grows. Most of the remaining 10% of
cases can be successfully treated by using a back brace to prevent further curvature. Three out
of every 1,000 children with scoliosis will need surgical treatment.
 Scoliosis can develop at any time during childhood and adolescence. It is more common in girls
than boys, most commonly occurring at the start of adolescence.
 In approximately 80% of scoliosis cases, the causes are unknown (idiopathic).
 Scoliosis is normally not a serious condition, but treatment is essential. Left untreated, the
curve of the spine can worsen, and cause damage to the spine, chest, pelvis, heart and lungs.
 In approximately 80% of cases, the cause of scoliosis is unknown (idiopathic). However, it is
thought that idiopathic scoliosis runs in families, and researchers have recently discovered a
gene that may make people more susceptible to idiopathic scoliosis.
99

100. 2.Acquired torticollis: Torticollis, or wry neck, is a condition in which
the head is tilted toward one side (cervical Lateral flexion), and the chin is elevated
and turned toward the opposite side (cervical extension).
Acquired torticollis occurs because of another problem and usually presents in
previously normal children and adults.
 Trauma to the neck can cause atlantoaxial rotatory subluxation, in which the two
vertebrae closest to the skull slide with respect to each other, tearing stabilizing
ligaments; this condition is treated with traction to reduce the subluxation, followed
by bracing or casting until the ligamentous injury heals.
 Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to
the neck and cause torticollis, and these problems must be treated surgically.
 Infections in the posterior pharynx can irritate the nerves supplying the neck muscles
and cause torticollis, and these infections may be treated with antibiotics if they are
not too severe, but could require surgical debridement in intractable cases.
 Ear infections and surgical removal of the adenoids can cause an entity known as
Grisel's syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial
joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge
must either be broken through manipulation of the neck, or surgically resected.
 The use of certain drugs, such as antipsychotics, can cause torticollis.
 There are many other rare causes of torticollis.
100

101. Knee Joint
1.Genu varum: Genu varum (also called bow-leggedness or
bandiness), is a deformity marked by medial angulation of the leg in relation to the thigh, an
outward bowing of the legs, giving the appearance of a bow. It is also known as bandy-leg,
bowleg, bow-leg, and tibia vara. Usually there is an outward curvature of both femur and tibia.
"Genu varum" is distinguished from Blount's disease because it involves both the femur and the
tibia, while Blount's disease affects only the tibia with no femur involvement.
Causes
If a child is sickly, either with rickets or suffering from any ailment that prevents the due
ossification of the bones, or is improperly fed, the bowed condition may remain persistent. Thus
the chief cause of this deformity is rickets. Skeletal problems, infection, and tumors can also
affect the growth of the leg, sometimes giving rise to a one-sided bow-leggedness. The remaining
causes are occupational, especially among jockeys, and from physical trauma, the condition
being very likely to supervene after accidents involving the condyles of the femur.
Adults with rickets are thought to be bowlegged due to horse back riding.
101

102. 2.Genu valgum: Genu valgum, commonly called
"knock-knees", is a condition where the knees angle in and touch one
another when the legs are straightened. Females have a wider pelvis
than men and a relatively shorter length of the thigh bone, and as a
result, have a greater static genu valgum than men. Individuals with
severe valgus deformities are typically unable to touch their feet together
while simultaneously straightening the legs. The term originates from
the Latin genu, "knee", and valgus, "bent inward". For a discussion of
the etymology of valgus, see the entry under varus.
Mild genu valgum can be seen in children from ages 2 to 5, and is often
corrected naturally as children grow. However, the condition may
continue or worsen with age, particularly when it is the result of a
disease, such as rickets or obesity. Idiopathic is the term used to
describe genu valgum that is congenital or has no known cause.
102

103. 3.Genu Recurvatum: Etymology: L, genu, knee, recurvare, to
bend back: A deformity in which the lower leg is hyperextended at the knee
joint. Also called back knee.
Genu recurvatum denotes hyperextension of the tibiofemoral joint. It can be
subdivided into constitutional physiological and acquired pathological
variants. Constitutional genu recurvatum is generally bilateral, symmetric, <
15°, and asymptomatic. Acquired genu recurvatum usually is unilateral, >
15°, and often symptomatic. Acquired genu recurvatum is known to have
multiple causative factors including physeal
trauma, osteomyelitis, poliomyelitis, tibial wire traction, and soft-tissue
trauma. To emphasize the pathoanatomical changes responsible for genu
recurvatum, Moroni et al qualified the deformity into three subtypes:
bony, soft tissue, and combined bony and soft tissue. Signs and symptoms of
pathological genu recurvatum include weakness, pain, and instability. The
degree of deformity differed between them, but deformities began at the same
age in both (17 years) and progressed over a short period.
103

104. Foot
1.Flat feet: Flat feet (also called pes planus
or fallen arches) is an informal reference to a
medical condition in which the arch of the foot
collapses, with the entire sole of the foot coming into
complete or near-complete contact with the ground. In
some individuals (an estimated 20–30% of the general
population) the arch simply never develops in one foot
(unilaterally) or both feet (bilaterally).
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105. Flat feet in children: The appearance of flat feet is normal and common in infants,
partly due to "baby fat" which masks the developing arch and partly because the arch has not
yet fully developed. The human arch develops in infancy and early childhood as part of
normal muscle, tendon, ligament and bone growth. Training of the feet, especially by foot
gymnastics and going barefoot on varying terrain, can facilitate the formation of arches
during childhood, with a developed arch occurring for most by the age of four to six years.
Flat arches in children usually become proper arches and high arches while the child
progresses through adolescence and into adulthood.
 Because young children are unlikely to suspect or identify flat feet on their own, it is a good
idea for parents or other adult caregivers to check on this themselves. Besides visual
inspection, parents should notice whether a child begins to walk oddly, for example on the
outer edges of the feet, or to limp, during long walks, and to ask the child whether he or she
feels foot pain or fatigue during such walks.
 Flat feet of a child are usually expected to develop into high or proper arches, as shown by
feet of the mother.
 Children who complain about calf muscle pains or any other pains around the foot area, may
be developing or have flat feet. Pain or discomfort may also develop in the knee joints. A
recent randomized controlled trial found no evidence for the treatment of flat feet in children
either for expensive prescribed orthoses (shoe inserts) or less expensive over-the-counter
orthoses.
105

106. Flat feet in adults:
 Flat feet can also develop as an adult ("adult acquired flatfoot") due to
injury, illness, unusual or prolonged stress to the foot, faulty biomechanics,
or as part of the normal aging process. Flat feet can also occur in pregnant
women as a result of temporary changes, due to increased elastin (elasticity)
during pregnancy. However, if developed by adulthood, flat feet generally
remain flat permanently.
 Flatfoot in a 55 years old female with ankle and knee arthritis.
 If a youth or adult appears flatfooted while standing in a full weight bearing
position, but an arch appears when the person dorsiflexes (stands on heel or
pulls the toes back with the rest of the foot flat on the floor), this condition is
called flexible flatfoot. This is not a true collapsed arch, as the medial
longitudinal arch is still present and the Windlass mechanism still operates;
this presentation is actually due to excessive pronation of the foot (rolling
inwards), although the term 'flat foot' is still applicable as it is a somewhat
generic term. Muscular training of the feet, while generally helpful, will
usually not result in increased arch height in adults, because the muscles in
the human foot are so short that exercise will generally not make much
difference, regardless of the variety or amount of exercise. However, as long
as the foot is still growing, it may be possible that a lasting arch can be
created.
106

107. 2.Foot drop: Foot drop is a deficit in turning the ankle and
toes upward, known as dorsiflexion. Therefore, the foot will hang inferiorly.
The deep fibular/peroneal nerve innervates the anterior compartment of the
leg. Damage to this nerve will lead to the inability for the leg to dorsiflex the
foot, therefore causing foot drop. Conditions leading to foot drop may be
neurologic, muscular or anatomic in origin, often with significant overlap.
The result is an abnormal gait.
Features
Foot drop is characterized by steppage gait. When the person with foot drop
walks, the foot slaps down onto the floor. To accommodate the toe drop, the
patient may use a characteristic tiptoe walk on the opposite leg, raising the
thigh excessively, as if walking upstairs, while letting the toe drop.
107

108. 3.Hammer toe: A hammer toe is a deformity of the
proximal interphalangeal joint of the second, third, or fourth toe causing it to be
permanently bent, resembling a hammer. Mallet toe is a similar condition affecting
the upper joint.
Causes
Hammer toe most frequently results from wearing poorly-fit shoes that can force the
toe into a bent position, such as excessively high heels or shoes that are too short or
narrow for the foot. Having the toes bent for long periods of time can cause the
muscles in them to shorten, resulting in the hammer toe deformity. This is often found
in conjunction with bunions or other foot problems. It can also be caused by
muscle, nerve, or joint damage resulting from conditions such as
osteoarthritis, rheumatoid arthritis, stroke, Charcot-Marie-Tooth disease or diabetes.
Treatment
In many cases, conservative treatment consisting of physical therapy and new shoes
with soft, spacious toe boxes is enough to resolve the condition, while in more severe
or longstanding cases orthopedic surgery may be necessary to correct the deformity.
108

109. 4.Hallux rigidus: Hallux rigidus is a condition restricting
dorsiflexion of the hallux ("big toe").
Symptoms
 Pain in the big toe when walking, standing, running or even during rest
 Inflammation around the toe
Cure
 During the early stages, one can place the foot in warm water for few
minutes which may relieve the pain and ointment can be applied after drying
the foot completely
 Taking enough rest
 Removing the dead skin with pumice stone
 Foot massage releaves pain
109

110. 5.Hallux varus: Hallux varus is a deformity
of the great toe joint where the hallux is deviated
medially (towards the midline of the body) away
from the first metatarsal bone. The hallux usually
moves in the transverse plane.
110

111. 6.Bunion(hellux velgus):
A bunion is a structural deformity of the bones and the joint between the foot and big toe,
and may be painful. A bunion is an enlargement of bone or tissue around the joint at the
base of the big toe (metatarsophalangeal joint).The big toe may turn in toward the second
toe (angulation), and the tissues surrounding the joint may be swollen and tender.
 Today the term usually is used to refer to the pathological bump on the side of the great toe
joint. The bump is the swollen bursal sac and/or an osseous (bony) deformity that has
grown on the mesophalangeal joint (where the first metatarsal bone and hallux meet).
Symptoms
 The symptoms of bunions include irritated skin around the bunion, pain when walking, joint
redness and pain, and possible shift of the big toe toward the other toes.
Treatment
 Bunions may be treated conservatively with changes in shoe gear, different orthotics
(accommodative padding and shielding), rest, ice, and medications. These sorts of
treatments address symptoms more than they correct the actual deformity. Surgery, by a
podiatrist or an orthopeadist, may be necessary if discomfort is severe enough or when
.
correction of the deformity is desired
111

112. Bunion cont….
Hallux Valgus (Bunion Deformity): The big toe of
the foot is called the hallux. If the big toe starts to deviate inward in
the direction of the baby toe the condition is called hallux valgus. As
the big toe drifts over into valgus, a bump starts to develop on the
inside of the big toe over the metatarsal bone. This bone prominence
on the inner edge for the metatarsal is referred to as a bunion.
112

113. 6.Metatarsalgia: Metatarsalgia (literally metatarsal pain, colloquially
known as stone bruise) is a general term used to refer to any painful foot condition
affecting the metatarsal region of the foot. This is a common problem that can affect
the joints and bones of the metatarsals. Metatarsalgia is most often localized to the
first metatarsal head (the ball of the foot just behind the big toe). There are two small
sesamoid bones under the first metatarsal head. The next most frequent site of
metatarsal head pain is under the second metatarsal. This can be due to either too
short a first metatarsal bone or to "hypermobility of the first ray" (metatarsal bone +
medial cuneiform bone behind it), both of which result in excess pressure being
transmitted into the second metatarsal head.
Common causes of metatarsalgia include interdigital neuroma (also known as Morton
neuroma), metatarsophalangeal synovitis, avascular necrosis, sesamoiditis, and
inflammatory arthritis; however, these causes are often diagnosed separately.
113

114. 7.Cock-up deformity: Cockup of the great toe is
characterized by persistent extension of the first
metatarsophalangeal joint; the interphalangeal joint also may be
involved. The syndrome has many causes, all easily diagnosed.
Surgery is indicated in nearly every instance and will produce a
corrected or improved result. The type of surgery--whether reefing,
lengthening, or transposition of tendons, implant arthroplasty, or
arthrodesis--is tailored to the underlying cause.
114

115. Patella
1.Luxating patella: Luxating patella (or trick
knee, subluxation of patella, or floating patella), is a condition in which
the patella, or kneecap, dislocates or moves out of its normal location.
Patellar luxation is a common condition in dogs, particularly small and
miniature breeds. The condition usually becomes evident between the ages of 4
to 6 months. It can occur in cats as well, especially the Domestic Shorthair.
Causes:
Rarely, it can be caused by some form of blunt trauma, but most frequently, it
is a developmental congenital defect. In congenital cases, it is frequently
bilateral. The condition can also be inherited through genetics.
115