Tarsal Coalition

Tarsal coalition is a congenital anomaly in which the tarsal bones fuse together, leading to a rigid flat foot, foot pain, and multiple ankle sprains. There are two types of tarsal coalition. The first is known as a Talocalcaneal Coalition, which is a coalition between the talus and the calcaneus. The second is referred to as a calcaneonavicular coalition which is a coalition between the calcaneus and the navicular. When talocalcaneal coalition occurs, it usually happens around 12-15 years of age. The calcaneonavicular coalition presents at an earlier age. About 50% of coalitions are bilateral, and around 20% have multiple coalitions in the same foot. Coalition may be fibrous, cartilaginous, or bony and occurs due to failure of segmentation. It could be associated with fibular hemimelia or Apert’s syndrome.

tarsal anatomy

Symptoms typically consist of patient’s complaining of a painful foot, a history of repeated ankle sprains, and a flat foot deformity. Tarsal coalition may result in a peroneal spastic flat foot. During the physical examination, the physician may find hindfoot valgus. On toe standing, the arch does not reconstitute and heel cord contracture may also be evident during the exam. Furthermore, there may be restriction in the subtalar joint’s range of motion. It is important to check both feet as the condition may be bilateral.

hindfoot

The best imaging study is a CT scan. It can determine the size and location of the coalition. And MRI is also useful in detecting a fibrous or cartilaginous coalition. AP, Lateral, and Oblique view x-rays should be ordered. On a lateral view x-ray, the Calcaneonavicular Coalition can be identified by the “anteater nose sign” and the elongation of the anterior calcaneal process.

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A lateral view of a Talocalcaneal Coalition may show talar beaking which is a traction spur that occurs due to the limited motion of the subtalar joint. Additionally, the C sign may be seen which is a radiological sign outlining the talar dome and the sustentaculum. A 45° oblique view is the best for showing calcaneonavicular coalitions.

45oblique

Nonoperative treatment usually consists of anti-inflammatory drugs, modified activities, or the use of a brace or cast. Surgical treatment for the calcaneonavicular coalition usually consists of resection with an interposition of the extensor digitorum brevis muscle or a fat graft no matter the size of the coalition. Similarly, Talocalcaneal coalitions that involve less than 50% of the subtalar joint are also resected. A triple arthrodesis procedure is performed for large coalitions, failed resections, or advanced conditions.

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Low Back Pain- Disc Herniation

The spine is comprised of bony vertebrae separated by discs. The neural structures of the spine include the spinal cord (T12-L1), The conus medullaris—which is the lower end of the spinal cord, and the Cauda Equina, which is the division of multiple nerve roots beginning at the level of L1. Conditions of the lumbar spine including disc herniation are a main cause of lower back pain.

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The lumbar spine (lower back) consists of five vertebrae numbered L1-L5. These vertebrae are attached to the sacrum at the lower end of the spine. The discs between the vertebrae are round cushioning pads which act as shock absorbers. In a normal disc, there are two layers—the inner disc layer, which is comprised of soft gelatinous tissue and known as the Nucleus Pulposus, and the outer disc layer—which is made up of thick strong tissue, which is known as the Annulus Fibrosis. Behind this disc lies the spinal nerve root and the cauda equina. A major disc herniation of the lumbosacral region could affect the nerve roots.

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In about 95% of all disc herniation cases, the L4-L5 or L5-S1 disc levels are involved. Herniation of the L4-L5 disc will affect the L5 nerve root. Herniation of the L5-S1 disc will affect the S1 nerve root.

spinesections

There are three types of disc herniation:

  1. Protrusion/ Bulge- A bulging disc with intact annular and posterior longitudinal ligament fibers
  2. Disc Herniation
    • Type A—Disruption of inner annular fibers with intact outer annular fibers
    • Type B—Disrupted annulus with tail of disc material extending into the disc space
  3. Sequestration
    • Free fragment without tail extending into disc space
    • Fragment may be reabsorbed spontaneously
    • May get better with the use of an epidural

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There are three typical locations for disc herniation as well:

  1. Central
    • Involves multiple nerve roots
    • Predominantly causes low back pain more than leg pain
    • May cause incontinence of the bladder and bowel
    • Urgent surgical treatment if patient presents with neurological deficits
  2. Posterolateral—usual location, most commonly involving one nerve root (the lower one)
    • For example: L4-L5 posterolateral herniation will involve L5 nerve root
  3. Foraminal
    • Occurs in 8-10% of cases
    • Involves the exiting nerve
    • Example: L4-L5 foraminal herniation will involve the L4 nerve root

Discogenic Back Pain is an internal disc disruption with early disc degeneration. Pain gets worse with flexion and sitting but, gets slightly better with extension. Forward flexion is limited on the exam and there are no radicular symptoms.

Child Abuse

Child abuse most often occurs under 3 years of age, and if it is not recognized and reported, repeat abuse may occur in 40% of the cases. Death can occur in up to 5% of cases.

Risk factors for Child Abuse include:

  • Being the first born child
  • Single Parent
  • Stepchild
  • Disabled Child
  • Parents were abused

It is important to rule out osteogenesis imperfecta and metabolic bone disease.

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Suspect Child abuse if:

  • There is a fractured femur in an infant before walking age
    • The most common orthopaedic injury associated with child abuse is a femur fracture
  • Multiple fractures in different stages of healing
    • Callus and periosteal reaction is seen
  • Unwitnessed spiral fracture
    • Spiral fractures are not a good criteria because most of them are accidental
  • Multiple soft tissue bruising
    • Skin lesions are the most common
    • Bone fracture is the second most common

skin lesions

  • Corner fracture
    • Metapheseal fracture especially in the distal femur and proximal tibia
    • Child abuse should be considered when health care providers see cornercornerfx fractures in children before they are of walking age.
  • Posterior rib fracture from a squeezing injury
  • If there is a transepiphyseal separation in the humerus
    • In Newborns
      • The olecranon moves posteriorly
      • Looks like an elbow dislocation
    • Older Child
      • Separation of the distal humerus usually occurs in younger ages

Discrepancy in the history is a clue. It is hard to explain the injury and match it with the given mechanism of the injury. Injuries in abuse mostly occur at the humerus, tibia, and femur (more in the diaphysis). When child abuse is suspected in a patient it is important to recognize the symptoms, be non-judgmental, and obtain a skeletal survey. If you suspect abuse and a skeletal survey is negative, obtain a bone scan to verify. Then consult protective services. The most frequent cause of long-term morbidity in an abused child is a head injury.

Stiff Knee

Extension contracture of the knee can result from different causes, but it usually occurs from trauma. The patient is unable to bend the knee to a functional level.

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Trauma will cause adhesions inside the knee, fibrosis, and shortening of the knee ligaments.

There will also be adhesions and shortening of the quadriceps muscles.

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Treatment

Treatment will usually begin with therapy. The first surgical option will include an arthroscopy and the release of any adhesions. The second surgical option that may be considered as a quadricepsplasty (Thompson or Judet) or a combination of treatments.

An example of a combination treatment plan would be a modified Judet quadricepsplasty with the release of the quadriceps muscle from the femur and a release of the adhesions that are located inside the knee.

After surgery the surgeon can usually achieve 90° plus flexion.