Problems
1. Lower limb
All walk
- Ankle > knee > hip
Ankle
- most require operations for ankles
LLD
- unilateral underdevelopment
- LLD 0-5cm (average 2cm)
2. Lower limb
- one handedness
- decrease movement in swing
- astereogenesis
- usual upper limb contractures
Ankle
4 problems
1. Equinus
2. Weak Dorsiflexion
3. STJ Varus
4. Valgus
Equinus
Non operative
Up to age 4
- AFO
- Botox
- corrective casts for fixed equinus
Operative
Indications
- > age 4
- nil heel strike
- recurvatum with fixed equinus
Options
- Bauman
- Strayer
Remember "Little equinus better than calcaneus"
- use Gait analysis
Foot Drop after T Achilles Release
Non-operative
Leaf spring AFO / Articulated AFO
Operative
Tendong transfer
- tendon active in swing phase to foot dorsum
- FDL is the best option
- dynamic EMG to decide
Dynamic Equinovarus
Non-operative
Passively correctable
- Botox
- AFO
Operative
Gait analysis important
- caused by T anterior: varus in swing
- caused by T posterior: varus in stance and swing
T posterior
- split transfer to PB
- + T achilles lengthening
T anterior
- SPLATT + T achilles lengthening
Bony changes
Triple arthrodesis
Valgus Deformity
Less Common
Aetiology
- often due to tight T achilles
- attempt DF by escape into valgus
Management
Respond to T achilles lengthening
If severe need Triple arthrodesis
Upper limb
4 problems
1. Thumb in palm
2. Flexed wrist / fingers
3. Elbow contracture
4. Shoulder IR and Adducted
Concepts
If astereognosis, correcting the hand posture is unlikely to give functional gains
Need voluntary control & desire to manipulate environment
Thumb in Palm Deformity
Common but difficult to treat
Options
A. Adductor Pollicis & Short flexors released
- may need release web space contractures
- FPL lengthened
B. EPB ± EPL reinforced with PL, FCR or BR
C. MCPJ stabilized by capsulodesis or arthrodesis
Wrist & Finger Deformity
Findings
Flexed and pronated wrist
Flexed fingers + Swan Neck
Pathology
Shortening of FCU / FDP / FDS / Pronator
Weakness of wrist extension
Management
Wrist deformity
- FCU to ECRL / EDC
- wrist arthrodesis salvage
Finger Flexion
- lengthening at musculotendinous junction
Swan-Neck Deformity
- FDS Slip tenodesis PIPJ
Elbow Flexion Contracture
Indications
- >45°
Management
Botox
Z-Lengthen of Biceps insertion / release of lacertus fibrosis / Release of brachialis
Distal release of PT for pronation contracture
4. Shoulder
Usually IR & Add
Management
Release of SSC & T major ± P major