Mark and others:
Mark wrote:
"Colleagues
This morning I examined a six-month-old girl with extremely restricted
range of motion in right ankle joint - approximately 5-10 degrees. The
foot is held in a neutral mid-stance position. Radiographic examination
reveals no bony abnormality or malformation. Forced extension or flexion
causes obvious distress. Birth was unremarkable except that the baby was
in a breached position until two weeks prior to delivery then she
righted herself. Normal delivery - no forceps or suction. The left ankle
ROM is as one would expect in a six-month-old baby - more than adequate.
No adverse family history. No neurological symptoms. No sensory loss.
My thoughts were that she may have had the ankle extended for a
protracted period - perhaps against the womb wall - during pregnancy and
this has caused contracture of the anterior muscle compartment and
associated soft tissues. Is this feasible given six months have elapsed?
Also, is there any other investigations/treatment that can be offered
aside from gradual manipulation?
Thanks in anticipation.
Mark Russell"
I have been following this query since yesterday which Mark posted here
as well as on Craig Payne's Podiatry Arena web site.
My first thought when I read it was that the infant has a calcanevalgus
which Tony Achilles has already suggested. This is consistent with the
dorsiflexed position of the foot described. However, these feet usually
have quite a bit of range of motion in the direction of dorsiflexion
which does not seem to be the case here. That makes me suspicious of a
vertical or oblique talus which present more often with reduced
dorsiflexion and plantarflexion. Here, however, overall subtalar and
midtarsal motion would be reduced as well. If as you said in the
original post that radiographs were normal this would also argue against
out vertical talus which would exhibit a dislocated talo-navicular joint
with severe plantarflexion of the talus and the neck of the talus
articulating with the cartilaginous anlog of the navicular. That leads
me to the likelihood of either severe calcaneovalgus or obligue talus
syndrome which is a variant with severe obliquity of the talus in the
sagittal plane making it more like vertical talus but without the
dislocated T-N joint. I would take another look at that lateral x-ray
and assess the T-N joint more carefully. I would also make sure there
are no neurological problems if vertical talus is a possibility.
If oblique talus or severe calcanevalgus is the diagnosis, then attempts
to improve the sagittal plane position and range of motion of the ankle
with manipulations, tapings or plaster cast applications are my
management suggestions.
You ask, too, if positional etiologies stemming from intra-uterine
pressure are possible presenting at 6 months out from delivery. I say,
indeed, as all too many conditions present to us at older ages than they
should because no one notices, no one refers, or parents just wait until
gait and the onset of bigger problems. There, I feel better...
Regards,
Russ
Russell G. Volpe, DPM
Professor
Department of Pediatrics and Orthopedics
New York College of Podiatric Medicine
Foot Clinics of New York
1800 Park Avenue
New York, New York 10035
phone 212 410-8129
fax 212-410-8440
-----Original Message-----
From: A group for the academic discussion of current issues in podiatry
[mailto:[log in to unmask]] On Behalf Of Mark Russell
Sent: Tuesday, November 09, 2004 9:58 AM
To: [log in to unmask]
Subject: Re: Paediatric problem - advice requested.[Scanned]
Thanks Kevin. Often the simple approach works best - I'll let you know
how
we get on. Yes and of course you are right - it should have read
six-month-
old.
Best wishes
Mark Russell
-----------------------------------------------------------------
This message was distributed by the Podiatry JISCmail list server
All opinions and assertions contained in this message are those of
the original author. The listowner(s) and the JISCmail service take
no responsibility for the content.
to leave the Podiatry email list send a message containing the text
leave podiatry
to [log in to unmask]
Please visit http://www.jiscmail.ac.uk for any further information
-----------------------------------------------------------------
-----------------------------------------------------------------
This message was distributed by the Podiatry JISCmail list server
All opinions and assertions contained in this message are those of
the original author. The listowner(s) and the JISCmail service take
no responsibility for the content.
to leave the Podiatry email list send a message containing the text
leave podiatry
to [log in to unmask]
Please visit http://www.jiscmail.ac.uk for any further information
-----------------------------------------------------------------
|
