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1、Mb1,小組教學,兒童非創傷性骨科急症,Mb2,個案討論一,15個月大小女孩活潑好動,走路很穩,但是跑步常跌倒,媽媽注意到她的腳趾頭和哥哥相比,較朝向內側彎,雖然常跌倒,但可立即爬起並繼續遊戲,小女生其它方面很健康,沒有其他疾病,沒有服用藥物,也沒過敏病史.,Mb3,醫生,嚴不嚴重?,Mb4,初級評估(1/2),PATAppearance:Playful and alertWork of breathing:Normal Circulation:Normal Vital sign PR 100/min RR 22/min BT 36C,Mb5,初級評估(2/2),ABCDE:normal ex
2、cept bilateral toes pointed in.,Mb6,重要病史,S:often falls when she runsA:No allergies,formulafedM:No medicne P:L:2 hours agoE:bilateral toes point inward when she walk,Mb7,過去史,出生史:NSVD,Full-term,Apgar score 1(9)5(9),BBW 3700gmNormal developmental milestones on scheduled and started walking at 12 months
3、.She eats a diverse diet,including meats,fruits,and vegetables,and drinks whole milk.No prefenerce for either hand and uses both well.,Mb8,家族史,There is no family history of cerebral palsy,learning disabilities,brain tumors,progressive neurological diseases,or spina bifida.The childs fathers toes poi
4、nted in when he was a toddler;he wore corrective shoes connectly by a bar and currently has a normal gait.,Mb9,詳細理學檢查(1/3),She is at the 50th percentile for height,weight,and head circumference.HEENT,Chest,Heart,ABD:normal Neuro:Normal neurologic exam and a normal spine without evidence of a dimple
5、or tuft of hair at the sacrum.,Mb10,詳細理學檢查(2/3),ExtrimitiesHer legs are of equal lengthNo clicks or clunks with Ortolani and Barlow maneuvers and the hips have a full range of motion.The lateral aspect of the the feet are straight,the feet are easy dorsiflexed above the neutral position(90 degree)an
6、d the heel is midline without varus or valgus deformity.,Mb11,詳細理學檢查(3/3),The child sit on the examination table with her leg dangling over the edge,you find the lateral malleolus to be aligned with the medial malleolus.Her feet pointed inward and her patellae point forward as she ambulate.No eviden
7、ce of spasticity,ataxia,or pain.,Mb12,問題,診斷為何?如何治療?需要轉診小兒骨科嗎?,Mb13,Metatarsus adductus,Mb14,“v”finger test,Mb15,Severity of Metatarsus adductus,Mb16,Metatarsus adductus,Mb17,治療metatarsus Adductus,2-4月大前可用stretching exercise,效果不顯著則採用casting,通常6個月大前用casting效果較好.嚴重個案則在出生1-2個月內轉診做 serial casting night s
8、plinting.85-90%個案會自行痊癒,Mb18,Internal tibia torsion(ITT),Mb19,診斷 ITT(1),Bimalleolar axis(the degrees that lateral malleolar is posterior to the medial)-In the newborn:2-4 degrees-By 5 Y/O:9 degree-At maturation:15-22 degrees*ITT(+)if the lateral malleolar is less posterior than this,Mb20,Bimalleolar
9、axis,Mb21,診斷 ITT(2),An internal Thigh foot angle is indicative of internal tibial torsionObservation of the gait of the childs gait can also aid in the diagnosis.,Mb22,Thigh-Foot angle,Mb23,處置,By the time 95%of children with ITT reach 7 to 8 years old,the ITT has resolved and no intervention is requ
10、ired.Denis Browne splintRotational osteotomy of the tibia,Mb24,Denis-Browne bar at night for 6-12 months,Mb25,Wheaton Bracing-Night wear for 6 months usually corrects the ITT.,Mb26,Femoral anteversion,Mb27,Femoral anteversion,Mb28,臨床表徵,e.g.Internal rotation as much as 90 degrees and external rotatio
11、n is only 10 to 30 degrees.On observation the gait,note that both the patellae and feet point inward.,Mb29,the normal range being equal,approximately 70 degrees each way,Mb30,還有其他鑑別診斷,Radiography of the pelvis,knees,wrists and spine to confirm or exclude skeletal dysplasia or metabolic bone diseaseR
12、adiography or MRI of the hip to exclude DDHMRI to exclude cerebral palsy,spinal bifida,and intracranial abnormalityBlood tests to exclude metabolic bone disease,Mb31,預後,Spontaneous resolution of intoeing secondary to femoral anteversion occurs in more than 95%of affected children.If intoeing persist
13、s after 8 to 10 years of age,is cosmetically unaceptable,and functional problems with gait,some recommend derotational osteotomy.Complications occur in approximately 15%of patients.,Mb32,足內翻應多方面考慮,Mb33,個案討論(二),12歲女生由媽媽帶來急診室,主訴右膝疼痛近一個月,越來越嚴重,尤其上下樓梯及踢足球時最明顯,壓痛也明顯.右膝外觀腫脹,但無紅熱現像.右膝不曾跌傷也無其它疾病.檢查起來,右側tibi
14、al tubercle是痛點,右膝伸展抗力檢查時很痛,活動範圍正常,靭帶穩定而且無膝關節積水.,Mb34,問題,診斷為何?需要X光檢查嗎?如何治療?,Mb35,診斷及治療方法,診斷為Osgood-Schlatter disease診斷依據年齡,病史,及理學檢查,X光不一定需要治療-NSAID+RICE-休息(避免持續收縮股四頭肌)預後:可以完全緩解,通常12-24months,Mb36,Mb37,Osgood-Schlatter disease,常見於生長高峯期之青少年,男孩12-14歲,女孩10-12 歲男孩女孩常見單側,也有25%雙側長見相關活動如籃球,足球,芭蕾舞,體操等,Mb38,重點
15、,常見非創傷性骨科疾病隨年齡變化有異完整病史應包括疼痛特徵,位置,性質,及變化多數病患和創傷病史及較大活動量有關膝部疼痛別遺漏髖關節（hip）檢查X光用於排除其它診斷骨科轉診是有必要的,Mb39,個案討論(三)-1/2,三歲男生因為膝內翻(bowleg)由母親帶來門診,主訴小孩自開使學走路便膝內翻,因其哥哥也有相同情形,不過三歲前就自然消失,所以原本不以為意,但是小男生並位改善,而且走路有一點搖擺,跑跳 時並不會痛,過去不曾受傷,除感冒吃藥外,未曾吃藥.,Mb40,個案討論(三)-2/2,出生史正常,頭部先露,經因產道生產,出生體重3450公克,和一般兒童相同,飲食正常,成長mile-ston
16、es並未落後或提早,也差不多11月開使走路,媽媽也未提及特別家族使或異常之處.走路時膝部擠向外,平躺時雙腳等長,無法拉直,膝關節打直時穩定,但彎屈10-20度時,medial femoral condyles 會往內側後面sublux.,Mb41,理學檢查,Speak well and interacts appropriately for ageHeight:50th percentileWeight:90th percentileHEENT,Lung,CV,ABD,Neuro are normal,Mb42,Intercondylar distance 12 cm,Mb43,問題,下一步如
17、何評估?一般成長孩童常見嗎?是什麼病?,Mb44,Mb45,Blount disease,最常見病理性（pathological）膝內翻脛骨（tibia）近端內側內生軟骨骨化異常脛骨內轉（internal torsion of tibia）導致膝內翻惡化嬰兒型(infantile type)常見於三歲以下肥胖黑人小孩,75%雙側皆受影響,較青少年型嚴重(aldolescent type);後者多見於六歲以後,單側居多,多因膝內翻遲未改善而被發現.,Mb46,診斷方法,病史臨床表現影像檢查,Mb47,Blount disease臨床徵象(1/2),Medial metaphysis 的鳥嘴變化(
18、beaking)可以在膝內側觸摸到走路時步態不穩且膝關節被擠向外膝關節打直時穩定,彎屈20度時會因為medial tibia plateau depressed而有向內後方subluxation現像,稱之為Siffert-Katz sign,在X光便化之前就會表現出來,Mb48,Blount disease臨床徵象(2/2),Intercondyle distance 6cmShort statureWeight excessive for height Severe deformityPalpable metaphyseal beakingKnee instabilityKnee painP
19、resence of Siffert-Katz sign,Mb49,影像學發現,Metaphyseal beakingVarus angulation of proximal tibiaIrregularity ossified epiphysisExcessive Drennan angle(metaphyseal-diaphyseal angle-in children 2 Y/O:11 degrees-in children 16 degrees,Mb50,處置,觀察轉診至骨科評估治療 若是生理足性膝內翻至7-8歲仍未改善,要高度懷疑病理性.,Mb51,Langenskiolds six
20、 stages of Blount disease,Mb52,鑑別診斷,Inflammatory-Infection,postinfectious,rheumatoid arthritis TumorOsteochondromaPosttraumatic-Growth arrest and angular overgrowthCongenital deformitiesBlount diseaseOsteogenesis imperfectaMetabolic-Rickets and Renal osteodystrophy,Mb53,Tibiofemoral angle,Mb54,Devel
21、opment of TFA during growth,Mb55,Leg alignment 依年齡產生之變化,Mb56,Bowleg of child,Mb57,個案討論四:“跛行”,六歲男生右腳跛行三個月,多次在診所看診吃止痛藥,一直未改善最進並無發燒發冷或其它疾病除右髖關節移動會痛之外,兩側膝關節及踝關節活動範圍正常,無壓痛.,Mb58,問題,可能診斷為何?鑑別診斷為何?處置優先次序為何?,Mb59,鑑別診斷,Toxic synovitisSeptic arthritis/osteomyelitisFractureTumor/metastasisAvascular necrosis(Le
22、gg-Calv-Perthes disease LCP),Mb60,放射檢查,你有什麼發現?,Mb61,Radiograph:LCP,Mb62,Legg-Calv-Perthes Disease,Avascular necrosis leading to collapse,fragmentation,and then reossificationMost frequent between 4 and 9 years Boys more often than girlsBilateral in 10%of cases,Mb63,臨床表徵:你的線索,Knee or hip painLimpShor
23、tened limbLimited range of motion of hip,Mb64,診斷工具,RadiologyAP and frog-leg pelvis radiographsFindingsFemoral head smaller and cartilage space appears widerCrescent signFragmented femoral headless radiopaqueMRI,Mb65,處置,LCP為自限性疾病,但症狀會持續好幾年 NSAIDs限制活動丁形柺杖或支架也會有些幫助,可減輕股骨頭負重越年輕發病預後越好,Mb66,個案進展及結果,向家屬解釋LCP disease安排病人定期於骨科門診追蹤治療患者需限制活動併服用 NSAIDs多數患者在兩年內關節功能可完全恢復,
