《Mb--兒童非創傷之骨科急症(2)-邱德發+張玉》由会员分享，可在线阅读，更多相关《Mb--兒童非創傷之骨科急症(2)-邱德發+張玉（66页珍藏版）》请在金锄头文库上搜索。
1、小組教學兒童非創傷性 骨科急症Mb1個案討論一n15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.2醫生,嚴不嚴重?3初級評估(1/2)PATnAppearance: Playful and alertnWork of breathing: Normal nCirculation: Normal Vital signPR 100/min RR 22/min BT 36C 4初級評估(2/2)nABCDE: normal except bi
2、lateral toes pointed in.5重要病史nS: often falls when she runsnA: No allergies, formulafednM: No medicne nP:nL: 2 hours agonE: bilateral toes point inward when she walk6過去史n出生史: NSVD,Full-term,Apgar score 1(9)5(9), BBW 3700gmnNormal developmental milestones on scheduled and started walking at 12 months.
3、nShe eats a diverse diet,including meats, fruits,and vegetables,and drinks whole milk.nNo prefenerce for either hand and uses both well.7家族史nThere is no family history of cerebral palsy, learning disabilities, brain tumors, progressive neurological diseases, or spina bifida.nThe childs fathers toes
4、pointed in when he was a toddler; he wore corrective shoes connectly by a bar and currently has a normal gait.8詳細理學檢查(1/3)nShe is at the 50th percentile for height, weight, and head circumference.nHEENT,Chest,Heart,ABD: normal nNeuro: Normal neurologic exam and a normal spine without evidence of a d
5、imple or tuft of hair at the sacrum.9詳細理學檢查(2/3) ExtrimitiesnHer legs are of equal lengthnNo clicks or clunks with Ortolani and Barlow maneuvers and the hips have a full range of motion. nThe lateral aspect of the the feet are straight, the feet are easy dorsiflexed above the neutral position(90 deg
6、ree) and the heel is midline without varus or valgus deformity.10詳細理學檢查(3/3)nThe 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.nHer feet pointed inward and her patellae point forward as she ambulate.nNo
7、evidence of spasticity, ataxia, or pain. 11問題n診斷為何?n如何治療?n需要轉診小兒骨科嗎?12Metatarsus adductus13“v” finger test14Severity of Metatarsus adductus15Metatarsus adductus16治療metatarsus Adductusn2-4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.n嚴重個案則在出生1-2個月內轉診做 serial casting night splinting.
8、n85-90% 個案會自行痊癒17Internal tibia torsion(ITT)18診斷 ITT(1)nBimalleolar 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 19Bimalleolar axis 20診斷
9、ITT(2)nAn internal Thigh foot angle is indicative of internal tibial torsionnObservation of the gait of the childs gait can also aid in the diagnosis.21Thigh-Foot angle22處置nBy the time 95% of children with ITT reach 7 to 8 years old, the ITT has resolved and no intervention is required.nDenis Browne
10、 splintnRotational osteotomy of the tibia23Denis-Browne bar at night for 6- 12 months 24Wheaton Bracing- Night wear for 6 months usually corrects the ITT. 25Femoral anteversion26Femoral anteversion27臨床表徵ne.g.Internal rotation as much as 90 degrees and external rotation is only 10 to 30 degrees.nOn o
11、bservation the gait, note that both the patellae and feet point inward. 28the normal range being equal, approximately 70 degrees each way29還有其他鑑別診斷nRadiography of the pelvis,knees,wrists and spine to confirm or exclude skeletal dysplasia or metabolic bone diseasenRadiography or MRI of the hip to exc
12、lude DDHnMRI to exclude cerebral palsy,spinal bifida, and intracranial abnormalitynBlood tests to exclude metabolic bone disease30預後nSpontaneous resolution of intoeing secondary to femoral anteversion occurs in more than 95% of affected children.nIf intoeing persists after 8 to 10 years of age, is c
13、osmetically unaceptable, and functional problems with gait, some recommend derotational osteotomy.nComplications occur in approximately 15% of patients.31足內翻應多方面考慮32個案討論(二)n12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tibial tubercle是痛點,右膝伸展抗力檢查時很 痛,活動範圍正
14、常,靭帶穩定而且無膝關 節積水.33問題n診斷為何?n需要X光檢查嗎?n如何治療?34診斷及治療方法n診斷為Osgood-Schlatter diseasen診斷依據年齡,病史,及理學檢查,X光不 一定需要n治療-NSAID+RICE-休息(避免持續收縮股四頭肌)n預後:可以完全緩解,通常12-24months 3536Osgood-Schlatter diseasen常見於生長高峯期之青少年,男孩12-14 歲,女孩10-12 歲n男孩女孩n常見單側,也有25%雙側n長見相關活動如籃球,足球,芭蕾舞,體操 等 37重點n常見非創傷性骨科疾病隨年齡變化有異n完整病史應包括疼痛特徵,位置,性質,
15、及 變化n多數病患和創傷病史及較大活動量有關n膝部疼痛別遺漏髖關節（hip）檢查nX光用於排除其它診斷n骨科轉診是有必要的38個案討論(三)-1/2n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.39個案討論(三)-2/2n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-stones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
16、家族使或 異常之處.n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.40理學檢查nSpeak well and interacts appropriately for agenHeight : 50th percentilenWeight : 90th percentilenHEENT,Lung,CV,ABD,Neuro are normal41Intercondylar distance 12 cm42問題n下一步如何評估?n一般成長孩童常見嗎?n是什麼病?43Plain film?44Blount diseasen最常見病理性（pathological）膝內翻n脛骨（tibia）近端內側內生軟骨骨化異常n脛骨內轉（internal torsion of tibia）導 致膝內翻惡化n嬰兒型(infantile t
