Spine and Limb Deformities
Introduction
Introduction Spinal and limb deformities are malformations that occur in bones, joints, or soft tissues, causing abnormalities in the shape and function of the trunk and limbs of the body. Spinal and limb deformities can be either a primary disease or injury, or a manifestation of a systemic disease. According to the incidence of spinal and limb deformities, it can be divided into local deformities and general malformations. Systemic malformations are mostly caused by developmental disorders, genetic, metabolic abnormalities or other systemic diseases (such as dysplasia of the cartilage, multiple epithelial osteochondromas, polysaccharide disease, river rickets, Kashin-Beck disease and rheumatoid arthritis) .
Cause
Cause
Etiology classification
Spinal and limb deformities can be divided into congenital malformations and acquired (acquired) malformations according to the time sequence of onset. Congenital malformations are often found at birth, or have not been discovered but already exist, and gradually appear as individuals grow and develop. Acquired malformations can be divided into two categories: one is the malunion caused by trauma, so type malformation does not require differential diagnosis and will not be detailed. The other type is a deformity caused by a lesion of bone, joint or soft tissue. In addition, according to the incidence of spinal and limb deformities, it can be divided into local deformities and general malformations. Systemic malformations are mostly caused by developmental disorders, genetic, metabolic abnormalities or other systemic diseases (such as dysplasia of the cartilage, multiple epithelial osteochondromas, polysaccharide disease, river rickets, Kashin-Beck disease and rheumatoid arthritis) .
mechanism
Bone, joint, muscle, fascia, nerves, blood vessels, skin and other diseases can cause deformities of the spine and limbs. Most of the bone malformations are due to abnormalities in the number of bones (increased or absent from human-to-line alignment abnormalities (bending, angulation, and rotation of human length anomalies (excessive or too short eight-connected anomalies (fusion or pseudo-joint) The cause of bone abnormalities can be divided into congenital malformations of bone, abnormal development of bone, developmental disorders of bone marrow, malunion of fractures, bone diseases and bone tumors.
The deformity of the joint is mostly caused by dislocation or subluxation of the joint, increase or limitation of joint mobility, and deformity of the joint bone end. The cause may be congenital dysplasia, congenital medullary dislocation, traumatic or pathological (inflammation, etc.) dislocation, joint adhesion and rigidity (such as infection or trauma), muscle contracture, long-term paralysis or braking, etc. Skin or fascia contracture large areas of post-traumatic scars contracture human nervous system diseases (cerebral palsy, polio sequelae, peripheral nerve injury or disease, etc.), and other diseases with unclear causes (idiopathic Scoliosis, etc.).
Examine
an examination
Related inspection
Limb CT examination of the spine MRI examination of the limbs and joints of the extremities, limbs, limbs, limbs and joint movement function
First, medical history:
Diagnosing the spine and extremities, the medical history is very important. It should first be distinguished whether it is a congenital malformation or an acquired deformity. Congenital malformations are discovered at the time of birth, or are not found at birth but already exist, and gradually appear as the patient grows. Congenital malformations generally have a younger age of onset, and the deformity will not disappear once it is discovered, and it often increases with age. For those patients who are not easy to distinguish between these two types of malformations, carefully ask about the condition of the disease during pregnancy, whether there are patients with the same or other malformations in the family, the passage of childbirth, the physical examination of the newborn, whether it is Congenital malformations provide clues.
The medical history query should be followed by an indication of whether the deformity is a primary disease or injury or a secondary systemic disease. Primary malformations often occur in a single site, and there are no other systemic diseases associated with this in addition to malformations. Malformations secondary to systemic diseases can occur in multiple locations. Patients are accompanied by systemic diseases in addition to the deformity itself. Patients often have changes in laboratory blood or urine tests. Malformations are only a manifestation of systemic diseases. .
Second, physical examination:
Check the spine and extremities deformity should be strictly in accordance with the four steps of seeing, touching and measuring. The examination of the limbs is particularly important to emphasize the bilateral control. The dynamic observation of the trunk and limbs is very important, including the flexion and extension of the trunk when standing, the gait of walking on the lower limbs, and the use of the upper limbs. The examination of the deformity should clarify the structure, nature and extent of the deformity, and distinguish whether the deformed part is bone, joint or soft tissue. The examination of joint mobility should include active and passive activities, measuring activity in all directions and requiring bilateral comparison. The length and thickness of the limb should be measured correctly. Muscle strength should be measured for malformations with neurological symptoms. In addition, there are some specific tests or signs for different joints. These are tests or signs that can be very effective in the diagnosis of deformities.
Third, laboratory inspection:
Separate malformations generally do not require laboratory tests to confirm the diagnosis, but for some malformations secondary to systemic diseases, laboratory tests can often achieve a clear diagnosis, it is necessary.
Fourth, equipment inspection:
The most valuable and most valuable instrumental examination in the diagnosis of spinal and limb deformities is radiography. X-rays should generally be taken from two different directions in order to locate the malformation of the deformity, but for some overlapping parts of the bone, such as the pelvis, it can only be taken from one direction. It is often necessary for some limb deformities that are difficult to be diagnosed. The contralateral radiographs were used for comparison, and regular X-ray radiographs were also observed for the development of malformations. However, X-ray film is of little value in the diagnosis of malformation of soft tissue.
In recent years, with the wide application of CT and MRI, the diagnosis of spinal and limb deformities has been newly developed. Especially for the malformation of soft tissue, or the location that is difficult to observe due to overlapping bones, CT and MRI have obvious advantages, which are of great help to the accuracy of diagnosis.
Diagnosis
Differential diagnosis
First, multiple bone and joint deformities
(1) Kashin-Beck disease
Also known as "Kashin-Beck disease", the cause is still unclear, mostly in the eastern part of Siberia in the former Soviet Union and adjacent areas in the northeast of China, and distributed in a strip shape from northeast to southwest in China. The age of onset of this disease is mostly from pre-school to pre-puberty, and adults can also develop disease, but it is rare. Kaschin-Beck disease mainly invades the bones and joint system, usually chronic, with few systemic symptoms. The whole body joints are generally affected, and the limbs are more common. The damage is bilateral but not necessarily symmetrical. Among them, the interphalangeal joint is more common and early, followed by the elbow, ankle, knee, wrist, marrow and shoulder. The damage of the spine is rare. Can be heavier. The onset is more insidious. At first, there is often only pain, numbness, ant movement, or joint activity is not flexible. After the morning, the joints are stiff. The first thing to pay attention to is the interphalangeal joint or the ankle joint. Sometimes the patient has no symptoms and the joints are found to be thick or frizzy. Individual patients have only symptoms such as fatigue and fatigue, but lack local symptoms. In the examination, the joints are thickened, and there are frictional sounds during flexion and extension. The early joint movements are not necessarily limited, and the X-ray examination can also be seen without abnormalities. As the disease progresses, the joints gradually thicken and dysfunction occurs. In the later stage, the limbs and fingers were significantly shortened, the joints were thick, the pain was limited, the muscles were atrophied, and there were severe short-finger deformities and short stature. X-ray films with interphalangeal joints, tendons and knee joints are more typical, showing that the joint surface is uneven, and the subchondral bone is dense. There is currently no specific method for the diagnosis of Kashin-Beck disease, and the diagnosis is generally based on a comprehensive analysis of medical history, physical examination and X-ray examination. The area where the patient lives is helpful for diagnosis.
(two) rheumatoid arthritis
The disease is a systemic disease characterized by joint inflammation and unclear etiology. The disease is most common in women aged 25-45. Prodromal symptoms are weakness, fatigue, and loss of appetite. Then there is a joint lesion characterized by multiple, symmetric joint involvement, slow and recurrent episodes, joint swelling and pain with progressive aggravation. In general, early manifestations of the disease include joint exudation, tenderness and limited mobility, and finally deformities, including incomplete dislocation of the joints, and joint contractures. Laboratory tests can have mild anemia, increased white blood cell counts, and increased erythrocyte sedimentation rate. About 75% of patients are positive for rheumatoid factor. The joint fluid is turbid, the formation of partial protein blocks is poor, the cell count is increased, and polymorphonuclear granulocytes are increased. X-ray examination showed soft tissue swelling and osteoporosis in the early stage, and the joint space was narrowed, erosion and deformity in the later stage.
(3) Congenital polyarticular contracture
The disease is a congenital malformation, involving the joints of the extremities. It is characterized by limited active and passive activities of the joint, fixed in the straight or flexed position, and the joint has only a few degrees of painless passive activity. The skin is not normally wrinkled and tightened; the skin of the joint has a small pit flexion deformity on the flex side with a span formed by skin and subcutaneous tissue. Often there are deformities such as clubfoot, dislocation of the silver joint, dislocation of the bones, scoliosis, etc., and may be accompanied by congenital heart disease and kidney deformity.
(4) Vitamin D deficiency
Mainly due to the lack of vitamin D, the absorption of calcium and phosphorus in the intestine is reduced, and the product of blood calcium and phosphorus is decreased, causing the temporary calcification zone to thicken and bone. It can increase the rib beading and hand silver seen in the clinic. The ankles are marked by X and the growth of the bones is stagnant. The main skeletal system of the disease changes as follows;
l, the head skull softens, more common in 3-6 months of babies, fingers gently press the occipital bone or the center of the parietal bone, like the feeling of pressing table tennis. Square skull, more common in patients 8-9 months or more, severe cases can be saddle-shaped, cruciform cranial. The front bunker is closed. Delayed teething.
2, chest ribs beading, rib groove, chicken chest or funnel chest, the above deformity is more common in children around 1 year old.
3, limbs wrist deformity, more common in patients over 6 months, the distal end of the forearm calf long bone can and even see the thick bone marrow, forming a blunt ring-shaped bulge, called rickets hand or foot silver. An "O" shaped leg or an "X" shaped leg may appear after the patient walks.
4, other pediatrics can cause posterior or lateral curvature of the spine after sitting, and the anterior and posterior diameter of the severe pelvis becomes shorter to form a flat pelvis.
The diagnosis of this disease is not difficult to make based on the child's nutritional history and X-ray examination.
(5) Cartilage malnutrition
The head is large, the forehead is prominent, the long bone marrow bulges, the chest is easy to see beading, the abdomen is similar to the rickets, but the limbs and fingers are short and thick, the five fingers are flush, the lumbar vertebrae are lordosis, and the hips are kyphosis. Blood calcium and phosphorus are normal. The X-ray shows that the long bone is short and thick and curved, and the dry energy end is widened and has a flared shape, but the contour is still smooth, and sometimes some of the bone marrow is buried in the dry energy end.
Second, spinal deformity
(a) congenital short neck
Congenital short neck, also known as Klippel-Fei syndrome, due to the fusion of some or all of the cervical vertebrae, the appearance of the neck is shorter and the activity is limited. The soft tissue on both sides of the neck is warm from the mastoid to the shoulder, also known as the "winged neck." The posterior hairline of the occipital region is reduced. X-ray examination can clearly diagnose and understand the extent of deformity. However, the shadow of the cervical vertebra often plagues the shadows of the bone and mandible and overlaps. Common tomosynthesis of the vertebral body through tomography, widening, narrowing or disappearing of the intervertebral disc, cervical vertebrae or semi-vertebral body, and sometimes neck ribs and skull base widening.
(two) congenital muscular torticollis
Congenital muscular torticollis is caused by contracture of one side of the sternocleidomastoid muscle, more women than men, more common on the right side. Generally, the deformity can occur one month after birth, the head is biased toward the affected side, the lower jaw points to the healthy side, the neck is rotated to the affected side, and the activity toward the healthy side is limited. Some 1-2 months after birth, a hard fusiform mass can be reached in the middle of one side of the sternocleidomastoid muscle. The mass can disappear within 2-6 months, and the neck activity is more restricted. Untreated patients may have secondary head and facial deformities. The affected side is shortened, making the face asymmetrical, and the eyes and ears are not at the same level. Extensive contracture of the affected soft tissue. In addition, the scoliosis of the lower cervical spine and the upper thoracic vertebra may be secondary, and the concave side of the spine faces the affected side.
(three) scoliosis deformity
One or more segments of the spine are offset from the median line of the body and protrude toward one side. Viewed from the rear, the body is asymmetrical, the shoulders are not equal, the spine is bent to the side, the concave side ribs are close together, and the thorax is close to the tendon wing. The first occurrence of the arc is called the primary arc or the main arc, and the subsequent arc is called the secondary or secondary arc. Usually, the range of the primary arc is long, the deformity is fixed, and it is accompanied by rotation. With the development of scoliosis, the vertebral body itself rotates. The rotation of the thoracic vertebrae moves the ribs back to the convex side of the side curve, causing a hump in the local thorax, the so-called "razor back" deformity. The diagnosis of scoliosis is not difficult, but X-rays are still needed to understand the extent, extent, curvature, shape of the vertebral body, degree of rotation, and concurrent malformations.
Most of the scoliosis deformities are idiopathic, but there are still some other causes of scoliosis, which are described as follows:
1. Non-structural scoliosis
1) Postural scoliosis: milder, disappearing in the lying position, more common in school-age children. Compensatory scoliosis: often the lower limbs are unequal, and the pelvis is inclined to one side of the short limb. Temporary scoliosis
2) sciatic scoliosis: not true scoliosis, the intervertebral disc is stimulated by the nerve root caused by the scoliosis, and the patient has a neurostimulation.
3) Sick scoliosis: rare, with mental symptoms.
4) Inflammatory scoliosis: seen in the peri-renal abscess or tuberculosis and other similar infections, combined with medical history and examination is not difficult to make a diagnosis.
2. Structural scoliosis
1) Idiopathic scoliosis: about 70% of all scoliosis. According to the age of onset, it can be divided into three types: infant-type pediatrics and adolescents. Infants develop from 3 years of age and have scoliosis at birth, most of which disappear after one year. Pediatric type is 4-9 years old, more common in boys, scoliosis to the left, most disappear automatically, and a few can progress. Adolescents develop symptoms over the age of 10, with girls accounting for the majority, with the curvature to the right and rapid progress.
2) Congenital scoliosis: the cause of vertebral body and the cause of vertebral body. The causes of vertebral body are: posterior spinal column with meningocele or recessive spina bifida. X-postal posterior non-defective door mitosis, vertebral Body malformation, etc. * In the case of spinal schizophrenia, the spinal cord divides into two, and there are bony prominences from the vertebral body to the central part of the spinal cord cavity. X-ray film can be seen T12~L1; There is a bone in the center of the vertebral body. CT can clearly find that the bone is divided into two parts. The patient often has weakness in both lower limbs, difficulty in urinating, and often accompanied by other deformities. Vertebral malformations include partial vertebral hypoplasia, hemivertebra, upper and lower vertebral body fusion, disc disappearance, and one side of vertebral body dysplasia with bone bridge. Vertebral causes: such as congenital rib fusion. Diagnosis can be confirmed by X-ray, CT or MRI.
3) Others: Congenital polyarticular contracture and rheumatoid arthritis are not difficult to identify according to the aforementioned characteristics. Other scoliosis caused by vertebral fractures, spinal cord tumors, intrathoracic lesions or burns and seizures can also be diagnosed according to the history and characteristics of the primary disease.
(4) Posterior vertebral deformity
Such malformations are generally caused by anterior horny kyphosis caused by destructive lesions or compression fractures in front of the vertebral body. The main causes of malformations are the following:
1, spinal tuberculosis does not appear in the early stage of the spine, if it occurs, it is generally late. The disease occurs mostly in children and young people, except for general malaise and afternoon hot flashes. In addition to the systemic symptoms of tuberculosis such as night sweats and weight loss, low back pain, back muscle tendon and limited mobility are often found in the early stages. With the development of the disease, the original symptoms gradually worsened, and there were cold abscesses and kyphosis. The occurrence of malformation is caused by the destruction and collapse of the vertebral body. The thoracic vertebra is more obvious. The cervical vertebrae and the lumbar vertebrae are not obvious because of the anterior protrusion. X-ray and CT examination can determine the extent and extent of vertebral destruction and determine the location and size of the cold abscess.
2, spinal tumors generally have two kinds of primary malignant tumors and metastatic cancers. It is characterized by severe pain in the back, kyphosis, vertebral body destruction, and pathological fracture. X-ray films showed bone destructive lesions. Radionuclide bone scans can also be confirmed.
3, spinal fracture has a significant history of trauma, the lordosis of the spine is mainly kyphosis, which can be paralyzed by spinal cord injury. X-ray examination showed a fracture in the spine.
Third, the bank
Lesions or injuries of the lower limbs, joints, and muscles can cause damage. The reasons can be divided into congenital and acquired, and the latter has traumatic (acute or chronic), infectious and other factors. When examining patients, detailed medical history should be asked. The common causes of broken deformities are as follows:
(1) Muscle weakness
The most common reason for breaking the line. The location and extent of muscle weakness determine the type of limp. In the gait stage of the patient with gluteal muscle paralysis, the center of gravity of the body is always tilted toward the paralyzed side. In patients with gluteus maximus paralysis, when the affected limb is weight-bearing, the trunk is always extended backwards, moving the center of gravity of the body to the axis of the pith. Patients with quadriceps completely paralyzed with knee flexion deformity and weak gluteal muscles can only walk by hand to the front of the affected thigh. When the volar muscles and the soleus muscle paralysis, the patient walks on the heel of the heel. The cause of the foot gait is the paralysis of the dorsal extension of the foot.
(2) Structural deformities of bones and joints
1, lower limb unequal length deformity is caused by the following factors: 1 old forged joint dislocation; 2 avascular necrosis of the bone; 3 myeloid joint tuberculosis; 4 lower limb fracture healing or malunion; 5 femur or embryonic bone Pathological curvature, etc.
2, congenital enough joint dislocation femoral head lost from the internal fixed position and across it, so that the muscle strength of the gluteus medius weakened. The patient's gait is "the gluteal muscles" or the gait of the Kundernerberg. When unilateral dislocation, the gait breaks; when the bilateral dislocation is standing, the pelvis is leaning forward, the lumbar lordosis, and the buttocks are particularly obvious. When walking, the left and right swings are like "duck steps."
The signs of congenital dislocation of the medullary joint depend on the age of the patient and the type of dislocation. The Ortolani test is used to examine the joint dislocation of the newborn by the patient lying down, knees, and flexion 90 degrees, abducting the thighs, and touching the bed outside the knees. If the above abduction angle cannot be achieved or it can be reached after the abduction, the mouth is Ortolani test positive.
When the patient stands and walks, the dislocation of the femoral head to the upper part of the femoral head can produce the following signs: 1 The skin wrinkles of the thighs and buttocks are asymmetrical, and the lower limbs of the affected side are shortened. The outer side of the large trochanter is prominent and the hips are flattened. There are 15 gums. -20. The external rotation is more obvious when standing. 2 abduction is limited when reaming. 3 The appearance of the thigh is shortened, and the height of the two knees is different when the two feet are aligned and the knees are flexed (Galeazzi sign). The 5 femurs did not hold the femoral artery deep, so the femoral artery pulsation was unclear. 6 Involved in the affected limb, there is a piston-like or telescopic sense when pulling the pushel. The above signs suggest that there is dislocation of the hip, and the diagnosis still needs to be confirmed by X-ray film.
(three) nervous system disorders
1. Spastic gait is a typical manifestation of cerebral palsy. The reason may be congenital (such as congenital development of the nervous system or fetal uterine hypoxia during pregnancy), but also acquired (such as cerebral hypoxia caused by asphyxia during childbirth, encephalitis or cerebral hemorrhage, sequelae of brain trauma) The performance of the child is increased muscle tension, hyperreflexive, and pathological reflex. When walking, the knees rub against each other, and the heavy and even the legs completely cross, forming a typical "scissor" gait.
2, uncoordinated gait
1) Spinal ataxia gait: caused by spinal cord or brain stem intrinsic access disorder. Pediatric fever is common in peripheral neuritis or brainstem lesions. Adults are more common in spinal cord spasm and lateral sclerosis. It is characterized by the fact that the patient's gait is basically normal when walking in the blink of an eye, but when he closes his eyes, he does not know where to walk and cannot walk.
2) Cerebellar ataxia gait: Disorders occur in both blinking and closed eyes. The gait is unstable, irregular and cannot walk along a single line. There is generalized jitter and muscle twitching. This gait is seen in
Cerebellar disease. If the lesion is confined to one side of the cerebellar hemisphere, the affected side strabismus
Fourth, the horseshoe inversion foot four, the horseshoe
Horseshoe varus is the most common foot deformity. It is characterized by adduction of the forefoot, inversion and sagging, inversion of the hindfoot, and contraction of the key. The cause can be congenital (most common) or acquired, including spasticity (cerebral palsy, cerebral palsy), neuropathy (posterior spina) or traumatic.
1. Congenital clubfoot babies are born with two-legged varus, adduction and horseshoes, mostly bilateral, and men are 2 times more than women. The typical symptom is that the soft tissue inside the foot is tight, the front can not be abducted, and the heel can not be stretched. The diagnosis is not difficult, but it must be identified with the following clubfoot.
2, neonatal foot varus and congenital clubfoot look similar, mostly for one side, the foot is horseshoe varus, but the inner side of the foot is not tight, the foot can reach the front of the femur, after fixed dressing for 1~2 months The wash is back to normal.
3, recessive spina bifida is mostly unilateral, the medial aspect of the forefoot can be abducted, the outside of the foot may have numbness, and some may be associated with symptoms of urinary incontinence. X-ray or CT can confirm the presence of spina bifida.
4, after the myelitis, the incidence of horseshoe trotters is older, in the age of 4 years old, with a history of fever, more common on one side, Yao Chang, short tendon, no fixed deformity, other muscle spasm is obvious, urine is not influences.
5, the cerebral palsy in the horseshoes after the birth of the horseshoes turned into feet, disappeared during sleep, once stimulated, the deformity is mainly horseshoe foot, less varus and less adduction, deformity is bilateral or ipsilateral Upper and lower limbs, both lower extremities have cross gait, adductor muscles are obviously paralyzed, often accompanied by intellectual changes.
6, congenital polyarticular contractures horseshoe varus is double-cis and accompanied by multiple joint deformities, see the above, easier to identify.
