Other orthopaedic problems

There are many of these. Here are some of those you can help.

OTHER ORTHOPAEDIC PROBLEMS PROBLEMS [s7]IN NEONATES If a child is born with an EXTRA DIGIT (common and often bilateral), it usually consists of skin and subcutaneous tissue only. If so, tie cotton tightly round its base; it will soon necrose and fall off. If it is larger and contains bone, leave it for six months, when anaesthesia will be safer, and do a formal amputation (75.24).

If his FINGERS ARE FUSED TOGETHER, (syndactyly, fairly common), this is serious, especially if several of them are involved. Don't try to separate them with straight cuts through the webs, because a severe flexion contracture will follow. When he is 2 or 3 years old he needs multiple Z-plasties, an inverted ''V' procedure for the web, and skin grafts for the defects, so refer him. The importance of doing this depends on: (1) how many fingers are involved, and (2) which fingers are involved. A web between his index and middle finger is more serious than one between his ring and little finger.

If his TOES ARE FUSED TOGETHER, leave them.

If he is born with CONSTRICTIONS OF A LIMB OR LIMBS (rare), they are probably due to compression by bands in the wall of the amnion[md]AMNIOTIC BANDS. A scar is formed which leads to amputation in utero (as in E, Fig. 27-20), or to circumferential constriction. If nothing is done, his limb may become ischaemic, because the constricting tissue does not grow. If possible refer him; surgery is not urgent.

If you cannot refer him, operate under ketamine or general anaesthesia. Apply a tourniquet; but not above 150 mm or for [lt]30 minutes.

Excise the lesion down to normal tissue (usually, only his skin and subcutaneous tissue are involved) as in B, Fig. 27-20. Sew up the defect with multiple Z-plasties. Bring A to A['1] and B to B['1], etc. See also G, I, or K, Fig. 58-20. If you join the skin edges side to side, the constriction is more likely to recur.

If he is born with his LEGS FOLDED IN 50[de] OF HYPEREXTENSION (genu recurvatum), flex them to 45[de] and hold them there with plaster backslabs for 3 weeks. He will probably grow normally without any disability. Occasionally, this is due to a true congenital contracture of his quadriceps which needs surgery.

PROBLEMS [s7]IN OLDER PATIENTS If a patient, usually a child, develops a LESION WHICH LOOKS CYSTIC ON X-RAY, usually in the shaft of his humerus or femur, the possibilities include a benign bone cyst, fibrous dysplasia, benign osteoblastoma, non-osteogenic fibroma, enchondroma, Brodie's abscess, and tuberculosis. If it is benign, it is probably a BENIGN BONE CYST, or an area of fibrous dysplasia. Aim to avoid a pathological fracture. Refer him to have the cyst opened, scraped out, and filled with a cancellous bone graft. If his bone fractures across a small cyst, it will probably heal spontaneously.

If a patient has a BONY OUTGROWTH on a metaphysis, complete with a marrow cavity and a normal bony structure, he has an EXOSTOSIS (diaphyseal achalasia). He may have one or many. If possible, leave it until he has stopped growing, unless it is in an an awkward place, and is causing disability. Then chip it off with an osteotome. If you have to remove a prominence before growth has stopped, take care not to damage the epiphyseal line. If you damage it, a severe growth deformity may result.