《小組教學(xué)》ppt課件

1、小組教學(xué)兒童非創(chuàng)傷性骨科急癥個案討論一n15個月大小女孩活潑好動,走路很穩(wěn),但是跑步常跌倒,媽媽留意到她的腳趾頭和哥哥相比,較朝向內(nèi)側(cè)彎,雖然常跌倒,但可立刻爬起並繼續(xù)遊戲,小女生其它方面很安康,沒有其他疾病,沒有服用藥物,也沒過敏病史.醫(yī)生,嚴(yán)不嚴(yán)重?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 初級評估(2/2)nABCDE: normal except bilateral toes p

2、ointed in.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 n walk過去史n出生史: NSVD,Full-term,Apgar score n 1(9)5(9), BBW 3700gmnNormal developmental milestones on scheduled and started walking at 12 months.nShe eats a

3、diverse diet,including meats, fruits,and vegetables,and drinks whole milk.nNo prefenerce for either hand and uses both well.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 pointed in wh

4、en he was a toddler; he wore corrective shoes connectly by a bar and currently has a normal gait.詳細(xì)理學(xué)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 dimple or tuft

5、of hair at the sacrum.詳細(xì)理學(xué)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) and the heel i

6、s midline without varus or valgus deformity.詳細(xì)理學(xué)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 evidence of spasticit

7、y, ataxia, or pain. 問題n診斷為何?n如何治療?n需求轉(zhuǎn)診小兒骨科嗎?Metatarsus adductus“v finger testSeverity of Metatarsus adductusMetatarsus adductus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(yán)重個案則在出生1-2個月內(nèi)轉(zhuǎn)診做 serial casting night splinting.n85-90% 個案會自行痊癒Internal tibia torsi

8、on(ITT)診斷 ITT(1)nBimalleolar axis(the degrees that lateral malleolar is posterior to the medial )n -In the newborn: 2-4 degreesn -By 5 Y/O: 9 degree n -At maturation: 15-22 degreesn * ITT (+) if the lateral malleolar is less n posterior than this n Bimalleolar axis 診斷 ITT(2)nAn internal Thigh foot a

9、ngle is indicative of internal tibial torsionnObservation of the gait of the childs gait can also aid in the diagnosis.Thigh-Foot angle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 splintnRotational osteotomy of the

10、 tibiaDenis-Browne bar at night for 6-12 months Wheaton Bracing- Night wear for 6 months usually corrects the ITT. Femoral anteversionFemoral anteversion臨床表徵ne.g.Internal rotation as much as 90 degrees and external rotation is only 10 to 30 degrees.nOn observation the gait, note that both the patell

11、ae and feet point inward. the normal range being equal, approximately 70 degrees each way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 exclude DDHnMRI to exclude cerebral palsy,spinal bifi

12、da, and intracranial abnormalitynBlood tests to exclude metabolic bone disease預(yù)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 cosmetically unaceptable, and functional problems wit

13、h gait, some recommend derotational osteotomy.nComplications occur in approximately 15% of patients.足內(nèi)翻應(yīng)多方面考慮個案討論(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(yán)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(xiàn)像.右膝不曾跌傷也無其它疾病.檢查起來,右側(cè)tibial tubercle是痛點(diǎn),右膝伸展抗力檢查時很痛,活動範(fàn)圍正常,靭帶穩(wěn)定而且無膝關(guān)節(jié)積水.問題n診斷為何?n需求X光檢查嗎?n如何治療?診斷及治療方法n診斷為Osgood-Schla

14、tter diseasen診斷依據(jù)年齡,病史,及理學(xué)檢查,X光不一定需求n治療n -NSAID+RICEn -休憩(防止持續(xù)收縮股四頭肌)n預(yù)後:可以完全緩解,通常12-24months Osgood-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(cè),也有25%雙側(cè)n長見相關(guān)活動如籃球,足球,芭蕾舞,體操等 重點(diǎn)n常見非創(chuàng)傷性骨科疾病隨年齡變化有異n完好病史應(yīng)包括疼痛特徵,位置,性質(zhì),及變化n多數(shù)病患和創(chuàng)傷病史及較大活動量有關(guān)n膝部疼痛別遺漏髖關(guān)節(jié)hip檢查nX光用於排除其它診斷n骨科轉(zhuǎn)診是有必要的個案討論(三)-1/2n三

15、歲男生因?yàn)橄?nèi)翻(bowleg)由母親帶來門診,主訴小孩自開使學(xué)走路便膝內(nèi)翻,因其哥哥也有一樣情形,不過三歲前就自然消逝,所以本來不以為意,但是小男生並位改善,而且走路有一點(diǎn)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.個案討論(三)-2/2n出生史正常,頭部先露,經(jīng)因產(chǎn)道生產(chǎn),出生體重3450公克,和普通兒童一樣,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(guān)節(jié)打直時穩(wěn)定,但彎屈10-20度時,medial femoral condyles 會往內(nèi)側(cè)後面subl

16、ux. 理學(xué)檢查nSpeak well and interacts appropriately for agenHeight : 50th percentilenWeight : 90th percentilenHEENT,Lung,CV,ABD,Neuro are normalIntercondylar distance 12 cm問題n下一步如何評估?n普通成長孩童常見嗎?n是什麼病?Plain film?Blount diseasen最常見病理性pathological膝內(nèi)翻n脛骨tibia近端內(nèi)側(cè)內(nèi)生軟骨骨化異常n脛骨內(nèi)轉(zhuǎn)internal torsion of tibia導(dǎo)致膝內(nèi)翻惡化

17、n嬰兒型(infantile type)常見於三歲以下肥胖黑人小孩,75%雙側(cè)皆受影響,較青少年型嚴(yán)重(aldolescent type);後者多見於六歲以後,單側(cè)居多,多因膝內(nèi)翻遲未改善而被發(fā)現(xiàn).診斷方法n病史n臨床表現(xiàn)n影像檢查Blount disease臨床徵象(1/2)nMedial metaphysis 的鳥嘴變化(beaking)可以在膝內(nèi)側(cè)觸摸到n走路時步態(tài)不穩(wěn)且膝關(guān)節(jié)被擠向外n膝關(guān)節(jié)打直時穩(wěn)定,彎屈20度時會因?yàn)閙edial tibia plateau depressed而有向內(nèi)後方subluxation現(xiàn)像,稱之為Siffert-Katz sign,在X光便化之前就會表現(xiàn)出來

18、Blount disease臨床徵象(2/2)nIntercondyle distance 6cmnShort staturenWeight excessive for height nSevere deformitynPalpable metaphyseal beakingnKnee instabilitynKnee painnPresence of Siffert-Katz sign影像學(xué)發(fā)現(xiàn)nMetaphyseal beakingnVarus angulation of proximal tibianIrregularity ossified epiphysisnExcessive Dr

19、ennan angle(metaphyseal-diaphyseal anglen -in children 2 Y/O : 11 degrees n -in children 16 degrees處置n觀察n轉(zhuǎn)診至骨科評估治療n 假設(shè)是生理足性膝內(nèi)翻至7-8歲仍未改善,要高度懷疑病理性.Langenskiolds six stages of Blount disease 鑑別診斷nInflammatoryn - Infection, postinfectious, rheumatoid arthritis nTumornOsteochondromanPosttraumaticn -Growt

20、h arrest and angular overgrowthnCongenital deformitiesnBlount diseasenOsteogenesis imperfectanMetabolicn -Rickets and Renal osteodystrophyTibiofemoral angleDevelopment of TFA during growth Leg alignment 依年齡產(chǎn)生之變化Bowleg of child個案討論四: “跛行n六歲男生右腳跛行三個月,多次在診所看診吃止痛藥,不斷未改善n最進(jìn)並無發(fā)燒發(fā)冷或其它疾病n除右髖關(guān)節(jié)移動會痛之外,兩側(cè)膝關(guān)節(jié)及踝關(guān)節(jié)活動範(fàn)圍正常,無壓痛.問題n能夠診斷為何?n鑑別診斷為何?n處置優(yōu)先次序?yàn)楹?鑑別診斷nToxic synovitisnSeptic arthritis/osteomyelitisnFracturenTum