Tibial Bowing

Tibial bowing is not uncommon. The direction and the apex of the tibial bow can alert the clinician to the type of the deformity, its treatment, and its prognosis. Tibial bowing can occur anteriorly, laterally, anterolaterally, and posteromedially.

Anterior bowing is often associated with fibular hemimelia. This bowing may be associated with the loss of the lateral rays of the foot, equinovalgus foot deformity, tarsal coalition, and significant leg length discrepancy.

Lateral bowing is a common variation, which occurs bilaterally. This condition is mild and not associated with other problems.

Anterolateral bowing is a serious tibial bowing that may increase and lead to a fracture as well as pseudoarthrosis of the tibia. This type of bowing occurs early in infancy. Pseudoarthrosis is usually associated with neurofibromatosis. 10% of patients with neurofibromatosis will have anterolateral tibial bowing. Neurofibromatosis is found in 50% of the patients with ALB. The patient should be carefully examined for café-au-lait spots. In this type of bowing, bone ends are usually thin and the fibula may also be involved. Treatment of anterolateral bowing is bracing with total contact orthosis. In order to treat pseudoarthosis in the tibia, surgery is usually needed. Multiple options are available for surgery, and none of these options are perfect. 50% of patients may undergo amputation due to the inability to achieve healing of pseudoarthrosis.

Posteromedial bowing is a rare calcaneovalgus deformity of the foot plus leg length discrepancy. This condition usually resolves, but may have residual leg length discrepancy.

Freiberg's Disease

Freiberg’s Disease is caused by avascular necrosis of the head of the 2^nd metatarsal. This condition is more common in patients who have a longer 2^nd metatarsal bone relative to the 1^st metatarsal. This leads to the transfer of excessive loads onto the 2^nd metatarsal, which may interfere with the blood supply. This disease tends to occur more commonly in young females during growth spurts.

Freiberg’s Disease usually presents itself as pain and swelling at the 2^nd metatarsophalangeal joint that is related to activities and walking in high heels. There may be point tenderness and swelling over the head of the 2^nd metatarsal. There may also be limited range of motion in the 2^nd metatarsophalangeal joint. Early in the disease, x-rays may only show minimal changes. Radiological evidence of the condition may only be clearly visible on an MRI and bone scan. In more severe cases, sclerosis, fragmentation, collapse of the metatarsal head, and severe arthritis, may make the condition easily visible on an x-ray.

Treatment

Conservative treatment consists of nonsteroidal anti-inflammatory medications, activity modification, orthotics, and immobilization with a short leg cast. Surgical intervention involving a joint debridement is indicated only after the failure of all conservative measures. Other procedures may be indicated depending on the complexity and severity of the case.

Pes Anserine Bursitis

Several bursa are seen around the knee area. These bursa include the suprapatellar, prepatellar, infrapatellar, and pes anserine. The pes answerine bursa is a small fluid filled sac located between the tibia and the three tendons of the Sartorius, Gracilis, and Semi-tendinosus.

These muscles are innervated by three separate nerves, the femoral, obturator, and the tibial branch of the sciatic nerve, respectively. Pes Anserine bursitis, or “breast stroke knee”, is an inflammatory condition of the medial knee at the pes anserine bursa that is common in swimmers.

What is the pes anserine?

The pes anserine is the common area of insertion for the three tendons along the proximal medial aspect of the tibia. This condition is also sometimes referred to as a “goosefoot” because the pes anserinus tendons resemble the shape of a goose foot. Pes Anserine bursitis is usually seen as causing pain, tenderness, and localized swelling after trauma or total knee replacement. The pain is seen below the joint line on the medial part of the proximal tibial with the bursa being deep to the tendons.

Treatment

Treatment consists of physical therapy, nonsteroidal anti-inflammatory medications, and injections. The physician will need to rule out meniscal tears, stress fractures, or osteonecrosis of the tibia, as these are all differential diagnosis.

Cauda Equina—Central Disc Herniation

Disc herniations usually occurs posterolaterally, but it may also be central. The cauda equina is composed of several nerves within the lower end of the spinal canal. The top of the spinal cord is a tubular bundle of nervous tissue extending from the brain.

The following section of the spinal cord is called the Conus Medullaris and is the lower end of the spinal cord. The Cauda Equina is made up of multiple nerve roots beginning at the level of L1.

The most common disc herniation is the Posterolateral Disc Herniation. This type of herniation is a nerve root injury, which will cause changes to both the sensory and motor skills as well as the reflexes. A posterolateral disc herniation usually affects the foot and ankle, and may cause unilateral leg pain and weakness. Observe for a positive straight leg raising test. These herniations are usually initially treated with conservative methods.  

A central disc herniation will cause cauda equina syndrome, which is a compression over the lumbosacral nerve roots. This compression will cause more back pain than leg pain, and bladder and bowel symptoms will be evident. This herniation is considered a surgical emergency.

Heel Pain & The Baxter's Nerve

Pain located at the heel can have several different causes. It is important to make the correct diagnosis for the cause of the heel pain, so that appropriate treatment can be given to the patient. Common causes of heel pain include:

1. Baxter’s Nerve Compression
2. Plantar Fasciitis
3. Fat Pad Atrophy
4. Achilles Tendonitis
5. Stress Fractures of the Calcaneus
6. Lumbar Spine Radiculopathy

The sites and locations from different causes of the pain are all very close to each other, making it difficult to determine the source of the pain and to diagnose injuries.

In plantar fasciitis, irritation and swelling will occur at the thick tissue on the bottom of the foot. This fascia can become inflamed and painful, making walking more difficult. Plantar fasciitis is most severe in the morning when patients first stand on their feet. Stretching exercises or walking, often helps in relieving the painful tightening associated with plantar fasciitis. Pain symptoms will intensify with prolonged exercise or standing.  Plantar fasciitis is usually associated with a tight heel cord.

During fat pad atrophy, the fat that cushions the calcaneus is thinned. This condition is common in elderly people and can cause significant pain while walking. It also commonly occurs in patients with a history of steroid injections.

Achilles Tendonitis is a chronic injury to the tendon that joins the heel to the muscles of the lower leg, primarily occurring from overuse. The Achilles tendon gives us the ability to rise up on our toes, allowing for the act of walking. If a patient has Achilles tendonitis, walking can be painful and difficult.

Stress fractures of the calcaneus can occur due to overuse injuries. The patient will experience weight bearing pain. Stress fracture injuries of the heel are typical in patients who engage in running sports, due to the repetitive shock being placed on the heel. Side to side compression of the calcaneus is painful.

Pain on the lateral side of the foot may be a result of L5-S1 radiculopathy.

The Baxter’s nerve is the first branch of the lateral plantar nerve. It also contributes to 20% of all heel pain causes. The Baxter’s nerve provides motor innervation to the abductor digiti minimi muscle. When the nerve is affected by compression, the symptoms are similar to planter fasciitis. Entrapment of the Baxter’s nerve may cause up to 20% of heel pain, but is still overlooked. The first branch of the lateral planter nerve is the inferior calcaneal nerve (Baxter’s Nerve).

The nerve courses vertically between the abductor hallucis and the quadratus plantae muscles, then makes a 90° horizontal turn, coursing laterally beneath the calcaneus to innervate the abductor digiti minimi muscle. The Baxter’s nerve can become entrapped within the medial heel. The entrapment will result in heel pain, paresthesia, abnormal sensations on the plantar aspect (bottom) of the heel, and medial heel tenderness. There are two sites of entrapment that are typical with Baxter’s nerve impingements. The first site is located between the fascia of the abductor hallucis and quadratus plantae muscles. The second site is where the nerve passes along the anterior aspect of the medial calcaneal tuberosity.

Treatment

Management is usually conservative and consists of heel stretching exercises, rest, NSAIDs, and Orthotics. Surgery is done as a last resort with neurolysis of the nerve after release of the deep fascia of the abductor hallucis muscle. There is a good-excellent result in about 90% of patients after decompression of the nerve. Involvement of the Baxter’s nerve may affect running athletes causing pain on the medial plantar aspect of the foot.

Malunions of the Clavicle

It is difficult to reduce and maintain the reduction of clavicle fractures as there will be deforming forces in the midshaft area of the clavicle. The clavicle will heal regardless as to if a sling or figure 8 strap is used. Despite the presence of a bump, fracture displacement, and deformity, healing of the fracture still occurs rapidly. Healing occurs in about 85% of cases, however, the clavicle will not look aligned due to the difficulty in reducing the fracture. It is hard to achieve a reduction of these fracture without surgery. Without surgical reduction, the fracture may end with some degree of malunion and possible shortening of the clavicle. The fragments will not line up with the distal fragment appearing to be downward and anteriorly rotated. Shortening is clinically significant because it alters the dynamics of the muscles around the shoulder. It also narrows the costoclavicular space. The patient may complain of decreased shoulder strength and endurance if the patient had a displaced midshaft clavicle fracture that healed with more than 2 cm of shortening.

What are the symptoms of clavicle malunion?

Pain, easy fatigability, cosmetic problems (especially in females), neurological dysfunction (possible involvement of the brachial plexus—especially the ulnar nerve), and the patient may have thoracic outlet syndrome.

X-rays should be done of both shoulders. Bilateral panoramic views are beneficial in order to measure the shortening. The physician will also want to check the amount of overlap at the ends of the clavicle.

Treatment

Surgical treatment of the malunion may be successful in restoring the function and relieving the pain. A clavicle osteotomy is done in the plane of the healed fracture. The fracture is recreated with correction of the deformity and the length of the clavicle is restored. A local or iliac crest bone graft can be used if needed.

If an osteotomy is done with reduction of the clavicle to its preinjury position and leaves a significant bone defect, the physician will need a tricortical piece of bone at the osteotomy area. It is probably better to use a precontoured clavicle plate in the superior position with six cortices, three placed on each side of the osteotomy.

Elbow Joint Dislocations

An Elbow dislocation occurs when the radius and ulna bones of the forearm move out of place from the humerus bone of the upper arm. There are two basic types of elbow dislocations:

1. Simple

   No fracture of the bones around the elbow joint

   Usually ligamentous injury

2. Complex

   Fracture has occurred along with ligamentous injury

Simple elbow dislocations typically occur when the patient falls onto an outstretched hand. Injury progression from lateral to medial in most patients. Posterolateral simple dislocations are the most common, occurring approximately 90% of the time.

The proximal ulna and radius are displaced posterolaterally relative to the distal humerus. Postemedial dislocations occur at the proximal ulna and radius and are displaced posteromedially relative to the distal humerus. In medial dislocations, the proximal ulna and radius are displaced medially relative to the distal humerus. With lateral dislocations, the proximal ulna and radius are displaced laterally relative to the distal humerus. Anterior dislocations are rare, as they result from a direct force applied to the posterior aspect of the forearm with the elbow in a flexed position. Anterior dislocations occur when the proximal ulna and radius are displaced anteriorly relative to the distal humerus. If stable, simple acute fractures can be treated with a closed reduction and a splint for two to three days (no more than two weeks) in addition to range-of-motion exercises and physical therapy. Unstable simple fractures are rare, but can be stabilized by ligament repair and/or by the use of an external fixator or cross pinning of the joint in the elderly.

Chronic Elbow dislocations will need to be treated with an open reduction and external fixator and is usually hinged. Recurrent elbow dislocations (diagnosed by pivot shift) occurs due to a deficiency of the lateral collateral ligament and is treated by a reconstruction of the ulnohumeral ligament with a tendon graft.