Common Lower Limb Deformities in Children
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Transcript of Common Lower Limb Deformities in Children
Common Lower Limb Deformities in Children
Prof. Mamoun KremliAlMaarefa College
ObjectivesAngular deformities of LLs
Bow legsKnock knees
Rotational deformities of LLsIn-toeingEx-toeing
Feet problems
Angular LL Deformities of LL
Nomenclature
Bow legs Knock knees
Genu Varus Genu Valgus
Normal range varies with age
During first year: Lateral bowing of Tibiae
During second year: Bow legs (knees & tibiae)
Between 3 – 4 years: Knock knees
EvaluationShould differentiate between
“physiologic” and “pathologic” deformities
Evaluation
Physiologic Pathologic
• Expected for age
• Generalized• Regressive• Mild – moderate• Symmetrical
•Not expected for age• Localized• Progressive• Severe• Asymmetrical
Causes
PhysiologicPathologic
- Use of walker?
- Early wt. bearing - Overweight
• Exaggerated :• Normal for age
• Idiopathic
• Injury to Epiphys. Plate - Infection / Trauma
• Metabolic disease• Endocrine disturbance
• Rickets
Evaluation
Symmetrical deformity
Evaluation
Asymmetrical deformity
Evaluation
Generalized deformity
Evaluation
Blount’s
Localized deformity
Evaluation
Rickets
Localized deformity
Improves in time
Assess angulation - standing/supine
Bow Legs
(genu varus)Inter- condylar distance
Assess angulation - standing/supine
knock knees
(genu valgus)Inter- malleolar distance
Measure angulation - standing/supine
Use GoniometerMeasure angles directly
More accurate
More appropriate
Investigations / LaboratorySerum Calcium / Phosphorous ?
Serum Alkaline Phosphatase
Serum Creatinine / Urea – Renal function
Investigations / RadiologicalX-ray when severe or possibly pathologic
Standing AP film:long film (hips to ankles) with patellae directed
forwards
Look for diseases:Rickets / Tibia vara (Blount’s) / Epiphyseal injury..Measure angles
Femoral-Tibial AxisMedial Physeal Slope
Investigations / Radiological
When To Refer ?Pathologic deformities:
AsymmetricalLocalizedProgressiveNot expected for age
Exaggerated physiologic deformitiesDefinition ?
Surgery
Rotational LL Deformities
In-toeing / Ex-toeingFrequently seen
Concerns parents
Frequently prompts varieties of treatmentoften un-necessary / incorrect
Rotational DeformitiesLevel of affection:
Femur
Tibia
Foot
FemurAnte-version = more medial rotation
Retro-version = more lateral rotation
Normal DevelopmentFemur: Ante-version:
30 degrees at birth10 degrees at maturity
Tibia: Lateral rotation:5 degrees at birth15 degrees at maturity
Normal DevelopmentBoth Femur and Tibia laterally rotate with
growth in children
Medial Tibial torsion and Femoral ante-version improve ( reduce ) with time
Lateral Tibial torsion usually worsens with growth
Clinical ExaminationRotational Profile
At which level is the rotational deformity?How severe is the rotational deformity?
Four components:1. Foot propagation angle2. Assess femoral rotational arc3. Assess tibial rotational arc4. Foot assessment
Rotational Profile1. Foot propagation angle – Walking
Normal Range: ( +10o to -10o )
? In Eastern SocietiesNormal range: ( +25o to - 5o )
Fundamentals of Pediatric Orthopedics, L Stahili
Rotational Profile 2. Assess femoral rotation arc
SupineExtende
d
Rotational Profile 2. Assess femoral rotation arc
SupineFlexed
Rotational Profile3. Assess tibial rotational arc
Foot-thigh angle in prone
Rotational Profile4. Foot assessment
Metatarsus adductusSearching big toeEverted footFlat foot
Common PresentationsInfants: out-toeing
Toddlers: In-toeing
Early childhood: In-toing
Late childhood: Out-toing
Infants: out-toeingNormal
seen when infant positioned upright(usually hips laterally rotate in-utero)
Metatarsus adductus:medial deviation of forefoot90% resolve spontaneouslycasting if rigid or persists
late in 1st year
Fundamentals of Pediatric Orthopedics, L Stahili
Toddlers: In-toeingMost common during second year
(at beginning of walking)
Causes:Medial tibial torsion: does not need treatmentMetatarsus adductus: if sever, casting worksAbducted great toe: resolves spontaneously
Rotational DeformitiesCommon Presentations
ChildIn-toeing : due to medial femoral torsion
Out-toeing : in late childhoodlateral femoral / tibial torsion
Medial Femoral TorsionStarts at 3 - 5 years
Peaks at 4 – 6 years
Resolves spontaneously by 8-9 years
Girls > boys
Look at relatives - family history – normal
Treatment usually not recommended
If persists > 8 years and severe, may need surgery
Medial Femoral Torsion (Ante-version)
Stands with knees medially rotated(kissing patellae)
Sits in “W” position
Runs awkwardly (egg-beater)
Family History
Lateral Tibial TorsionUsually worsens
May be associated with knee pain (patellar)specially if LTT is associated with MFT(knee medially rotated and ankle laterally rotated)
Fundamentals of Pediatric Orthopedics, L Stahili
Medial Tibial TorsionLess common than LTT in older child
May need surgery if :persists > 8 year,and causes functional disability
Fundamentals of Pediatric Orthopedics, L Stahili
Management of Rotational Deformities
Challenge : dealing effectively with family
In-toeing:Spontaneously corrects in vast majority of children
as LL externally rotates with growthBest Wait !
Management of Rotational Deformities
Convince family that only observation is appropriate
Only < 1 % of femoral & tibial torsional deformities fail to resolve and may require surgery in late childhood
Management of Rotational Deformities
Attempts to control child’s walking, sitting and sleeping positions is impossible and ineffective, cause frustration and conflicts
Shoe wedges and inserts:ineffective
Bracing with twisters:ineffective - and limits activity
Night splints:better tolerated - ? Benefit
Management of Rotational Deformities
Shoe wedges Ineffective
Twister cables Ineffective
Fundamentals of Pediatric Orthopedics, L Stahili
When To Refer ?Severe & persistent deformity
Age > 8-10y
Causing a functional disability
Progressive
SummaryAngular deformities are common:
Genu varusGenu valgusDifferentiate between physiologic and pathologic
deformities
Rotational deformities are commonPart of normal developmentIn-toing Vs Out-toingCause may be in femur, tibia, or footMost improve with time