common lower limb deformities in children
DESCRIPTION
Common Lower Limb Deformities in Children. Prof. Mamoun Kremli AlMaarefa Medical College. Objectives. Angular deformities of LLs Bow legs Knock knees Rotational deformities of LLs In-toeing Ex-toeing Feet problems. Angular LL Deformities of LL. Nomenclature. Bow legs. Knock knees. - PowerPoint PPT PresentationTRANSCRIPT
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Common Lower Limb Deformities in Children
Prof. Mamoun KremliAlMaarefa Medical College
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Objectives
• Angular deformities of LLs• Bow legs
• Knock knees
• Rotational deformities of LLs• In-toeing
• Ex-toeing
• Feet problems
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Angular LL Deformities of LL
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Nomenclature
Bow legs Knock knees
Genu Varus Genu Valgus
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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
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Evaluation
Should differentiate between
• “physiologic” and “pathologic” deformities
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Evaluation
Physiologic Pathologic
• Expected for age
• Generalized
• Regressive
• Mild – moderate
• Symmetrical
•Not expected for age
• Localized
• Progressive
• Severe
• Asymmetrical
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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
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Evaluation
Symmetrical deformity
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Evaluation
Asymmetrical deformity
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Evaluation
Generalized deformity
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Evaluation
Blount’s
Localized deformity
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Evaluation
Rickets
Localized deformity
Improves in time
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Assess angulation - standing/supine
Bow Legs
(genu varus)
• Inter- condylar distance
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Assess angulation - standing/supine
knock knees
(genu valgus)
• Inter- malleolar distance
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Measure angulation - standing/supine
Use Goniometer
• Measure angles directly
• More accurate
• More appropriate
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Investigations / Laboratory
• Serum Calcium / Phosphorous ?
• Serum Alkaline Phosphatase
• Serum Creatinine / Urea – Renal function
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Investigations / Radiological
• X-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
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Femoral-Tibial AxisMedial Physeal Slope
Investigations / Radiological
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When To Refer ?
• Pathologic deformities:• Asymmetrical
• Localized
• Progressive
• Not expected for age
• Exaggerated physiologic deformities
• Definition ?
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Surgery
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Rotational LL Deformities
In-toeing / Ex-toeing
• Frequently seen
• Concerns parents
• Frequently prompts varieties of treatment• often un-necessary / incorrect
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Rotational Deformities
• Level of affection:
• Femur
• Tibia
• Foot
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Femur
• Ante-version = more medial rotation
• Retro-version = more lateral rotation
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Normal Development
• Femur: Ante-version:• 30 degrees at birth
• 10 degrees at maturity
• Tibia: Lateral rotation:• 5 degrees at birth
• 15 degrees at maturity
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Normal Development
• Both 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
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Clinical Examination
• Rotational Profile• At which level is the rotational deformity?
• How severe is the rotational deformity?
• Four components:1. Foot propagation angle
2. Assess femoral rotational arc
3. Assess tibial rotational arc
4. Foot assessment
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Rotational Profile
1. Foot propagation angle – Walking• Normal Range: ( +10
o to -10
o )
• ? In Eastern Societies• Normal range: ( +25
o to - 5
o )
Fundamentals of Pediatric Orthopedics, L Stahili
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Rotational Profile
2. Assess femoral rotation arc
SupineExtende
d
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Rotational Profile
2. Assess femoral rotation arc
SupineFlexed
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Rotational Profile
3. Assess tibial rotational arc• Foot-thigh angle in prone
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Rotational Profile
4. Foot assessment• Metatarsus adductus
• Searching big toe
• Everted foot
• Flat foot
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Common Presentations
• Infants: out-toeing
• Toddlers: In-toeing
• Early childhood: In-toing
• Late childhood: Out-toing
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Infants: out-toeing
• Normal
• seen when infant positioned upright• (usually hips laterally rotate in-utero)
• Metatarsus adductus:• medial deviation of forefoot
• 90% resolve spontaneously
• casting if rigid or persists
late in 1st year
Fundamentals of Pediatric Orthopedics, L Stahili
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Toddlers: In-toeing
• Most common during second year• (at beginning of walking)
• Causes:• Medial tibial torsion: does not need treatment
• Metatarsus adductus: if sever, casting works
• Abducted great toe: resolves spontaneously
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Child
• In-toeing: due to medial femoral torsion
• Out-toeing: in late childhood• lateral femoral / tibial torsion
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Medial Femoral Torsion
• Starts at 3 - 5 years
• Peaks at 4 – 6 years
• Resolves spontaneously by 8-10 years
• Girls > boys
• Look at relatives - family history – normal
• Treatment usually not recommended
• If persists > 8-10 years and severe, may need surgery
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Medial Femoral Torsion (Ante-version)
• Stands with knees medially rotated• (kissing patellae)
• Sits in “W” position
• Runs awkwardly (egg-beater)
Family History
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Lateral Tibial Torsion
• Usually 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
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Medial Tibial Torsion
• Less common than LTT in older child
• May need surgery if :• persists > 8 year,
• and causes functional disability
Fundamentals of Pediatric Orthopedics, L Stahili
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Management of Rotational Deformities
• Challenge : dealing effectively with family
• In-toeing:• Spontaneously corrects in vast majority of children
as LL externally rotates with growth
• Best Wait !
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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
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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
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Management of Rotational Deformities
Shoe wedges Ineffective
Twister cables Ineffective
Fundamentals of Pediatric Orthopedics, L Stahili
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When To Refer ?
• Severe & persistent deformity
• Age > 8-10y
• Causing a functional disability
• Progressive
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Summary
• Angular deformities are common:• Genu varus
• Genu valgus
• Differentiate between physiologic and pathologic deformities
• Rotational deformities are common• Part of normal development
• In-toing Vs Out-toing
• Cause may be in femur, tibia, or foot
• Most improve with time