Angular deformities of LL:

Bow legs.
Knock knees.
Rotational deformities of LL:
In-toeing.
Ex-toeing.
Leg aches.
CDH.
Feet problems.
Irritable hip.
Common Orthopedic Problems
in Children
Angular LL Deformities of LL
Angular Deformities
Nomenclature
Bow legs Knock knees
Genu Varus
Genu Valgus
Angular Deformities
Range of Normal Varies With Age
During first year : Lateral bowing of Tibiae

During second year : Bow legs (knees & tibiae)

Between 3 4 years : Knock knees
Angular Deformities
Evaluation
Should differentiate between
physiologic and pathologic
deformities
Angular Deformities
Evaluation
Physiologic Pathologic
Expected for age
Generalized
Regressive
Mild moderate
Symmetrical
Not expected for age
Localized
Progressive
Severe
Asymmetrical
Angular Deformities
Causes
Physiologic Pathologic
- Use of walker?
- Early wt. bearing
- Overweight
Exaggerated :
Normal for age
Idiopathic
Injury to Epiphys. Plate
Infection / Trauma
Metabolic disease
Endocrine disturbance
Rickets
Angular Deformities
Evaluation
Symmetrical deformity
Angular Deformities
Evaluation
Asymmetrical Deformity
Angular Deformities
Evaluation
Generalized deformity
Angular Deformities
Evaluation
Localized deformity
Blounts
Angular Deformities
Evaluation
Rickets
Localized deformity
in bow legs / genu varum
Inter-condylar distance
Measure Angulation
( standing / supine )
Angular Deformities
Evaluation
in knock knees /genu valgum
Inter- malleolar distance
Measure Angulation
( standing / supine )
Angular Deformities
Evaluation
Measure Angulation
Angular Deformities
Evaluation
Use goneometer
measures angles directly
Serum Calcium / Phosphorous ?
Serum Alkaline Phosphatase
Serum Creatinine / Urea Renal function
Angular Deformities
Evaluation
Investigations / Laboratory
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 (Blounts) / Epiphyseal injury..
Measure angles.
Angular Deformities
Evaluation
Investigations / Radiological
Femoral-Tibial Axis Medial Physeal Slope
Angular Deformities
Evaluation
Investigations / Radiological
Angular Deformities
When To Refer ?
Pathologic deformities:
Asymmetrical.
Localized.
Progressive.
Not expected for age.

Exaggerated physiologic deformities:
Definition ?

Angular Deformities
Surgery
Rotational LL Deformities
Frequently seen.
Concerns parents.
Frequently prompts varieties of treatment.
( often un-necessary / incorrect )
In-toeing / Ex-toeing
Rotational Deformities
Level of affection :
Femur
Tibia
Foot

Rotational Deformities
Femur
Ante-version = more medial rotation
Retro-version = more lateral rotation
Rotational Deformities
Normal Development
Femur : Ante-version :
30 degrees at birth.
10 degrees at maturity.
Tibia : Lateral rotation :
5 degrees at birth.
15 degrees at maturity.
Rotational Deformities
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.
Rotational Deformities
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.
Rotational Deformities
Clinical Examination
Rotational Profile

1- Foot propagation angle Walking

Normal Range:
+10
o _
10
o
? In Eastern Societies
+25
o _
10
o

Rotational Deformities
Clinical Examination

Rotational Profile
2- Assess Femoral Rotational Arc
Supine
Extended
Rotational Deformities
Clinical Examination

Rotational Profile
2- Assess Femoral Rotational Arc
Supine
flexed
Rotational Deformities
Clinical Examination
Rotational Profile
3- Tibial Rotational Arc
Thigh-foot angle in prone
foot position is critical
leave to fall into natural position
Rotational Deformities
Clinical Examination

Rotational Profile
4- Foot assessment
Metatarsus adductus
Searching big toe
Everted foot
Flat foot

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
Rotational Deformities
Common Presentations
Infants
Rotational Deformities
Common Presentations
Toddlers

In-toeing most common during second year.
( at beginning of walking )
Causes :
medial tibial torsion.
metatarsus adductus.
abducted great toe.
Rotational Deformities
Common Presentations
Toddlers - Medial Tibial Torsion

The commonest cause of in-toeing
Observational management is best
Avoid special shoes / splints / braces
unnecessary, ineffective, interferes with activity and
cause psychological and behavioral problems.
Rotational Deformities
Common Presentations
Serial casting is effective in this age-group
Usually correctable by casting up to 4 years
Toddler - Metatarsus Adductus
Rotational Deformities
Common Presentations
Dynamic deformity
Over-pull of Abductor
Hallucis Muscle during
stance phase
Toddlers - Abducted Great Toe
Spontaneously resolve - no treatment
Rotational Deformities
Common Presentations

Child
In-toeing : due to medial femoral torsion

Out-toeing : in late childhood
lateral femoral / tibial torsion
Rotational Deformities
Common Presentations

Child
Medial Femoral Torsion
Usually: - starts at 3 - 5 years,
- peaks at 4 6 years,
- then resolves spontaneously.
Girls > boys.
Look at relatives - family history normal.
Treatment usually not recommended.
If persists > 8 years and severe, may need surgery.
Rotational Deformities
Common Presentation
Stands with knees medially rotated (kissing patellae).
Sits in W position.
Runs awkwardly (egg-beater).

Family History
Medial Femoral Torsion (Ante-version)
Rotational Deformities
Common Presentations

Child
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 )
Rotational Deformities
Common Presentations

Child
Medial Tibial Torsion
Less common than LTT in older
child
May need surgery if :
persists > 8 year,
and causes functional disability
Rotational Deformities
Management
Challenge : dealing effectively with family

In-toeing : spontaneously corrects in vast
majority of children as LL externally rotates
with growth - Best Wait !
Rotational Deformities
Management
Convince family that only observation is
appropriate

< 1 % of femoral & tibial torsional
deformities fail to resolve and may require
surgery in late childhood.
Rotational Deformities
Management
Attempts to control childs walking, sitting and
sleeping positions is impossible and ineffective cause
frustration and conflicts.

She wedges and inserts : ineffective.
Bracing with twisters :ineffective - and limits activity.
Night splints : better tolerated - ? Benefit.
Rotational Deformities
Management
Shoe wedges Ineffective Twister cables Ineffective
Rotational Deformities
When To Refer ?
Severe & persistent deformity.
Age > 8-10y.
Causing a functional dysability.
Progressive.
Rotational Deformities
Management

When Is Surgery Indicated ?
In older child ( > 8 10 years ).
Significant functional disability.
Not prophylactic !
Leg Aches / Growing Pains
Leg Aches / Growing Pains
Incidence : 15-30 % of children.
More In girls / At night / In LL.
Diagnosis is made by exclusion.
Leg Aches / Growing Pains
History
Vague pain.
Poorly localised.
Bilateral.
Nocturnal.
Seldom alters activity.
Long duration.
Leg Aches / Growing Pains
Examination
General health is normal.
No deformities.
No joint stiffness.
No tenderness.
Normal gait.
No limping.
Leg Aches / Growing Pains
Management
When atypical history or signs present on
examination:
Imaging and lab. Studies.
If all negative :
Symptomatic treatment :
Heat / Analgesics.
Reassure family :
Benign.
Self-limiting.
Advise to re-evaluate if clinical features change.
Leg Aches / Growing Pains
Feature Growing Pain Serious Problem
History :
Long duration Often Usually not
Pain localised No Often
Pain bilateral Often Unusual
Ulters activity No Often
Cause limping No Sometimes
General health Good May be ill
From Stahili : Practice of Pediatric Orthopedics 2001
Leg Aches / Growing Pains
Feature Growing Pain Serious Problem
Physical examination :
Tenderness No May show
Guarding No May show
Reduced rang of motion No May show
Laboratory :
CBC Normal ? Abnormal
ESR Normal ? Abnormal
From Stahili : Practice of Pediatric Orthopedics 2001
CDH / DDH
Congenital Dislocation of Hip.
Developmental Dysplasia of Hip.
CDH Spectrum
Teratologic Hip : Fixed dislocation
Often with other anomalies
Dislocated Hip : Completely out
May or may not be reducible
Subluxated Hip : Only partially in
Unstable Hip : Femoral head can be dislocated
Acetabular Dysplasia : Shallow Acetabulum
Head Subluxated or in place

CDH
Etiology & Risk Factors
Prenatal :
Positive family history (increases risk 10X)
Primi-gravida
Female (4-6 X > Males)
Oligo-hydramnious
Breech position (increases risk 5-10 X)
Postnatal :
Swaddling / Strapping ( ? Knees extended)
Ligament Laxity
Torticollis (CDH in 10-20 % cases)
Cong. Knee recurvatum / dislocation
Metatarsus adductus / calcaneo-valgus

CDH
Risk Factors

When Risk Factors Are Present
The infant should be examined repeatedly
The hip should be imaged by
U/S
or X-ray
CDH
Clinical Examination
CDH
Neonatal Examination
LOOK :
Asymmetric thigh
folds
Posterior
anterior
CDH
Clinical Examination
Look :
Shortening ( not in neonates )
- Galeazzy sign

- in supine

CDH
Neonatal Examination
MOVE :
Hip instability
in early infancy
Limited hip abduction
in flexion - later
(careful in bilateral)
if <60
0
on both sides:
request imaging
CDH
Neonatal Examination
CDH
Neonatal Examination
Hip Flexion Deformity
SPECIAL :
Loss of fixed flexion
deformity of hips in
early infancy.
Normally FFD:
newborn 28
o

at 6 weeks 19
o

at 6 months 7
o

Normal
FFD
CDH
No FFD
Thomas Test
CDH
Neonatal Examination
Ortolani Barlow


Feel Clunk
Not hear click !
CDH
Neonatal Examination

Ortolani / Barlow
clunk
Ortolani Barlow
CDH
Neonatal Examination
Ortolani Test Barlow Test
CDH
Clinical Examination
Hip clicks :
- fine, short duration, high pitched sounds
- common and benign from soft tissues
Hip clunks :
- sensation of the hip displacing over the
acetabular margin
If in doubt : U/S in young infants
single radiograph if > 2-3 months
CDH
Clinical Examination
Neonate (up to 2-3 months) :
Instability/ Ortolani-Barlow
Infant ( > 2-3 months) :
Limited abduction
Shortening ( Galeazzi )
Toddler :
Limited abduction
Shortening ( Galeazzi )
Walker :
Trendelenburgh limpimg
CDH
Ultrasound Screening
Early U/S screening not recommended
Delayed U/S screening :
Older than 3 weeks
Those at risk or suspicious by:
History
Clinical exam
CDH
Treatment
Birth to 6 months :
Pavlik harness or hip spica cast
6 months 12 months :
closed reduction UGA and hip spica casts
12 months 18 months :
possible closed / possible open reduction
Above 18 months :
open reduction and ? Acetabuloplasty
Above 2 years :
open reduction,acetabulplasty, and femoral osteotomy
CDH
Treatment
Method depends on Age
The earlier started, the easier the treatment
& the better the results
Should be detected EARLY
UREGENT referral once an abnormality is
detected.