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