Genu valgus

1
Genu valgus Genu Varus
2
(No Transcript)
3
Natural History of normal evolution of the
alignment of the lower limbs

• Bowlegs in new born and infant
• With medial tibial torsion fetal position
• Becomes straight by 18/12
• By 2 or 3 genu valgus develop (avg. 12)
• By 7 spontaneous correction
• To the normal of adult valgus ( 8? and 7?)

4
Persistent genu varum

• Worried parents
• About 3 years old bow legs mild lateral thrust
  at the knees in-toeing
• Assessment
• - History
• - etiologic factors

5
Examination

• Height
• See ( front, back side)
• Measure
• IC distance,
• lateral thigh-leg angle,
• center of gravity
• Site of varus

6
Causes

• Lateral ligament laxity
• Blounts disease
• Congenital pseudoarthrosis of tibia
• Coxa vara

7
In ligamentous laxity notelat.Widening Of knee
joints
In Blount angulation at med.tib metaphysis
8

• In coxa vara ,angulation at the neck shaft level

In cong. Pseudarthrosis of tibia,the angulation
is in the distal ?
9

• Gait intoeing, lateral thrust-the fibular head
  and upper tibia shift laterally in Blount due to
  laxity and incompetence of the lat. Collat. Lig.
• Stability
• Symmetry
• Level of fibular head, normally at the level of
  the upper tibial growth plate, while it is
  proximal in Blount, cong.longitudinal dificiency
  of the tibia and achondroplasia

10
X-ray

• 3 years and older
• Getting worse
• Abnormal site of angulation
• Large physis and epiphysis
• History taruma, infection, possible metal
  intoxication(lead or floride)

Metaphysial/diaphysial angle 18
11
Finding

• Metaphysis, thick and frayed in rickets
• In physiologic genu varum no intrinsic bone
  disease, gentle curve, medial cortices
  thickening, horizontal joint lines of the knee
  ankle are tilted medially

12
Knock Knees / Genu Valgum

• Legs are bowed inwards in the standing position.
  Bowing occurs at or around the knee. On standing
  with knees together, the feet are far apart.

13
Investigations 1

• Measurement of intermalleolar distance. i.e
  Distance between two malleoli when the knees are
  gently touching with legs in adduction.
• Up to 3 and a half inches (9 centimeters) with
  child lying down is acceptable.
• 75 of children aged 2 - 4 years have some degree
  of intermalleolar separation.

14
Investigations2

• Intermalleolar separation under 3 inches is
  normal at any age.
• Periodic observation and measurement if less than
  3.5 inches.
• If gt 3.5 inches, need AP X-Ray with both legs on
  same film for knee deformity, hip and ankle
  joints and view of both long bones.

15
Indicators of Serious Disease

• Pronounced asymmetry
• Short stature
• Other skeletal abnormalities
• Intermalleolar separation greater than 3.5 inches

16
Aetiology

• Developmental
• Miscellaneous syndromes e.g Rickets (Alk Phos
  raised, with x-ray changes)
• Rare Genetic disorders e.g Cohen Syndrome
• Nutritional conditions e.g Vitamin C deficiency
• Autoimmune e.g RA
• Degenerative e.g OA

17
When to refer

• Age gt 7 with knock knee
• Unilateral problem i.e Asymmetry of legs
• Intermalleolar distance gt 3.5 inches (9 cms)
• Associated symptoms e.g Pain, Limp

18
Treatment

• No evidence that shoe modification, splints, or
  exercises affect condition
• No evidence to justify surgical intervention
  under 6 inches of intermalleolar separation.
• Surgical options
• Medial epiphyseal stapling at 10 to 11 years
• Corrective osteotomy at maturity.

19
Flat Feet / Pes Planus

• Arch of the foot is low. Medial arch is lost.
  There may be some valgus and eversion deformity
  of the foot.

20
Normal Development

• Flat feet are normal when learning to walk.
• Medial arch does not develop until 2nd / 3rd year
  of life.
• Normal arch functions as a shock absorber.

21
Investigation

• Ask patient to stand on tiptoes.
• If medial arch restores itself when standing on
  tiptoe or when foot is unloaded, no action is
  needed.

22
Presentations

• 2 Groups
• Pain free feet with normal mobility and muscle
  power.
• Painful, stiff, hypermobile feet with abnormal
  muscle power i.e weak or spastic feet.

23
Causes of Flat Feet

• Loose - ligamented flat foot
• Commonest type.
• Always bilateral.
• Arch looks normal when non weight bearing /
  standing on tip toe.
• Laxity can often be demonstrated in other joints.

24
Rare Causes of Flat Feet

• Rocker bottom foot Congenital vertical talus.
• Coalition Syndrome Peroneal spastic flat foot.
• In both, subtalar joint movement is limited.
• In peroneal spastic flat foot, attempting to
  invert hind foot produces painful spasm of
  peroneal muscles.

25
Rare Causes of Flat Feet

• May be part of a more generalized condition
• Severe joint laxity
• Cerebral Palsy
• Peroneal spastic flat foot
• Downs Syndrome

26
Treatment

• No proven benefit from insoles, shoe
  modification, foot exercises.
• Spasmodic type
• Hindfoot fusion for pain relief.
• Subtalar arthrodesis corrects deformity.

27
Developmental dysplasia of the hip (DDH)
28
DDH

• Very important condition as early diagnosis and
  correction prevent major damage.
• All newborns are screened for DDH by Barlows and
  Ortolanis manoevre
• Developmental dysplasia of the hip (DDH) is a
  dislocation of the hip joint that is present at
  birth. The condition is found in babies or young
  children.

29
Causes, incidence, and risk factors

• The hip is a ball and socket joint.
• In some newborns, the acetabulum is too shallow
  and the femoral head may slip out of the socket,
  either part of the way or completely. One or both
  hips may be involved.
• The cause is unknown. Low levels of amniotic
  fluid in the womb during pregnancy can increase a
  baby's risk of DDH. Other risk factors include
• Being the first child
• Being female
• Breech position during pregnancy
• Family history of the disorder
• DDH occurs in about 1 out of 1,000 births.

30
Symptoms

• There may be no symptoms. Symptoms that may occur
  can include
• Leg with hip problem may appear to turn out more
• Reduced movement on the side of the body with the
  dislocation
• Shorter leg on the side with the hip dislocation
• Uneven skin folds of thigh or buttocks
• After 3 months of age, the affected leg may turn
  outward or be shorter than the other leg.

31
Signs and tests

• Pediatric health care providers routinely screen
  all newborns and infants for hip dysplasia. There
  are several methods to detect a dislocated hip or
  a hip that is able to be dislocated.
• The most common method of identifying the
  condition is a physical exam of the hips, which
  involves applying pressure while moving the hips.
  The health care provider listens for any clicks,
  clunks, or pops.
• Ultrasound of the hip is used in younger infants
  to confirm the problem. An x-ray of the hip joint
  may help diagnose the condition in older infants
  and children.
• A hip that is truly dislocated in an infant
  should be detected at birth, but some cases are
  mild and symptoms may not develop until after
  birth, which is why multiple exams are
  recommended. Some mild cases are silent and
  cannot be found during a physical exam.

32
(No Transcript)
33
Treatment

• When the problem is found during the first 6
  months of life, a device or harness is used to
  keep the legs apart and turned outward (frog-leg
  position). This device will usually hold the hip
  joint in place while the child grows.
• This harness works for most infants when it is
  started before age 6 months, but it is less
  likely to work for older children.
• Children who do not improve, or who are diagnosed
  after 6 months often need surgery. After surgery,
  a cast will be placed on the child's leg for a
  period of time.

34
(No Transcript)
35
Prognosis

• If hip dysplasia is found in the first few months
  of life, it can almost always be treated
  successfully with a positioning device (bracing).
  In a few cases, surgery is needed to put the hip
  back in joint.
• Hip dysplasia that is found after early infancy
  may lead to a worse outcome and may need more
  complex surgery to fix the problem.

36
Perthes disease
37
Pathology

• Legg-Calvé-Perthes disease (LCPD) is the name
  given to idiopathic osteonecrosis of the capital
  femoral epiphysis of the femoral head. 

38
Causes, incidence, and risk factors

• Legg-Calve-Perthes disease usually occurs in boys
  4 - 10 years old. There are many theories about
  the cause of this disease, but little is actually
  known.
• Without enough blood to the area, the bone dies.
  The ball of the hip will collapse and become
  flat. Usually only one hip is affected, although
  it can occur on both sides.
• The blood supply returns over several months,
  bringing in new bone cells. The new cells
  gradually replace the dead bone over 2 - 3 years.

39
Symptoms

• The first symptom is often limping, which is
  usually painless. Sometimes there may be mild
  pain that comes and goes.
• Other symptoms may include
• Hip stiffness that restricts movement in the hip
• Knee pain
• Limited range of motion
• Persistent thigh or groin pain
• Shortening of the leg, or legs of unequal length
• Wasting of muscles in the upper thigh

40
Signs and tests

• During a physical examination, the health care
  provider will look for a loss in hip motion and a
  typical limp. A hip x-ray or pelvis x-ray may
  show signs of Legg-Calve-Perthes disease. An MRI
  scan may be needed.

41
Treatment

• The main treatment method is containment. That is
  to keep the femoral head inside the acetabulum
  for moulding.  In some cases, bracing is used to
  help with containment.
• Physical therapy and anti-inflammatory medicine
  (such as ibuprofen) can relieve stiffness in the
  hip joint.
• Health care providers no longer recommend several
  months of bedrest, although a short period of bed
  rest may help those with severe pain.
• Surgery may be needed if other treatments fail.
  Surgery ranges from lengthening a groin muscle to
  major hip surgery to reshape the pelvis, called
  an osteotomy. The type of surgery depends on the
  severity of the problem and the shape of the ball
  of the hip joint

42
Prognosis

• The outlook depends on the child's age and the
  severity of the disease. In general, the younger
  the child is when the disease starts, the better
  the outcome.
• Children younger than 6 years old who receive
  treatment are more likely to end up with a normal
  hip joint. Children older than age 6 are more
  likely to end up with a deformed hip joint,
  despite treatment, and may later develop
  arthritis.

43
Slipped Upper Femoral Epiphysis
44
SUFE

• Often a traumatic or associated with a minor
  injury, slipped upper femoral epiphysis is one of
  the most common adolescent hip disorders and
  represents a unique type of instability of the
  proximal femoral growth plate

45
Epidemiology

• Incidence is 30-60/100,000 children per year.
• Most commonly it occurs in boys of 10-17 years of
  age. Peak age is 13 years for boys and 11.5 years
  for girls.
• It is the most common hip disorder in
  adolescents.
• The left hip is more commonly affected than the
  right it is bilateral in 20-40 of cases.2
• it is three times as common in boys.

46
Risk factors

• Mechanical local trauma, obesity.
• Inflammatory conditions neglected septic
  arthritis.
• Hypothyroidism, hypopituitarism, growth hormone
  deficiency, pseudohypoparathyroidism.
• Previous radiation of the pelvis, chemotherapy,
  renal osteodystrophy-induced bone dysplasia.

47
Symptoms

• Discomfort in the hip, groin, medial thigh or
  knee (knee pain is referred from the hip joint)
  during walking pain is accentuated by running,
  jumping, or pivoting activities.
• Mild symptoms with the child able to walk with
  altered gait. In a significant number of cases
  knee pain is reported as the only symptom.
• External rotation of the leg during walking.
  Range of motion of the hip shows reduced internal
  rotation with additional external rotation.
• When flexed up, the hip tends to move in an
  externally rotated position.
• Mild-to-moderate shortening of the affected leg.
• Atrophy of the thigh muscle may be noted.

48
DD

• Acute hip fracture
• Perthes' disease
• Acute transient synovitis
• Osteomyelitis
• Septic arthritis

49
Investigations

• Anteroposterior and 'frog-leg' lateral X-rays
  show widening of epiphyseal line or displacement
  of the femoral head.

50
Management

• Avoid moving or rotating the leg. The patient
  should not be allowed to walk.
• Provide analgesia and immediate orthopaedic
  referral if the diagnosis is suspected.
• The patient should be scheduled for surgery
  immediately.
• Surgical closure of the epiphysis, usually by
  inserting screws percutaneously.
• Corrective osteotomy is usually reserved for
  treatment of severe deformities after the patient
  has stopped growing.

51
Prognosis

• Prognosis depends on the initial degree of
  epiphyseal slippage.
• The end result is good to excellent in 94-96 of
  cases if fragments are displaced by less than one
  third of the diameter of the femoral neck.
• With increasing displacement, complications
  increase and up to 45 of patients have a
  fair-to-poor surgical result.