ANGULARROTATIONAL DEFORMITIES OF THE LOWER LIMBS IN CHILDREN

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ANGULAR/ROTATIONAL DEFORMITIES OF THE LOWER LIMBS
IN CHILDREN

• Faris A. AbuShaaban A.B.C.Ortho
• Al-Khor Hospital

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Terminology

• Version normal twisting of long bone on its
  anatomic longitudinal axis
• Torsion Abnormal / deformity, version beyond
  (or-)2 SD
• Reference axis a line joining designated bony
  landmarks at the end of a long bone
• Anteversion the prox ref axis is lat twisted
  relative to the distal (X-retroversion(

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Fetal development of L.L.rotation

• 4-5/52 Paddle bud appear on the anterolateral
  wall.
• 8/52 toes apposed praying feet.
• Differential growth of ectoderm and mesoderm
  medial rotation of the L.L bringing the
  big toe to the midline i.e. plantegrade feet.

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• Intrauterine mechanical molding
• lat. femoral and med. tibial torsion.
• Lat. Femoral torsion creates the normal femoral
  antitorsion angle
• average 32 at one year
• decline to 16 at 16 years
• After birth the tibia start to rotate lat.
  reaching 15 at skeletal maturity.

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Femoral anetorsion

• Angle of line joining head centre - shaft center
  and line joining post. points of the femoral
  condyles
• Avg.35 at birth
• 8 ? and 14 ?
• After 8 very slow regression

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Measuring Femoral Torsion

• Clinical
• Prone with 90 knee flexion
• Feel midpoint of greater troch.it should be the
  most lateral
• In antitorsion it is post.
• Rotate the hip medially until the gr. troch. is
  most lat.
• degree of antitorsion

Lat. hip rotation
Med. hip rotation
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• CT
• Very accurate
• Done if surgery is
• Planned
• Coast, radiation

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IN and OUT- TOEING

• Generally in-toeing(good boy) is usually
  associated with normal developmental causes
  (metatarsus varus, tibiofibular med. rotation,
  femoral anteversion)
• Out-toeing(bad boy) is more with pathologic
  causes
• ( DDH, coxa vara, SCFE, CP)

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IN-TOEING

• In the infant metatarsus varus
• In 2nd year excessive med. tibiofibular
• torsion
• 3 years Femoral antetorsion, evidenced by ?
  hip med. rotation and restricred lat. rotation

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• Protective in-toeing
• In developmental genu valgum and flat foot
  (flexible pes planovalgus)
• Here the child is shifting the center of gravity
  to the foot center
• Neuromuscular (all ages)
• Spasticity of ant and/or post tibial muscles,
• hip med rotators and hip adductors

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Rare causes

• Relative fibular overgrowth, seen in cong
  longitudinal deficiency of the tibia and in
  Achondroplasia
• Tarsal coalition (rigid flat foot), spastic varus
  posture of the foot

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OUT- TOEING

• Intrauterine fetal posture
• contracture of the hips lat rotators, masking
  hip anteversion, by time such contracture resolve

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Rare causes

• Missed DDH
• Coxa vara, due to associated femoral retroversion
  (the rare primary hip retroversion doesnt
  correct with growth and may lead to O.A.)
• SCFE, adolescent obesity
• Cong longitudinal deficiency of the fibula
• Missed vertical talus

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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?)

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Persistent genu varum

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

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Examination

• Height
• See ( front, back side) bowlegs is ? by lat.
  Hip rotation
• /- medial tibial torsion/- knee flexion
• Measure IC distance,
• lateral thigh-leg angle,
• center of gravity
• Site of varus

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In ligamentous laxity notelat.Widening Of knee
joints
In Blount angulation at med.tib metaphysis
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• In coxa vara ,angulation at the neck shaft level

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

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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
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Finding

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

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FLAT FOOT

• Flat foot(Pes Planus) Absent or depressed
  longitudinal arch
• Pes Planovalgus associated hindfoot eversion,
  forefoot abd and everted

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Types

• Flexible
• Developmental the most common
• Hypermobile (ligamentous hyperlaxity
  Ehlers-Donlos, Marfan, Down)
• Neurogenic( rare and usually cause the
  reverse-Pes Cavus)
• Rigid, very rare
• Congenital (Tarsal coalition,Vertical talus)
• Aquired ) inflammatory)

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Management

• Physiologic flat foot is NORMAL up to 6 years (
  the foot fat pad shrinks and ligaments become
  taut)
• If there is pain look for other pathologic
  conditions
• Foot orthoses not a ttt but relief strain,
  improve gait pattern,even shoe wear, may prevent
  structural tarsal deformities
• Surgery- very rare, not before 12 years

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CONCLUSION

• Stick to basics
• History
• Look, feel, move
• Most of these common presentation needs assurance
  and follow up
• Surgery is rarely needed