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Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional PowerPoint Presentation
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Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional Medical Center 5/01/06. Objectives:.

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Common Pediatric Disorders of the Lower Extremity Affecting GaitGregory A. Schmale, MDChildren’s Hospital and Regional Medical Center 5/01/06

objectives

Objectives:

1. Describethe commonly seen pediatric disorders involving gait, children's feet, and children's legs, including problems innormal development(and the ages at which these problems are commonly seen).

objectives3
Objectives:

2. Discuss theevaluationof common pediatric foot, gait, and leg disorders.

3. Describe their optimal management.

approach
Approach
  • Learn the range of normal
    • It’s huge
    • “Normal” changes with growth and development
    • Before saying something is “normal”, rule out the pathologies
  • Know the common pathologies

“The eye sees what the mind knows”

common and often benign orthopaedic concerns
Common and often benign orthopaedic concerns
  • In-toeing
  • Out-toeing
  • Bowed legs
  • Knock-knees
  • Flat feet
pathologies
Pathologies
  • Cerebral Palsy
  • Hip dysplasia
  • Legg-Calve-Perthes’s disease
  • Slipped Capital Femoral Epiphysis
  • Clubfoot
systematic approach where s the source
Systematic approach - Where’s the source?
  • Hip joint
  • Thigh (femur)
  • Knee joint
  • Leg (tibia)
  • Ankle joint
  • Foot (tarsals and metatarsals)

X

X

group pathologies by age
Group pathologies by age
  • Newborns and infants (< 1 yr)
  • Toddlers (1-3 yr)
  • Older children (4-10 yr)
  • Pre-teens and teens (> 10 yrs)
is in toeing a problem
Is in-toeing a problem?
  • Not painful in and of itself
  • Not associated with early arthritis
  • Can be associated with knee pain and patellofemoral problems
  • May be a cosmetic problem

Why does this patient in-toe?

history
History
  • What is the specific concern?
  • Who is concerned?
  • When does it manifest?
  • Duration?
  • Improving or worsening?
evaluation
Evaluation
  • Medical History
    • Developmental delay(s)?
    • Precipitating event/birth complication?
  • Family History
  • Screening examination
    • Spasticity?
    • Asymmetry?
  • Rotational Profile
rotational profile
Rotational Profile
  • Gait: determine foot progression angles
  • Assess hip rotation
  • Assess tibial rotation
  • Determine the alignment of the footGait = f [(BRAIN) + (hip & femur) + (leg & foot) + (knee + ankle)]
rotational profile13
Rotational Profile
  • Gait: foot progression angles
rotational profile14
Rotational Profile
  • Range of normal: foot progression angles
structural toeing and bowing
Terminology:

“Normal” - within two standard deviations of the mean

Version: the normal twist to a bone

Torsion: abnormal twist to a bone

Medial = internal

Lateral = external

Structural toeing and bowing
rotational profile16
Rotational Profile
  • Gait: foot progression angles
rotational profile17
Rotational Profile
  • Gait: foot progression angles
rotational profile18
Rotational Profile
  • Gait: determine foot progression angles
  • Assess hip rotation
  • Assess tibial rotation
  • Determine the alignment of the footWhere is the source???
assessing hip rotation
Assessing hip rotation

MedialRotationHip

LateralRotation

Hip

is the hip rotation normal
Within two standard deviations of the mean?

Symmetric?

Painless?

Without spasticity?What is the cause of the increased medial (or lateral) rotation?

Is the hip rotation normal?
causes of excess rotation
Soft tissues vs. bony anatomy

Hip joint - soft tissue contractures

Newborns have an posterior capsular contracture, producing excessive lateral rotation of the hips

Femoral antetorsion - bony anatomy

produces excessive medial rotation at the hip

Causes of excess rotation
what is femoral anteversion

Leftfoot

Leftfoot

Leftfoot

What is femoral anteversion?

Excessive anteversionequalsantetorsion

Anteversion

Femoral antetorsion produces intoeing

femoral antetorsion
Femoral antetorsion
  • Usually 3-5 yo girls
  • Sits in the “W”
  • “Kissing patellae”
  • “Egg-beater” run
  • Severe if > 90°
  • Resolves with growth - no association with osteoarthritis
rotational profile28
Rotational Profile
  • Gait: determine foot progression angles
  • Assess hip rotation
  • Assess tibial rotation
  • Determine the alignment of the footWhere is the source???
tibia
Torsion

Tibial torsion can lead to intoeing:

Internal or medial tibial torsion is a twist to the leg, pointing the toe inwards

Tibia
assessing tibial torsion
Assessing tibial torsion:
  • Thigh-foot angle
  • Transmalleolar axis
  • Determine axes
  • Measure angles
slide36
Metatarsus adductus curves the foot inwards

Searching great toe pulls the foot inwards

Flatfoot may produce out-toeing from “wringing-out” of the foot:

Supinated forefoot with valgus heel

Foot
assessing alignment of the foot
Assessing alignment of the foot
  • Shape of the foot
  • Heel-bisector angle
metatarsus adductus
Metatarsus Adductus
  • Majority are flexible
  • Adductus resolves by 3-4 yrs
  • 10% stiff and may benefit from casting
assessing foot alignment
Assessing foot alignment

PrettyMuchNormal

toeing and bowing determining the source
Toeing and bowing:Determining the source
  • Excessive medial rotation of hips?

Does he have it? NO on antetorsion, but YES on excessive medial rotation

  • Internally rotated thigh-foot angle = internal tibial torsion? No
  • Curved foot = metatarsus adductus? No
in summary
Femoral antetorsion produces excessive medial rotation at the hip which leads to in-toeing

Medial tibial torsion is a twist to the leg, pointing the foot inwards

Metatarsus adductus curves the foot inwards

A searching or abducted great toe produces in-toeing

In Summary
slide42
refer to orthopaedics for bracing or surgery

have the child put her shoes on the opposite feet and recheck her in a year

just recheck her in a year

obtain an AP pelvis radiograph and full length lower extremity films to look for hip dysplasia

A five year old girl presents with knock-knees and intoeing. You should obtain a rotational profile and…
how to treat intoeing
How to treat intoeing?
  • Shoe wedges? No.
  • Twister cables? No.
  • Observation? Yes.
pathologies to consider why is there an abnormal range of motion of the hip
Infants and toddlers

Hip dysplasia

Neuromuscular disease -Cerebral palsy

Toddlers

Legg-Calve-Perthes disease

Pre-teens

Legg-Calve-Perthes disease

Slipped Capital femoral epiphysis

Pathologies to consider“Why is there an abnormal range of motion of the hip?”
the most likely diagnosis is
cerebral palsy

arthrogryposis

Perthe’s disease

septic arthritis of the hip

hip dysplasia

The most likely diagnosis is…
arthrogryposis
Congenital contractures

Arthrogryposis multiplex congenita

1/3000 births

Amyoplasia = 1/2 of cases

Due to fetal akinesia

May include

radial head dislocations

Hip dislocations

Knee dislocations

Clubfoot

Rx order - reduce the knee, then treat the feet, then the hips

Arthrogryposis
arthrogryposis48
Amyoplasia

Classic arthrogryposis

Muscle replaced by fibrous tissue

Multiple congenital contractures

60% with all limbs affected,

Lower only in 25%

Upper only in 15%

Normal IQ

Surgery changes the range of the arc of motion, not the total arc itself

Arthrogryposis
the most likely diagnosis is49
cerebral palsy

arthrogryposis

Perthe’s disease

septic arthritis of the hip

hip dysplasia

The most likely diagnosis is…
the most likely diagnosis is51
cerebral palsy

arthrogryposis

Perthe’s disease

septic arthritis of the hip

hip dysplasia

The most likely diagnosis is…
developmental dysplasia of the hip ddh
Developmental dysplasia of the hip (DDH)
  • Incidence
    • dislocation 1:1000
    • neonatal hip instability 1:100
  • Increased risks for first-born, girls, breech positioning, family history
  • L>R
ddh detection
DDH detection
  • Newborn nursery exam
    • Galiazzi test
    • Ortolani test
    • Barlow test
    • Good up to 2-3 mos of age
  • Loss of abduction, pistoning
  • Pavlik harness for instability or dislocated hip
ddh detection55
DDH detection
  • Ultrasound (dedicated center)
    • Better at > 2 wks of age
    • Dynamic exam
  • Radiography
    • Gold standard
    • Best after 6-8 weeks of age
rx for dysplasia refer
Rx for dysplasia -REFER
  • Pavlik for both dysplastic and dislocated hips
    • Never exceed about four weeks of Pavlik treatment for a persistently dislocated hip
  • Unstable hips deserve a referral to orthopaedics
  • Abduction orthoses may help correct hip dysplasia in the older child
hip dysplasia
Hip dysplasia
  • Early treatment enables quick resolution
  • Delayed treatment risks a poor result/multiple surgeries
  • Over-treatment is generally benign for the located hip
cerebral palsy
Mild developmental delays?

Mild spasticity or increased tone?

Asymmetry of motion, tone, reflexes?

You may be the first to make the diagnosis

Cerebral palsy
perthes ds
Perthes ds
  • Peak age of onset 3-8yr
  • Spontaneous osteonecrosis of the femoral head
  • Follow with serial radiographs
  • Prognosis depends on age of onset / severity
    • < 6 yrs at onset, less than whole-head involvement do better
  • Rx- decrease synovitis and weight bearing
slipped capital femoral epiphysis
Slipped capital femoral epiphysis
  • Peak incidence in pre-teens, 50% obese(50% not!)
  • Anterior thigh or knee pain
  • Bilateral in cases of endocrinopathy or renal ds
  • Dx - AP and frog pelvis * radiograph
  • If present, immediate wheel chair and referral
knee angular deformities
Genu varum - bowing

Genu valgum - knock-kneesWhat’s normal?

Knee angular deformities
slide68

Physiologic genu valgum

  • Maximum varus at birth
  • Maximum valgus > 10°, ages 3 - 4 yrs
  • At maturity, mean is ~ 6° anatomic valgus
bowing or genu varum
Bowing or genu varum
  • Physiologic bowing
  • Pathologic bowing
    • Rickets
    • Tibia vara
    • Skeletal dysplasia
knock knees or genu valgum
Knock- knees or genu valgum
  • Physiologic
  • Pathologic
slide75

Physiologic genu valgum

  • Maximum varus at birth
  • Maximum valgus > 10°, ages 3 - 4 yrs
  • At maturity, mean is ~ 6° anatomic valgus
knock knees
Knock- knees
  • Pathologic genu valgum
    • Rickets - later onset such as with renal osteodystrophy, because the disease is active when knock knees are the norm
    • Skeletal dysplasias
      • Diastrophic dysplasia
      • Morquio’s syndrome
      • Ellis-van Creveld or chondroectodermal dysplasia
      • Spondyloepiphyseal and multiple epiphyseal dysplasias
pathologies to consider leg
Pathologies to consider - leg
  • Angulation or bowing of the tibia
    • Very unusual!
      • Antero-lateral ?neurofibromatosis?
      • Postero-medial ?leg length difference?
      • Antero-medial ?fibular deficiency?
pathologies to consider foot
Pathologies to consider: foot

Flatfoot

  • All infants have it
  • Most children have it
  • More than 15% of adults have it
flexible flatfoot
Flexible flatfoot
  • Often resolves with growth
  • Not affected by specific shoes, heel cups, or UCBL inserts
  • Not correlated with disability in military populations
  • May be protective against stress fractures
more foot pathologies to consider
More foot pathologies to consider
  • Stiff or rigid metatarsus adductus
  • Clubfoot
  • Calcaneovalgus
  • Cavovarus foot
clubfoot
Clubfoot
  • Incidence 1:1000
  • Talipes equinovarus
  • True congenital vs positional
  • Cavus, adductus, varus, equinus
  • If present, examine hips carefully!
clubfoot treatment
Clubfoot treatment
  • Serial manipulations and casting
  • Begin first week of life, if possible
  • Perform weekly
  • 90% of routine clubfoot respond
calcaneovalgus foot
Calcaneovalgus foot
  • Most common foot deformity at birth
  • Forefoot abducted, ankle dorsiflexed - foot lies on anterior leg
  • Resolves spontaneously
  • Associated with hip dysplasia
cavovarus foot
Cavovarus foot
  • High arch = cavus
  • Heel in varus
  • Often rigid
  • Look to spinal cord or peripheral nervous system
out toeing less commonly seen
Out-toeing(Less commonly seen)

Causes:

  • External rotation contracture at the hip?
  • Lateral tibial torsion?
  • Flatfoot?
  • Little hope of improvement over time, unless it’s a result of flatfoot
summary normal development
Summary: Normal Development
  • Femoral anteversion: 30° at birth, only 10° at maturity (= lateral rotation)
    • Femoral antetorsion improves over time
  • Tibial version: 0° at birth, 15° externally rotated at maturity (= laterally rotation)
    • Medial tibial torsion improves over time
  • Growth: lateral rotation of both femur and tibia
    • In-toeing decreases with growth
summary
Summary
  • Most toe-ing and bow-ing deformities are benign
    • Resolution may take many years
  • Use history and exam to rule-out the pathologic causes
  • Reassure for what appear to be non-pathologic but extreme cases
    • Check back for re-exam, 6-12 months
  • Beware unilateral deformities and those associated with pain
    • Radiographs indicated
who needs a referral for toeing and bowing
Who needs a referral for toeing and bowing?
  • Over three years of age with documented progression of deformity
  • Stiff metatarsus adductus
  • Bowing
    • below the 5th percentile for height
    • marked asymmetry or lateral thrust with ambulation
  • Marked knock-knees or in-toeing in patients over 8 years of age
who needs a referral
Who needs a referral?
  • A newborn with a hip click?
  • A newborn with a hip clunk?
  • A ten year old girl with marked out-toeing on the side of groin pain?
  • A newborn with flat feet?
references
References:
  • Herring, JA: Tachdjian’s Pediatric Orthpaedics, WB Saunders, Philadelphia, 2002.
  • Staheli, LT: Fundamentals of Pediatric Orthopedics, Raven Press, New York, 1992.
  • Staheli, LT: Practice of Pediatric Orthopedics, Lippincott, 2002.
  • Tolo, VT: “In-toeing and Out-toeing,” Lovell and Winter’s Pediatric Orthopaedics, 4th ed., Morrissey and Weinstein, eds., Lippincott-Raven, Philadelphia, 1996.
  • Wenger, DA and M Rang: The Art and Practice of Pediatric Orthopaedics, Raven, New York, 1993.