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°♂)
Persistent genu varum • Worried parents • About 3 years old +bow legs +mild lateral thrust at the knees + in-toeing • Assessment: - History - etiologic factors
Examination • Height • See ( front, back & side) • Measure • IC distance, • lateral thigh-leg angle, • center of gravity • Siteof varus
Causes • Lateral ligament laxity • Blount’s disease • Congenital pseudoarthrosis of tibia • Coxa vara
In ligamentous laxity notelat.Widening Of knee joints In Blount angulation at med.tib metaphysis
Incoxa vara ,angulation at the neck shaft level In cong. Pseudarthrosis of tibia,the angulation is in the distal ⅓
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
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°
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
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.
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.
Investigations2 • Intermalleolar separation under 3 inches is normal at any age. • Periodic observation and measurement if less than 3.5 inches. • If > 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.
Indicators of Serious Disease • Pronounced asymmetry • Short stature • Other skeletal abnormalities • Intermalleolar separation greater than 3.5 inches
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
When to refer • Age > 7 with knock knee • Unilateral problem i.e Asymmetry of legs • Intermalleolar distance > 3.5 inches (9 cms) • Associated symptoms e.g Pain, Limp
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.
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.
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.
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.
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.
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.
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.
Rare Causes of Flat Feet • May be part of a more generalized condition • Severe joint laxity • Cerebral Palsy • Peroneal spastic flat foot • Downs Syndrome
Treatment • No proven benefit from insoles, shoe modification, foot exercises. • Spasmodic type : • Hindfoot fusion for pain relief. • Subtalar arthrodesis corrects deformity.
DDH • Very important condition as early diagnosis and correction prevent major damage. • All newborns are screened for DDH by Barlow’s and Ortolani’s 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.
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.
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.
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.
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.
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.
Pathology • Legg-Calvé-Perthes disease (LCPD) is the name given to idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head.
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.
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
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.
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
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.
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
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.
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.
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.
DD • Acute hip fracture • Perthes' disease • Acute transient synovitis • Osteomyelitis • Septic arthritis
Investigations • Anteroposterior and 'frog-leg' lateral X-rays show widening of epiphyseal line or displacement of the femoral head.
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.