Common Pediatric Lower Limb Disorders

Prof.M. Zamzam Dr.Kholoud Al-Zain Dr.Khalid Bakarman

Assistant Professors Consultant Pediatric Orthopedic Surgeons

Topics

1. In-toeing & out-toeing 2. Genu varus & valgus 3. Proximal tibia vara 4. Growing pain 5. Club foot 6. L.L deformities in C.P patients 7. Limping 8. Leg length inequality

1) In-toing & Out-toing

In-toeing and Out-toeing

• Terminology: – Version: • Describes normal variations of limb rotation • It may be exaggerated – Torsion: • Describes abnormal limb rotation • Internal or external

In-toeing and Out-toeing

• Evaluation: – History – Screening examination (head to toe) – Foot-progression-angle – Asses rotational profile: • • • Hips  Hips Rotational Profile Tibiae  Foot Thigh Axis Feet  Heal Bisector Line

In-toeing and Out-toeing

• Special tests  Foot Propagation Angle (N= -5 to +15)

In-toeing and Out-toeing

• Special tests  hips rotational profile

In-toeing and Out-toeing

• Special tests  Foot Thigh Axis

In-toeing and Out-toeing

• Special tests  Foot Thigh Axis (N= 10°-15°)

A) In-toeing

1) In-toeing: Femoral Anteversion

2) In-toeing: Tibial Torsion

Supine position Sitting position

2) In-toeing: Tibial Torsion

2) In-toeing: Tibial Torsion

3) In-toeing: Forefoot Adduction

4) In-toeing: Adducted Big Toe

B) Out-toeing

In-toeing and Out-toeing

• Management principles: – Establishing correct diagnosis – Allow spontaneous correction (observational management) – Control child’s walking, sitting or sleeping is extremely difficult and frustrating – Shoe wedges or inserts are ineffective – Bracing with twister cables limits child’s activities – Night splints have no long term benefit

In-toeing and Out-toeing

• In-toeing: – Annual clinic F/U  asses degree of deformity – Femoral anti-version  sit cross legged – Tibial torsion  spontaneous improvement – Forefoot adduction  proper shoes reversal anti-version shoes, or – Adducted big toe  spontaneous improvement

In-toeing and Out-toeing

• Out-toeing: – Usually does not improve spontaneously – Will need an operation: • After the age 8y • Foot propagation angle >30°

In-toeing and Out-toeing

• Operative correction indicated for children: – – (> 8) years of age With significant cosmetic and functional deformity  <1%

2) Genu Varus & Valgus

Genu Varum and Genu Valgum

• Definition: Bow legs Knock knees

Genu Varum and Genu Valgum

• Etiology: – Physiologic – Pathologic

Genu Varum and Genu Valgum

• Note: – Physiological is usually  bilateral.

– Pathological  can be unilateral.

Genu Varum and Genu Valgum

• Evaluation – History – Examination (signs of Rickets) – Laboratory

Genu Varum and Genu Valgum

Genu Varum and Genu Valgum

• Evaluation: – Imaging

Genu Varum and Genu Valgum

• Management principles: – Non-operative: • • Physiological  usually Pathological  must treat underlying cause, as rickets – Epiphysiodesis – Corrective osteotomies

3) Proximal Tibia Vara

Proximal Tibia Vara

• • “Blount disease”: damage of tibial proximal medial growth plate of unknown cause Usually: – Overweight – Dark skinned

Proximal Tibia Vara

• Types: – Infantile  < 3y of age, & usually early walkers – Juvenile  3 -10 y, combination – Adolescent  > 10y, & usually unilateral

Proximal Tibia Vara

• Classification (radiological): – XR (M.D.A) – M.D.A < 11°  observe closely – M.D.A > 15°  operate

Proximal Tibia Vara

• MRI is mandatory: – When: • Sever cases • Recurrence – Why?

Bilateral

Proximal Tibia Vara

Unilateral

4) Growing Pain

Leg Aches

• What is leg aches?

– “Growing pain” – Benign – In 15 – 30 % of normal children – F > M – Unknown cause – No functional disability, or limping – Resolves spontaneously, over several years

Leg Aches

• • • Clinical features  diagnosis by exclusion H/O: – At long bones of L.L (Bil) – Dull aching, poorly localized – Can be without activity – At night – Of long duration (months) – Responds to analgesia O/E: – Long bone tenderness  – Normal joints motion nonspecific, large area, or none

Leg Aches

• D.D from serious problems, mainly tumor: – Osteoid osteoma – Osteosarcoma – Ewing sarcoma – Leukemia – SCA – Subacute O.M

Leg Aches

• Management: – Reassurance – Symptomatic: • Analgesia (oral, local) • • Rest Massage

5) Club Foot

Clubfoot

• Etiology – Postural  fully correctable – Idiopathic (CTEV)  partially correctable – Secondary (Spina Bifida)  rigid deformity

Clubfoot

• Diagnosis by exclusion: – Neurological lesion that can cause: • As  Spina Bifida, excluded by spine XR – Abnormalities that can explain: • As  Arthrogryposis – With other congenital anomalies: • As  tibial hemimelia, exclude by XR – Syndromatic clubfoot: • As: – Larsen’s Syndrome – Amniotic Band Syndrome

Clubfoot

• Clinical examination

Characteristic Deformity :

–

Hind foot:

• Equinus (Ankle joint) • Varus (Subtalar joint) –

Mid & fore foot:

• • Forefoot Adduction Cavus

Clubfoot

Clubfoot

• Clinical examination: – Deformities don’t prevent walking – Calf muscles wasting – Internal torsion of the leg – Foot is smaller in unilateral affection – Callosities at abnormal pressure areas – Short Achilles tendon – Heel is high and small – No creases behind Heel – Abnormal crease in middle of the foot

Clubfoot

• Management:

The goal of treatment for is to obtain a foot that is plantigrade, functional, painless, and stable over time A cosmetically pleasing appearance is also an important goal sought by surgeon and family

Clubfoot

• Manipulation and serial casts: – – Validity up to 12 months  soft tissue becomes more tight Technique “Ponseti”  3 stages, weekly basis (usually by 6-8w)

Clubfoot

• Manipulation and serial casts: – Maintaining correction “Dennis Brown Splint”  3-4y old

Clubfoot

• Manipulation and serial casts: – – – Follow up  watch and avoid recurrence, till 9y old Avoid false correction  by going in sequence When to stop ?  not improving, pressure ulcers

Clubfoot

• Indications of surgical treatment: – Late presentation (>12 months of age) – Complementary to conservative treatment (residual forefoot adduction) – Failure of conservative treatment – Recurrence after conservative treatment

• Types of surgery: – Soft tissue

Clubfoot

• Types of surgery: – Bony

Clubfoot

Clubfoot

• Types of surgery: – If sever, rigid, and in an older child

Clubfoot

• Types of surgery: – If sever, rigid, and in an older child (salvage)

6) L.L Deformities in C.P Patients

Lower Limb Deformities in CP Child

• • • • C.P is  a non-progressive brain insult that occurred during the peri-natal period.

Causes  skeletal muscles imbalance that affects joint’s movements.

Can be associated with: – Mental retardation (various degrees) – Hydrocephalus and V.P shunt – Convulsions Its not-un-common

Lower Limb Deformities in CP Child

• Physiological classification: – – Spastic Athetosis – Ataxia – Rigidity – Mixed • Topographic classification: – – Monoplegia Diplegia – Paraplegia – Hemiplegia – Bilateral hemiplegia – Triplegia – Quadriplegia or tetraplegia

Lower Limb Deformities in CP Child

• • • • Hip – – – Flexion Adduction Internal rotation Knee – Flexion Ankle – Equinus – Varus or valgus Gait – – Intoeing Scissoring

Lower Limb Deformities in CP Child

• Assessment: – Hips

Lower Limb Deformities in CP Child

• Assessment: – Knees

Lower Limb Deformities in CP Child

• Assessment: – Ankles

Lower Limb Deformities in CP Child

• Management is multidisciplinary: – Parents education – Pediatric neurology  diagnosis, F/U, treat fits – P.T (home & center)  joints R.O.M, gait training – Orthotics  maintain correction, aid in gait – Social / Government aid – Others: • Neurosurgery (V.P shunt), • • Ophthalmology (eyes sequent), …etc.

Lower Limb Deformities in CP Child

• Indications of Orthopedic surgery: – Sever contractures preventing P.T

– P.T plateaued due to contractures – Perennial hygiene (sever hips adduction) – In a non-walker to sit confortable in wheelchair – Prevent: • Neuropathic skin ulceration (as feet) • Joint dislocation (as hip)

Lower Limb Deformities in CP Child

• Options of Surgery: – Tenotomy – Tenoplasty – Muscle lengthening – Neurectomy – Tendon Transfer – Bony surgery  Osteotomy/Fusion

7) Limping

Limping Definition

• It is: – An abnormal gait – Due to: • Pain • • Weakness (general or nerve or muscle) Or deformity (bone or joint) – In one or both limbs

Limping

• Diagnosis by: – History  age of onset – Examination: • Gait in the clinic hallway • Is it: – Above pelvis  Back (scoliosis) – Below pelvis  Hips, knees, ankles, & feet • Neuro.Vascular

Limping

• Management: – Generalization can’t be made – Treatment of the cause:

8) Limb Length Inequality

Limb Length Inequality

• • True vs. apparent Etiology:

Limb Length Inequality

• • True vs. apparent Etiology: – Congenital  as DDH

Limb Length Inequality

• • True vs. apparent Etiology: – Congenital  as DDH – Developmental  as Blount’s

Limb Length Inequality

• • True vs. apparent Etiology: – Congenital  as DDH – – Developmental  as Blount’s Traumatic  as oblique # (short), or multifragmented (long)

Limb Length Inequality

• • True vs. apparent Etiology: – Congenital  as DDH – – – Developmental  as Blount’s Traumatic  as oblique # (short), or multifragmented (long) Infection  stunted growth or dissolved part of bone

Limb Length Inequality

• • True vs. apparent Etiology: – Congenital  as DDH – – – – Developmental  as Blount’s Traumatic  as oblique # (short), or multifragmented (long) Infection  stunted growth or dissolved part of bone Metabolic  as rickets

Limb Length Inequality

• • True vs. apparent Etiology: – Congenital  as DDH – – – – Developmental  as Blount’s Traumatic  as oblique # (short), or multifragmented (long) Infection  stunted growth or dissolved part of bone Metabolic  as rickets (unilateral) – Tumor  affecting physis

Limb Length Inequality

• Adverse effects & clinical picture: – – Gait disturbance Equinus deformity – Pain: back, leg – Scoliosis (secondary)

Limb Length Inequality

• Evaluation: – – Screening examination Clinical measures of discrepancy – Imaging methods (Centigram)

Limb Length Inequality

• Clinical measures of discrepancy: – – Measuring tape Giliazi test

Limb Length Inequality

• Management depends on the severity (>2cm): – For shorter limb: • • Shoe raise Bone lengthening – For longer limb: • • Epiphysiodesis (temporary or permanent) Bone shortening

Remember …

Conclusion 1. In & out toeing  torsion vs. version, proper assessment to know cause & level, mainly observe, operate >8y old 2. Genu varus & valgus  when operate physiological vs. pathological, rickets, 3. Blount  medial physis, D.M.A, MRI, types, surgery 4. Leg aches  of exclusion, D.D, long bone, activity ±, symptomatic treatment 5. CTEV  3 types, diagnosis of exclusion, clinical picture, Ponseti, better to avoid surgery 6. L.L in C.P  muscle imbalance, of different types, proper pt assessment, PT ± surgery 7. Limping  assessment due (pain- week- deformed), uni or bi, , proper 8. L.L.I  true vs. apparent, proper assessment to know cause & level, if not treated, >2cm, options of treat