GENU VALGUS & GENU

VARUS

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

Site of varus

Causes

Lateral ligament laxity

Blounts disease
Congenital pseudoarthrosis of tibia
Coxa vara

In ligamentous laxity
notelat.Widening
Of knee joints

In Blount angulation at
med.tib metaphysis

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

In coxa vara ,angulation at the

neck shaft level

 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/diaphys
ial 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.

DEVELOPMENTAL
DYSPLASIA OF THE HIP
(DDH)

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.

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 (frogleg 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.

PERTHES DISEASE

Pathology
Legg-Calv-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 stiffnessthat 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 hipx-rayorpelvis 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 asibuprofen) 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.

Slipped Upper Femoral

Epiphysis

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 osteodystrophyinduced 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

Acutehip 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.

Prognosis
Prognosis depends on the initial degree of
epiphyseal slippage.
The end result is good to excellent in 9496% 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.