3Natural History of normal evolution of the alignment of the lower limbs Bowlegs in new born and infantWith medial tibial torsion = fetal positionBecomes straight by 18/12By 2 or 3 genu valgus develop (avg. 12°)By 7 spontaneous correctionTo the normal of adult valgus ( 8°♀ and 7°♂)
4Persistent genu varum Worried parents About 3 years old +bow legs +mild lateral thrust at the knees + in-toeingAssessment:- History- etiologic factorsHistory= family history any ttt check parents &siblings-if short ?bone dysplasia. When did it appear? ↑=↓
5Examination Height See ( front, back & side) Measure Site of varus IC distance,lateral thigh-leg angle,center of gravitySite of varusShort = rickets or dysplasiaGentle bowing involving the femur-distal⅓ and tibia-junc.of middle and proximal ⅓ s
6Causes Lateral ligament laxity Blount’s disease Congenital pseudoarthrosis of tibiaCoxa vara
7In ligamentous laxity notelat.Widening Of knee jointsIn Blount angulation at med.tib metaphysis
8In cong. Pseudarthrosis of tibia,the angulation is in the distal ⅓ In coxa vara ,angulation at the neck shaft level
9Gait: intoeing, lateral thrust-the fibular head and upper tibia shift laterally in Blount due to laxity and incompetence of the lat. Collat. Lig.StabilitySymmetryLevel 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
10X-ray 3 years and older Getting worse Abnormal site of angulation Large physis and epiphysisHistory – taruma, infection, possible metal intoxication(lead or floride)Metaphysial/diaphysial angle ≥ 18°
11Finding 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
12Knock 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.
13Investigations 1Measurement 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 years have some degree of intermalleolar separation.
14Investigations2Intermalleolar 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.
15Indicators of Serious Disease Pronounced asymmetryShort statureOther skeletal abnormalitiesIntermalleolar separation greater than 3.5 inches
16Aetiology Developmental Miscellaneous syndromes e.g Rickets (Alk Phos raised, with x-ray changes)Rare Genetic disorders e.g Cohen SyndromeNutritional conditions e.g Vitamin C deficiencyAutoimmune e.g RADegenerative e.g OA
17When to refer Age > 7 with knock knee Unilateral problem i.e Asymmetry of legsIntermalleolar distance > 3.5 inches (9 cms)Associated symptoms e.g Pain, Limp
18TreatmentNo evidence that shoe modification, splints, or exercises affect conditionNo evidence to justify surgical intervention under 6 inches of intermalleolar separation.Surgical options:Medial epiphyseal stapling at 10 to 11 yearsCorrective osteotomy at maturity.
19Flat Feet / Pes PlanusArch of the foot is low. Medial arch is lost. There may be some valgus and eversion deformity of the foot.
20Normal 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.
21Investigation Ask patient to stand on tiptoes. If medial arch restores itself when standing on tiptoe or when foot is unloaded, no action is needed.
22Presentations 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.
23Causes 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.
24Rare 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.
25Rare Causes of Flat Feet May be part of a more generalized conditionSevere joint laxityCerebral PalsyPeroneal spastic flat footDowns Syndrome
26TreatmentNo proven benefit from insoles, shoe modification, foot exercises.Spasmodic type :Hindfoot fusion for pain relief.Subtalar arthrodesis corrects deformity.
28DDHVery important condition as early diagnosis and correction prevent major damage.All newborns are screened for DDH by Barlow’s and Ortolani’s manoevreDevelopmental 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.
29Causes, 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 childBeing femaleBreech position during pregnancyFamily history of the disorderDDH occurs in about 1 out of 1,000 births.
30SymptomsThere may be no symptoms. Symptoms that may occur can include:Leg with hip problem may appear to turn out moreReduced movement on the side of the body with the dislocationShorter leg on the side with the hip dislocationUneven skin folds of thigh or buttocksAfter 3 months of age, the affected leg may turn outward or be shorter than the other leg.
31Signs and testsPediatric 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.
33TreatmentWhen 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.
35PrognosisIf 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.
37PathologyLegg-Calvé-Perthes disease (LCPD) is the name given to idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head.
38Causes, incidence, and risk factors Legg-Calve-Perthes disease usually occurs in boys 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 years.
39SymptomsThe 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 hipKnee painLimited range of motionPersistent thigh or groin painShortening of the leg, or legs of unequal lengthWasting of muscles in the upper thigh
40Signs and testsDuring 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.
41TreatmentThe 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
42PrognosisThe 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.
44SUFEOften 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
45Epidemiology Incidence is 30-60/100,000 children per year. Most commonly it occurs in boys of 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.2it is three times as common in boys.
46Risk 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.
47SymptomsDiscomfort 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.
49InvestigationsAnteroposterior and 'frog-leg' lateral X-rays show widening of epiphyseal line or displacement of the femoral head.
50ManagementAvoid 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.
51PrognosisPrognosis depends on the initial degree of epiphyseal slippage.The end result is good to excellent in 94-96% 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.