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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.

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

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

3 Objectives: Describe normal development 1. Describe the commonly seen pediatric disorders involving gait, children's feet, and children's legs, including problems in normal development (and the ages at which these problems are commonly seen).

4 Objectives: evaluation 2. Discuss the evaluation of common pediatric foot, gait, and leg disorders. optimal management. 3. Describe their optimal management.

5 Approach Learn the range of normalLearn the range of normal –It’s huge –“Normal” changes with growth and development –Before saying something is “normal”, rule out the pathologies common pathologiesKnow the common pathologies “ The eye sees what the mind knows”

6 Common and often benign orthopaedic concerns In-toeing Out-toeing Bowed legs Knock-knees Flat feet

7 Pathologies Cerebral Palsy Hip dysplasia Legg-Calve-Perthes’s disease Slipped Capital Femoral Epiphysis Clubfoot

8 Systematic approach - Where’s the source? Hip joint Thigh (femur) Knee joint Leg (tibia) Ankle joint Foot (tarsals and metatarsals) X X

9 Group pathologies by age Newborns and infants (< 1 yr) Toddlers (1-3 yr) Older children (4-10 yr) Pre-teens and teens (> 10 yrs)

10 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 this Why does this patient in-toe?

11 History What is the specific concern? Who is concerned? When does it manifest? Duration? Improving or worsening?

12 Evaluation Medical History –Developmental delay(s)? –Precipitating event/birth complication? Family History Screening examination –Spasticity? –Asymmetry? Rotational Profile

13 Gait: determine foot progression angles Assess hip rotation Assess tibial rotation f [(BRAIN) + ]Determine the alignment of the foot Gait = f [(BRAIN) + (hip & femur) + (leg & foot) + (knee + ankle) ]

14 Rotational Profile Gait: foot progression angles

15 Rotational Profile Range of normal: foot progression angles

16 Structural toeing and bowing Terminology: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

17 Rotational Profile Gait: foot progression angles

18 Rotational Profile Gait: foot progression angles

19 Rotational Profile Gait: determine foot progression angles Assess hip rotationAssess hip rotation Assess tibial rotation Where is the source???Determine the alignment of the foot Where is the source???

20 Assessing hip rotation Medial Rotation Hip Lateral Rotation Hip

21 Assessing hip rotation

22 Normals: medial femoral rotation

23 Normals: lateral femoral rotation

24 Is the hip rotation normal? Within two standard deviations of the mean?Within two standard deviations of the mean? Symmetric?Symmetric? Painless?Painless? Without spasticity? What is the cause of the increased medial (or lateral) rotation?Without spasticity? What is the cause of the increased medial (or lateral) rotation?

25 Causes of excess rotation Soft tissues vs. bony anatomySoft tissues vs. bony anatomy Hip joint - soft tissue contracturesHip joint - soft tissue contractures –Newborns have an posterior capsular contracture, producing excessive lateral rotation of the hips Femoral antetorsion - bony anatomyFemoral antetorsion - bony anatomy –produces excessive medial rotation at the hip

26 What is femoral anteversion? Left foot Anteversion Excessive anteversion equals antetorsion Femoral antetorsion produces intoeing

27 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

28 Femoral antetorsion

29 Rotational Profile Gait: determine foot progression angles Assess hip rotation Assess tibial rotationAssess tibial rotation Determine the alignment of the foot Where is the source???

30 Tibia TorsionTorsion –Tibial torsion can lead to intoeing: Internal or medial tibial torsion is a twist to the leg, pointing the toe inwards Internal or medial tibial torsion is a twist to the leg, pointing the toe inwards

31 Assessing tibial torsion: Thigh-foot angle Transmalleolar axis Determine axes Measure angles

32 Assessing tibial rotation L TFAR TFA

33 Assessing tibial rotation

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35 Normals: tibial rotation

36 Medial tibial torsion

37 Foot Metatarsus adductus curves the foot inwardsMetatarsus adductus curves the foot inwards Searching great toe pulls the foot inwardsSearching great toe pulls the foot inwards Flatfoot may produce out-toeing from “wringing-out” of the foot:Flatfoot may produce out-toeing from “wringing-out” of the foot: Supinated forefoot with valgus heel Supinated forefoot with valgus heel

38 Assessing alignment of the foot Shape of the foot Heel-bisector angle

39 Metatarsus Adductus Majority are flexible Adductus resolves by 3-4 yrs 10% stiff and may benefit from casting

40 Assessing foot alignment Pretty Much Normal

41 Toeing and bowing: Toeing and bowing: Determining the source Excessive medial rotation of hips? NO YES on excessive medial rotation Does he have it? NO on antetorsion, but YES on excessive medial rotation NoInternally rotated thigh-foot angle = internal tibial torsion? No NoCurved foot = metatarsus adductus? No

42 In Summary Femoral antetorsion produces excessive medial rotation at the hip which leads to in-toeingFemoral 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 inwardsMedial tibial torsion is a twist to the leg, pointing the foot inwards Metatarsus adductus curves the foot inwardsMetatarsus adductus curves the foot inwards A searching or abducted great toe produces in-toeingA searching or abducted great toe produces in-toeing

43 A five year old girl presents with knock- knees and intoeing. You should obtain a rotational profile and… 1.refer to orthopaedics for bracing or surgery 2.have the child put her shoes on the opposite feet and recheck her in a year 3.just recheck her in a year 4.obtain an AP pelvis radiograph and full length lower extremity films to look for hip dysplasia

44 How to treat intoeing? Shoe wedges? No. Twister cables? No. YesObservation? Yes.

45 Pathologies to consider “Why is there an abnormal range of motion of the hip?” Infants and toddlersInfants and toddlers –Hip dysplasia –Neuromuscular disease –Neuromuscular disease - Cerebral palsy ToddlersToddlers –Legg-Calve-Perthes disease Pre-teensPre-teens –Legg-Calve-Perthes disease –Slipped Capital femoral epiphysis

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47 The most likely diagnosis is… 1. cerebral palsy 2. arthrogryposis 3. Perthe’s disease 4. septic arthritis of the hip 5. hip dysplasia

48 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

49 Arthrogryposis 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

50 The most likely diagnosis is… 1. cerebral palsy 2. arthrogryposis 3. Perthe’s disease 4. septic arthritis of the hip 5. hip dysplasia

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52 The most likely diagnosis is… 1. cerebral palsy 2. arthrogryposis 3. Perthe’s disease 4. septic arthritis of the hip 5. hip dysplasia

53 Bilateral hip dislocations

54 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

55 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

56 DDH detection Ultrasound (dedicated center) –Better at > 2 wks of age –Dynamic exam Radiography –Gold standard –Best after 6-8 weeks of age

57 Rx for dysplasia -REFER PavlikPavlik 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 orthopaedicsUnstable hips deserve a referral to orthopaedics Abduction orthoses may help correct hip dysplasia in the older child

58 Hip dysplasia Early treatment enables quick resolution Delayed treatment risks a poor result/multiple surgeries Over-treatment is generally benign for the located hip

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60 R hip after OR, fem short, pelvic osteotomy

61 Cerebral palsy Mild developmental delays?Mild developmental delays? Mild spasticity or increased tone?Mild spasticity or increased tone? Asymmetry of motion, tone, reflexes?Asymmetry of motion, tone, reflexes? You may be the first to make the diagnosis

62 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

63 Perthes ds

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65 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

66 Slipped capital femoral epiphysis

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68 Knee angular deformities Genu varum - bowing What’s normal?Genu valgum - knock-knees What’s normal?

69 Maximum varus at birth Maximum valgus > 10°, ages yrs At maturity, mean is ~ 6° anatomic valgus Physiologic genu valgum

70 Bowing or genu varum Physiologic bowing Pathologic bowing –Rickets –Tibia vara –Skeletal dysplasia

71 Apparent bowing

72 Vit-D deficient/resistant rickets

73 Bowing of tibia vara

74 Knock- knees or genu valgum Physiologic Pathologic

75 Physiologic valgus

76 Maximum varus at birth Maximum valgus > 10°, ages yrs At maturity, mean is ~ 6° anatomic valgus Physiologic genu valgum

77 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

78 leg Pathologies to consider - leg AngulationAngulation or bowing of the tibia –Very unusual! Antero-lateral ?neurofibromatosis?Antero-lateral ?neurofibromatosis? Postero-medial ?leg length difference?Postero-medial ?leg length difference? Antero-medial ?fibular deficiency?Antero-medial ?fibular deficiency?

79 foot Pathologies to consider: foot Flatfoot All infants have it Most children have it More than 15% of adults have it

80 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

81 More foot pathologies to consider Stiff or rigid metatarsus adductus Clubfoot Calcaneovalgus Cavovarus foot

82 Clubfoot Incidence 1:1000 Talipes equinovarus True congenital vs positional Cavus, adductus, varus, equinus If present, examine hips carefully!

83 Clubfoot treatment Serial manipulations and casting Begin first week of life, if possible Perform weekly 90% of routine clubfoot respond

84 Calcaneovalgus foot Most common foot deformity at birth Forefoot abducted, ankle dorsiflexed - foot lies on anterior leg Resolves spontaneously Associated with hip dysplasia

85 Cavovarus foot High arch = cavus Heel in varus Often rigid Look to spinal cord or peripheral nervous system

86 Out-toeing (Less commonly seen) Causes: External rotation contracture at the hip? Lateral tibial torsion? Flatfoot? unlessLittle hope of improvement over time, unless it’s a result of flatfoot

87 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

88 Summary Most toe-ing and bow-ing deformities are benign many years –Resolution may take many years Use history and exam to rule-out the pathologic causes ReassureReassure 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

89 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

90 Who needs a referral? 1) A newborn with a hip click? 2) A newborn with a hip clunk? 3) A ten year old girl with marked out-toeing on the side of groin pain? 4) A newborn with flat feet?

91 References: Herring, JA: Tachdjian’s Pediatric Orthpaedics, WB Saunders, Philadelphia, Staheli, LT: Fundamentals of Pediatric Orthopedics, Raven Press, New York, Staheli, LT: Practice of Pediatric Orthopedics, Lippincott, Tolo, VT: “In-toeing and Out-toeing,” Lovell and Winter’s Pediatric Orthopaedics, 4th ed., Morrissey and Weinstein, eds., Lippincott-Raven, Philadelphia, Wenger, DA and M Rang: The Art and Practice of Pediatric Orthopaedics, Raven, New York, 1993.


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