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
Blount’s 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 ⅓
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/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.
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
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.
PERTHES DISEASE
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.
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 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.
Prognosis
• Prognosis 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 fairto-poor surgical result.