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

Objectives: 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).

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

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

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

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

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

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

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 Why does this patient in-toe?

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

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

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

Rotational Profile Gait: foot progression angles

Rotational Profile Range of normal: foot progression angles

Structural toeing and bowing 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

Rotational Profile Gait: foot progression angles

Rotational Profile Gait: foot progression angles

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

Assessing hip rotation Medial Rotation Hip Lateral Rotation Hip

Assessing hip rotation

Normals: medial femoral rotation

Normals: lateral femoral rotation

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

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

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

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

Femoral antetorsion

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

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

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

Assessing tibial rotation L TFA R TFA

Assessing tibial rotation

Assessing tibial rotation

Normals: tibial rotation

Medial tibial torsion

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

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

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

Assessing foot alignment Pretty Much Normal

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

In Summary Femoral 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 inwards Metatarsus adductus curves the foot inwards A searching or abducted great toe produces in-toeing

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

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

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

The most likely diagnosis is… cerebral palsy arthrogryposis Perthe’s disease septic arthritis of the hip hip dysplasia

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

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

The most likely diagnosis is… cerebral palsy arthrogryposis Perthe’s disease septic arthritis of the hip hip dysplasia

The most likely diagnosis is… cerebral palsy arthrogryposis Perthe’s disease septic arthritis of the hip hip dysplasia

Bilateral hip dislocations

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

DDH detection Newborn nursery exam Loss of abduction, pistoning 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

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

Rx for dysplasia -REFER Pavlik 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 orthopaedics Abduction orthoses may help correct hip dysplasia in the older child

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

R hip after OR, fem short, pelvic osteotomy

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

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

Perthes ds

Perthes ds

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

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis

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

Physiologic genu valgum Maximum varus at birth Maximum valgus > 10°, ages 3 - 4 yrs At maturity, mean is ~ 6° anatomic valgus

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

Apparent bowing

Vit-D deficient/resistant rickets

Bowing of tibia vara

Knock- knees or genu valgum Physiologic Pathologic

Physiologic valgus

Physiologic genu valgum Maximum varus at birth Maximum valgus > 10°, ages 3 - 4 yrs At maturity, mean is ~ 6° anatomic valgus

Knock- knees Pathologic genu valgum Skeletal dysplasias 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

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

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

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

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

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

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

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

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

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

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

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

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

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

References: Herring, JA: Tachdjian’s Pediatric Orthpaedics, WB Saunders, Philadelphia, 2002. Staheli, LT: Fundamentals of Pediatric Orthopedics, Raven Press, New York, 1992. Staheli, LT: Practice of Pediatric Orthopedics, Lippincott, 2002. Tolo, VT: “In-toeing and Out-toeing,” Lovell and Winter’s Pediatric Orthopaedics, 4th ed., Morrissey and Weinstein, eds., Lippincott-Raven, Philadelphia, 1996. Wenger, DA and M Rang: The Art and Practice of Pediatric Orthopaedics, Raven, New York, 1993.