Common Pediatric Lower Limb Disorders Dr.Khalid Bakarman & Dr.Kholoud Al-Zain Assistant Professors Consultant Pediatric Orthopedic Surgeons KKUH Dr.Mohammed M. Zamzam Professor & Consultant Pediatric Orthopedic Surgeon

Topics Leg aches Limping In-toeing & out-toeing Leg length inequality Genu varus & valgus Proximal tibia vara Club foot L.L deformities in C.P patients

1) Leg Aches

Leg Aches What is leg aches? “Growing pain” Benign In 15 – 30 % of normal children F > M Unknown cause No functional disability, or limping Resolves spontaneously, over several years Growth spert

Leg Aches Clinical features  diagnosis by exclusion H/O: O/E: At long bones of L.L (Bil) Dull aching, poorly localized Can be without activity At night Of long duration (months) Responds to analgesia O/E: Long bone tenderness  nonspecific, large area, or none Normal joints motion

Screening Examination Leg Aches What is leg aches? Growing pain Benign No functional disability Resolves spontaneously Unknown cause Clinical features Diagnosis by exclusion History Screening Examination Tenderness Joint Motion

Leg Aches D.D from serious problems, mainly tumor: Osteoid osteoma Osteosarcoma Ewing sarcoma Leukemia SCA Subacute O.M

Leg Aches Management Reassurance Symptomatic: Analgesia (oral, local) Rest Massage

Leg Aches Differential Diagnosis from serious problems mainly tumor Osteoid osteoma Osteosarcoma Ewing sarcoma Management Symptomatic Reassurance

2) Limping

Limping Definition It is: An abnormal gait, Due to: Pain, Weakness (general or nerve or muscle), Or deformity (bone or joint). In one or both limbs.

Limping Diagnosis by: History  mainly age of onset Examination: Mainly gait in the clinic hallway, Is it: Above pelvis  Back (scoliosis) Below pelvis  Hips, knees, ankles, & feet Neuro.Vascular.

Abnormal gait due to pain, weakness or deformity Limp Abnormal gait due to pain, weakness or deformity Evaluation History (Mainly age of onset) Observation Evaluate the limp by studying the child’s gait while the child walks in the clinic hallway

Limping Management: Generalization can’t be made. Treatment of the cause:

3) In-toing & Out-toing

In-toeing and Out-toeing Terminology: Version: Describes normal variations of limb rotation. It may be exaggerated. Torsion: Describes abnormal limb rotation. Internal or external.

In-toeing and Out-toeing Evaluation: History, Screening examination (head to toe), Asses rotational profile: Hips  Hips Rotational Profile. Tibiae  Foot Thigh Axis. Feet  Heal Bisector Line.

In-toeing and Out-toeing Special tests  Foot Propagation Angle (N= -5 to +15)

In-toeing and Out-toeing Special tests  hips rotational profile

In-toeing and Out-toeing Special tests  Foot Thigh Axis

In-toeing and Out-toeing Special tests  Foot Thigh Axis (N= 10°-15°)

In-toeing and Out-toeing Special tests  hips rotational profile

A) In-toeing

1) In-toeing: Femoral Anteversion

2) In-toeing: Tibial Torsion Supine position Sitting position

2) In-toeing: Tibial Torsion

2) In-toeing: Tibial Torsion

3) In-toeing: Forefoot Adduction

4) In-toeing: Adducted Big Toe

D) In-toeing: Adducted Big Toe

A) In-toeing Evaluation: History, Screening examination, Asses rotational profile.

B) Out-toeing

B) Out-toeing Evaluation: History, Screening examination, Asses rotational profile.

In-toeing and Out-toeing Management principles: Establishing correct diagnosis Allow spontaneous correction (observational management) Control child’s walking, sitting or sleeping is extremely difficult and frustrating Shoe wedges or inserts are ineffective Bracing with twister cables limits child’s activities Night splints have no long term benefit

In-toeing and Out-toeing Annual clinic F/U  asses degree of deformity Femoral anti-version  sit cross legged Tibial torsion  spontaneous improvement Forefoot adduction  anti-version shoes, or proper shoes reversal Adducted big toe  spontaneous improvement

In-toeing and Out-toeing Usually does not improve spontaneously Will need an operation: After the age 8y Foot propagation angle >30°

In-toeing and Out-toeing Operative correction indicated for children: (> 8) years of age With significant cosmetic and functional deformity  <1%

4) Limb Length Inequality

Limb Length Inequality True vs. apparent Etiology: Congenital  as DDH Developmental  as Blount’s Traumatic  as oblique # (short), or multifragmented (long) Infection  stunted growth or dissolved part of bone Metabolic  as rickets (unilateral) Tumor  affecting physis

Limb Length Inequality True and apparent Etiology Congenital Developmental Traumatic Infection Metabolic Tumor

Limb Length Inequality Adverse effects & clinical picture: Gait disturbance Equinus deformity Pain: back, leg Scoliosis (secondary) Evaluation: Screening examination Clinical measures of discrepancy Imaging methods (Centigram)

Limb Length Inequality Clinical measures of discrepancy: Measuring tape Giliazi test

Limb Length Inequality Adverse effects Gait disturbance Equinous deformity Back pain Scoliosis Evaluation Screening examination Clinical measures of discrepancy Imaging methods (Centigram)

Limb Length Inequality Management depends on the severity (>2cm): For shorter limb: Shoe raise Bone lengthening For longer limb: Epiphysiodesis (temporary or permanent) Bone shortening

Limb Length Inequality Management principles Severity Lifts Shortening Epiphysiodesis Lengthening

5) Genu Varus & Valgus

Genu Varum and Genu Valgum Definition: Bow legs Knock knees

Genu Varum and Genu Valgum Etiology: Physiologic Pathologic

Genu Varum and Genu Valgum Note: Physiological is usually  bilateral. Pathological  can be unilateral.

Genu Varum and Genu Valgum Definitions Bow legs Knock knees Etiology Physiologic Pathologic

Genu Varum and Genu Valgum Evaluation History Examination (signs of Rickets) Laboratory Re take the rickets picture

Genu Varum and Genu Valgum

Genu Varum and Genu Valgum Evaluation: Imaging Put mechanical axsis

Genu Varum and Genu Valgum Evaluation Imaging

Genu Varum and Genu Valgum Management principles: Non-operative: Physiological  usually Pathological  must treat underlying cause, as rickets Epiphysiodesis Corrective osteotomies

Genu Varum and Genu Valgum Management principles: Non-operative ? Epiphysiodesis Corrective osteotomies

6) Proximal Tibia Vara

Proximal Tibia Vara “Blount disease”: damage of proximal medial tibial growth plate of unknown cause Staging: Radiological (M.D.A) M.D.A < 11°  observe M.D.A > 15°  operate

Proximal Tibia Vara MRI is mandatory: When: Why? Sever cases Recurrence Why? Is it physis defect

Tibia Vara Blount disease Damage of proximal medial tibial growth plate of unknown cause MRI is mandatory …. Why? Is it physis defect

Proximal Tibia Vara Types: Infantile  usually in over weight & early walkers Adolescent  usually over weight & unilateral Is it physis defect

Proximal Tibia Vara Bilateral Unilateral

7) Club Foot

Clubfoot Etiology Postural  fully correctable Idiopathic (CTEV)  partially correctable Secondary (Spina Bifida)  rigid deformity

Clubfoot Etiology Postural Idiopathic (CTEV) Secondary (Spina Bifida)

Clubfoot Diagnosis by: Neurological lesion that can cause: As  Spina Bifida Excluded by spine X-rays Abnormalities that can explain: As  Arthrogryposis With other congenital anomalies: As  Proximal femoral focal deficiency (PFFD) Syndromatic clubfoot: As  Larsen’s Syndrome, Amniotic Band Syndrome Why this seqwence Why #2 & #4 are not the same

Clubfoot Diagnosis by exclusion Exclude Neurological lesion that can cause the deformity “Spina Bifida” (excluded by spine x-rays) Other abnormalities that can explain the deformity “Arthrogryposis, Myelodysplasia” Presence of concomitant congenital anomalies “Proximal femoral focal deficiency” Syndromatic clubfoot “Larsen’s syndrome, Amniotic band Syndrome”

Clubfoot Clinical examination Characteristic Deformity : Hind foot: Equinus (Ankle joint) Varus (Subtalar joint) Mid & fore foot: Forefoot Adduction Cavus

Clubfoot

Clubfoot Clinical examination: Deformities don’t prevent walking Calf muscles wasting Internal torsion of the leg Foot is smaller in unilateral affection Callosities at abnormal pressure areas Short Achilles tendon Heel is high and small No creases behind Heel Abnormal crease in middle of the foot

A cosmetically pleasing appearance is also an important goal sought by Clubfoot Management: The goal of treatment for is to obtain a foot that is plantigrade, functional, painless, and stable over time A cosmetically pleasing appearance is also an important goal sought by surgeon and family

Clubfoot Manipulation and serial casts: Validity up to 12 months  soft tissue becomes more tight Technique “Ponseti”  3 stages, weekly basis (usually by 6-8w)

Clubfoot Manipulation and serial casts: Maintaining correction “Dennis Brown Splint”  3-4y old

Clubfoot Manipulation and serial casts: Follow up  watch and avoid recurrence, till 9y old Avoid false correction  by going in sequence When to stop ?  not improving, pressure ulcers All pictures put better / Why only to 12 m / when stop

Clubfoot Manipulation and serial casts: Validity up to 12 months  soft tissue becomes more tight Technique “Ponseti”  3 stages, weekly basis (usually by 6-8w) Maintaining correction “Dennis Brown Splint”  3-4y old Follow up  watch and avoid recurrence, till 9y old Avoid false correction  by going in sequence When to stop ?  not improving, pressure ulcers All pictures put better / Why only to 12 m / when stop

Manipulation and serial casts Clubfoot Manipulation and serial casts Validity, up to 12 months ! Technique “Ponseti” Avoid false correction When to stop ? Maintaining the correction Follow up to watch and avoid recurrence

Clubfoot Indications of surgical treatment: Late presentation (>12 months of age) Complementary to conservative treatment (residual forefoot adduction) Failure of conservative treatment Recurrence after conservative treatment

Clubfoot Types of surgery: Soft tissue

Clubfoot Types of surgery: Bony New pictures

Clubfoot Types of surgery: If sever, rigid, and in an older child New pictures

Clubfoot Indications of surgical treatment Types of surgery Late presentation, after 12 months of age ! Complementary to conservative treatment Failure of conservative treatment Recurrence after conservative treatment Types of surgery Soft tissue Bony Salvage

Clubfoot Types of surgery: If sever, rigid, and in an older child (salvage)

Clubfoot

8) L.L Deformities in C.P Patients

Lower Limb Deformities in CP Child C.P is  a non-progressive brain insult that occurred during the peri-natal period. Causes  skeletal muscles imbalance that affects joint’s movements. Can be associated with: Mental retardation (various degrees) Hydrocephalus and V.P shunt Convulsions Its not-un-common

Lower Limb Deformities in CP Child Physiological classification: Spastic Athetosis Ataxia Rigidity Mixed Topographic classification: Monoplegia Diplegia Paraplegia Hemiplegia Bilateral hemiplegia Triplegia Quadriplegia or tetraplegia

Lower Limb Deformities in CP Child Hip Flexion Adduction Internal rotation Knee Ankle Equinus Varus or valgus Gait Intoeing Scissoring

Lower Limb Deformities in CP Child Assessment: Hips

Lower Limb Deformities in CP Child Assessment: Knees

Lower Limb Deformities in CP Child Assessment: Ankles

Lower Limb Deformities in CP Child Assessment: Hips Knees Ankles New pictures

Lower Limb Deformities in CP Child Management is multidisciplinary: Parents education Pediatric neurology  diagnosis, F/U, treat fits P.T (home & center)  joints R.O.M, gait training Orthotics  maintain correction, aid in gait Social / Government aid Others: Neurosurgery (V.P shunt), Ophthalmology (eyes sequent), …etc.

Lower Limb Deformities in CP Child Indications of Orthopedic surgery: Sever contractures preventing P.T P.T plateaued due to contractures Perennial hygiene (sever hips adduction) In a non-walker to sit confortable in wheelchair Prevent: Neuropathic skin ulceration (as feet) Joint dislocation (as hip)

Lower Limb Deformities in CP Child Options of Surgery: Tenotomy Tenoplasty Muscle lengthening Neurectomy Tendon Transfer Bony surgery  Osteotomy/Fusion

Lower Limb Deformities in CP Child Management principles Multidisciplinary Options of Surgery Neurectomy Tenotomy Tenoplasty Muscle lengthening Tendon Transfer Bony surgery Osteotomy/Fusion

Remember …

Conclusion Leg aches  of exclusion, D.D, long bone, activity ±, symptomatic treatment Limping  due (pain- week- deformed), uni or bi, , proper assessment In & out toeing  torsion vs. version, proper assessment to know cause & level, mainly observe, operate >8y old L.L.I  true vs. apparent, proper assessment to know cause & level, if not treated, >2cm, options of treat Genu varus & valgus  physiological vs. pathological, rickets, when operate Blount  medial physis, D.M.A, MRI, types, surgery CTEV  3 types, diagnosis of exclusion, clinical picture, Ponseti, better to avoid surgery L.L in C.P  muscle imbalance, of different types, proper pt assessment, PT ± surgery