1. Common Pediatric Lower Limb Disorders
Dr.Kholoud Al-Zain
Assistant Professors
Consultant Pediatric Orthopedic Surgeons

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

3. 1) Growing Pain

4. 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

5. 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

6. 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

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

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

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

10. 2) Limping

11. 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

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

13. 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

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

15. 3) In-toing & Out-toing

16. 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

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

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

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

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

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

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

23. A) In-toeing

24. 1) In-toeing: Femoral Anteversion

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

26. 2) In-toeing: Tibial Torsion

27. 2) In-toeing: Tibial Torsion

28. 3) In-toeing: Forefoot Adduction

29. 4) In-toeing: Adducted Big Toe

30. D) In-toeing: Adducted Big Toe

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

32. B) Out-toeing

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

34. 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

35. 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

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

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

38. 4) Limb Length Inequality

39. Limb Length Inequality
True vs. apparent
Etiology:

40. Limb Length Inequality
True vs. apparent
Etiology:
Congenital  as DDH

41. Limb Length Inequality
True vs. apparent
Etiology:
Congenital  as DDH
Developmental  as Blount’s

42. Limb Length Inequality
True vs. apparent
Etiology:
Congenital  as DDH
Developmental  as Blount’s
Traumatic  as oblique # (short), or multifragmented (long)

43. 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

44. 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

45. 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

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

47. Limb Length Inequality
Adverse effects & clinical picture:
Gait disturbance
Equinus deformity
Pain: back, leg
Scoliosis (secondary)

48. Limb Length Inequality
Evaluation:
Screening examination
Clinical measures of discrepancy
Imaging methods (Centigram)

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

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

51. 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

52. Limb Length Inequality
Management principles
Severity
Lifts
Shortening
Epiphysiodesis
Lengthening

53. 5) Genu Varus & Valgus

54. Genu Varum and Genu Valgum
Definition:
Bow legs
Knock knees

55. Genu Varum and Genu Valgum
Etiology:
Physiologic
Pathologic

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

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

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

59. Genu Varum and Genu Valgum

60. Genu Varum and Genu Valgum
Evaluation:
Imaging
Put mechanical axsis

61. Genu Varum and Genu Valgum
Evaluation
Imaging

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

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

64. 6) Proximal Tibia Vara

65. Proximal Tibia Vara
“Blount disease”: damage of tibial proximal medial growth plate of unknown cause
Usually:
Overweight
Dark skinned

66. Proximal Tibia Vara Types:
Infantile  < 3y of age, & usually early walkers
Juvenile  y, combination
Adolescent  > 10y, & usually unilateral
Is it physis defect

67. Proximal Tibia Vara Classification (radiological): XR (M.D.A)
M.D.A < 11°  observe closely
M.D.A > 15°  operate

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

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

70. Proximal Tibia Vara
Bilateral
Unilateral

71. 7) Club Foot

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

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

74. Clubfoot Diagnosis by exclusion: Neurological lesion that can cause:
As  Spina Bifida, excluded by spine XR
Abnormalities that can explain:
As  Arthrogryposis
With other congenital anomalies:
As  tibial hemimelia, exclude by XR
Syndromatic clubfoot:
As:
Larsen’s Syndrome
Amniotic Band Syndrome
Why this seqwence
Why #2 & #4 are not the same

75. 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”

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

77. Clubfoot

78. 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

79. 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

80. 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)

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

82. 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

83. 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

84. 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

85. 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

86. Clubfoot
Types of surgery:
Soft tissue

87. Clubfoot
Types of surgery:
Bony
New pictures

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

89. 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

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

91. Clubfoot

92. 8) L.L Deformities in C.P Patients

93. 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

94. 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

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

96. Lower Limb Deformities in CP Child
Assessment:
Hips

97. Lower Limb Deformities in CP Child
Assessment:
Knees

98. Lower Limb Deformities in CP Child
Assessment:
Ankles

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

100. 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.

101. 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)

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

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

104. Remember …

105. 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