1. Deformities of the Lower Limb
Dr. Fadel Naim
Consultant Orthopedic Surgeon
Faculty of Medicine
IUG

2. Common variations include:
Rotational problems
Intoeing
Out-toeing
Angular problems
Genu varum [bowlegs]
Genu valgum [knock-knees]
In most cases, the complaint is a variation of normal growth and development
In most cases, the problem resolves without treatment as the child grows

3. Positional deformations::
abnormalities mechanically produced by alterations of the normal fetal environment
restrict fetal movement and/or cause significant fetal compression.

4. Generalized Ligamentous Laxity
Passive foot dorsiflexion in excess of 45 degrees
The ability to hyperextend the knees (recurvatum)
The ability to hyperextend the elbows
Passive extension of the metacarpal phalangeal joints of the hands beyond 90 degrees
The ability to touch the thumb to the forearm with the wrist fully flexed
Evidence of joint laxity mimics the appearance of a torsional/angular deformity
The majority of children less than three years of age will have all the findings

5. Sitting habits Sitting on the feet ( internal tibial torsion )
Sitting in a "W" position (increased femoral anteversion)

6. Rotational Profile
The child’s rotational profile, as described by Staheli, should be recorded.
The four components in this profile are:
Hip rotation
Internal rotation
External rotation
Thigh foot axis
Heel bisection line
Foot progression angle

7. Torsional Profile
Measuring a child’s torsional profile and comparing values with published normal values can differentiate conditions that cause intoeing and determine the level and severity of the problem

8. Foot progression angle (FPA)
The angle formed between the longitudinal axes of the feet relative to the line of forward progression during ambulation.
For children and adults, the normal FPA measures 0-30° external rotation
When estimating the FPA, focus on one foot at a time, because the FPA will often change with each step

9. Foot Progression Angle

10. Prone Hip Rotation

11. Assessing hip rotation
Medial Rotation Hip
Lateral Rotation
Hip

12. Thigh-foot Axis (TFA) By walking age, the normal TFA measures 0-30°
external rotation

13. Thigh-foot Axis (TFA)
L TFA
R TFA

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

15. Intoeing
The most common rotational deformity seen in the growing child
This term applied to ambulatory children who consistently point their feet toward the midline
Quantified by measuring the “foot progression angle” (FPA)
Significant intoeing has both functional (tripping) and cosmetic implications

16. Intoeing
More likely than outtoeing to be brought to the attention of the parents and health providers
Intoeing is often worse when children are tired or when running
The intoeing can be expected to resolve spontaneously in >95% by the age of 8 years

17. the underlying anatomical and physiological basis for an in-toed gait
In-toed gait can be due to any rotational forces applied to the lower extremity at any point from the pelvis to the toe
the underlying anatomical and physiological basis for an in-toed gait
Osseous involvement
soft tissue involvement
a combination of both

18. Causes Of Intoeing
The causes of in-toeing can be divided into three broad categories
At the level of the hip (Femoral anteversion)
At the level of the leg (Internal tibial torsion )
At the level of the foot (Metatarsus adductus)
In order to manage the problem effectively, the level of the deformity must be determined

19. In the first year of life:
Cause Of Intoeing In Relation To The Age Of The Child
In the first year of life:
Metatarsus adductus, alone or combined with internal tibial torsion
In toddlers:
Internal tibial torsion alone or combined with metatarsus adductus
In early childhood:
Femoral anteversion

20. Benefits of Intoeing?
Some evidence that persistent intoeing is actually beneficial for some sports that require quick directional shifts:
Tennis
Basketball
Soccer
Etc.

21. In-toeing at the Level of the Foot
Metatarsus adductus is one of the causes of in-toeing at the level of the foot
Overpowering:
tibialis anterior muscle
tibialis posterior muscle
adductor hallucis muscle
Fatigue has also been stated as one of the causes of in-toeing in a child, in particular associated with stiff, heavy shoes

22. Metatarsus Adductus The most common congenital foot deformity
Occurring in one out of 1,000 live births
More frequently in female children and on the left side more than the right
The most likely cause is intrauterine packing (first born children)

23. Metatarsus Adductus
Forefoot is pulled inward at the tarso-metatarsal joints as viewed in the transverse plane
% of cases of metatarsus adductus identified at birth resolve without treatment by one year of age
The ankle has normal motion

24. Mild cases Moderate cases Severe cases
manually correctable without force
Moderate cases
manually correctable only with force
Severe cases
fixed and not manually correctable
The heel bisector should pass between toes two and three

25. Conservative Treatment
Stretching and manipulation
Plaster/serial casting
Splints and braces
Modification of sleeping habits
Shoe therapy
Often, combinations of these treatment options

26. Flexible metatarsus adductus is managed by stretching exercises during the first 8 months of life
Parents are instructed to hold the infant's hindfoot in one hand, the forefoot in the other, and stretch the midfoot, opening the "c"-shaped curve and slightly overcorrecting it
This exercise should be performed five times at each diaper change
This position is then held for a period of about seconds, then released. This should be continued for about 10 to 15 minutes
Better results occur if treatment is begun before 8 months of age but can succeed up to age 2 years

27. Flexible deformities that persist beyond 8 months, and rigid deformities, may need a cast
Casts should be changed biweekly with correction usually achieved after three or four casts
Generally, if treated early, 1 or 2 casts over a period of weeks is enough to achieve a full correction of the deformity
Following the use of serial casting use of a splint or brace should be used to maintain the correction

28. Internal Tibial Torsion (ITT)
Inward or medial torque of the tibial shaft an inward rotation of the ankle joint
The most common cause of intoeing
Affects males and females equally
Often asymmetrical with the left side affected more than right
Walking with the patella facing forward and the feet pointing inward
The cause is believed to be:
Intrauterine position
Sleeping in the prone position after birth
Sitting on the feet

29. Transmalleolar Axis medially rotated compared to Transcondylar Axis

30. Persistent ITT less than 10° is of little consequence if femoral torsion is normal
since the hips may readily compensate with sufficient external rotation to prevent tripping
Asymmetrical tibial torsion, with > 10° difference requires a more thorough evaluation for
growth disturbance (infantile tibia vara)
a neurological etiology (spastic monoparesis)
ITT ( > 15°) associated with progressive bowleg warrants radiographic evaluation of the knees
rule out infantile tibia vara (blount’s disease) in a child greater than 20 months of age

31. 90% of ITT cases resolve by the time the child reaches 8 years of age
Avoiding
prone sleeping
sitting on feet
No efficacy in the treatment of tibial torsion, and their expense is rarely justified
braces,casts
twister cables
exercises
orthopedic shoes have shown

32. Orthopedic management for:
A toddler with asymmetrical ITT,
Severe ITT > 15°,
ITT associated with progressive bowleg
Surgical derotation of the tibia, usually at the level of the distal metaphysis, is typically reserved for
Older than 8 years of age
A child with significant or functional deformity
A thigh-foot angle of greater than 3 STD beyond the mean
Osteotomy of the tibia has been associated with a high complication rate
(Compartment syndrome or peroneal nerve injury)

33. Excessive Femoral Anteversion
Femoral “anteversion” relates to the anterior projection of the femoral neck relative to the transverse axis of knee flexion
One of the most common diagnoses in a general pediatric orthopedic clinic
occurs more frequently in girls
usually diagnosed after 3 years of age
peaks at 4 to 6 years
then gradually resolves usually bilateral,
Other than patellar mal-tracking, there is little evidence that EFA predisposes to any other orthopedic problems

34. Problems primarily cosmetic
an increased incidence of patello-femoral pain in females
no evidence of hip or back problems or functional deficit in adults

35. Infants frequently 30°-40° of femoral anteversion,
When an adult stands in the anatomic position with the patellae facing anteriorly, the femoral neck typically points forward approximately 15°
Infants frequently 30°-40° of femoral anteversion,
gradually regresses by 1-2° per year until skeletal maturity

36. ("kissing patellae“ ”squinty patella sign” )
The child with increased femoral anteversion walks with his or her patellae and feet pointing inward
With the knee in neutral rotation, the greater trochanter can be palpated posteriorally rather than in its normal lateral presentation

37. Intoeing tends to become clinically evident (assuming neutral tibial torsion) when hip internal rotation exceeds 70° or measures at least 30° greater than hip external rotation
Each increment of 10° femoral torsion above 70° increases the degree of severity ( mild, moderate, and severe )
The hip range of motion can be measured every six to 12 months to document gradual decrease in femoral anteversion

38. Femoral antetorsion

39. Nonoperative treatment is ineffective
Spontaneous resolution occurs in more than 80 % of cases by late childhood
Nonoperative treatment is ineffective
Spontaneous correction of EFA cannot be accelerated with:
Braces
including twister cables
denis-browne bars)
Orthopedic shoes
Exercises
Sleeping in the prone position

40. Correction can be obtained only by femoral osteotomy
Orthotic devices are contraindicated because they will produce an external tibial torsion rather than derotating the femur

41. Conditions that may support a surgical approach include:
(1) older than 8 years of age
(2) severe deformity with significant cosmetic and functional disability
(3) anteversion in excess of 50 degrees
(4) deformity more than 3 STD beyond the mean
(5) a family who is aware of the risks of the procedure
The derotation osteotomy at the proximal femur
One must carefully consider the relative cosmetic effect of intoeing versus the surgical scars required for femoral derotation

42. Metatarsus adductus
Internal Tibial Torsion
Femoral Anteversion
Age
4-12 Months
1-2 Years
3-6 Years
Natural History
85% Resolve Spontaneously
99% Resolve Spontaneously
Most Resolve Spontaneously
Normal Values
Heel Bisector Between Toes 2 and 3
5 degree external-Newborn 20 degree external-Adult
45 degree-Newborn 32 degree-Age 1 Year 15 degree-Adult
Problems
Cosmesis Shoe Wear Foot Pain if Severe and Rigid
Usually None
Cosmesis Occasionally Knee Pain
Early Tr.
Seria Manipulation and Casts
None
Treatment-Late for Persistent Deformity
Mid-foot osteotomy or Metatarsal Osteotomy
Derotational Osteotomy (Supra-Malleolar)
Derotational Osteotomy (Intertrochanteric

43. Out-toeing less common than intoeing
Its causes are similar but opposite to those of in-toeing
Toddlers may walk with outtoeing due to
external rotation contracture of newborn hips
decreased femoral anteversion
The contracture of external hip rotators typically resolves within 1 year after ambulation
Outtoeing after age 2 is probably due to
to external tibial torsion
Both typically resolve spontaneously, but may take up to 8 years

44. Femoral Retroversion Common in early infancy
Unilateral, R side > L side
More common in obese children
apparent when the pre-walking child stands with his or her feet turned out to nearly 90 degrees ("Charlie Chaplin appearance")
It may gradually improve on its own during the first year of walking

45. Femoral Retroversion Nonoperative treatment is ineffective
Tx ultimately surgical if required
Refer if:
>3 yrs old (higher risk osteoarthritis in hip, stress fracture, SCFE)

46. External Femoral Torsion

47. External Tibial Torsion
usually seen between 4 to 7 years of age
often unilateral and more common on the right side
Disability from lateral tibial torsion is usually caused by PF instability and pain
Refer if:
>10 yrs old
severe deformity (thigh-foot angle >40°)
pain

48. Surgery has a high complication rate
Lateral tibial torsion is a more common indication for osteotomy than internal torsion
Surgery has a high complication rate
Should not be done until after the child is more than 10 years of age
Deformity should be severe
a thigh-foot angle of more than 40 degrees

49. No treatment is indicated for painless flexible flat foot
Flat Feet
(pes planus, pes planovalgus)
common in children
arch development primarily before four years of age with a wide variation in the rate or onset
The most common etiology of the flexible flat foot is ligamentous laxity,
Test for Flexibility:
arch reconstruction
on toe standing
foot is dependent
hanging over the examination table
No treatment is indicated for painless flexible flat foot

50. significant pain is a warning signal
foot rolls out:
abnormal wear on the inner side of the shoe
No pain except
an older child or adolescent with severe flatfoot after excessive standing or walking
significant pain is a warning signal
often associated with
peroneal muscle spasm
a rigid flatfoot

51. Assessment of the child's shoes should be done.
Shoe wear patterns can give an excellent clue to the severity of the condition.

52. Classification of Flat foot
Flexible 1. Idiopathic 2. Familial 3. Secondary to tight heel cord 4. Ligamentous Hyperlaxity-Connective Tissue Disorders     a. Marfan's Syndrome     b. Down's Syndrome     c. Ehlers-Danlos Syndrome 5. Neuromuscular     a. C.P.     b. Polio     c. Muscle disease     d. Peripheral nerve injury
Rigid 1. Tarsal Coalition 2. Arthritis     a. Inflammatory     b. Traumatic 3. Congenital convex pes valgus-vertical talus 4. Infection 5. Neoplasm

53. Flexible Flat Foot usually caused by laxity of ligaments in the foot
idiopathic or familial in origin
Increased angulation between the talus and the os calcis in weight-bearing AP and lateral planes

54. Cause of A Stiff And Painful Flat Foot
Trauma
Juvenile rheumatoid arthritis
Occult infection
A foreign body
Congenital vertical talus
Tarsal coalition
Bone tumors
Osteochondrosis of the tarsal navicular bone

55. do not require any treatment
It is now recognized that the vast majority of mild to moderate flexible flatfeet
do not require any treatment
parental reassurance

56. No therapy is for a mild or moderate flexible flatfoot
Treatment Principles
The longitudinal arch of children under the age of three years is often filled with a fat pad that does not disappear until this age
No type of shoe support or orthosis will produce a lasting structural improvement in a flatfoot.
No therapy is for a mild or moderate flexible flatfoot
Exercise programs for foot or leg muscles (other than for a tight heelcord) have no therapeutic value

57. Treatment Principles Flatfoot in the older child with discomfort
treated with a scaphoid pad and one eighth inch medial heel wedge for relief of pain
Severe flexible flatfoot with heel valgus and no underlying neurologic or muscular disorder
a foot orthosis
Rigid flat feet
orthopaedic evaluation and management

58. Angular Variations
The gradual change from varum to valgum may be caused by a widening pelvis
Genu varum (bowlegs) is seen from birth until two years of age, while genu valgum (knock-knees) peaks from two to four years

59. The Natural History Of The Tibial Femoral Angle
At birth,
approximately 15 degrees of genu varum
At one and one-half to two years of age
Gradual spontaneous correction to zero degrees
During the next year
a valgus of 10 degrees to 12 degrees
Gradually correction to the normal adult value
5 to 6 degrees valgus at about age 7 years
This process is identical in boys and girls.

61. Angular Deformities Evaluation
Should differentiate between
“physiologic” and pathologic”
deformities

62. Angular Deformities Evaluation
Physiologic
Pathologic
Symmetrical
Asymmetrical
Mild – moderate
Severe
Progressive
Regressive
Generalized
Localized
Expected for age
Not expected for age

63. Monitoring Varus/Valgus Deformities

64. Bowlegs (Genu Varum)
Many infants are born with mild bowleg deformities known as “physiologic genu varum”
Torsion of the lower extremity long bones can affect the “appearance” of angulation

65. Treatment reassurance Observation
Shoe corrections, splints and exercise programs do not produce any change different than the normal expected spontaneous correction

66. When to Work Up and/or Refer?
Asymmetry (or Unilateral)
Associated with pain
Associated with short stature
Associated with poor nutrition
Progression defers from expected

67. Non-physiologic Conditions Causing Genu Varum
Blount’s disease
Osteodystrophy
Bone dysplasia
Trauma
Tumors
Congenital anomalies

68. Knock Knees (Genu Valgum)
Between the ages of 2.5 and 5 years, many normal children develop significant genu valgum
The peak physiologic valgus angulation was 12° ± 8° at this age
Parents reassurance if:
Child has normal stature
Symmetrical genu valgum <15°
intermalleolar distance = 8 cm
Full-length lower extremity a-p roentgenograms should be reserved for children who do not meet these criteria.

69. Physiologic genu valgum rarely requires treatment.
Shoe wedges are ineffective, and long leg braces are rarely appropriate

70. This usually will be after age 5 years
Treatment for significant physiologic genu valgum may commence as soon as one is sure that spontaneous correction is not occurring
This usually will be after age 5 years
Initially, a knock knee brace may be tried at night time and for most of the day.
If the deformity persists,
a medial epiphyseal stapling or epiphyseodesis
if there is sufficient growth potential for correction (usually at a skeletal age of 10 in girls and 11 in boys).
This is most often performed in the distal femur, but can be done in the proximal tibia if the deformity appears to be arising there.

71. Surgical treatment
Knee valgus more than 15 degrees can cause medial foot strain, synovitis of the knee joint, patello-femoral instability, and gait abnormalities.
(hemi-epiphysiodesis) is typically performed only for those rare children with >15° genu valgum (mechanical axis) after adolescence

72. Angular Deformities

73. Progressive or asymmetrical genu valgum usually suggests the presence of a non-physiologic condition
Osteodystrophy
Bone dysplasia
Trauma
Tumors
Congenital anomalies
Neuromuscular