1. Common Pediatric Lower Limb Disorders
Dr.Kholoud Al-Zain
Assistant Professor
Consultant, Pediatric Orthopedic Surgeon
Dec- 2016
Acknowledgement:
Dr.Abdalmonem Alsiddiky
Dr.Khalid Bakarman
Prof. M. Zamzam

2. Topics to Cover In-toeing Genu (varus & valgus), & proximal tibia vara
Club foot
L.L deformities in C.P patients
Limping & leg length inequality
Leg aches

3. 1) Intoeing

4. Intoeing- Evaluation Detailed history
Onset, who noticed it, progression
Fall a lot
How sits on the ground
Screening examination (head to toe)
Pathology at the level of:
Femoral anteversion
Tibial torsion
Forefoot adduction
Wandering big toe

5. Intoeing- Asses rotational profile
Pathology Level
Special Test
Femoral anteversion
Tibial torsion
Forefoot adduction
Wandering big toe
Hips rotational profile:
Supine
Prone
Inter-malleolus axis:
Foot thigh axis
Heel bisector line

6. Intoeing- Special Test
Foot Propagation Angle  normal is (-10°) to (+15°)

7. Intoeing- Femoral Anteversion
Hips rotational profile, supine  IR/ER normal = 40-45/45-50°

8. Intoeing- Femoral Anteversion
Hips rotational profile  prone

9. Intoeing- Tibial Torsion
Inter-malleolus axis
Supine position
Sitting position
Inter-malleolus axis

10. Intoeing- Tibial Torsion
Foot Thigh Axis  normal (0°) to (-10°)

11. Intoeing- Tibial Torsion
Foot Thigh Axis  normal (0°) to (-10°)

12. Intoeing- Forefoot Adduction
Heel bisector line  normal along 2 toe

13. Intoeing- Adducted Big Toe

14. Intoeing- Treatment Establish correct diagnosis Parents education
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

15. Intoeing- Treatment Operative correction indicated for children:
(> 8) years of age
With significant cosmetic and functional deformity  <1%

16. 2) Genu Varus & Valgus

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

18. Normal Genu Varum and Genu Valgum

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

20. Genu Varum and Genu Valgum
Types:
Physiologic
Pathologic

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

22. Genu Varum and Genu Valgum
Re take the rickets picture

23. Genu Varum and Genu Valgum

24. Genu Varum and Genu Valgum
Evaluation:
Imaging
Rickets
Put mechanical axsis

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

26. “Proximal Tibia Vara”

27. Proximal Tibia Vara
“Blount disease”: damage of proximal medial tibial growth plate of unknown cause
Usually:
Overweight
Dark skinned
Types:
Infantile  < 3y of age, & usually early walkers
Juvenile  y, combination
Adolescent  > 10y, & usually unilateral

28. Blount Disease Bilateral Unilateral Types:
Infantile  usually in over weight & early walkers
Adolescent  usually over weight & unilateral

29. Blount Disease
Staging:

30. Blount Disease

31. Blount Disease MRI is mandatory: When: Why? Sever cases Recurrence
Is it physis defect

32. 3) Club Foot

33. Clubfoot Etiology Postural  fully correctable
Idiopathic (CTEV)  partially correctable
Secondary (Spina Bifida)  rigid deformity, pt needs workup

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

35. Clubfoot

36. 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

37. 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

38. 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)

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

40. 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

41. 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

42. Clubfoot
Types of surgery:
Soft tissue

43. Clubfoot
Types of surgery:
Bony
New pictures

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

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

46. 4) L.L Deformities in C.P Patients

47. 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

48. 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

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

50. Lower Limb Deformities in CP Child
Assessment:
Gait

51. Lower Limb Deformities in CP Child
Assessment:
Hips

52. Lower Limb Deformities in CP Child
Assessment:
Knees

53. Lower Limb Deformities in CP Child
Assessment:
Ankles

54. 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.

55. Lower Limb Deformities in CP Child

56. 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)

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

58. 5) Limping

59. Limping Definition Limping  an abnormal gait, Due to:
Pain (where),
Deformity (bone or joint), or
Weakness (general or nerve or muscle)
In one or both limbs

60. Limping Diagnosis by: History (detailed) Examination:
Gait good analysis
Is it:
Above pelvis  Back (scoliosis)
Below pelvis  Hips, knees, ankles, & feet
Neuro.Vascular

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

62. If The Cause Was MSK That Led To Limb Length Inequality

63. Limb Length Inequality
True vs. apparent
Etiology:

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

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

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

67. 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

68. 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

69. 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

70. 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)

71. 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

72. 6) Leg Aches

73. 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

74. 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

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

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

77. Any Question ?

78. Remember

79. Take Home Message
Intoeing  is one of 4 causes, treatment depends on the level, mainly observe, operate >8y old
Genu varus & valgus  phys vs. patho, rickets, when operate
Blount  early walkers, treatment mainly surgery
CTEV  3 types, treat as young as possible, Ponseti better to avoid surgery
L.L in C.P  mainly treat spastic, PT importance, surgery indications
Limping  due (pain- week- deformed), above or below pelvis
L.L.I  proper assess (cause & level), treated >2cm, options of treat
Leg aches  symptomatic treatment