1. 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

2. 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

3. 1) Leg Aches

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

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

8. 2) Limping

9. 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.

10. 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.

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

12. 3) In-toing & Out-toing

13. 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.

14. 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.

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

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

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

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

19. A) In-toeing

20. 1) In-toeing: Femoral Anteversion

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

22. 2) In-toeing: Tibial Torsion

23. 2) In-toeing: Tibial Torsion

24. 3) In-toeing: Forefoot Adduction

25. 4) In-toeing: Adducted Big Toe

26. B) Out-toeing

27. 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

28. 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

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

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

31. 4) Limb Length Inequality

32. 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

33. 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)

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

35. 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

36. 5) Genu Varus & Valgus

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

38. Genu Varum and Genu Valgum
Etiology:
Physiologic
Pathologic

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

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

41. Genu Varum and Genu Valgum

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

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

44. 6) Proximal Tibia Vara

45. 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

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

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

48. Proximal Tibia Vara
Bilateral
Unilateral

49. 7) Club Foot

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

51. 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

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

53. Clubfoot

54. 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

55. 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

56. 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)

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

58. 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

59. 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

60. Clubfoot
Types of surgery:
Soft tissue

61. Clubfoot
Types of surgery:
Bony
New pictures

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

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

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

65. 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

66. 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

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

68. Lower Limb Deformities in CP Child
Assessment:
Hips

69. Lower Limb Deformities in CP Child
Assessment:
Knees

70. Lower Limb Deformities in CP Child
Assessment:
Ankles

71. 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.

72. 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)

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

74. Remember …

75. 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