1. Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional Medical Center 5/01/06

2. Objectives:
1. Describe the commonly seen pediatric disorders involving gait, children's feet, and children's legs, including problems in normal development (and the ages at which these problems are commonly seen).

3. Objectives:
2. Discuss the evaluation of common pediatric foot, gait, and leg disorders.
3. Describe their optimal management.

4. Approach Learn the range of normal It’s huge
“Normal” changes with growth and development
Before saying something is “normal”, rule out the pathologies
Know the common pathologies
“The eye sees what the mind knows”

5. Common and often benign orthopaedic concerns
In-toeing
Out-toeing
Bowed legs
Knock-knees
Flat feet

6. Pathologies Cerebral Palsy Hip dysplasia Legg-Calve-Perthes’s disease
Slipped Capital Femoral Epiphysis
Clubfoot

7. Systematic approach - Where’s the source?
Hip joint
Thigh (femur)
Knee joint
Leg (tibia)
Ankle joint
Foot (tarsals and metatarsals) X X

8. Group pathologies by age
Newborns and infants (< 1 yr)
Toddlers (1-3 yr)
Older children (4-10 yr)
Pre-teens and teens (> 10 yrs)

9. Is in-toeing a problem? Not painful in and of itself
Not associated with early arthritis
Can be associated with knee pain and patellofemoral problems
May be a cosmetic problem
Why does this patient in-toe?

10. History What is the specific concern? Who is concerned?
When does it manifest?
Duration?
Improving or worsening?

11. Evaluation Medical History Family History Screening examination
Developmental delay(s)?
Precipitating event/birth complication?
Family History
Screening examination
Spasticity?
Asymmetry?
Rotational Profile

12. Rotational Profile Gait: determine foot progression angles
Assess hip rotation
Assess tibial rotation
Determine the alignment of the foot Gait = f [(BRAIN) + (hip & femur) + (leg & foot) + (knee + ankle)]

13. Rotational Profile
Gait: foot progression angles

14. Rotational Profile
Range of normal: foot progression angles

15. Structural toeing and bowing
Terminology:
“Normal” - within two standard deviations of the mean
Version: the normal twist to a bone
Torsion: abnormal twist to a bone
Medial = internal
Lateral = external

16. Rotational Profile
Gait: foot progression angles

17. Rotational Profile
Gait: foot progression angles

18. Rotational Profile Gait: determine foot progression angles
Assess hip rotation
Assess tibial rotation
Determine the alignment of the foot Where is the source???

19. Assessing hip rotation
Medial Rotation Hip
Lateral Rotation
Hip

20. Assessing hip rotation

21. Normals: medial femoral rotation

22. Normals: lateral femoral rotation

23. Is the hip rotation normal?
Within two standard deviations of the mean?
Symmetric?
Painless?
Without spasticity? What is the cause of the increased medial (or lateral) rotation?

24. Causes of excess rotation
Soft tissues vs. bony anatomy
Hip joint - soft tissue contractures
Newborns have an posterior capsular contracture, producing excessive lateral rotation of the hips
Femoral antetorsion - bony anatomy
produces excessive medial rotation at the hip

25. What is femoral anteversion?
Left foot
Left foot
Left foot
Excessive anteversion equals antetorsion
Anteversion
Femoral antetorsion produces intoeing

26. Femoral antetorsion Usually 3-5 yo girls Sits in the “W”
“Kissing patellae”
“Egg-beater” run
Severe if > 90°
Resolves with growth - no association with osteoarthritis

27. Femoral antetorsion

28. Rotational Profile Gait: determine foot progression angles
Assess hip rotation
Assess tibial rotation
Determine the alignment of the foot Where is the source???

29. Tibia
Torsion
Tibial torsion can lead to intoeing:
Internal or medial tibial torsion is a twist to the leg, pointing the toe inwards

30. Assessing tibial torsion:
Thigh-foot angle
Transmalleolar axis
Determine axes
Measure angles

31. Assessing tibial rotation
L TFA
R TFA

32. Assessing tibial rotation

33. Assessing tibial rotation

34. Normals: tibial rotation

35. Medial tibial torsion

36. Foot Metatarsus adductus curves the foot inwards
Searching great toe pulls the foot inwards
Flatfoot may produce out-toeing from “wringing-out” of the foot:
Supinated forefoot with valgus heel

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

38. Metatarsus Adductus Majority are flexible Adductus resolves by 3-4 yrs
10% stiff and may benefit from casting

39. Assessing foot alignment
Pretty Much Normal

40. Toeing and bowing: Determining the source
Excessive medial rotation of hips?
Does he have it? NO on antetorsion, but YES on excessive medial rotation
Internally rotated thigh-foot angle = internal tibial torsion? No
Curved foot = metatarsus adductus? No

41. In Summary
Femoral antetorsion produces excessive medial rotation at the hip which leads to in-toeing
Medial tibial torsion is a twist to the leg, pointing the foot inwards
Metatarsus adductus curves the foot inwards
A searching or abducted great toe produces in-toeing

42. A five year old girl presents with knock-knees and intoeing
A five year old girl presents with knock-knees and intoeing. You should obtain a rotational profile and…
refer to orthopaedics for bracing or surgery
have the child put her shoes on the opposite feet and recheck her in a year
just recheck her in a year
obtain an AP pelvis radiograph and full length lower extremity films to look for hip dysplasia

43. How to treat intoeing? Shoe wedges? No. Twister cables? No.
Observation? Yes.

44. Pathologies to consider “Why is there an abnormal range of motion of the hip?”
Infants and toddlers
Hip dysplasia
Neuromuscular disease -Cerebral palsy
Toddlers
Legg-Calve-Perthes disease
Pre-teens
Slipped Capital femoral epiphysis

46. The most likely diagnosis is…
cerebral palsy
arthrogryposis
Perthe’s disease
septic arthritis of the hip
hip dysplasia

47. Arthrogryposis Congenital contractures
Arthrogryposis multiplex congenita
1/3000 births
Amyoplasia = 1/2 of cases
Due to fetal akinesia
May include
radial head dislocations
Hip dislocations
Knee dislocations
Clubfoot
Rx order - reduce the knee, then treat the feet, then the hips

48. Arthrogryposis Amyoplasia Classic arthrogryposis
Muscle replaced by fibrous tissue
Multiple congenital contractures
60% with all limbs affected,
Lower only in 25%
Upper only in 15%
Normal IQ
Surgery changes the range of the arc of motion, not the total arc itself

49. The most likely diagnosis is…
cerebral palsy
arthrogryposis
Perthe’s disease
septic arthritis of the hip
hip dysplasia

51. The most likely diagnosis is…
cerebral palsy
arthrogryposis
Perthe’s disease
septic arthritis of the hip
hip dysplasia

52. Bilateral hip dislocations

53. Developmental dysplasia of the hip (DDH)
Incidence
dislocation 1:1000
neonatal hip instability 1:100
Increased risks for first-born, girls, breech positioning, family history
L>R

54. DDH detection Newborn nursery exam Loss of abduction, pistoning
Galiazzi test
Ortolani test
Barlow test
Good up to 2-3 mos of age
Loss of abduction, pistoning
Pavlik harness for instability or dislocated hip

55. DDH detection Ultrasound (dedicated center) Radiography
Better at > 2 wks of age
Dynamic exam
Radiography
Gold standard
Best after 6-8 weeks of age

56. Rx for dysplasia -REFER
Pavlik for both dysplastic and dislocated hips
Never exceed about four weeks of Pavlik treatment for a persistently dislocated hip
Unstable hips deserve a referral to orthopaedics
Abduction orthoses may help correct hip dysplasia in the older child

57. Hip dysplasia Early treatment enables quick resolution
Delayed treatment risks a poor result/multiple surgeries
Over-treatment is generally benign for the located hip

59. R hip after OR, fem short, pelvic osteotomy

60. Cerebral palsy Mild developmental delays?
Mild spasticity or increased tone?
Asymmetry of motion, tone, reflexes?
You may be the first to make the diagnosis

61. Perthes ds Peak age of onset 3-8yr
Spontaneous osteonecrosis of the femoral head
Follow with serial radiographs
Prognosis depends on age of onset / severity
< 6 yrs at onset, less than whole-head involvement do better
Rx- decrease synovitis and weight bearing

62. Perthes ds

63. Perthes ds

64. Slipped capital femoral epiphysis
Peak incidence in pre-teens, 50% obese (50% not!)
Anterior thigh or knee pain
Bilateral in cases of endocrinopathy or renal ds
Dx - AP and frog pelvis * radiograph
If present, immediate wheel chair and referral

65. Slipped capital femoral epiphysis

66. Slipped capital femoral epiphysis

67. Knee angular deformities
Genu varum - bowing
Genu valgum - knock-knees What’s normal?

68. Physiologic genu valgum
Maximum varus at birth
Maximum valgus > 10°, ages yrs
At maturity, mean is ~ 6° anatomic valgus

69. Bowing or genu varum Physiologic bowing Pathologic bowing Rickets
Tibia vara
Skeletal dysplasia

70. Apparent bowing

71. Vit-D deficient/resistant rickets

72. Bowing of tibia vara

73. Knock- knees or genu valgum
Physiologic
Pathologic

74. Physiologic valgus

75. Physiologic genu valgum
Maximum varus at birth
Maximum valgus > 10°, ages yrs
At maturity, mean is ~ 6° anatomic valgus

76. Knock- knees Pathologic genu valgum Skeletal dysplasias
Rickets - later onset such as with renal osteodystrophy, because the disease is active when knock knees are the norm
Skeletal dysplasias
Diastrophic dysplasia
Morquio’s syndrome
Ellis-van Creveld or chondroectodermal dysplasia
Spondyloepiphyseal and multiple epiphyseal dysplasias

77. Pathologies to consider - leg
Angulation or bowing of the tibia
Very unusual!
Antero-lateral ?neurofibromatosis?
Postero-medial ?leg length difference?
Antero-medial ?fibular deficiency?

78. Pathologies to consider: foot
Flatfoot
All infants have it
Most children have it
More than 15% of adults have it

79. Flexible flatfoot Often resolves with growth
Not affected by specific shoes, heel cups, or UCBL inserts
Not correlated with disability in military populations
May be protective against stress fractures

80. More foot pathologies to consider
Stiff or rigid metatarsus adductus
Clubfoot
Calcaneovalgus
Cavovarus foot

81. Clubfoot Incidence 1:1000 Talipes equinovarus
True congenital vs positional
Cavus, adductus, varus, equinus
If present, examine hips carefully!

82. Clubfoot treatment Serial manipulations and casting
Begin first week of life, if possible
Perform weekly
90% of routine clubfoot respond

83. Calcaneovalgus foot Most common foot deformity at birth
Forefoot abducted, ankle dorsiflexed - foot lies on anterior leg
Resolves spontaneously
Associated with hip dysplasia

84. Cavovarus foot High arch = cavus Heel in varus Often rigid
Look to spinal cord or peripheral nervous system

85. Out-toeing (Less commonly seen)
Causes:
External rotation contracture at the hip?
Lateral tibial torsion?
Flatfoot?
Little hope of improvement over time, unless it’s a result of flatfoot

86. Summary: Normal Development
Femoral anteversion: 30° at birth, only 10° at maturity (= lateral rotation)
Femoral antetorsion improves over time
Tibial version: 0° at birth, 15° externally rotated at maturity (= laterally rotation)
Medial tibial torsion improves over time
Growth: lateral rotation of both femur and tibia
In-toeing decreases with growth

87. Summary Most toe-ing and bow-ing deformities are benign
Resolution may take many years
Use history and exam to rule-out the pathologic causes
Reassure for what appear to be non-pathologic but extreme cases
Check back for re-exam, 6-12 months
Beware unilateral deformities and those associated with pain
Radiographs indicated

88. Who needs a referral for toeing and bowing?
Over three years of age with documented progression of deformity
Stiff metatarsus adductus
Bowing
below the 5th percentile for height
marked asymmetry or lateral thrust with ambulation
Marked knock-knees or in-toeing in patients over 8 years of age

89. Who needs a referral? A newborn with a hip click?
A newborn with a hip clunk?
A ten year old girl with marked out-toeing on the side of groin pain?
A newborn with flat feet?

90. References:
Herring, JA: Tachdjian’s Pediatric Orthpaedics, WB Saunders, Philadelphia, 2002.
Staheli, LT: Fundamentals of Pediatric Orthopedics, Raven Press, New York, 1992.
Staheli, LT: Practice of Pediatric Orthopedics, Lippincott, 2002.
Tolo, VT: “In-toeing and Out-toeing,” Lovell and Winter’s Pediatric Orthopaedics, 4th ed., Morrissey and Weinstein, eds., Lippincott-Raven, Philadelphia, 1996.
Wenger, DA and M Rang: The Art and Practice of Pediatric Orthopaedics, Raven, New York, 1993.