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Common Pediatric Lower Limb Disorders

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Presentation on theme: "Common Pediatric Lower Limb Disorders"— Presentation transcript:

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 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  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.

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), 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: 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

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

41 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)

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

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

44 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

45 Limb Length Inequality
Management principles Severity Lifts Shortening Epiphysiodesis Lengthening

46 5) Genu Varus & Valgus

47 Genu Varum and Genu Valgum
Definition: Bow legs Knock knees

48 Genu Varum and Genu Valgum
Etiology: Physiologic Pathologic

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

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

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

52 Genu Varum and Genu Valgum

53 Genu Varum and Genu Valgum
Evaluation: Imaging Put mechanical axsis

54 Genu Varum and Genu Valgum
Evaluation Imaging

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

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

57 6) Proximal Tibia Vara

58 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

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

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

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

62 Proximal Tibia Vara Bilateral Unilateral

63 7) Club Foot

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

65 Clubfoot Etiology Postural Idiopathic (CTEV) Secondary (Spina Bifida)

66 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

67 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”

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

69 Clubfoot

70 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

71 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

72 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)

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

74 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

75 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

76 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

77 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

78 Clubfoot Types of surgery: Soft tissue

79 Clubfoot Types of surgery: Bony New pictures

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

81 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

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

83 Clubfoot

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

85 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

86 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

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

88 Lower Limb Deformities in CP Child
Assessment: Hips

89 Lower Limb Deformities in CP Child
Assessment: Knees

90 Lower Limb Deformities in CP Child
Assessment: Ankles

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

92 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.

93 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)

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

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

96 Remember …

97 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


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