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Unformatted text preview: Prof. Mamoun Kremli , FRCS
Consultant Pediatric Orthopedics
College of Medicine & King Khaled University Hospital Common Orthopedic Problems
• Angular deformities of LL:
– Bow legs.
– Knock knees. • Rotational deformities of LL:
– Ex-toeing. •
• Leg aches.
Irritable hip. Angular LL Deformities of LL Angular Deformities
Bow legs Knock knees Genu Varus Genu Valgus Angular Deformities Range of Normal Varies With Age • During first year : Lateral bowing of Tibiae
• During second year : Bow legs (knees & tibiae)
• Between 3 – 4 years : Knock knees Angular Deformities Evaluation Should differentiate between “physiologic” and “pathologic”
deformities Angular Deformities Evaluation
Physiologic Pathologic • Symmetrical • Asymmetrical • Mild – moderate • Severe • Regressive • Progressive • Generalized • Localized • Expected for age •Not expected for age Angular Deformities Causes
Physiologic Pathologic • Normal – for age • Rickets • Exaggerated : • Endocrine disturbance - Overweight
- Early wt. bearing
- Use of walker? • Metabolic disease
• Injury to Epiphys. Plate
Infection / Trauma
• Idiopathic Angular Deformities Evaluation
Symmetrical deformity Angular Deformities Evaluation
Asymmetrical Deformity Angular Deformities Evaluation
Generalized deformity Angular Deformities Evaluation
Localized deformity Blount’s Angular Deformities Evaluation
Localized deformity Rickets Angular Deformities Evaluation
( standing / supine ) in bow legs / genu varum Inter-condylar distance Angular Deformities Evaluation
( standing / supine ) in knock knees /genu valgum Inter- malleolar distance Angular Deformities Evaluation
Measure Angulation Use goneometer
measures angles directly Angular Deformities Evaluation
Investigations / Laboratory • Serum Calcium / Phosphorous ?
• Serum Alkaline Phosphatase
• Serum Creatinine / Urea – Renal function Angular Deformities Evaluation
Investigations / Radiological
X-ray when severe or possibly pathologic
• Standing AP film
– long film ( hips to ankles ) with patellae directed forwards • Look for diseases :
– Rickets / Tibia vara (Blount’s) / Epiphyseal injury..
– Measure angles. Angular Deformities Evaluation
Investigations / Radiological
Medial Physeal Slope Femoral-Tibial Axis Angular Deformities When To Refer ?
• Pathologic deformities:
Not expected for age. • Exaggerated physiologic deformities:
Definition ? Angular Deformities Surgery Rotational LL Deformities
In-toeing / Ex-toeing
• Frequently seen.
• Concerns parents.
• Frequently prompts varieties of treatment.
( often un-necessary / incorrect ) Rotational Deformities • Level of affection :
Foot Rotational Deformities Femur
Ante-version = more medial rotation
Retro-version = more lateral rotation Rotational Deformities Normal Development
• Femur : Ante-version :
– 30 degrees at birth.
– 10 degrees at maturity. • Tibia : Lateral rotation :
– 5 degrees at birth.
– 15 degrees at maturity. Rotational Deformities Normal Development
Both Femur and Tibia laterally rotate with
growth in children
• Medial Tibial torsion and Femoral ante-version
improve ( reduce ) with time.
• Lateral Tibial torsion usually worsens with growth. Rotational Deformities Clinical Examination
• At which level is the rotational deformity?
• How severe is the rotational deformity? • Four components:
1- Foot propagation angle.
2- Assess femoral rotational arc.
3- Assess tibial rotational arc.
4- Foot assessment. Rotational Deformities Clinical Examination
1- Foot propagation angle – Walking
+10o _10o ? In Eastern Societies
+25o _10o Rotational Deformities Clinical Examination
2- Assess Femoral Rotational Arc
Extended Rotational Deformities Clinical Examination
2- Assess Femoral Rotational Arc
flexed Rotational Deformities Clinical Examination
3- Tibial Rotational Arc
Thigh-foot angle in prone foot position is critical
leave to fall into natural position Rotational Deformities Clinical Examination
4- Foot assessment
• Metatarsus adductus
Searching big toe
Flat foot Rotational Deformities
Common Presentations Infants
• Out-toeing : Normal • seen when infant positioned upright
( usually hips laterally rotate in-utero ) • Metatarsus adductus :
• medial deviation of forefoot
90 % resolve spontaneously
• casting if rigid or persists late in 1st year
• Rotational Deformities
Common Presentations Toddlers
• In-toeing most common during second year.
( at beginning of walking )
• Causes :
– medial tibial torsion.
– metatarsus adductus.
– abducted great toe. Rotational Deformities
Common Presentations Toddlers - Medial Tibial Torsion
• The commonest cause of in-toeing
• Observational management is best
• Avoid special shoes / splints / braces
– unnecessary, ineffective, interferes with activity and
cause psychological and behavioral problems. Rotational Deformities
Common Presentations Toddler - Metatarsus Adductus • Serial casting is effective in this age-group
• Usually correctable by casting up to 4 years Rotational Deformities
Common Presentations Toddlers - Abducted Great Toe
• Dynamic deformity
• Over-pull of Abductor
Hallucis Muscle during
• Spontaneously resolve - no treatment Rotational Deformities
Common Presentations Child
• In-toeing : due to medial femoral torsion
• Out-toeing : in late childhood
lateral femoral / tibial torsion Rotational Deformities Common Presentations Child
Medial Femoral Torsion
• Usually: - starts at 3 - 5 years,
- peaks at 4 – 6 years,
- then resolves spontaneously.
• Girls > boys.
• Look at relatives - family history – normal.
• Treatment usually not recommended.
• If persists > 8 years and severe, may need surgery. Rotational Deformities Common Presentation
Medial Femoral Torsion (Ante-version)
• Stands with knees medially rotated (kissing patellae).
• Sits in W position.
• Runs awkwardly (egg-beater). Family History Rotational Deformities Common Presentations
Lateral Tibial Torsion
• Usually worsens.
• May be associated with knee pain (patellar)
specially if LTT is associated with MFT.
( knee medially rotated and ankle laterally rotated ) Rotational Deformities Common Presentations
Medial Tibial Torsion
• Less common than LTT in older
• May need surgery if :
– persists > 8 year,
– and causes functional disability Rotational Deformities Management
• Challenge : dealing effectively with family
• In-toeing : spontaneously corrects in vast
majority of children as LL externally rotates
with growth - Best Wait ! Rotational Deformities Management
Convince family that only observation is
• < 1 % of femoral & tibial torsional
deformities fail to resolve and may require
surgery in late childhood. Rotational Deformities
• Attempts to control child’s walking, sitting and
sleeping positions is impossible and ineffective cause
frustration and conflicts.
• She wedges and inserts : ineffective.
• Bracing with twisters :ineffective - and limits activity.
• Night splints : better tolerated - ? Benefit. Rotational Deformities
Shoe wedges Ineffective Twister cables Ineffective Rotational Deformities When To Refer ?
• Severe & persistent deformity.
Age > 8-10y.
Causing a functional dysability.
Progressive. Rotational Deformities
When Is Surgery Indicated ?
•In older child ( > 8 – 10 years ).
•Significant functional disability.
•Not prophylactic ! Leg Aches / Growing Pains Leg Aches / Growing Pains • Incidence : 15-30 % of children.
• More In girls / At night / In LL.
• Diagnosis is made by exclusion. Leg Aches / Growing Pains History
• Vague pain.
Seldom alters activity.
Long duration. Leg Aches / Growing Pains Examination
• General health is normal.
No joint stiffness.
No limping. Leg Aches / Growing Pains Management
• When atypical history or signs present on
– Imaging and lab. Studies. • If all negative :
– Symptomatic treatment :
• Heat / Analgesics. – Reassure family :
• Advise to re-evaluate if clinical features change. Leg Aches / Growing Pains
Feature Growing Pain Serious Problem Often Usually not Pain localised No Often Pain bilateral Often Unusual Ulters activity No Often Cause limping No Sometimes General health Good May be ill History :
Long duration From Stahili : Practice of Pediatric Orthopedics 2001 Leg Aches / Growing Pains
Feature Growing Pain Serious Problem Tenderness No May show Guarding No May show Reduced rang of motion No May show CBC Normal ? Abnormal ESR Normal ? Abnormal Physical examination : Laboratory : From Stahili : Practice of Pediatric Orthopedics 2001 CDH / DDH
Congenital Dislocation of Hip.
Developmental Dysplasia of Hip. CDH Spectrum
• Teratologic Hip : Fixed dislocation
Often with other anomalies
• Dislocated Hip : Completely out
May or may not be reducible
• Subluxated Hip : Only partially in
• Unstable Hip : Femoral head can be dislocated
• Acetabular Dysplasia : Shallow Acetabulum
Head Subluxated or in place CDH Etiology & Risk Factors
• Prenatal :
– Positive family history (increases risk 10X)
Female (4-6 X > Males)
Breech position (increases risk 5-10 X) • Postnatal :
– Swaddling / Strapping ( ? Knees extended)
Torticollis (CDH in 10-20 % cases)
Cong. Knee recurvatum / dislocation
Metatarsus adductus / calcaneo-valgus CDH Risk Factors
When Risk Factors Are Present
• The infant should be examined repeatedly
• The hip should be imaged by
– or X-ray CDH Clinical Examination CDH Neonatal Examination
• Asymmetric thigh
– anterior CDH Clinical Examination
• Shortening ( not in neonates )
- in supine
- Galeazzy sign CDH Neonatal Examination
• Hip instability
in early infancy
• Limited hip abduction
in flexion - later
• (careful in bilateral)
if <600 on both sides:
request imaging CDH Neonatal Examination CDH Neonatal Examination
Hip Flexion Deformity
• Loss of fixed flexion
deformity of hips in
• Normally FFD:
– at 6 weeks 19o
– at 6 months 7o Thomas Test
No FFD CDH Neonatal Examination Ortolani Barlow
Not hear click ! CDH Neonatal Examination
Ortolani / Barlow clunk Ortolani Barlow CDH Neonatal Examination Ortolani Test Barlow Test CDH Clinical Examination
• Hip clicks :
- fine, short duration, high pitched sounds
- common and benign – from soft tissues
• Hip clunks :
- sensation of the hip displacing over the
• If in doubt : U/S in young infants
single radiograph if > 2-3 months CDH Clinical Examination
• Neonate (up to 2-3 months) :
– Instability/ Ortolani-Barlow • Infant ( > 2-3 months) – Limited abduction
– Shortening ( Galeazzi ) • Toddler :
– Limited abduction
– Shortening ( Galeazzi ) • Walker :
– Trendelenburgh limpimg : CDH Ultrasound Screening
• Early U/S screening not recommended
• Delayed U/S screening :
– Older than 3 weeks
– Those at risk or suspicious by:
• Clinical exam CDH Treatment
• Birth to 6 months :
– Pavlik harness or hip spica cast • 6 months – 12 months :
– closed reduction UGA and hip spica casts • 12 months – 18 months :
– possible closed / possible open reduction • Above 18 months :
– open reduction and ? Acetabuloplasty • Above 2 years :
– open reduction,acetabulplasty, and femoral
osteotomy CDH Treatment
• Method depends on Age
• The earlier started, the easier the treatment
& the better the results
• Should be detected EARLY
• UREGENT referral once an abnormality is
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- Fall '11