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Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional

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

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Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children’s Hospital and Regional

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

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

  3. Objectives: 2. Discuss theevaluationof 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 • 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 footGait = 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. 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 Structural toeing and bowing

  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 footWhere is the source???

  19. Assessing hip rotation MedialRotationHip LateralRotation Hip

  20. Assessing hip rotation

  21. Normals: medial femoral rotation

  22. Normals: lateral femoral rotation

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

  24. 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 Causes of excess rotation

  25. Leftfoot Leftfoot Leftfoot What is femoral anteversion? Excessive anteversionequalsantetorsion 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 footWhere is the source???

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

  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. 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 Foot

  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 PrettyMuchNormal

  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. 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 In Summary

  42. 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 A five year old girl presents with knock-knees and intoeing. You should obtain a rotational profile and…

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

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

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

  46. 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 Arthrogryposis

  47. 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 Arthrogryposis

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

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