Common Pediatric Lower Limb Disorders

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

5. Leg Aches • Clinical features  diagnosis by exclusion • H/O: • 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 gaitin 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 • In-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 • 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 correctionindicated 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

41. Genu Varum and Genu Valgum

42. Genu Varum and Genu Valgum • Evaluation: • Imaging

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: • Sever cases • Recurrence • Why?

47. Proximal Tibia Vara • Types: • Infantile  usually in over weight & early walkers • Adolescent  usually over weight & unilateral

48. Proximal Tibia Vara Unilateral Bilateral

49. 7) Club Foot

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