Deformities of the Lower Limb

1. Deformities of the Lower Limb Dr. Fadel Naim Consultant Orthopedic Surgeon Faculty of Medicine IUG

2. Positional deformations: abnormalities mechanically produced by alterations of the normal fetal environment, which restrict fetal movement and/or cause significant fetal compression.

3. Common variations include: • Rotational problems • Intoeing • Out-toeing • Angular problems • Genu varum [bowlegs] • Genu valgum [knock-knees] • In most cases, the complaint is a variation of normal growth and development • In most cases, the problem resolves without treatment as the child grows

4. The normal range of rotation of the foot, leg, and hip includes measurements that fall within 2standard deviations of the mean • A variation becomes a deformity when the amount of deviation from normal for that particular age is more than two standard deviations • A careful history and physical examination are all that are necessary to determine whether a complaint requires further evaluation

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

6. History Taking • Chief complaint. • Know exactly what concerns the parents in order to provide prognostic information and discussion of natural history. • Complete medical history. • Maternal pregnancy, birth, and development. • Questioning perinatal events and motor development ( cerebral palsy?). • Duration of complaint and progression. • History should clarify if the problem began at birth, or before or after walking. • How has the problem changed during the past few months? • Family history. • Frequently familial tendency. • Parents' experience and attitudes toward similar problems.

7. History Taking • Signs and symptoms • Pain • Limping • Tripping • Falling • Why the concern • Gait or cosmoses • A lack of understanding regarding the maturation of the gait • Sitting habits • Sitting on the feet ( internal tibial torsion ) • Sitting in a "W" position (increased femoral anteversion) • Aggravating factors • Torsional deformities become more apparent with fatigue

8. Physical Examination • Assessment of height and weight • Normal size for agemakes pathologic conditions unlikely (e.g. Hypo-phosphatemic rickets, metabolic bone disease) • Examination of the spine: • Scoliosis • Hairy patches • Sinus openings • A neurologic examination should be done to rule out neuromuscular disorders

9. Generalized Ligamentous Laxity • Passive foot dorsiflexionin excess of 45 degrees • The ability to hyperextend the knees (recurvatum) • The ability to hyperextend the elbows • Passive extension of the metacarpal phalangeal joints of the hands beyond 90 degrees • The ability to touch the thumb to the forearm with the wrist fully flexed • Evidence of joint laxity mimics the appearance of a torsional/angular deformity • The majority of children less than three years of age will have all the findings

10. Rotational Profile • The child’s rotational profile, as described by Staheli, should be recorded. • The four components in this profile are: • Hip rotation • Internal rotation • External rotation • Thigh foot axis • Heel bisection line • Foot progression angle

11. Torsional Profile Measuring a child’s torsional profile and comparing values with published normal values can differentiate conditions that cause intoeing and determine the level and severity of the problem

12. Foot progression angle (FPA) • The angle formed between the longitudinal axes of the feet relative to the line of forward progression during ambulation. • For children and adults, the normal FPA measures 0-30° external rotation • When estimating the FPA, focus on one foot at a time, because the FPA will often change with each step

13.  Foot Progression Angle

14. Prone Hip Rotation

15. Assessing hip rotation MedialRotationHip LateralRotation Hip

16. Femoral Anteversion Values • Birth = average 40º • Usually corrects 25º by 10 years old • Adult = average 15º

17. Thigh-foot Axis (TFA) • With the relaxed child’s ankle held gently in neutral dorsiflexion, a goniometer may be used to measure the angle formed by the longitudinal axis of the heel and the long axis of the thigh • By walking age, the normal TFA measures 0-30° • external rotation

18. Normal TFA Values • Birth = -5º (-30º to 20º) • Age 10 = 8º (-5º to 30º) • Adult = 23º (0º to 40º)

19. L TFA R TFA Thigh-foot Axis (TFA)

20. Assessing alignment of the foot • Shape of the foot • Heel-bisector angle

21. Intoeing • Toeing-in is the most common rotational deformity seen in the growing child • This term applied to ambulatory children who consistently point their feet toward the midline • Quantified by measuring the “foot progression angle” (FPA) • Significant intoeing has both functional (tripping) and cosmetic implications • More likely than outtoeing to be brought to the attention of the parents and health providers • Intoeing is often worse when children are tired or when running • The intoeing can be expected to resolve spontaneously in >95% by the age of 8 years

22. In-toed gait can be due to any rotational forces applied to the lower extremity at any point from the pelvis to the toe • the underlying anatomical and physiological basis for an in-toed gait • Osseous involvement • soft tissue involvement • a combination of both

23. Causes Of Intoeing • The causes of in-toeing can be divided into three broad categories • At the level of the hip (Femoral anteversion) • At the level of the leg (Internal tibial torsion ) • At the level of the foot (Metatarsus adductus) • In order to manage the problem effectively, the level of the deformity must be determined

24. Cause Of Intoeing In Relation To The Age Of The Child • In the first year of life: • Metatarsus adductus, alone or combined with internal tibial torsion • In toddlers: • Internal tibial torsion alone or combined with metatarsus adductus • In early childhood: • Femoral anteversion

25. The most common causes of intoeing are: • internal tibial torsion • internal femoral torsion (excessive femoral anteversion) • These two deformities may be additive, occurring together to cause significant intoeing • The diagnosis of both of these conditions can be reasonably made using physical examination alone, and imaging studies are rarely indicated

26. In-toeing at the Level of the Foot • Metatarsus adductus is one of the causes of in-toeing at the level of the foot • Overpowering: • tibialis anterior muscle • tibialis posterior muscle • adductor hallucis muscle • An overactive tibialis posterior muscle: • a reducible forefoot varus, with associated forefoot adduction • Tibialis anterior overactivity • an inversion of the forefoot • Fatigue has also been stated as one of the causes of in-toeing in a child, in particular associated with stiff, heavy shoes

27. Metatarsus Adductus • The most common congenital foot deformity • Occurring in one out of 1,000 live births • More frequently in female children and on the left side more than the right • The most likely cause is intrauterine packing (first born children) • Forefoot is pulled inward at the tarso-metatarsal joints as viewed in the transverse plane • 85 - 90 % of cases of metatarsus adductus identified at birth resolve without treatment by one year of age • The ankle has normal motion

28. The foot should be assessed for flexibility • If this cannot be done, then the deformity is rigid (i.E., Metatarsus varus) • The foot is placed in neutral with one hand, while the opposite hand forcibly attempts to reduce the deformity by grasping the metatarsals on the transverse plane

29. Mild cases • manually correctable without force • Moderate cases • manually correctable only with force • Severe cases • fixed and not manually correctable The heel bisector should pass between toes two and three

30. Placing the child's foot into a 'V' formed between the second and third fingers of the examiner's hand

31. Conservative Treatment • Stretching and manipulation • Plaster/serial casting • Splints and braces • Modification of sleeping habits • Shoe therapy • Often, combinations of these treatment options

32. Flexible metatarsus adductus is managed by stretching exercises during the first 8 months of life • Parents are instructed to hold the infant's hindfoot in one hand, the forefoot in the other, and stretch the midfoot, opening the "c"-shaped curve and slightly overcorrecting it • This exercise should be performed five times at each diaper change • This position is then held for a period of about 15 - 20 seconds, then released. This should be continued for about 10 to 15 minutes • Better results occur if treatment is begun before 8 months of age but can succeed up to age 2 years

33. Flexible deformities that persist beyond 8 months,and rigid deformities, may need a cast • Casts should be changed biweekly with correction usually achieved after three or four casts • Generally, if treated early, 1 or 2 casts over a period of 2 - 4 weeks is enough to achieve a full correction of the deformity • Following the use of serial casting use of a splint or brace should be used to maintain the correction

34. Internal Tibial Torsion (ITT) • Inward or medial torque of the tibial shaft an inward rotation of the ankle joint • The most common cause of intoeing • Affects males and females equally • Often asymmetrical with the left side affected more than right • Walking with the patella facing forward and the feet pointing inward • The cause is believed to be: • Intrauterine position • Sleeping in the prone position after birth • Sitting on the feet

35. Transmalleolar Axis medially rotated compared to Transcondylar Axis

36. Persistent ITT less than 10° is of little consequence if femoral torsion is normal • since the hips may readily compensate with sufficient external rotation to prevent tripping • Asymmetrical tibial torsion, with > 10° difference requires a more thorough evaluation for • growth disturbance (infantile tibia vara) • a neurological etiology (spastic monoparesis) • ITT ( > 15°) associated with progressive bowleg warrants radiographic evaluation of the knees • rule out infantile tibia vara (blount’s disease) in a child greater than 20 months of age

37. 90% of ITT cases resolve by the time the child reaches 8 years of age • Avoiding • prone sleeping • sitting on feet • No efficacy in the treatment of tibial torsion, and their expense is rarely justified • braces,casts • twister cables • exercises • orthopedic shoes have shown

38. Orthopedic management for: • A toddler with asymmetrical ITT, • Severe ITT > 15°, • ITT associated with progressive bowleg • Surgical derotation of the tibia, usually at the level of the distal metaphysis, is typically reserved for • Older than 8 years of age • A child with significant or functional deformity • A thigh-foot angle of greater than 3 STD beyond the mean • Osteotomy of the tibia has been associated with a high complication rate • (Compartment syndrome or peroneal nerve injury)

39. Excessive Femoral Anteversion • Femoral “anteversion” relates to the anterior projection of the femoral neck relative to the transverse axis of knee flexion • One of the most common diagnoses in a general pediatric orthopedic clinic • occurs more frequently in girls • usually diagnosed after 3 years of age • peaks at 4 to 6 years • then gradually resolves usually bilateral, • Other than patellar mal-tracking, there is little evidence that EFA predisposes to any other orthopedic problems

40. Problems primarily cosmetic • an increased incidence of patello-femoral pain in females • no evidence of hip or back problems or functional deficit in adults

41. When an adult stands in the anatomic position with the patellae facing anteriorly, the femoral neck typically points forward approximately 15° • Infants frequently 30°-40° of femoral anteversion, • gradually regresses by 1-2° per year until skeletal maturity • ("kissing patellae“ ”squinty patella sign” ) • The child with increased femoral anteversion walks with his or her patellae and feet pointing inward • With the knee in neutral rotation, the greater trochanter can be palpated posteriorally rather than in its normal lateral presentation

42. To objectively measure femoral neck anteversion a CT scan of the femoral neck and distal femoral condyles is needed, • Reserved only for preoperative evaluation of complex hip deformities • One of the easiest methods is to compare internal versus external hip rotation in the prone child • With increasing internal femoral torsion, the hip will show greater internal rotation with a corresponding decrease in external rotation

43. Intoeing tends to become clinically evident (assuming neutral tibial torsion) when hip internal rotation exceeds 70° or measures at least 30° greater than hip external rotation • Each increment of 10° femoral torsion above 70° increases the degree of severity ( mild, moderate, and severe ) • The hip range of motion can be measured every six to 12 months to document gradual decrease in femoral anteversion

44. 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

45. Femoral antetorsion

46. The hips of pre-walkers have limited internal rotation • later show excessive internal rotation after the external rotation contracture has resolved with ambulation • If there is sufficient external tibial torsion to compensate • may have a normal FPA • the knees rotate internally during ambulation • Soft tissue factors contributing to in-toeing include • spastic contracture or tight internal hip rotators • tight hip capsules • a tight ilio-tibial band

47. Spontaneous resolution occurs in more than 80 % of cases by late childhood • Nonoperative treatment is ineffective • Spontaneous correction of EFA cannot be accelerated with: • Braces • including twister cables • denis-browne bars) • Orthopedic shoes • Exercises • Sleeping in the prone position

48. Correction can be obtained only by femoral osteotomy • Orthotic devices are contraindicated because they will produce an external tibial torsion rather than derotating the femur

49. The spontaneous correction of intoeing from EFA is due to • gradual reduction in the anterior projection of the femoral neck with growth • as a result of the child’s development of self-image in the pre-teen years • The process of correction can be aided with • various stretching of affected muscles and muscle groups.

50. Conditions that may support a surgical approach include: (1) older than 8 years of age (2) severe deformity with significant cosmetic and functional disability (3) anteversion in excess of 50 degrees (4) deformity more than 3 STD beyond the mean (5) a family who is aware of the risks of the procedure • The derotation osteotomy at the proximal femur • One must carefully consider the relative cosmetic effect of intoeing versus the surgical scars required for femoral derotation