Primary Care Orthopedic Issues

chapter 22 Primary Care Orthopedic Issues

Kemedy K. McQuillen, MD, FAAP, FACEP Ronald I. Paul, MD, FAAP, FACEP

Objectives Chapter Outline Discuss the assessment 1 and management of Rotational Deformities rotational and angular Metatarsus Adductus pediatric orthopedic Internal Tibial Torsion conditions. Excessive Femoral Anteversion Identify the physical Angular Deformities 2 and radiographic findings for metatarsus adductus, internal tibial torsion (ITT), excessive femoral anteversion, and Blount disease.

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians A woman brings her 15-month-old daughter to your office because she has noticed that the child’s toes point inward when she walks and she often falls when she runs. After falling, the child gets up right away and continues on her way. She does not seem to be in pain and is not bothered by these frequent falls. She is otherwise healthy without any medical problems, takes no medications, and has no allergies.

The patient was a full-term infant delivered vaginally after an uncomplicated 1 antenatal course. She weighed 3.8 kg (8.4 lb) at birth and had Apgar scores of 9 and 9 at 1 and 5 minutes. She has achieved developmental milestones on schedule and started walking at 12 months. She eats a diverse diet, including meats, fruits, and vegetables, and drinks whole milk. She shows no preference for either hand and uses both well. There is no family history of cerebral palsy, learning disabilities, brain tumors, progressive neurologic diseases, or spina bifida. Of note, when her father was a toddler, his toes pointed in; he wore corrective shoes connected by a bar, and he currently has a normal gait. CASE SCENARIO SCENARIO CASE On examination the child is alert and playful and is toddling around the examination room. She is at the 50th percentile for height, weight, and head circumference. Significant physical examination findings include normal neurologic examination results and a normal spine without evidence of a dimple or tuft of hair at the sacrum. Her legs are of equal length. There are no clicks or clunks with Ortolani and Barlow maneuvers, and the hips have a full range of

22-3

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians motion. The lateral aspects of the feet are straight; the feet are easily dorsiflexed above the neutral position (90°), and the heel is midline without varus or valgus deformity. When you have the child sit on the examination table with her legs CONT. dangling over the edge, you find the lateral malleolus to be aligned with the medial malleolus. As you finish your physical examination, you have the child walk and

1 then run down the corridor while you observe her from the front and back. For best visualization, you do this part of the examination with the child wearing only a diaper. On observation you note that her feet point inward and her patellae point forward as she ambulates. Otherwise she has a normal gait without evidence of spasticity, ataxia, or pain.

1. What is the diagnosis? 2. What is the treatment? 3. Does the patient need a referral to an orthopedic surgeon? CASE SCENARIO SCENARIO CASE

Rotational Deformities Clinical Features Parents and grandparents are frequently dis- The diagnosis of metatarsus adductus is made tressed by their child’s intoeing and often seek by looking at the sole of the foot. Normally, the medical advice. Fortunately, most cases of lateral border of the foot is straight. In metatar- intoeing are related to age and development and sus adductus, the lateral aspect of the foot has a resolve spontaneously as the child grows. Knowl- C-shaped curve. To assess the flexibility of the edge of the normal musculoskeletal changes that defect, the heel is held in neutral alignment and occur through childhood in conjunction with a the forefoot is abducted. A flexible deformity can familiarity of the pathologic causes of intoeing be eliminated, and a fixed or rigid defect cannot. is essential for making the correct diagnosis and Grading of metatarsus adductus is based on the appropriate referrals. degree of flexibility and the relationship of the Most commonly, the cause of intoeing is toes to a line bisecting the heel. With a normal related to musculoskeletal development and foot, a line bisects the heel between the second is considered physiologic. Three physiologic and third toes. The line is at the third toe in a causes of intoeing include metatarsus adductus, mild deformity and between the third and fourth ITT, and excessive femoral anteversion. toes in a moderate deformity. The line is between the fourth and fifth toes in a severe deformity. The severity of metatarsus adductus is classified Metatarsus Adductus as mild/flexible, moderate/fixed, or severe/rigid. Metatarsus adductus is an intrinsic curving of the foot that results in intoeing. It is thought to Management result from compression in utero and occurs in Mild/flexible and moderate/fixed metatarsus approximately 1 in 1,000 live births. In the past adductus can initially be treated with stretch- it was associated with developmental dysplasia ing exercises; however, despite its commonly of the hip (DDH), although recent reports have prescribed use, the effectiveness of stretching questioned this association.1 Metatarsus adduc- exercises is uncertain.2 If the deformity does not tus can present in the hospital nursery or can resolve by 2 to 4 months, a referral for casting be brought to the attention of a physician at any is recommended. Every 2 to 3 weeks, two or time during infancy. three casts are applied. Treatment with casting

22-4 Primary Care Orthopedic Issues

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians is most effective before 6 months of age and ineffective after 2 to 3 years of age. In general, no further intervention is required after the casting is completed. Severe/rigid metatarsus adductus should be referred for serial casting in the first few weeks of life. These patients might require night splinting to maintain correction after the casting is completed. In 85% to 90% of cases, metatarsus adductus resolves spontaneously.3

Internal Tibial Torsion Usually, ITT presents at walking age with inward pointing of a child’s toes during walking or running. Some parents also comment on frequent falling, especially with running. With ITT, intoeing is a reflection of the normal rotational changes of the tibia. At birth, the mean tibial torsion is 5°. Over time, the tibia rotates out- ward to a mature torsion of 15° to 20°.2

Clinical Features

The diagnosis of ITT is made using the bimalleolar Figure 22.1 Normal bimalleolar axis due to the posterior axis (Figure 22.1). With the knee bent to a right position of the lateral malleolus. angle and the tibial tubercle pointing forward, the examiner places his or her hands on the medial and lateral malleoli. In newborns, the lateral malleolus is 2° to 4° posterior to the medial malleolus, by 5 years old it is 9° posterior, and at maturation it is 15° to 22° posterior. If the lateral malleolus is less posterior than this, ITT is present. Tibial rotation is also reflected in the thigh-foot angle (TFA) (Figure 22.2). With the child prone, the foot and the ankle in a neutral position, and the knees flexed to 90°, the TFA is the angle between the axis of the foot and the thigh. An internal TFA is indicative of ITT. Observation of the child’s gait can also aid in the diagnosis. When the child walks or runs, the patellae will face forward while the toes point inward. Encircling the patellae with ink will allow for better visualization of its alignment. Varus at the knee often is associated with ITT. Fortunately, by the time 95% of children with ITT reach 7 to 8 years old, the ITT has resolved and no intervention is required.

Management In the past, severe ITT was treated with a De- nis Browne splint (what our patient’s father had Figure 22.2 Determination of the thigh-foot angle.

Internal Tibial Torsion 22-5

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians worn as a child), twister cables that turn the feet pers and positioning of the child postnatally. out, and various shoe modifications. None of For this reason, although children with intoe- these interventions has been shown to hasten ing secondary to excessive femoral anteversion resolution of the malrotation. In addition, poor- can present as toddlers, they tend to present in ly applied Denis Browne splints can be harmful early childhood, with maximal average internal if they cause heel valgus to develop.3 In severe rotation in children between 3 and 7 years old. cases of ITT that do not resolve by 8 years of age, the treatment of choice is a rotational osteotomy Clinical Features of the tibia. However, this procedure is asso- As external rotation contracture of the hip re- ciated with significant complications, includ- solves, parents might notice a worsening of the ing malrotation, angular deformity, nonunion, child’s intoeing. In addition to intoeing, par- recurrence, and neurovascular complications. ents often note that the child sits in the “W” Only one study has addressed the arthritic com- position and is unable to sit cross-legged. Ex- 4 plications of unresolved ITT ; however, it was cessive femoral anteversion is often familial, is retrospective, was unsubstantiated by statistics, usually bilateral, and tends to affect girls more and is, thus far, unconfirmed. On the positive frequently than boys. The diagnosis is made by side, a recent study has suggested that ITT is as- internally and externally rotating the hips while 5 sociated with increased running speed. When the child lies either prone or supine with the sex-matched sprinters and nonathletes were hips extended (Figure 22.3). compared, sprinters were found to have more internally rotated tibias than did the control group. Without conclusive evidence that ITT can result in long-term disability, it might be A preferable to forgo the potentially destructive surgery required to repair the malrotation.

Excessive Femoral Anteversion Excessive femoral anteversion is the most common cause of intoeing and, as with metatarsus adductus and ITT, is related to normal rotational changes with skeletal maturation. Intrauterine positioning results in infants being born with externally rotated hips and feet. During infancy these findings resolve. In addition, the femur is anteverted relative to the axis of the femoral condyles at the knee. Normal degrees of anteversion are reported; however, there is a wide range of normal, with only 80% of patients’ values fall- B ing within 10° of the mean.6 Despite the wide range of values found, all studies document a gradual decrease in anteversion during childhood with an ultimate femoral neck anteversion of 8° to 25° by adulthood. The increased anteversion in newborns can be masked by the external rotation contracture of the soft tissues about the hip. The contracture originates from the externally rotated position of the hips in Figure 22.3 A. Internal hip rotation. B. External hip utero and is perpetuated by the wearing of dia- rotation.

22-6 Primary Care Orthopedic Issues

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians In children with excess femoral anteversion, most of the arc of rotation will be inward, with WHAT ELSE internal rotation as much as 90°. External rotation is only 10° to 30°. On observation of the child’s gait, it can be noted that both the patellae Differential Diagnosis of Intoeing and feet point inward. • Cerebral palsy • DDH Diagnostic Studies • Spina bifida Although radiography, computed tomography, • Rickets magnetic resonance imaging (MRI), and ultra- • Metatarsus adductus sonography can be used to measure the degree • ITT of femoral anteversion, the results from these • Femoral anteversion studies show a poor correlation with clinical examination and are not necessary to make the diagnosis of excessive femoral anteversion.1 In addition, there might not be a radiographic im- provement as the degree of intoeing resolves. Further workup should be done if the cause The absolute precision of clinical measurement of intoeing is thought to be pathologic. This of hip rotation has also been called into ques- workup might include radiographs of the pelvis, tion; however, the assessment of hip rotation knees, wrists, and spine to confirm or exclude remains the mainstay of diagnosis in the routine skeletal dysplasia or metabolic bone disease; ul- clinical setting. Research to evaluate the long- trasonography, radiography, or MRI of the hip term complications of excessive femoral ante- to exclude DDH; MRI to exclude cerebral palsy, version is contradictory. Smaller studies suggest spina bifida, and intracranial abnormality; and that excessive femoral anteversion predisposes blood tests to exclude metabolic bone disease. patients to osteoarthritis of the hip, although others contradict this claim.7 Differential Diagnosis The differential diagnosis of intoeing is varied; however, the diagnosis can often be made after YOUR FIRST CLUE a thorough history and physical examination, with normal growth and neurologic function excluding many of the causes of intoeing. Physical Examination Findings in The physician is able to systematically ex- Metatarsus Adductus, ITT, and Femoral clude many of the pathologic causes of intoeing Anteversion by asking directed questions: a history of hand Metatarsus adductus: preference during infancy, spasticity, problems • Line bisecting the heel lateral to the third during pregnancy and/or delivery, and unilateral toe intoeing suggest cerebral palsy; asymmetric leg • C-shaped lateral aspect of the foot length with limited external rotation or abduc- ITT: tion of the hip suggests DDH; a sacral dimple or • Bimalleolar axis shows lateral malleolus hair tuft suggests spina bifida; and a diet devoid anterior or less posterior than it should be of vitamin D suggests rickets. • TFA internal Femoral anteversion: Management • Child sits in the “W” position Nonsurgical treatments have included shoe • Arc of rotation of the hip is inward wedges, torque heels, night splints, and twister • Foot and patella are point inward cables. As with ITT, these interventions have not been shown to be effective. If intoeing persists after 8 to 10 years of age, is cosmetically unac-

Excessive Femoral Anteversion 22-7

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians ceptable, and causes functional problems with gait, some recommend derotational osteotomy. KEY POINTS Complications occur in approximately 15% of patients and include residual intoeing, avascu- lar necrosis of the femoral head, osteomyelitis, Management of Metatarsus Adductus, ITT, and Femoral Anteversion and late-developing valgus deformity. Patients • Metatarsus adductus and families should carefully consider the risks and benefits of surgery in light of a paucity of – Stretching or casting evidence for long-term sequelae. Spontaneous • ITT resolution of intoeing secondary to femoral an- – Observation or rotational osteotomy teversion occurs in more than 95% of affected • Femoral anteversion children.8 – Shoe wedges, torque heels, night splints, and twister or derotational osteotomy • Follow-up in a medical home.

22-8 Primary Care Orthopedic Issues

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians A woman brings her 3-year-old son to your office for evaluation of bowlegs. The boy has had bowlegs since he started walking. The mother was not initially concerned about this because her first son had the same problem and, by 3 years of age, his legs were straight. The child, however, has had progressive worsening and has started to waddle when he walks. He is able to walk and run without difficulty and never complains of pain. He has no history of major trauma to his legs and has never broken a bone. His medical history is remarkable only for the usual childhood viral illnesses. He is taking no medications, has no allergies, and has not received any specific therapy for bowlegs. He was born at term after an uncomplicated antenatal course. He was delivered vaginally and was born headfirst. At birth he weighed 3.9 kg (8.6 lb). He eats a well-balanced diet and tends

2 to snack between meals. He drinks at least 710 mL (24 oz) of whole milk a day. His milestones were achieved on time or early, and although he did not crawl, he walked at 11 months. The mother does not know of anyone else in the family with bowlegs or any other bone problems.

Physical examination reveals a husky boy in no distress. He speaks well and interacts appropriately for his age. His height is at the 50th percentile, and his weight is at the 90th percentile. His head, ears, eyes, nose, throat, lung, cardiovascular, abdominal, and neurologic examination results are normal. When CASE SCENARIO SCENARIO CASE he stands with his back to you, with his medial malleoli touching, you measure the intercondylar distance to be 12 cm. As he walks, his gait is even with lateral thrusting of both knees. Supine, his legs are the same length. You are unable to straighten the bowing with the derotational test. In full extension the knees are stable; however, at 10° to 20° of flexion, the medial femoral condyles sublux posteromedially.

1. What is the next step in the evaluation? 2. Do most children outgrow bowleggedness? 3. Will this patient outgrow his bowleggedness?

Angular Deformities amount that remains, results in children having varying degrees of bowleggedness when they Bowleggedness or genu varum is a common begin to walk. By 18 to 22 months, the contrac- physical finding in children younger than 2 tures stretch and the knees begin to straighten. years. The bowing tends to become more obvi- ous as the child starts to ambulate and in the The varus deformity (bowlegs) becomes a val- presence of a rotational abnormality, such as gus alignment (knock-kneed) during the second ITT, is exaggerated. and third years of life and then achieves the Secondary to intrauterine positioning, in- normal adult alignment of a slight valgus by 7 to fants are born with a contracture of the medial 8 years of age. Normal ranges for the tibiofemo- knee capsule, especially of the posterior oblique ral angle during growth are listed in Table 22-1.9 ligament. This results in external rotation of the In most cases, bowing is a physiologic ab- entire lower limb and the genu varum posture normality that corrects itself; however, any sig- of the infant’s legs. During the first year of life, nificant bowing beyond 2 years of age tends not this contracture loosens and, depending on the to be physiologic.

Angular Deformities 22-9

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Blount Disease with adolescent Blount disease have a history Blount disease, as the most common patho- of childhood bowing that improved but never logic condition that results in bowleggedness, resolved. When the child has a growth spurt, deserves special mention. Blount disease is the varus angle acutely worsens. characterized by disordered endochondral os- The cause of infantile Blount disease is un- sification of the medial proximal tibial physis. known, although it is most likely multifactorial, Clinically, it appears as an abrupt varus defor- with contributions from hereditary, develop- mity of the proximal tibia associated with an mental, and mechanical factors. Environmental internal torsion of the tibia. There are two major and mechanical factors are postulated to have a types of Blount disease: infantile and adolescent. role in the adolescent form of the disease.9 The infantile form is more common and usually The diagnosis of Blount disease is based on found in obese, black children younger than 3 historical features, clinical findings, and radio- 4414X_ch12_p410_p445.qxdyears. It is bilateral 6/2/06 in 1:41 up to PM 75% Page of cases.421 This graphs. Clinically, the varus deformity is readily form is more progressive than the adolescent apparent, and there is some medial tibial torsion. form. Adolescent Blount disease occurs after the The beaking of the medial proximal metaphysis age of 6 years and tends to be unilateral. Black is often palpable. Affected children might walk children and boys are more commonly affected with a waddle (or a limp in unilateral disease) than white children and girls. Most patients and demonstrate a lateral thrust of the knee dur-

TABLE 12-2 Development of Tibiofemoral Angle During Growth. Note TABLE 22-1 Developmentthe Normal Physiologic of the Tibiofemoral Progression Angle of Bowlegs During Growth.to Knock-Knees Note the Normal Physiologicand Then Progression to Normal of Bowlegs to Knock-Knees and Then to Normal.

+20° DEVELOPMENT OF THE TIBIO-FEMORAL ANGLE DURING GROWTH VARUS + +15° VALGUS –

+10° VARUS

+5°

Age 0° 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6 yrs 7 yrs 8 yrs 9 yrs 10 yrs 11 yrs 12 yrs 13 yrs

–5°

VALGUS –10°

–15° Extreme values +34 ± 0 +21–13 +20–20 +13–19 +4–17 ± 0–11 ± 0–11 ± 0–10 ± 0–14 ± 0–13 ± 0–12 ± 0–10 ± 0–12 ± 0–11

Source:Salenius SaleniusP, Vankka E. P,Vankka The development E. The developmentof the tibiofemoral of the angle tibiofemoral in children. J angleBone Joint in Surgchildren. Am. 1975;57A:260.J Bone Joint ReprintedSurg [Am]. with1975;57A:260. permission. ReprintedThe means ofwith the permission.measurement is the black line. (other colors represent errors of the mean)

alignment (knock-kneed) during the second and 22-10 AngularPrimary Care OrthopedicDeformities Issues third years of life and then achieves the normal Bowleggedness or genu varum, is a common Copyright © 2012 by the American Academy of Pediatrics and theadult American alignment College of of a Emergency slight valgus Physicians by 7 to 8 years physical finding in children younger than 2 of age. Normals for the tibiofemoral angle dur- years. The bowing tends to become more ob- ing growth are depicted in Table 12-2. vious as the child starts to ambulate and, in In most cases, bowing is a physiologic ab- the presence of a rotational abnormality such normality that corrects itself however, any sig- as ITT, is exaggerated. nificant bowing beyond 2 years of age tends Secondary to intrauterine positioning, in- not to be physiologic. fants are born with a contracture of the medial knee capsule, especially of the posterior oblique ligament. This results in external rotation of the Blount Disease entire lower limb and the genu varum posture of Blount disease, as the most common pathologic the infant’s legs. During the first year of life, this condition that results in bowleggedness, deserves contracture loosens and, depending on the special mention. Blount disease is characterized amount that remains, results in children having by disordered endochondral ossification of the varying degrees of bowleggedness when they be- medial proximal tibial physis. Clinically, it ap- gin to walk. By 18 to 22 months, the contractures pears as an abrupt varus deformity of the prox- stretch and the knees begin to straighten. The imal tibia associated with an internal torsion varus deformity (bowlegs) becomes a valgus of the tibia. There are two major types of Blount

Blount Disease 421 ing ambulation. The knee tends to be stable in knee capsule and the deformity disappears. The full extension but at 20° flexion can have pos- intercondylar distance is determined by measur- teromedial subluxation of the femoral condyle ing the distance between the femoral condyles into the depressed medial tibial plateau. The while the child is standing with medial malleoli subluxation, or Siffert-Katz sign, can be present touching; distances greater than 6 cm are abnor- before there are any changes on radiographs. In mal. Other concerning findings on physical ex- the later stages of the disease, clinical features amination include small size, excessive weight for can include pain and instability of the knee with height, significant asymmetry, severe deformity, ambulation. palpable metaphyseal beaking, knee pain, and Clinical Features knee instability or lateral thrust with ambulation. Adolescent Blount disease is more commonly Diagnostic Studies unilateral, and leg shortening is common. The Children with persistent bowing beyond 2 varus deformity tends to be less than 20°, and years old and those patients with concerning medial torsion of the tibia is mild or absent. Lock- findings on history or physical examination ing or popping of the knee and pain are more should undergo radiography from hip to ankle, common than in the infantile form. The patient’s with the focus being on the knees. The child gait can be antalgic and show a mild lateral knee should be standing with both kneecaps pointing thrust; instability of the knee is uncommon, but forward.10 On plain radiographs, physiologic at 20° flexion there can be mild laxity of the bowing might show an exaggerated metaphy- medial collateral ligament. Varus deformity of the seal-diaphyseal angle of the proximal tibia, a knee is common in children; however, patho- finding also seen in Blount disease. In physi- logic causes should be excluded. The history of ologic bowing, however, this change also tends present illness should include onset and progres- to be seen in the distal femur and distal tibia. sion of symptoms, alleviators and exacerbators, Radiographic findings in pathologic causes and any prior interventions. A comprehensive of bowing can include widened physes at all medical history, including birth, growth, and de- the joints and bowing of the femur and tibia velopmental histories, dietary habits, and family as is seen in rickets or overgrowth of the fibula history, should be elicited. Children with patho- compared with the tibia and asymmetry in the logic genu varum frequently have a history of growth of the proximal tibial metaphysis as is walking at an early age, being overweight, and seen in achondroplasia, the most common ge- having pain with ambulation. Physical exami- netic condition that leads to bowing. nation components include the assessment of weight, height, and nutritional status, a comprehensive neurologic examination, skin evaluation for signs of neurofibromatosis, and joint inspec- tion for evidence of inflammatory changes. On YOUR FIRST CLUE examination of the affected extremity, the derotation test and the determination of the intercon- Signs and Symptoms of Blount Disease dylar distance will help differentiate physiologic • Intercondyle distance >6 cm from pathologic causes of bowing. The derotation • Short stature test differentiates physiologic bowing secondary • Weight excessive for height to tight knee ligaments from more serious dis- • Severe deformity ease. It is done by flexing the knee to 90°, holding • Palpable metaphyseal beaking the femur steady in one hand, and attempting to externally rotate the knee. Alternatively, it can • Knee instability be done with the child on his or her back by • Knee pain externally rotating the tibia to match the external • Presence of Siffert-Katz sign rotation of the femur. With physiologic bowing, these maneuvers derotate the contracted medial

Angular Deformities 22-11

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians Radiographically, infantile Blount disease Blood tests in the evaluation of bowlegs are is a progressive disease classified according to directed by the suspected diagnosis. radiographic findings as defined by Langenski- Differential Diagnosis old’s six stages of Blount disease (Figure 22.4).11 In most cases, bowing is a physiologic abnor- Radiographic findings include abrupt varus mality that corrects itself. However, any signifi- angulation at the metaphysis of the proximal cant bowing beyond 2 years of age tends not to tibia, a widened and irregular physeal line medi- be physiologic and can be due to a number of ally, a medially sloped and irregularly ossified pathologic conditions. epiphysis, and prominent beaking of the medial metaphysis with lucent cartilage island within the beak. The Drennan angle, or the metaphyse- Stage I Stage II Stage III Stage IV Stage V Stage VI al-diaphyseal angle, is measured. If it is greater than 11° in children older than 2 years or greater than 16° in children younger than 2 years, it is abnormal.12 It is important to remember that to diagnose Blount disease there must be other radiographic findings in addition to an exces- Figure 22.4 Langenskiold’s six stages of Blount disease. sive Drennan angle. The isolated finding of an Langensklold A, Riska EB. Tibia vara (osteochondrosis deformans increased metaphyseal-diaphyseal angle might tibiae): a survey of seventy-one cases. J Bone Joint Surg Am. represent nothing more than physiologic bow- 1964;46:1405-20. ing that will resolve spontaneously. The progno- sis for infantile Blount disease is variable, with Management progression being the norm. Complete regres- The management of bowleggedness is based on sion has been documented in early stages of the underlying cause. Most cases are physiologic the disease. and resolve spontaneously. They are treated with There is not a radiographic classification observational management and can be followed system for adolescent Blount disease. Radio- up by the primary care physician. If physiologic graphic findings include widening of the medial genu varum fails to resolve by 7 to 8 years old, growth plate, a normal or slightly wedge-shaped orthopedic referral is appropriate. Pathologic epiphysis, and a narrow area about midway in conditions should be referred for specialized the medial physeal line, with sclerosis on the management. The treatment of Blount disease is epiphyseal and metaphyseal sides of this area. determined by patient age, severity of the varus In addition to diagnosing disease, ra- deformity, and Langenskiold stage. Milder cases diographs can also be helpful in alerting the of infantile Blount disease in children younger physician to those children who need close than 3 years are initially treated with braces. observation. Levine and Drennan noted that a More severe or progressive angular deformities metaphyseal-diaphyseal angle of the tibia great- are treated surgically with a corrective oste- er than 11° was a marker for increased risk for the development of Blount disease.10 In their study, 29 of 30 extremities with metaphyseal-di- THE CLASSICS aphyseal angles greater than 11° later developed Blount disease, whereas only 3 of 58 extremi- Radiographic Signs of Blount Disease ties with angles less than 11° had subsequent changes consistent with Blount disease. These • Metaphyseal beaking high-risk children should not be treated until • Varus angulation of proximal tibia they show definitive signs of Blount disease • Irregularly ossified epiphysis because some children with significant varus • Excessive Drennan angle deformities eventually experience complete spontaneous resolution.

22-12 Primary Care Orthopedic Issues

Copyright © 2012 by the American Academy of Pediatrics and the American College of Emergency Physicians otomy with or without physeal bar resection. Mild, nonprogressive adolescent Blount disease KEY POINTS is treated with observation. If the deformity is progressive or causes significant disability, surgical treatment should be considered. Management of Blount Disease • Observation and follow-up in medical home • Referral to pediatric orthopedist— WHAT ELSE? evaluate for surgical management

Differential Diagnosis of Blount Disease Inflammatory: • Infection • Postinfectious • Rheumatoid arthritis Tumor: • Fibrous dysplasia • Osteochondromata • Enchondroma • Neurofibromatosis Osteochondrodysplasia: • Focal fibrocartilaginous dysplasia • Metaphyseal chondrodysplasia • Multiple epiphyseal dysplasia Posttraumatic: • Growth arrest • Angular overgrowth Congenital deformities: • Pseudarthrosis • Posteromedial bow • Congenitally short femur • Fibular hemimelia Osteogenesis imperfecta Metabolic: • Rickets • Renal osteodystrophy

Angular Deformities 22-13

Check Your Knowledge 4. A 10-year-old black boy is diagnosed as having Blount disease after acute 1. Which of the following statements are worsening of his varus deformity of his true about intoeing in a 2-year-old child? right leg. Which of the following signs is A. Most cases are caused by premature not compatible with his diagnosis? closure of the proximal tibia medial A. Tall stature epiphysis. B. Severe deformity B. Corrective braces are frequently C. Weight excessive for height needed for long-term correction. D. Palpable metaphyseal beaking C. Most cases resolve spontaneously as the child grows. D. Most cases are considered pathologic. References 2. A 2-month-old infant is noted to have 1. Karol LA. Rotational deformities in the lower extremities. Curr excessive but flexible curvature of her Opinion Pediatr. 1997;9:77–80. feet causing intoeing. This examination 2. Dietz FR. Intoeing—fact, fiction and opinion.Am Fam Physician. 1994;50:1249–1259. is most compatible with which of the 3. Pontes IV, Becker JR. Congenital metatarsus adductus: the results following diagnoses? of treatment. J Bone Joint Surg Am. 1966;48:702–711. 4. Turner MS, Smillie IS. The effect of tibial torsion on the A. Internal tibia torsion pathology of the knee. J Bone Joint Surg Br. 1981;63:396–398. B. Metatarsus adductus 5. Fuchs R, Staheli LT. Sprinting and intoeing. J Pediatr Orthop. 1996;16:489–491. C. Excessive femoral anteversion 6. Heinrich SD, Sharps CH. Lower extremity torsional deformities D. Blount disease in children: a prospective comparison of two treatment modalities. Orthopedics. 1991;14:655–659. 3. Which of the following statements is true 7. Eckhoff DG, Kramer RC, Alongi CA, VanGervon DP. Femoral about internal tibia torsion? anteversion and arthritis of the knee. J Pediatr Orthop. A. In nearly 50% of children with 1994;14:608–610. 8. Bruce RW. Torsional and angular deformities. Pediatr Clin North internal tibial torsion, the condition Am. 1996;43:867–881. will resolve by the time they are 7 to 8 9. Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg [Am]. 1975;57A:260. years old. 10. Levine AM, Drennan JC. Physiological bowing and tibia vara: B. The mean tibial torsion in degrees is the metaphyseal-diaphyseal angle in the measurement of bowleg deformities. J Bone Joint Surg Am. 1982;64:1158–1163. usually greater in newborns than at 11. Bradway JK, Klassen RA, Peterson HA. Blount disease: a review maturity. of the English literature. J Pediatr Orthop. 1987;7:472–480. 12. Do TT. Clinical and radiographic evaluation of bowlegs. Curr C. The lateral malleolus is on average 20° Opinion Pediatr. 2001;13:42–46. posterior to the medial malleolus at maturity. D. Splints with cables are often needed to correct internal tibia torsion.

22-14 Primary Care Orthopedic Issues

1 A woman brings her 15-month-old daughter to your office because she has noticed that the child’s toes point inward when she walks and she often falls when she runs. After falling, the child gets up right away and continues on her way. She does not seem to be in pain and is not bothered by these frequent falls. She is otherwise healthy without any medical problems, takes no medications, and has no allergies.

CASE SUMMARY SUMMARY CASE The patient was a full-term infant delivered vaginally after an uncomplicated antenatal course. She weighed 3.8 kg (8.4 lb) at birth and had Apgar scores of 9 and 9 at 1 and 5 minutes. She has achieved developmental milestones on schedule and started walking at 12 months. She eats a diverse diet, including meats, fruits, and vegetables, and drinks whole milk. She shows no preference for either hand and uses both well. There is no family history of cerebral palsy, learning disabilities, brain tumors, progressive neurologic diseases, or spina bifida. Of note, when her father was a toddler, his toes pointed in; he wore corrective shoes connected by a bar, and he currently has a normal gait.

On examination the child is alert and playful and is toddling around the examination room. She is at the 50th percentile for height, weight, and head circumference. Significant physical examination findings include a normal neurologic examination results and a normal spine without evidence of a dimple or tuft of hair at the sacrum. Her legs are of equal length. There are no clicks or clunks with Ortolani and Barlow maneuvers, and the hips have a full range of motion. The lateral aspects of the feet are straight; the feet are easily dorsiflexed above the neutral position (90°), and the heel is midline without varus or valgus deformity. When you have the child sit on the examination table with her legs dangling over the edge, you find the lateral malleolus to be aligned with the medial malleolus. As you finish your physical examination, you have the child walk and then run down the corridor while you observe her from the front and back. For best visualization, you do this part of the examination with the child wearing only a diaper. On observation you note that her feet point inward and her patellae point forward as she ambulates. Otherwise she has a normal gait without evidence of spasticity, ataxia, or pain.

1. What is the diagnosis? 2. What is the treatment? 3. Does the patient need a referral to an orthopedic surgeon?

Reassurance is the mainstay of treatment in most cases of rotational deformities. The girl has internal tibial torsion and can be observed for the next several years to ensure that her lower extremity rotational development progresses as expected and her intoeing resolves. If, however, her intoeing persists or worsens as she approaches school age, a referral to an orthopedic surgeon might be indicated. The mother was given a thorough explanation of the abnormality and reassured that this problem should resolve on its own. The other rotational abnormalities can be treated in much the same way with orthopedic referrals made in a timely manner (by 2 to 4 months of age for a flexible metatarsus adductus and sooner for a rigid metatarsus adductus and by 8 to 10 years of age for excessive femoral anteversion) to allow for treatment at the optimal time.

Chapter Review 22-15

2 A woman brings her 3-year-old son to your office for evaluation of bowlegs. The boy has had bowlegs since he started walking. The mother was not initially concerned about this because her first son had the same problem and, by 3 years of age, his legs were straight. This child, however, has had progressive worsening and has started to waddle when he walks. He is able to walk and run without difficulty and never complains of pain. He has no history of major trauma to his legs and has never broken CASE SUMMARY SUMMARY CASE a bone. His medical history is remarkable only for the usual childhood viral illnesses. He is taking no medications, has no allergies, and has not received any specific therapy for bowlegs. He was born at term after an uncomplicated antenatal course. He was delivered vaginally and was born headfirst. At birth he weighed 3.9 kg (8.6 lb). He eats a well-balanced diet and tends to snack between meals. He drinks at least 710 mL (24 oz) of whole milk a day. His milestones were achieved on time or early, and although he did not crawl, he walked at 11 months. The mother does not know of anyone else in the family with bowlegs or any other bone problems.

Physical examination reveals a husky boy in no distress. He speaks well and interacts appropriately for his age. His height is at the 50th percentile, and his weight is at the 90th percentile. His head, ears, eyes, nose, throat, lung, cardiovascular, abdominal, and neurologic examination results are normal. When he stands with his back to you, with his medial malleoli touching, you measure the intercondylar distance to be 12 cm. As he walks, his gait is even, with lateral thrusting of both knees. Supine, his legs are the same length. You are unable to straighten the bowing with the derotational test. In full extension the knees are stable; however, at 10° to 20° of flexion, the medial femoral condyles sublux posteromedially.

1. What is the next step in the evaluation? 2. Do most children outgrow bowleggedness? 3. Will this patient outgrow his bowleggedness?

In this case, the boy had multiple red flags in his history and physical examination. He is an obese child whose deformity is worsening. While walking he had lateral thrusting of the knees, a finding that is never seen with physiologic bowing. His intercondylar distance was excessive, and the derotational maneuver was ineffective. Findings on the boy’s radiographs were consistent with stage II infantile Blount disease. He was referred to an orthopedic surgeon, who treated him with braces and will follow his progress closely.

Photo Credits Opener © Ellen B. Senisi/Photo Researchers, Inc. Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or the American Academy of Pediatrics. Some images in this book feature models. These models do not necessarily endorse, represent, or participate in the activities represented in the images.

22-16 Primary Care Orthopedic Issues