Lower Extremity Malalignment: When to Refer and When to Reassure? Mary Aschenbrener, PA-C Minnesota Academy of Physician Assistants 03/18/16 Cary H. Mielke, MD Chief of Staff Orthopaedic Burn Spinal cord injury Cleft lip and palate Disclosure Statement: I have no relevant personal financial relationships with commercial interests to disclose relative to this presentation. I have not presented any promotional talks for any pharmaceutical companies within the past 12 months. Objectives: Understand various lower extremity malalignment problems. Understand diagnostic criteria. Identify appropriate follow up and parent education. Indicate when to refer to a pediatric orthopaedic specialist. Intoeing Femoral Anteversion Most common cause of intoeing in preschoolers Born with femoral anteversion Reach adult rotation between ages 8 to 10 Femoral Anteversion Internal Tibial Torsion • Most common cause of intoeing in toddlers • Thought to be due to intrauterine positioning Metatarsus Adductus Metatarsus Adductus Passively Correctable Intoeing History W-sit? Knee pain with prolonged sitting, stairs, squats? Increased tripping, falling? Patellar instability? Intoeing Exam Evaluate gait - look at foot progression angle, kissing knees Evaluate run – egg beater run Assess flexibility of foot in metatarsus adductus Prone exam: Hip internal and external rotation, thigh foot angle Intoeing Most rotational variations will resolve spontaneously as child grows Does not cause hip, knee or ankle osteoarthritis Bracing is not effective treatment Intoeing Refer if: Rigid metatarsus adductus Increased tripping, falling, patellar instability, knee pain or activity limited due to intoeing Surgery is only way to treat rotational abnormality Case #1 16 y.o. female with 3 year history of bilateral patellofemoral instability and knee pain, left greater than right Left patella dislocates with ADL’s 5 patellar dislocations in the last year No known injury or inciting event No right patellar dislocations, but feels like it Sports medicine physician prescribed patellar stabilizing brace and physical therapy Case #1 Exam Non-antalgic gait. No limping Neutral foot progression angle Hip internal rotation 60 degrees, external rotation 30 degrees Thigh/foot angle 15 degrees externally rotated Patellar subluxation on patellar mobilization exam Lower extremity CT scan, University of Wisconsin protocol, showed bilateral femoral anteversion, bilateral external tibial torsion & bilateral patellar subluxation Genu Varum/ Genu Valgum, i.e. Bowlegs/Knock knees Normal Development Genu Varum Easy Alignment Check: Measure intercondylar distance Should not exceed 6 cm at any age Genu Varum Differential diagnosis includes: • Physiologic bowing • Blount’s disease • Rickets • Skeletal Dysplasia • Infection, fracture, neoplasm Genu Varum Physiologic: • Between birth to 2 years old • Bilateral and Symmetrical • Bowing of both femurs and tibias • Normal Stature • No lateral thrust with ambulation Blount’s Disease • Infantile • Adolescent Genu Varum Blount’s Disease Predisposing factors: • Obesity • African American ethnicity • Early walking Infantile Blount's Disease Not a metabolic problem Malformed growth plate Diagnosed before age 4 Usually bilateral Worsens when the child begins walking. Difficult to distinguish from physiologic bowing in kids under 2 years old By age 3 the bowing worsens and abnormalities are seen on x-ray Adolescent Blount's Disease Diagnosed after age 4 Usually caused by obesity More often unilateral than bilateral Genu Varum Blount’s Disease Treatment: •Brace • Surgical Genu Varum Rickets Disease of bone mineralization Calcipenic or Nutritional Phosphopenic Associated with both genu varum & genu valgum Parathyroid hormone, Alkaline phosphatase, phosphorus, calcium, Vitamin D Genu Varum: Rickets Genu Varum: Rickets Treatment: • Managed with Medications • Surgical Correction Genu Varum Skeletal Dysplasia Genu Varum Asymmetric growth from: • Infection •Fracture • Neoplasm Case #2 20 month old Nigerian/American twin with concerns of bowed legs Noticed when she started walking at 10 months old Seems to be worsening No difficulty walking Full term infant Delivered by C-section due to breech position 4 year old sister had bowed legs when she was younger and resolved as she grew Case #2 Exam Non-antalgic gait Lateral thrust on the left No femoral anteversion X-rays showed borderline metaphyseal/diaphyseal angles of 12° on the right and 15 degrees on the left Case #2 Plan Diagnosed with physiologic genu varum Did not diagnose Blount's disease because of her age Screened for Rickets with Vitamin D, Calcium, Phosphorus, alkaline phosphatase,& Parathyroid Hormone Follow up in 4 months with repeat x-rays Case #3 Genu Varum 19 month old Caucasian male 1st child to this family Full term, normal pregnancy and delivery Started walking at 71/2 months old Noticed bowed legs and intoeing since started to walk Seems to trip and fall more than other children his age No pain; doesn’t limit his activity Family History: uncle with bowed legs who wore a brace at age 6 Case #3 Exam Very active in the exam room Mild inward foot progression angle of about 20° Femoral anteversion of 70° bilaterally Mild Internal tibial torsion of 10° bilaterally No metatarsus adductus Case #4 13 year old female from Nigeria Oldest of 8 children Full term, normal pregnancy and delivery Born with severe bowing deformity of both legs Started walking at 10 months old Left corrected spontaneously Diagnosed with Blount's disease At age 9 had a right proximal tibial osteotomy in Nigeria Case #4 Exam Significant gait disturbance Significant internal foot progression on the right Severe bowing deformity of the right tibia, internal tibial torsion, leg length difference secondary to the bowing deformity Genu Valgum Genu Valgum Alignment check: • Measure the intermalleolar distance • Distance of more than 8 cm is abnormal at any age Genu Valgum Differential diagnosis includes: • Physiologic valgus • Rickets • Skeletal Dysplasia • Trauma, Infection or neoplasm Genu Valgum Physiologic : • Between 2-5 years old • Symmetrical • Normal Stature • Lack of Symptoms Genu Varum/Genu Valgum Management Physiologic: • Reassure • Monitor • Braces, splints, inserts are ineffective Genu Varum/Genu Valgum When to Refer? • If pathological varum/valgum is expected • Worsening varus between birth and 2 years of age • Worsening valgum after 4-5 years of age • Intercondylar distance of more than 6 cm with genu varum deformity • Intermalleolar distance of more than 8 cm with genu valgum deformity Genu Varum/Genu Valgum Surgical Management: • Hemiepiphysiodesis (guided growth) • Opening or closing wedge osteotomy Case #5 Genu Varum 2 y.o. African American male. Concerns of bowing and intoeing. Full term, normal pregnancy and delivery. Walked early at 10 months old. Trips frequently. Family thinks the bowing is worse. Case #5 Exam Waddling gait. More intoeing on left. Thigh foot angle 20 to 30 degrees internal on the left. 5 degrees internal on the right. More external rotation of the hips than internal rotation Case #6 Genu Valgum 10 year old Native American female. Adopted at age 2. Birth history is unknown. Started walking at age 2. Increased tripping and falling. No pain. X-ray taken elsewhere showed a leg length difference Case #6 Genu Valgum Neutral foot progression angle. Hip internal rotation of 30 degrees, external rotation of 20 degrees. Genu Varum/Genu Valgum Orthopedic Management: Osteotomy Pes Planus Image from: http://orthoinfo.aaos.org/topic.cfm?topic=a00046 AKA: Flat Feet Determine if deformity is flexible or rigid Pes Planovalgus Determine if there is associated heelcord tightness Pes Planus Treatment: Flexible Flat Foot • Physical Therapy • Orthotics • NSAIDS Pes Planus Rigid Flat Foot: • Tarsal Coalition • Iatrogenic/Posttraumatic Pes Planus Tarsal Coalition: Symptoms: • Pain with activity • Repeated sprains • Symptoms typically start at 8 -12 years of age Pes Planus Tarsal Coalition: • Most often Talocalcaneal or Calcaneonavicular • Can be fibrous, cartilaginous, or bony connection Tarsal Coalition Pes Planus Tarsal Coalition Treatment • Cam Boot •Cast • Surgery Pes Planus In Summary: • Determine if foot is flexible or rigid Refer if: • Rigid flat foot • Painful flat foot References Rosenfeld, SB. Approach to the child with bow-legs. In: UpToDate, Phillips W, Drutz JE (Sec Ed), Torchia MM (Dep Ed), (Accessed on at www.uptodate.com©2016 UpToDate® ). Rosenfeld, SB. Approach to the child with knock-knees. In: UpToDate, Phillips W, Dureya TK (Sec Ed), Torchia MM (Dep Ed), (Accessed on at www.uptodate.com©2016 UpToDate® ). Rosenfeld, SB. Approach to the child with in-toeing. In: UpToDate, Phillips W (Sec Ed), Torchia MM (Dep Ed), (Accessed on at www.uptodate.com©2016 UpToDate® ). Carpenter, T. Overview of rickets in children. In: UpToDate, Wolfsdorf, JI (Ed), Hoppin AG (Dep Ed), (Accessed on at www.uptodate.com©2016 UpToDate® ). References Con’t… Gurd, DP, Thomas H. Wuerz, TH. Blount Disease. American Academy of Orthopaedic Surgeons Web site: Orthopaedic Knowledge Online Journal 2011 9(8): Accessed on February 2016 at http://orthoportal.aaos.org/oko/article.aspx?article=OKO_PED036. Grottkau, BE, Hart, ES, Kavadi, N, Kristan Pierz, K. Rotational Variations of the Lower Extremity in Children. American Academy of Orthopaedic Surgeons Web site: Orthopaedic Knowledge Online Journal 2013 11(1): Accessed on February 2016 at http://orthoportal.aaos.org/oko/article.aspx?article=OKO_PED044. Weiner, DS.(2004). Lower extremity developmental attitudes in infancy and early childhood. In K. Jones (Ass Ed.), Pediatric Orthopedics for Primary Care Physicians (pp.9-18). Cambridge University Press: Cambridge, UK. References Con’t… Weiner, DS.(2004). From toddler to adolescence. In K. Jones (Ass Ed.), Pediatric Othopedics for Primary Care Physicians (pp.67-69). Cambridge University Press: Cambridge, UK. Weiner, DS.(2004). Adolescence and puberty. In K. Jones (Ass Ed.), Pediatric Othopedics for Primary Care Physicians (pp.92-93). Cambridge University Press: Cambridge, UK. Thank You.