dr. Zairin Noor Helmi, SpOT.(K).MM.FICS

Version: normal twisting of long bone on its anatomic longitudinal axis

Torsion: Abnormal / deformity, version beyond (+or-)2 SD Reference axis: a line joining designated bony landmarks at the end of a long bone

Anteversion: the prox ref axis is lat twisted relative to the distal (X-retroversion(

4-5/52 Paddle bud appear on the anterolateral wall.

8/52 toes apposed praying feet.

Differential growth of ectoderm and mesoderm medial rotation of the L.L bringing the big toe to the midline i.e. plantegrade feet.

Intrauterine mechanical moldinglat. femoral and med. tibial torsion. Lat. Femoral torsion creates the normal femoral antitorsion angleaverage 32 at one yeardecline to 16 at 16 years

After birth the tibia start to rotate lat. reaching 15 at skeletal maturity.

Angle of line joining head centre - shaft center and line joining post. points of the femoral condyles

Avg.35 at birth

8 and 14 After 8 very slow regression

ClinicalProne with 90 knee flexion Feel midpoint of greater troch.it should be the most lateral In antitorsion it is post.Rotate the hip medially until the gr. troch. is most lat.degree of antitorsionLat. hip rotationMed. hip rotation

CTVery accurate Done if surgery is Planned

Coast, radiation

Generally in-toeing(good boy) is usually associated with normal developmental causes (metatarsus varus, tibiofibular med. rotation, femoral anteversion)

Out-toeing(bad boy) is more with pathologic causes( DDH, coxa vara, SCFE, CP)

In the infant: metatarsus varus In 2nd year : excessive med. tibiofibular torsion

3 years + : Femoral antetorsion, evidenced by hip med. rotation and restricred lat. rotation

Protective in-toeingIn developmental genu valgum and flat foot (flexible pes planovalgus)Here the child is shifting the center of gravity to the foot center

Neuromuscular (all ages)Spasticity of ant and/or post tibial muscles,hip med rotators and hip adductors

Relative fibular overgrowth, seen in cong longitudinal deficiency of the tibia and in Achondroplasia

Tarsal coalition (rigid flat foot), spastic varus posture of the foot

Intrauterine fetal posturecontracture of the hips lat rotators, masking hip anteversion, by time such contracture resolve

Missed DDHCoxa vara, due to associated femoral retroversion (the rare primary hip retroversion doesnt correct with growth and may lead to O.A.)

SCFE, adolescent + obesity Cong longitudinal deficiency of the fibulaMissed vertical talus

Bowlegs in new born and infantWith medial tibial torsion = fetal position

Becomes straight by 18/12

By 2 or 3 genu valgus develop (avg. 12)

By 7 spontaneous correctionTo the normal of adult valgus ( 8 and 7)

Worried parents

About 3 years old +bow legs +mild lateral thrust at the knees + in-toeing

Assessment: - History - etiologic factors

Height

See ( front, back & side)bowlegs is by lat. Hip rotation +/- medial tibial torsion+/- knee flexion

Measure IC distance, lateral thigh-leg angle, center of gravity

Site of varus

In ligamentous laxity notelat.Widening Of knee joints In Blount angulation at med.tib metaphysis

In coxa vara ,angulation at the neck shaft levelIn cong. Pseudarthrosis of tibia,the angulation is in the distal

Gait: intoeing, lateral thrust-the fibular head and upper tibia shift laterally in Blount due to laxity and incompetence of the lat. Collat. Lig.StabilitySymmetryLevel of fibular head, normally at the level of the upper tibial growth plate, while it is proximal in Blount, cong.longitudinal dificiency of the tibia and achondroplasia

3 years and older Getting worseAbnormal site of angulationLarge physis and epiphysisHistory taruma, infection, possible metal intoxication(lead or floride)Metaphysial/diaphysial angle 18

Physis, thick and frayed in rickets

In physiologic genu varum no intrinsic bone disease, gentle curve, medial cortices thickening, horizontal joit lines of the knee & ankle are tilted medially

Legs are bowed inwards in the standing position. Bowing occurs at or around the knee. On standing with knees together, the feet are far apart.

Most children are bowlegged from birth until around3 years old, then become knock kneed until age 4 to 5, and straighten towards adult alignment by age 6 to 7.

Measurement of intermalleolar distance. i.e distance between two malleoli when the knees are gently touching with legs in adduction.Up to 3 and a half inches (9 centimeters) with child lying down is acceptable. 75% of children aged 2 - 4 years have some degree of intermalleolar separation.

Intermalleolar separation under 3 inches is normal at any age. Periodic observation and measurement if less than 3.5 inches. If > 3.5 inches, need AP X-Ray with both legs on same film for knee deformity, hip and ankle joints and view of both long bones.

Pronounced asymmetryShort statureOther skeletal abnormalitiesIntermalleolar separation greater than 3.5 inches

DevelopmentalMiscellaneous syndromes e.g Rickets (Alk Phos raised, with x-ray changes)Rare Genetic disorders e.g Cohen SyndromeNutritional conditions e.g Vitamin C deficiencyAutoimmune e.g RADegenerative e.g OA

Age > 7 with knock kneeUnilateral problem i.e Asymmetry of legsIntermalleolar distance > 3.5 inches (9 cms)Associated symptoms e.g Pain, Limp

No evidence that shoe modification, splints, or exercises affect conditionNo evidence to justify surgical intervention under 6 inches of intermalleolar separation.Surgical options:Medial epiphyseal stapling at 10 to 11 yearsCorrective osteotomy at maturity.

Flat foot(Pes Planus) Absent or depressed longitudinal arch

Pes Planovalgus: associated hindfoot eversion, forefoot abd and everted

Flexible

Developmental the most common Hypermobile (ligamentous hyperlaxity; Ehlers-Donlos, Marfan, Down)Neurogenic( rare and usually cause the reverse-Pes Cavus)

Rigid, very rare

Congenital (Tarsal coalition,Vertical talus)Aquired) inflammatory)

Physiologic flat foot is NORMAL up to 6 years ( the foot fat pad shrinks and ligaments become taut)

If there is pain look for other pathologic conditions

Foot orthoses not a ttt but relief strain, improve gait pattern,even shoe wear, may prevent structural tarsal deformities Surgery- very rare, not before 12 years

Stick to basicsHistoryLook, feel, moveMost of these common presentation needs assurance and follow upSurgery is rarely needed

***************History= family history any ttt check parents &siblings-if short ?bone dysplasia. When did it appear? =*Short = rickets or dysplasiaGentle bowing involving the femur-distal and tibia-junc.of middle and proximal s****************Surgery= achilles lengthening, medial displacement calcaneal osteotomy, lat column lengthening.**