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Knock Knees _ Pigeon Toes Rotational Deformities ... - SBH Peds Res

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					Knock Knees & Pigeon Toes
        Rotational and Angular
        Deformities in Children



   February 9th 2012
 Lauren Cochran MD
To-Do

•   Search PREP for more questions?
•   Email Myra to ensure no Mac-to-PC glitches?
•   Summary slide / reasons to refer
•   Clean up references slide
Objectives

•   To review the common causes of intoeing &
    outtoeing in children
•   To describe the progression of normal physiologic
    alignment over time & how to evaluate a child with
    genu varum or genu valgum
•   To describe the physical examination techniques
    used in assessing rotational and angular deformities
•   To review indications for imaging and/or
    Orthopedics referral
    4 Categories
    of Lower Extremity Problems
•   Rotational Deformities
    •   Intoeing (“Pigeon Toes”)
    •   Outtoeing
•   Angular Deformities
    •   Genu Varum (“Bow legs”)
    •   Genu Valgum (“Knock knees”)
•   Foot Deformities (e.g., clubfoot & pes planus)
•   Hip Disorders (e.g., DDH & SCFE)
Intoeing
Intoeing

•   Often raised as concern by parents
•   Sometimes associated with tripping/falling
•   Possible origin:
    •   Foot = metatarsus adductus
    •   Between knee & ankle = internal tibial torsion
    •   Between hip & knee = medial femoral torsion
Metatarsus Adductus
Metatarsus Adductus (MTA)

•   “Packaging Defect” (1st born children at higher risk)
•   Tarsal & phalangeal bones angled toward midline
•   + convex lateral curvature of foot
•   + medial instep crease
•   Evaluation includes:
    •   Degree of adduction (heel bisector)
    •   Degree of flexibility
Metatarsus Adductus
Heel Bisectors
Heel Bisectors
Metatarsus Adductus

•   Heel bisector (quantifies degree of adduction):
    •   Normal: between 2nd/3rd toes
    •   Mild MTA: 3rd toe
    •   Moderate MTA: 3rd/4th toe
    •   Severe MTA: 4th/5th toe
Metatarsus Adductus

•   Degree of Flexibility ® determines need for
    treatment!
    •   Actively correctable: tickle foot on lateral
        border ® no treatment required
    •   Passively correctable: gentle lateral pressure
        to 1st metatarsal head ® “stretching” 10sec
        per foot x5 with each diaper change ®
        REFER if not corrected by 4-6mo
    •   Rigid: REFER for possible casting/bracing
Metatarsus Adductus
Wheaton Brace
Metatarsus Adductus & DDH?
•   Previously reported association between
    MTA & DDH ® now disputed
•   Still warrants careful hip exam
What Metatarsus Adductus
is NOT…
Clubfoot
•   aka talipes equinovarus
•   Constellation of metatarsus adductus PLUS:
    •   Equinus positioning = inability to dorsiflex foot
        (shortening of gastroc/soleus & tendon)
    •   Hindfoot varus (supination)
    •   Inversion of the forefoot
•   Warrants early referral to Orthopedist
•   Famous athletes with clubfoot: Troy Aikman,
    Kristi Yamaguchi, Mia Hamm
Clubfoot
Where’s the Intoeing Origin?
Internal Tibial Torsion
•   Origin of intoeing between knee & ankle
•   Most common intoeing etiology for children less
    than 3yrs
•   “Packaging defect” ® present from birth but often
    noticed only when child begins to stand/walk
•   Almost never requires treatment:
    •   Most cases gradually resolve by age 2-3yrs
    •   REFER if persists beyond age 6
Where’s the Intoeing Origin?
Medial Femoral Torsion
•   Origin of intoeing between hip & knee
•   aka “femoral anteversion” but to a pathologic degree
    (> 60-65°)
•   Most common intoeing etiology for children
    older than 3yrs
•   Associated with “W sitting position” (unclear effect
    on progression/outcome)
•   “Egg beater” or “windmill” running pattern
•   Almost always corrects gradually by age 10
Medial Femoral Torsion
W Sitting Position
“Kissing Patellae”
Tibial Torsion vs.
Femoral Torsion
Intoeing: H&P
•   HPI: onset, progression, pain, disability, previous
    evaluation/treatment

•   Development: particularly gross motor milestones
    including walking

•   General screening exam:
    • Growth parameters
    • Evaluation for DDH (Ortolani/Barlow, Galeazzi, skin
      fold asymmetry)
    • Basic neurological exam (UE+LE reflexes, ankle
      clonus, heel/toe walking)
Intoeing: “Rotational Profile”

1.   Foot progression angle
2.   Heel bisector
3.   Thigh foot angle
4.   Hip rotation
Foot Progression Angle
Foot Progression Angle
•   Normal = -5 to +20°
•   Mild intoeing: -5 to -10°
•   Moderate intoeing: -10 to -15°
•   Severe intoeing: > -15°
Heel Bisector
The V-Finger Test
    Thigh Foot Angle
•   Patient prone with knees
    flexed to 90 degrees + natural
    foot position

•   Line down center of thigh to
    heel bisector

•   Normal = 0 to +10-15°

•   Negative = internal tibial
    torsion
Thigh Foot Angle
Thigh Foot Angle
Thigh Foot Angle
Hip Rotation

•   Child is prone with knees flexed to 90°
•   Assess both sides simultaneously
•   Normal (varies by age): ~-45 to +45°
Hip Rotation
Hip Rotation

•   If asymmetric ® get XR (AP pelvis AP) to
    evaluate for DDH or other hip problem

•   Increased internal rotation > 60-65° = femoral
    anteversion
    •   > 80 ° = moderate
    •   > 90 ° = severe
Hip Rotation
Ortho Referrals for Intoeing
Benefits of Intoeing?
l   Some evidence that persistent intoeing is actually
    beneficial for some sports that require quick
    directional shifts:

    l   Tennis

    l   Basketball

    l   Soccer

    l   Etc.
Outtoeing
Outtoeing
•   Much less common than intoeing
•   Origin:
    •   Foot: Calcaneovalgus deformity
    •   Between knee & ankle: External tibial torsion
    •   Between hip & knee: Femoral retroversion
    •   Hip: External rotation contracture
•   Most cases resolve within first 1-2yrs of
    ambulation
Calcaneovalgus Foot

•   Hyperdorsiflexion of foot
•   Abduction of forefoot
•   Forefoot often rests on anterior surface of leg
•   REFER for casting if foot cannot be plantar-
    flexed below neutral
Calcaneovalgus Foot
Calcaneovalgus Foot
External Tibial Torsion

•   Thigh foot angle > +20°
•   Possible compensation for
    femoral anteversion
•   REFER for severe cases
    (> 40°)
•   REFER if persistent > age
    6yrs
External Tibial Torsion
Femoral Retroversion

•   Rare cause of outtoeing
•   Characterized by increased external rotation
    (and decreased internal rotation) at the hip
•   Associated with obesity
•   Possibly associated with osteoarthritis, stress
    fractures, and SCFE
External Rotation Contracture

•   Normal intrauterine position = flexed and
    externally rotated hips
•   May result in external rotation contracture
•   Usually resolves spontaneously by 12
    months of age (or when child begins to walk)
Angular Deformities
Genu Varum
Genu Valgum
Mnemonics


•   Varus = “vAIRus” (more air between the legs)



•   Valgus ®Gum (knees stick together)
Normal Progression
Normal Progression
Normal Progression

•   Birth: genu varum ® improves by age 2

•   Age 3: genu valgum ® improves by age 6-7

•   Can monitor over time with distance between
    •   knees w/ ankles together (genu varum)
    •   ankles w/ knees together (genu valgum)
Monitoring Varus/Valgus
Deformities
Measurement: Genu _____
When to Work Up
and/or Refer?

•   Asymmetry (or Unilateral)

•   Associated with pain

•   Associated with short stature

•   Associated with poor nutrition

•   Progression defers from expected
NOT Physiologic Genu Varum…
Blount Disease
•   Pathologic varus deformity due to disruption of normal
    cartilage at the proximal tibial physis (medial aspect)
•   Infantile & adolescent types
•   Differentiate from physiologic genu varum based on:
    •   Atypical age/progression
    •   Asymmetry
    •   “Lateral thrust” with ambulation
    •   Focal angulation at proximal tibia
•   Risk factors: early walking, obesity, African American
    heritage, + family history

•   If any doubt ® get an x-ray!
Blount Disease
Blount Disease
NOT Physiologic Genu Valgum…
Rickets
•   Deficient growth plate mineralization associated
    with insufficient Ca/Phos
•   Differentiate from physiologic genu valgum or
    genu varum based on:
    •   Atypical age/progression
    •   Short stature (<10%ile for age)
    •   Poor nutrition
    •   Associated findings like frontal bossing, craniotabes,
        costochondral swelling (aka rachitic rosary), wrist
        widening
      PREP Question #1
     You are seeing a child born at home for the first time at
     his 2-week health supervision visit. The mother’s
     primary concern is the shape of her son’s foot. The
     best maneuver to differentiate metatarsus adductus
     from clubfoot is to:

a)     Abduct the forefoot
b)     Compare the appearance of the feet
c)     Dorsiflex the ankle
d)     Look for a transverse crease on the plantar surface
e)     Tickle along the lateral aspect of the foot
      PREP Question #1
     You are seeing a child born at home for the first time at
     his 2-week health supervision visit. The mother’s
     primary concern is the shape of her son’s foot. The
     best maneuver to differentiate metatarsus adductus
     from clubfoot is to:

a)     Abduct the forefoot
b)     Compare the appearance of the feet
c)     Dorsiflex the ankle
d)     Look for a transverse crease on the plantar surface
e)     Tickle along the lateral aspect of the foot
      PREP Question #2
     A 5-year-old girl continues to “intoe,” although this has
     no impact on her level of activity or function and she is
     otherwise healthy. The most likely cause for this
     condition is:

a)     Femoral anteversion
b)     Malignant malalignment syndrome
c)     Metatarsus adductus
d)     Talipes equinovarus
e)     Tibial torsion
      PREP Question #2
     A 5-year-old girl continues to “intoe,” although this has
     no impact on her level of activity or function and she is
     otherwise healthy. The most likely cause for this
     condition is:

a)     Femoral anteversion
b)     Malignant malalignment syndrome
c)     Metatarsus adductus
d)     Talipes equinovarus
e)     Tibial torsion
      PREP Question #3
     A 3-year old girl is “bowlegged,” and because her
     mother is certain that it is getting worse, she requests
     an immediate radiograph. The finding that would best
     support the parent’s request is:

a)     A “bowlegged” appearance at birth
b)     A normal sequence of achieving motor milestones
c)     A symmetric appearance to the lower extremities
d)     The absence of pain in the lower extremities
e)     The natural history of angular deformities in the lower
       extremities
      PREP Question #3
     A 3-year old girl is “bowlegged,” and because her
     mother is certain that it is getting worse, she requests
     an immediate radiograph. The finding that would best
     support the parent’s request is:

a)     A “bowlegged” appearance at birth
b)     A normal sequence of achieving motor milestones
c)     A symmetric appearance to the lower extremities
d)     The absence of pain in the lower extremities
e)     The natural history of angular deformities in the lower
       extremities
      PREP Question #4
     Which of the following is a characteristic of metatarsus
     adductus?

a)     Hindfoot equinus deformity
b)     Hindfoot varus deformity
c)     Hindfoot valgus deformity
d)     Lateral deviation of the forefoot
e)     Medial crease of the instep
      PREP Question #4
     Which of the following is a characteristic of metatarsus
     adductus?

a)     Hindfoot equinus deformity
b)     Hindfoot varus deformity
c)     Hindfoot valgus deformity
d)     Lateral deviation of the forefoot
e)     Medial crease of the instep
      PREP Question #5
     A 7-year-old girl is brought to your clinic for in-toeing that has
     persisted since she was about 3 years of age. She frequently sits
     in a “W” pattern on the floor while watching television. Physical
     examination reveals markedly increased internal rotation of the
     hips while prone. Which of the following statements regarding his
     girl’s condition is true?

a)      Computed tomography scan is indicated to confirm the diagnosis
b)      She is at high risk of developing osteoarthritis of the hips later in life
c)      She likely will be able to participate in spots without difficulty
d)      She should begin wearing medial pads in her shoes to correct the in
        -toeing
e)      The in-toeing likely is due to a dietary deficiency
      PREP Question #5
     A 7-year-old girl is brought to your clinic for intoeing that has
     persisted since she was about 3 years of age. She frequently sits
     in a “W” pattern on the floor while watching television. Physical
     examination reveals markedly increased internal rotation of the
     hips while prone. Which of the following statements regarding his
     girl’s condition is true?

a)      Computed tomography scan is indicated to confirm the diagnosis
b)      She is at high risk of developing osteoarthritis of the hips later in life
c)      She likely will be able to participate in spots without difficulty
d)      She should begin wearing medial pads in her shoes to correct the in
        -toeing
e)      The in-toeing likely is due to a dietary deficiency
      PREP Question #6
     You are evaluating an 18-month-old boy whose mother thinks he is
     “pigeon-toed”. He began walking at 12 months and walks well, but
     in-toeing is noted on examination. Range of motion at the hips,
     knees, and ankles is normal. Which of the following is the most
     likely cause of his gait disturbance?

a)      Blount disease
b)      Femoral anteversion
c)      Internal tibial torsion
d)      Metatarsus adductus
e)      Pes planus
      PREP Question #6
     You are evaluating an 18-month-old boy whose mother thinks he is
     “pigeon-toed”. He began walking at 12 months and walks well, but
     in-toeing is noted on examination. Range of motion at the hips,
     knees, and ankles is normal. Which of the following is the most
     likely cause of his gait disturbance?

a)      Blount disease
b)      Femoral anteversion
c)      Internal tibial torsion
d)      Metatarsus adductus
e)      Pes planus
Summary?
•   Most intoeing, outtoeing, knock knees, and
    bow legs are NORMAL & require only
    reassurance and observation
•   BUT… don’t want to miss clubfoot, DDH, CP,
    rickets, Blount disease
•   Systemic approach to exam
Reasons to Refer
•    Rigid metatarsus adductus, which may require serial casting (refer to pediatric
    orthopedic surgeon or an orthopedic surgeon with expertise in rotational
    problems)
•      Unilateral or asymmetric in-toeing associated with clinical findings suggestive
    of neurologic disorder (refer to a pediatric orthopedic surgeon, pediatric
    neurologist, or physical medicine and rehabilitation specialist)
•      Children ≥8 years with activity limiting or cosmetically unacceptable in-toeing
    due to internal tibial torsion (may be candidates for derotational osteotomy; refer
    to an orthopedic surgeon with expertise in rotational problems)
•      Children ≥11 years with activity limiting or cosmetically unacceptable in-toeing
    due to increased femoral anteversion (may be candidates for derotational
    osteotomy; refer to an orthopedic surgeon with expertise in rotational problems)
•      In-toeing that does not follow the expected course (eg, increased femoral
    anteversion that progresses after age five or six years) [16] (refer to pediatric
    orthopedic surgeon or an orthopedic surgeon with expertise in rotational
    problems)
References
•   Scherl SA. Common lower extremity problems in
    children. Pediatr Rev. 2004;25(2):52-62.
•   Smith BG. Lower extremity disorders in children and
    adolescents. Pediatr Rev. 2009;30(8):287-301.
•   Grottkau BE. Intoeing, outtoeing, and limping:
    making sense of common pediatric gait
    abnormalities.
•   UpToDate: Lower extremity positional deformations;
    Approach to the child with in-toeing; Approach to the
    child with outtoeing; Approach to the child with bow
    legs
Thank You!

				
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