Docstoc

Knock Knees and Flat Feet in Children

Document Sample
Knock Knees and Flat Feet in Children Powered By Docstoc
					Knock Knees and Flat Feet in
                   Children


     Dr Gillian Wilson
Knock Knees / Genu Valgum
          • 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.
                  Normal Development
• Most children are “bowlegged” from birth until
  around 3 years old, then become “knock kneed”
  until age 4 to 5, and straighten towards adult
  alignment by age 6 to 7.
                         Investigations 1
• 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.
                         Investigations2

• 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.
       Indicators of Serious Disease
• Pronounced
  asymmetry
• Short stature
• Other skeletal
  abnormalities
• Intermalleolar
  separation greater than
  3.5 inches
                               Aetiology
• Developmental
• Miscellaneous syndromes e.g Rickets (Alk
  Phos raised, with x-ray changes)
• Rare Genetic disorders e.g Cohen
  Syndrome
• Nutritional conditions e.g Vitamin C
  deficiency
• Autoimmune e.g RA
• Degenerative e.g OA
                             When to refer

•   Age > 7 with knock knee
•   Unilateral problem i.e Asymmetry of legs
•   Intermalleolar distance > 3.5 inches (9 cms)
•   Associated symptoms e.g Pain, Limp
                                Treatment

• No evidence that shoe modification, splints,
  or exercises affect condition
• No evidence to justify surgical intervention
  under 6 inches of intermalleolar separation.
• Surgical options:
      Medial epiphyseal stapling at 10 to 11
  years
      Corrective osteotomy at maturity.
                 Flat Feet / Pes Planus
• Arch of the foot is
  low. Medial arch is
  lost. There may be
  some valgus and
  eversion deformity of
  the foot.
                   Normal Development
• Flat feet are normal
  when learning to walk.
• Medial arch does not
  develop until 2nd / 3rd
  year of life.
• Normal arch functions
  as a shock absorber.
                            Investigation
• Ask patient to stand on
  tiptoes.
• If medial arch restores
  itself when standing
  on tiptoe or when foot
  is unloaded, no action
  is needed.
                              Presentations

• 2 Groups:

  – Pain free feet with normal mobility and muscle
    power.

  – Painful, stiff, hypermobile feet with abnormal
    muscle power i.e weak or spastic feet.
                    Causes of Flat Feet

• Loose - ligamented flat foot:
  – Commonest type.
  – Always bilateral.
  – Arch looks normal when non weight bearing /
    standing on tip toe.
  – Laxity can often be demonstrated in other
    joints.
            Rare Causes of Flat Feet

• Rocker bottom foot : Congenital vertical
  talus.
• Coalition Syndrome: Peroneal spastic flat
  foot.
• In both, subtalar joint movement is limited.
• In peroneal spastic flat foot, attempting to
  invert hind foot produces painful spasm of
  peroneal muscles.
               Rare Causes of Flat Feet

• May be part of a more generalized condition

  –   Severe joint laxity
  –   Cerebral Palsy
  –   Peroneal spastic flat foot
  –   Downs Syndrome
                                    Treatment

• No proven benefit from insoles, shoe
  modification, foot exercises.
• Spasmodic type :
  – Hindfoot fusion for pain relief.
  – Subtalar arthrodesis corrects deformity.
                                      Summary

• Knock Knees:
  – less than 3 inches intermalleolar separation is
    normal at any age.
  – Refer if age >7. Asymmetry, intermalleolar
    distance > 3.5 inches, short stature, pain or
    limp.
  – Remember normal developmental stages.
                                    Summary

• Flat Feet:
  – Test by standing patient on tip toes.
  – Refer if painful, stiff, hypermobile with
    abnormal muscle power.
  – Waiting time for Orthopaedic OPA at
    Birmingham Childrens Hospital is less than 4
    weeks, but > 13 weeks for physiotherapy.

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:451
posted:4/7/2010
language:English
pages:19