This patient is a 6-year-old boy presenting with bilateral genu valgum deformity of the knees. He has a history of vitamin D deficiency as a child. On examination, he walks with adduction of the knees such that his knees touch. Range of motion of the knees is normal. Imaging shows bilateral genu valgum deformity. Given the patient's young age and remaining growth potential, the treatment plan is to perform guided growth modulation using figure of 8 plates on both knees. This is the standard treatment for skeletally immature patients to gradually correct the deformity over time as the patient grows.

1. Guide: Dr. Jaswinder Sir
Presenter: Shubhanshu Ranjan Singh

2.  6 y old boy of Vitamin D Deficiency B/L Genu
Valgum having Tibiofemoral angle 16 degree
Intermalleolar distance of 11cm, Q angle of
15 degree with 0-140 ROM of knee joint
Bilaterally, Flexion test- femur deformity,
Blood Inv-ALP-317/S. Calcium 8.7/S. PO4- 5.2
Rasied eosinophils

3. More Medial

6.  Varun Kumar 6y/ M from Patna
 Gait- Adduction, patella centralised knee touching
knee
 C/O abonormal walking/ future concern
 Deformity first notice by her mother in 2019 and
progessive in nature for which patient got treatment
that time locally for 2 years and deformity get fixed.
 History of vitamin D deficiency (no previous record)
for which he took one weekly sachet and calcium
syrup
 No history of trauma/ infection/swelling/ burning
and pain in micturation/depression in between
thorax and abdomen

7.  Birth history- mother didn’t took iron and
calcium tablet during pregnancy, rest
uneventful and normal
 Developmental milestones attend
appropiately at his age group
 Family History- Mother h/o hypothyroidism
since 9 years on medication

8.  2019 diagnosed with vitamin D deficiency
for which she took tab calcium and vit d
sachet
 At age of 1 year left mid upper limb burn scar
mark present

9. 6 y/ M, FTNVD, C/o abnormal walking and
future concern of progression Mother noticed
deformity @ age 3 years age
Deformity progressive
No h/o trauma, infection or any swelling
F/H Mother hypothyroidsm since 9 years

10.  Height 115
 Weight 25
 General Exam- good nutrition, no skin lesion,
no polydactyly, no short stature spinal deformity
(for Rickets/ skeletal dysplasia/multiple hereditary
exostosis)
Gait- Adduction, Knee touch each other wide space ankle
(circumduction gait)
B/L Genu valgus no patellofemoral instability
ROM normal

11.  Valgum Alignment – Inward angulation of
extremity in coronal plane (Distal deviate
lateral wrt proximal)
 Valgum called be deformity
depends on
 Age
 Degree of Valgus – 7 degree normal upto 7
year

12.  Physiological- knock knee, apparent
(ligamentous laxity, rotational deformity, fat
thigh)
 Pathological- Idiopathic, trauma (malunion,
physeal arrest, metaphyseal tibial fracture, )
tumor, tumor like conditions (fibrous dysplesis,
enchondromatosis, MHE), Infection,
 Metabolic (Rickets, renal osteodystrophy)
 Inflammatory- RA
 Syndrome – Ellis Van Creveld syndrome
 Polio, Cerebral palsy
 Skeletal dysplasia- focal fibrocartilaginous
dysplasia, Osteogenic imperfecta

13.  Assymetric Involvement
 Short stature
 Limb length discrepancy

14.  Supine knee flexed touching each other both
feet medial malleoli approximated
 If defomity resolve than its femur otherwise
in tibia

15.  Tibio femoral angle- Clinical radiological
 Intermaleolar distance- Bet medial malleoli
<5/5-10/>10
standing erect wirth hips knee fully extended
and neutral rotation with patella both knee
touching each other
Marking ASIS, centre of patella centre of ankle,
malleoli

16.  Goniometer ?
 Rotational Profile Assesment
Foot Progression angle
Thigh foot angle
Medial hip rotation 70
Lateral hip rotation 30
Sole of foot (straight)
?femoral anteversion/ tibial torsion

17.  FPA-line of progession vs foot 10-15
external N
 Thigh foot axis- 20 IR +, ER –

18.  Apex @ Patella b/w ligamentum patellae and
extension of quadriceps resultant distally
 Patellar instability or not
 Measure – Standing/ Supine 30 flexed(patella
fixed into femoral condyle)(8-10M/15F)

19.  For ligamentous laxity

20.  Center of rotation of angulation- Apex of
deformity where osteotomy done in
orthoscanogram drawn.

23.  Imaging – Full length Xray of bilateral Lower
limbs, xray of wrist, knee
 Lab- Ca/P/PO4/S. VitD/ALP,CBC,ESR, PTYH U.
Ca/P
 Treatment-
Observation – Physiological
Acute Correction-Corrective Osteotomy
Gradual Correction-Guided growth
modulation/ six axis correction device or
ilizarov

24.  Mechanical Axis deviation ???? Stevans Zones
 Xray Wrist – Metapyseal splaying
/cupping/fraying/osteopenia/ Epiphyseal
thininng
 X-ray Ankle

25.  In our patient growth potential remaining
So,Guided growth modulation
Figure of 8 plate 16mm applied B/L
Now this is standard treatment for skeletally
immature
Removal?

26.  Iliotibial band contracture
Hip- abduction/ apparent lenthening/ true
shortening
ANKLE/FOOT- talipes equino varus
Leg- external tibial torsion
Knee- flexion contracture/ genu valgum
Hip- flexion/abduction/ER
Pelvic- pelvic obliquity
Spine- lumber lordosis/ scoliosis