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Knee and Foot Deformities in pediatrics.pdf
- 1. Congenital Knee and Foot Deformities Dr. Radwa Said
- 3. Classification Malalignment (angular) knee deformities Genu varum & Genu valgum Tibiofemoral angle Intercondylar & Intermalleolar distances Genu recurvatum Rotational deformities Tibial torsion Thigh-foot angle Foot progression angle Femoral anteversion/retrov ersion Femoral angle Craig’s test
- 4. Genu varum &Genu valgum
- 7. Physiologic angular knee deformities Pathologic angular knee deformities Evaluation - Symmetrical - Mild – moderate - Regressive - Generalized - Expected for age - Asymmetrical - Severe - Progressive - Localized - Not expected for age Causes - Normal – for age - Exaggerated § Overweight § Early wt. bearing § Use of walker? - Rickets - Endocrine disturbance - Metabolic disease - Injury to epiphyseal plate (Infection /Trauma) - Idiopathic
- 9. - Mean IC distance is 0.2 cm at 1 - 10 years of age. - The greatest IM distances of 2.5 cm and 2.2 cm were noted between the ages of 2 and 4 years.
- 10. Management –Most children with knock knees and bowlegs do not require any treatment. –Bracing, connective bars and orthotics might be prescribed in some cases. –Surgical osteotomy may be considered in severe, non-resolving cases.
- 11. Genu Recutrvatum 1. Dynamic knee recurvatum is defined as hyperextension of the knee during the stance period of the gait cycle and this impairment is neurologically based. – - quadriceps weakness – - ankle planter flexor spasticity – - heel cord contracture – - quadriceps spasticity – -gastrosoleus weakness 2.The structural genu recurvatum can be congenital due to abnormal intra- uterine posture.
- 12. Causes – A defined disorder of the connective tissues – Laxity of the knee ligaments – Ligament and joint capsule injuries – Irregular alignment of the femur and tibia – Lower limb discrepancy – Congenital defect Management – Knee support/brace as the Swedish knee cage or ground reaction force orthosis. – Strengthening exercise to weak muscles. – Kinesiotaping. – Tendon transfer operations in severe cases. Complications – Popliteal pain – Instability – Decreased mobility – Increased risk of ACL injury
- 13. TibialTorsion – -Toe-in andToe-out – - Normally, lateral rotation of the tibia increases from 5° at birth to 15° at maturity. – - Surgical management is avoided until > 10 years. – - If untreated = patellofemoral syndrome
- 14. Thigh-foot angle Foot progression angle
- 15. Femoral Anteversion/ Retroversion – It is more common in girls. – The normal angle at birth is 30-40 degrees anteversion. – The most common onset age is 3-5 years.
- 16. Femoral Anteversion Femoral Retroversion Clinical signs - Standing appearance: “kissing patellae” - Clumsy gait and awkward running appearance “egg-beater” - In-toeing feet “pigeon-toed” - Inverted W sitting position - Out-toeing “Charlie Chaplin walk” - Hip internal rotation decreased - Hip external rotation increased Causes - Infants: congenital hip dysplasia, cerebral palsy or other neuromuscular disorder - Toddlers: Legg-Calve-Perthes disease - Teen and pre-teen: slipped capital femoral epiphysis - Typically related to hip contracture from intrauterine positioning Complications - Chondromalacia patellae (patellofemoral syndrome) - Slipped capital femoral epiphysis (if persists >age 8 years old) - Leg stress fracture
- 17. - Normal hip: Femoral head is slightly anterior to femoral neck. - Anteverted hip: Femoral head is significantly anterior to femoral neck. § Associated with toeing-in. § Increased range for hip internal rotation while there is limited external rotation. - Retroverted hip: § Femoral head is posterior to femoral neck. § Associated with toeing-out § Increased range for hip external rotation while there is limited internal rotation.
- 19. –Spontaneously resolves to normal range in 80% of the cases by the age of 8 years. –Avoid non-helpful measures – Shoe modifications – Night splints – Dennis-Browne splint – Twister cables – Passive stretching exercises –Femoral rotational osteotomy indications – Comorbid neuromuscular disease (e.g. cerebral palsy) – Severe functional disability at age > 8 (0.1% of cases) – Femoral anteversion >50 degrees – Internal rotation >80 degrees Management:
- 21. Feature Newborn Adult Arch Flatter, less defined Well defined Typical ROM Greater ROM Lesser ROM End Point of ROM Soft, difficult to appreciate Firm, well defined Amount of subcutaneous fat tissue Greater Lesser Differences between newborn and adult foot
- 22. Types: • Bleck’s test for flexibility • Bleck’s test for appearance (Heel bisector method) • V-finger test Metatarsus adductus Clubfoot –Talipes equinovarus Talipes Calcaneovalgus Flatfoot
- 23. Metatarsus Adductus – 1-2:1000 live births – It is a transverse plane deformity – Deformity in Lisfranc's (tarsometatarsal) joints. – The forefoot is adducted with respect to the hindfoot. – Described as bean/kidney shaped.
- 24. Causes – unknown. – family history. – intrauterine positioning. – sleeping position of the baby (on stomach). – Absence of a medial cuneiform/ abnormal growth of medial cuneiform – Abnormal muscle position – Arrest of normal ontologic rotation of the foot
- 25. Bleck’s test for appearance (Heel bisector method)
- 26. V-FingerTest Bleck’s test for flexibility
- 27. Type Presentation Treatment I Flexible, with abduction beyond the midline of the heel bisector Actively corrects with stroking or tickling the lateral foot II Partly flexible, with abduction only to the midline Corrects only with passive stretching III Inflexible, rigid with no abduction possible Cannot be passively corrected (Casts or Surgery Bleck’s test for metatarsus adductus for flexibility
- 28. Reverse last shoes Wheaton ankle foot orthosis Bebax ‘‘boot’
- 29. Clubfoot –AKACongenitalTalipes Equinovarus –Malalignment of soft and bony structures. –Soles of the feet face each other.
- 30. Main Four clubfoot deformities: 1. Cavus in the midfoot 2. Forefoot Adductus movement 3.Varus of the hindfoot 4. Equinus 1 2 3 4
- 31. Causes of Clubfoot 1. Idiopathic clubfoot – the most common type of clubfoot and is present at birth. – 1:1000 babies, with half involving only one foot. – boys:girls = 2:1 2. Neurogenic clubfoot 3. Syndromic clubfoot – arthrogryposis, constriction band syndrome, tibial hemimelia and diastrophic dwarfism.
- 32. Signs and Symptoms –Heel inversion with internal rotation –Kidney shape: medial foot concave, lateral foot convex and foot inverted. –Plantar flexion with inability of dorsiflexion –Very tight heel cord. –Leg internal rotation. –Muscular changes: – Muscle weakness due to the continuous stretch mainly for the proneus tertius. – Muscle tightness due to their continuous contraction mainly for the tibialis posterior.
- 34. Treatment –Ponseti method: – Casting – Achilles tendon release – Bracing: Dennis-Browne splint –French method: (Daily for 2 months- 3/week for 4 months) – Realignment – Taping – Log-term home exercises – Night splinting –Surgery
- 35. TalipesCalcaneovalgus – Due to malpositioning intrauterine – The forefoot is abducted and dorsiflexed, and the heel with calcaneus valgus – The bones are normal – The foot evertors and dorsiflexors may be tight (mainly the proneus tertius) – The foot invertors and plantarflexors may be stretched and/or weak (mainly the tibialis posterior).
- 36. Treatment: –Mostly resolves spontaneously in the first year of walking. –Gentle stretching by caregivers. –If persists: –Exercises (stretching and strengthening) –Corrective shoes –Splinting: – Firm, high-top lace up shoes – Retention taping – Molded AFO –Serial casting in severe deformity
- 37. Flatfoot – Structural problem – The toddler may pronate the foot for stability – Variant of ligamentous laxity (no treatment) – Also called: – Pes planovalgus – Fallen arches – Pronation of feet – Pes planus
- 38. –It can be: Flexible: conservative ttt Rigid: (rare in children ) Surgical intervention
- 39. Treatment 1. Conservative mainly for flexible flatfoot –Stretching exercises (Achilles tendon) –Proper shoe wear –Arch supports (orthotic devices): –Medial wedge. –UCBL orthosis. –Heel seat cup with or without medial posting.
- 41. 2. Surgery mainly for rigid flatfoot –Types: –Tendon repair –Fuse joints –Postoperative treatment according to the type of surgery: –Strengthening exercises –Stretching exercises for foot muscles. –Mobilization.