Limb deformity, different types, evaluation, treatment

1. EXAMINATION OF A LIMB
DEFORMITY AND PLANNING
Moderator- Dr. Bipul Borthalur
Professor & HOD, Dept of Orthpaedics, SMCH
Presented by- Dr. Ujjal Rajnbangshi
PGT, Dept of Orthopaedics, SMCH

2. LEARNING OBJECTIVES
• Definition of deformity
• Evaluation of various types of deformity
• Evaluation of deformity by various methods
• Various treatment modalities for corrections of deformities

3. DEFORMITY
• Definition:
• It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical
position.

4. DEFORMITY
• Described as abnormalities of
• Length
• Angulation
• Rotation
• Translation
• The location, magnitude, and direction of the deformity complete the characterization of a bony
deformity

5. DEFORMITY
• Evaluation of Deformity :
• Clinical Examination
• Radiological Examination
• X-rays
• CT Scans

6. EVALUATION OF DEFORMITY : X RAYS
Radiographs of the lower limbs:
• Long films (51 Inches)
• Frontal plane (AP view)(Patella Forward)
Sagittal plane (Lateral view)

7. EVALUATION OF DEFORMITY : X RAYS
Radiographs of the lower limbs:
• Long films (51 Inches)
• Frontal plane (AP view)(Patella Forward)
Sagittal plane (Lateral view)

8. EVALUATION OF DEFORMITY : X RAYS
Radiographs of the lower limbs:
• Long films (51 Inches)
• Frontal plane (AP view)(Patella Forward)
Sagittal plane (Lateral view)

9. EVALUATION OF DEFORMITY : X RAYS
• Radiographs of the lower limbs:
• Long films (51 Inches)
• Frontal plane (AP view)(Patella Forward)
Sagittal plane (Lateral view)
Square the Pelvis in case of Limb Length
discrepancy

10. DEFORMITY
• Evaluation of Deformity : CT Scan
• CT Scanogram

11. DEFORMITY
• AXIS
• Each long bone has 2 axis :-
 Mechanical axis
 Anatomical axis.

12. MECHANICAL AXIS
• Straight line connecting the joint center points of the proximal & distal joints.
• Its always a straight line whether in frontal or sagittal plane.

13. ANATOMICAL AXIS
• it is mid diaphyseal line.
• In a normal bone, the anatomic axis is a single straight line.
• In a malunited bone with angulation, each bony segment can
be defined by its own anatomic axis

14. LIMB ALIGNMENT
• It involves assessment of the frontal plane mechanical
axis of the entire limb rather than single bones

15. LIMB ALIGNMENT
• Mechanical axis deviation (MAD) is measured as the
distance from the knee joint center to the line connecting
the joint centers of the hip and ankle.
• Normally, 1 mm to 15 mm medial to the knee joint center.

16. JOINT ORIENTATION LINES
• Line representing the orientation of a joint in a particular plane /projection.
• ANKLE
Frontal : along the flat subchondral line of tibial plafond.
Sagittal : line from distal tip of posterior lip to tip of anterior lip.

17. JOINT ORIENTATION LINES
Knee
• FRONTAL : along the subchondral line of tibial plateau.
• Line tangential to most distal point on the femoral condyle.
• SAGITTAL : along flat subchondral line of plateau.
• Line connecting 2 points where the condyles meet the
metaphysis.

18. JOINT ORIENTATION LINES
• Hip:
• FRONTAL : from tip of greater trochanter to center of femoral head.
• Also from the centre of femoral head along the anatomical axis of the
femoral neck

19. JOINT ORIENTATION ANGLES:
The relation between anatomical or mechanical axes and the joint
orientation lines can be referred to as joint orientation angles.

20. CENTRE OF ROTATION OF ANGULATION (CORA)
• The intersection of the proximal axis and distal axis of a
deformed bone is called the CORA , which is the point about
which a deformity may be rotated to achieve correction.
• Either Anatomical or Mechanical axis can be used to
identify CORA.

21. CENTRE OF ROTATION OF ANGULATION (CORA)
• Correction of angulation by rotating the bone around a point on the line that bisects the angle of
the CORA (the “bisector”) ensures realignment of the anatomic and mechanical axes without
introducing an iatrogenic translational deformity.
• All points that lie on the bisector can be considered to be CORAs because angulation about these
points will result in realignment of the deformed bone.

22. EVALUATION OF THE VARIOUS DEFORMITY TYPES
• Length
 Clinically
 Radiologically

23. EVALUATION OF THE VARIOUS DEFORMITY TYPES
• Angulation
• Characterized by Magnitude and direction of apex .
• Identification of the CORA is key in characterizing angular deformities and planning their
correction.
• Angulation can be in Frontal plane or in sagittal plane or in oblique plane.

24. EVALUATION OF THE VARIOUS DEFORMITY TYPES
• Angulation

25. EVALUATION OF THE VARIOUS DEFORMITY TYPES
• Rotation
Clinically
 Radiologically
• Axial CT scans
• Characterized by
• Position
• Magnitude

26. EVALUATION OF THE VARIOUS DEFORMITY TYPES
• Translation :
• Clinically
• Radiologically
• Axial CT scans
• Characterized by
• Plane
• Direction
• Magnitude
• Level

27. TREATMENT
• Following evaluation, the deformity is characterized by its
• type (length, angulation, rotational, translational, or combined),
• the direction of the apex (anterior, lateral, posterolateral, etc.),
• the orientation plane,
• It’s magnitude,
• and the level of the CORA

28. OSTEOTOMIES
• An osteotomy is used to separate the deformed bone segments to allow realignment of the
anatomic and mechanical axes.
• The ability of an osteotomy to restore alignment depends on -
• location of the CORA
• Axis about which correction is performed (the correction axis),
• Location of the osteotomy

29. RESULTS WHEN USING OSTEOTOMY
A. The CORA, the correction axis, and the osteotomy all lie
at the same location; the bone realigns through angulation alone,
without translation.
B. The CORA and the correction axis lie in the same location but
the osteotomy is proximal or distal to that location; the bone realigns
through both angulation and translation.
C. The CORA lies at one location and the correction axis and the
osteotomy lie in a different location; correction of angulation results
in an iatrogenic translational deformity.

30. WEDGE OSTEOTOMY
• The type of wedge osteotomy is determined by the location of the osteotomy relative to the
locations of the CORA and the correction axis.

31. WEDGE OSTEOTOMY
A. Opening wedge osteotomy
• The CORA and correction axis lie on the cortex on the convex
side of the deformity.
• The cortex on the concave side of the deformity is distracted to
restore alignment, opening an empty wedge that traverses the
diameter of the bone.
• Opening wedge osteotomy increases final bone length.

32. WEDGE OSTEOTOMY
B. Neutral wedge osteotomy:
• The CORA and correction axis lie in the middle of the bone.
• The concave side cortex is distracted and the convex side
cortex is compressed.
• A bone wedge is removed from the convex side.
• Neutral wedge osteotomy has no effect on final bone length.

33. WEDGE OSTEOTOMIES
C. Closing wedge osteotomy
• The CORA and correction axis lie on the concave cortex of the deformity.
• The cortex on the convex side of the deformity is compressed to restore
alignment, requiring removal of a bone wedge across the entire bone
diameter.
• A closing wedge osteotomy decreases final bone length.

34. DOME OSTEOTOMY
• In a dome osteotomy, the osteotomy site cannot pass through
both the CORA and the correction axis. Thus, translation will
always occur when using a dome osteotomy.

35. DOME OSTEOTOMY
Ideally, the CORA and correction axis are mutually located with
the osteotomy proximal or distal to that location such that the
angulation and obligatory translation that occurs at the
osteotomy site results in realignment of the bone axis.

36. DOME OSTEOTOMY
When the CORA and correction axis are not mutually located,
a dome osteotomy through the CORA location results in a
translational deformity.

37. DOME OSTEOTOMY
The CORA and correction axis are mutually located with the osteotomy
distal to that location in all of these examples.
A. Opening dome osteotomy:
The CORA and correction axis lie on the cortex on the convex side
of the deformity.
• Opening dome osteotomy increases final bone length.

38. DOME OSTEOTOMY
B. Neutral dome osteotomy:
The CORA and correction axis lie in the middle of the bone.
Neutral dome osteotomy has no effect on final bone length.

39. DOME OSTEOTOMY
C. Closing dome osteotomy:
• The CORA and correction axis lie on the concave cortex of the deformity.
• A closing dome osteotomy decreases final bone length .
• It can result in significant overhang of bone that may require resection

40. DEFORMITY
Treatment By Deformity type : Length
• Acute distraction or compression methods obtain immediate correction
of limb length by acute lengthening with bone grafting or acute shortening,
respectively .
• Gradual correction techniques for length deformities typically use Ilizarov
external fixation/ LRS

41. DEFORMITY
Treatment By Deformity type : Angulation
• Correction of angulation deformities involves making an osteotomy, obtaining realignment of the
bone segments, and securing fixation during healing.
• Alternatively, the correction may be made gradually using external fixation to both restore
alignment and provide stabilization during healing

42. DEFORMITY
Treatment By Deformity type : Rotation
• Correction of a rotational deformity requires an osteotomy and rotational realignment followed by
stabilization.

43. DEFORMITY
Treatment By Deformity type : Translation
• Translational deformities may be corrected in one of three
ways.

44. THANK YOU