Common Pediatric Disorders of the Lower Extremity Affecting Gait Gregory A. Schmale, MD Children

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Common Pediatric Disorders of the Lower
Extremity Affecting GaitGregory A. Schmale,
MDChildrens Hospital and Regional Medical
Center 5/01/06
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Objectives

• 1. Describe the commonly seen pediatric
  disorders involving gait, children's feet, and
  children's legs, including problems in normal
  development (and the ages at which these
  problems are commonly seen).

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Objectives

• 2. Discuss the evaluation of common pediatric
  foot, gait, and leg disorders.
• 3. Describe their optimal management.

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Approach

• Learn the range of normal
• Its huge
• Normal changes with growth and development
• Before saying something is normal, rule out the
  pathologies
• Know the common pathologies
• The eye sees what the mind knows

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Common and often benign orthopaedic concerns

• In-toeing
• Out-toeing
• Bowed legs
• Knock-knees
• Flat feet

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Pathologies

• Cerebral Palsy
• Hip dysplasia
• Legg-Calve-Perthess disease
• Slipped Capital Femoral Epiphysis
• Clubfoot

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Systematic approach - Wheres the source?

• Hip joint
• Thigh (femur)
• Knee joint
• Leg (tibia)
• Ankle joint
• Foot (tarsals and metatarsals)

X
X
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Group pathologies by age

• Newborns and infants (lt 1 yr)
• Toddlers (1-3 yr)
• Older children (4-10 yr)
• Pre-teens and teens (gt 10 yrs)

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Is in-toeing a problem?

• Not painful in and of itself
• Not associated with early arthritis
• Can be associated with knee pain and
  patellofemoral problems
• May be a cosmetic problem
• Why does this patient in-toe?

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History

• What is the specific concern?
• Who is concerned?
• When does it manifest?
• Duration?
• Improving or worsening?

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Evaluation

• Medical History
• Developmental delay(s)?
• Precipitating event/birth complication?
• Family History
• Screening examination
• Spasticity?
• Asymmetry?
• Rotational Profile

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Rotational Profile

• Gait determine foot progression angles
• Assess hip rotation
• Assess tibial rotation
• Determine the alignment of the footGait f
  (BRAIN) (hip femur) (leg foot)
  (knee ankle)

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Rotational Profile

• Gait foot progression angles

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Rotational Profile

• Range of normal foot progression angles

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Structural toeing and bowing

• Terminology
• Normal - within two standard deviations of the
  mean
• Version the normal twist to a bone
• Torsion abnormal twist to a bone
• Medial internal
• Lateral external

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Rotational Profile

• Gait foot progression angles

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Rotational Profile

• Gait foot progression angles

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Rotational Profile

• Gait determine foot progression angles
• Assess hip rotation
• Assess tibial rotation
• Determine the alignment of the foot Where is
  the source???

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Assessing hip rotation
MedialRotationHip
LateralRotation Hip
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Assessing hip rotation
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Normals medial femoral rotation
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Normals lateral femoral rotation
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Is the hip rotation normal?

• Within two standard deviations of the mean?
• Symmetric?
• Painless?
• Without spasticity?What is the cause of the
  increased medial (or lateral) rotation?

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Causes of excess rotation

• Soft tissues vs. bony anatomy
• Hip joint - soft tissue contractures
• Newborns have an posterior capsular contracture,
  producing excessive lateral rotation of the hips
• Femoral antetorsion - bony anatomy
• produces excessive medial rotation at the hip

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What is femoral anteversion?
Excessive anteversionequalsantetorsion
Anteversion
Femoral antetorsion produces intoeing
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Femoral antetorsion

• Usually 3-5 yo girls
• Sits in the W
• Kissing patellae
• Egg-beater run
• Severe if gt 90
• Resolves with growth - no association with
  osteoarthritis

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Femoral antetorsion
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Rotational Profile

• Gait determine foot progression angles
• Assess hip rotation
• Assess tibial rotation
• Determine the alignment of the footWhere is the
  source???

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Tibia

• Torsion
• Tibial torsion can lead to intoeing
• Internal or medial tibial torsion is a twist
  to the leg, pointing the toe inwards

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Assessing tibial torsion

• Thigh-foot angle
• Transmalleolar axis

• Determine axes

• Measure angles

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Assessing tibial rotation
L TFA
R TFA
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Assessing tibial rotation
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Assessing tibial rotation
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Normalstibial rotation
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Medial tibial torsion
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Foot

• Metatarsus adductus curves the foot inwards
• Searching great toe pulls the foot inwards
• Flatfoot may produce out-toeing from
  wringing-out of the foot
• Supinated forefoot with valgus heel

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Assessing alignment of the foot

• Shape of the foot
• Heel-bisector angle

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Metatarsus Adductus

• Majority are flexible
• Adductus resolves by 3-4 yrs
• 10 stiff and may benefit from casting

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Assessing foot alignment
PrettyMuchNormal
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Toeing and bowingDetermining the source

• Excessive medial rotation of hips?
• Does he have it? NO on antetorsion, but YES
  on excessive medial rotation
• Internally rotated thigh-foot angle
  internal tibial torsion? No
• Curved foot metatarsus adductus? No

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In Summary

• Femoral antetorsion produces excessive medial
  rotation at the hip which leads to in-toeing
• Medial tibial torsion is a twist to the leg,
  pointing the foot inwards
• Metatarsus adductus curves the foot inwards
• A searching or abducted great toe produces
  in-toeing

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A five year old girl presents with knock-knees
and intoeing. You should obtain a rotational
profile and

• refer to orthopaedics for bracing or surgery
• have the child put her shoes on the opposite feet
  and recheck her in a year
• just recheck her in a year
• obtain an AP pelvis radiograph and full length
  lower extremity films to look for hip dysplasia

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How to treat intoeing?

• Shoe wedges? No.
• Twister cables? No.
• Observation? Yes.

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Pathologies to considerWhy is there an abnormal
range of motion of the hip?

• Infants and toddlers
• Hip dysplasia
• Neuromuscular disease -Cerebral palsy
• Toddlers
• Legg-Calve-Perthes disease
• Pre-teens
• Legg-Calve-Perthes disease
• Slipped Capital femoral epiphysis

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The most likely diagnosis is

• cerebral palsy
• arthrogryposis
• Perthes disease
• septic arthritis of the hip
• hip dysplasia

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Arthrogryposis

• Congenital contractures
• Arthrogryposis multiplex congenita
• 1/3000 births
• Amyoplasia 1/2 of cases
• Due to fetal akinesia
• May include
• radial head dislocations
• Hip dislocations
• Knee dislocations
• Clubfoot
• Rx order - reduce the knee, then treat the feet,
  then the hips

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Arthrogryposis

• Amyoplasia
• Classic arthrogryposis
• Muscle replaced by fibrous tissue
• Multiple congenital contractures
• 60 with all limbs affected,
• Lower only in 25
• Upper only in 15
• Normal IQ
• Surgery changes the range of the arc of motion,
  not the total arc itself

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The most likely diagnosis is

• cerebral palsy
• arthrogryposis
• Perthes disease
• septic arthritis of the hip
• hip dysplasia

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The most likely diagnosis is

• cerebral palsy
• arthrogryposis
• Perthes disease
• septic arthritis of the hip
• hip dysplasia

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Bilateral hip dislocations
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Developmental dysplasia of the hip (DDH)

• Incidence
• dislocation 11000
• neonatal hip instability 1100
• Increased risks for first-born, girls, breech
  positioning, family history
• LgtR

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DDH detection

• Newborn nursery exam
• Galiazzi test
• Ortolani test
• Barlow test
• Good up to 2-3 mos of age
• Loss of abduction, pistoning
• Pavlik harness for instability or dislocated hip

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DDH detection

• Ultrasound (dedicated center)
• Better at gt 2 wks of age
• Dynamic exam
• Radiography
• Gold standard
• Best after 6-8 weeks of age

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Rx for dysplasia -REFER

• Pavlik for both dysplastic and dislocated hips
• Never exceed about four weeks of Pavlik treatment
  for a persistently dislocated hip
• Unstable hips deserve a referral to orthopaedics
• Abduction orthoses may help correct hip dysplasia
  in the older child

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Hip dysplasia

• Early treatment enables quick resolution
• Delayed treatment risks a poor result/multiple
  surgeries
• Over-treatment is generally benign for the
  located hip

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R hip after OR, fem short, pelvic osteotomy
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Cerebral palsy

• Mild developmental delays?
• Mild spasticity or increased tone?
• Asymmetry of motion, tone, reflexes?
• You may be the first to make the diagnosis

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Perthes ds

• Peak age of onset 3-8yr
• Spontaneous osteonecrosis of the femoral head
• Follow with serial radiographs
• Prognosis depends on age of onset / severity
• lt 6 yrs at onset, less than whole-head
  involvement do better
• Rx- decrease synovitis and weight bearing

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Perthes ds
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Perthes ds
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Slipped capital femoral epiphysis

• Peak incidence in pre-teens, 50 obese (50 not!)
• Anterior thigh or knee pain
• Bilateral in cases of endocrinopathy or renal ds
• Dx - AP and frog pelvis radiograph
• If present, immediate wheel chair and referral

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Slipped capital femoral epiphysis
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Slipped capital femoral epiphysis
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Knee angular deformities

• Genu varum - bowing
• Genu valgum - knock-knees Whats normal?

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Physiologic genu valgum

• Maximum varus at birth
• Maximum valgus gt 10, ages 3 - 4 yrs
• At maturity, mean is 6 anatomic valgus

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Bowing or genu varum

• Physiologic bowing
• Pathologic bowing
• Rickets
• Tibia vara
• Skeletal dysplasia

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Apparent bowing
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Vit-D deficient/resistant rickets
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Bowing of tibia vara
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Knock- knees or genu valgum

• Physiologic
• Pathologic

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Physiologic valgus
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Physiologic genu valgum

• Maximum varus at birth
• Maximum valgus gt 10, ages 3 - 4 yrs
• At maturity, mean is 6 anatomic valgus

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Knock- knees

• Pathologic genu valgum
• Rickets - later onset such as with renal
  osteodystrophy, because the disease is active
  when knock knees are the norm
• Skeletal dysplasias
• Diastrophic dysplasia
• Morquios syndrome
• Ellis-van Creveld or chondroectodermal dysplasia
• Spondyloepiphyseal and multiple epiphyseal
  dysplasias

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Pathologies to consider - leg

• Angulation or bowing of the tibia
• Very unusual!
• Antero-lateral ?neurofibromatosis?
• Postero-medial ?leg length difference?
• Antero-medial ?fibular deficiency?

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Pathologies to consider foot

• Flatfoot
• All infants have it
• Most children have it
• More than 15 of adults have it

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Flexible flatfoot

• Often resolves with growth
• Not affected by specific shoes, heel cups, or
  UCBL inserts
• Not correlated with disability in military
  populations
• May be protective against stress fractures

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More foot pathologies to consider

• Stiff or rigid metatarsus adductus
• Clubfoot
• Calcaneovalgus
• Cavovarus foot

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Clubfoot

• Incidence 11000
• Talipes equinovarus
• True congenital vs positional
• Cavus, adductus, varus, equinus
• If present, examine hips carefully!

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Clubfoot treatment

• Serial manipulations and casting
• Begin first week of life, if possible
• Perform weekly
• 90 of routine clubfoot respond

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Calcaneovalgus foot

• Most common foot deformity at birth
• Forefoot abducted, ankle dorsiflexed - foot lies
  on anterior leg
• Resolves spontaneously
• Associated with hip dysplasia

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Cavovarus foot

• High arch cavus
• Heel in varus
• Often rigid
• Look to spinal cord or peripheral nervous system

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Out-toeing (Less commonly seen)

• Causes
• External rotation contracture at the hip?
• Lateral tibial torsion?
• Flatfoot?
• Little hope of improvement over time, unless its
  a result of flatfoot

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Summary Normal Development

• Femoral anteversion 30 at birth, only 10 at
  maturity ( lateral rotation)
• Femoral antetorsion improves over time
• Tibial version 0 at birth, 15 externally
  rotated at maturity ( laterally rotation)
• Medial tibial torsion improves over time
• Growth lateral rotation of both femur and tibia
• In-toeing decreases with growth

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Summary

• Most toe-ing and bow-ing deformities are benign
• Resolution may take many years
• Use history and exam to rule-out the pathologic
  causes
• Reassure for what appear to be non-pathologic but
  extreme cases
• Check back for re-exam, 6-12 months
• Beware unilateral deformities and those
  associated with pain
• Radiographs indicated

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Who needs a referral for toeing and bowing?

• Over three years of age with documented
  progression of deformity
• Stiff metatarsus adductus
• Bowing
• below the 5th percentile for height
• marked asymmetry or lateral thrust with
  ambulation
• Marked knock-knees or in-toeing in patients over
  8 years of age

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Who needs a referral?

• A newborn with a hip click?
• A newborn with a hip clunk?
• A ten year old girl with marked out-toeing on the
  side of groin pain?
• A newborn with flat feet?

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References

• Herring, JA Tachdjians Pediatric Orthpaedics,
  WB Saunders, Philadelphia, 2002.
• Staheli, LT Fundamentals of Pediatric
  Orthopedics, Raven Press, New York, 1992.
• Staheli, LT Practice of Pediatric Orthopedics,
  Lippincott, 2002.
• Tolo, VT In-toeing and Out-toeing, Lovell and
  Winters Pediatric Orthopaedics, 4th ed.,
  Morrissey and Weinstein, eds., Lippincott-Raven,
  Philadelphia, 1996.
• Wenger, DA and M Rang The Art and Practice of
  Pediatric Orthopaedics, Raven, New York, 1993.