GENU VALGUS & GENU VARUS

LATIN

GENU KNEE

VALGUS OUTWARD
Natural History of normal evolution of the alignment of the
lower limbs

Bowlegs in new born and infant

With medial tibial torsion = fetal position

Becomes straight by 18/12

By 2 or 3 genu valgus develop (avg. 12°)

By 7 spontaneous correction
To the normal of adult valgus ( 8°♀ and 7°♂)
 Genu varum

• Worried parents

• About 3 years old +bow legs +mild lateral thrust at the

knees + in-toeing

• Assessment:
- History
- etiologic factors
 Examination
• Height
• See ( front, back & side)
• Measure
 IC distance, <6CM
 lateral thigh-leg angle,
 center of gravity

• Site of varus
 Causes
• Lateral ligament laxity
• Blount’s disease
• Congenital pseudoarthrosis of tibia
• OA
In ligamentous laxity notelat.Widening In Blount angulation at med.tib
Of knee joints metaphysis
In cong. Pseudarthrosis of tibia,the In coxa vara ,angulation at the neck shaft
angulation is in the distal ⅓ level
• Gait: intoeing, lateral thrust-the fibular head and
upper tibia shift laterally in Blount due to laxity and
incompetence of the lat. Collat. Lig.
• Stability
• Symmetry
• Level of fibular head, normally at the level
of the upper tibial growth plate, while it is proximal
in Blount, cong.longitudinal dificiency of the tibia
and achondroplasia
 X-ray

• 3 years and older

• Getting worse
• Abnormal site of
angulation
• Large physis and
epiphysis
• History – taruma, infection,
possible metal intoxication(lead or
floride)

Metaphysial/diaphysial
angle ≥ 18°
 Finding

• Metaphysis, thick and frayed

in rickets

• In physiologic genu
varum no intrinsic bone
disease, gentle curve, medial
cortices thickening, horizontal
joint lines of the knee & ankle are
tilted medially
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.
NORMALLY

• VALGUS
OR
• VARUS?

VALGUS 5-7 DEGREES

 Diagnosis
• 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.
• 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.
 Q Angle
• Measured to assess the degree and severity of
Genu Valgus
• Males 8 + 2
• Females 15+ 5
• Why Greater in Females ?

Wider Pelvis!
CONDITIONS AFFECTING Q ANGLE
Femoral anteversion
Genu Valgum
External Tibial Torsion
Lateral placed tibial tuberosity
Flat Feet
Tight Lateral Retinaculum
 Greater Q Angle
• Patellar Dislocation!
 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
 Bilateral genu valgum

• Physiologic
• Renal osteodystrophy (renal rickets)
• Skeletal dysplasia
• Morquio syndrome
• Spondyloepiphyseal dysplasia
• Chondroctodermal dysplasia
 Unilateral genu valgum

• Physeal injury from trauma, infection, or

vascular insult
• proximal metaphyseal tibia fracture
• Benign tumors
• Fibrous dysplasia
• osteochondromas
• Ollier's disease
• RA
 When to see the Doctor?
• 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, Arthritis
• Cosmetic Reasons
 Treatment
CONSERVATIVE
• Life style modification
• Braces
• Exercises and physical therapy
• No evidence that shoe modification, splints, or exercises affect
condition.
• No evidence to justify surgical intervention under 6 inches of
intermalleolar separation.
 SURGERY
• Medial epiphyseal stapling at 10 to 11 years
• Corrective osteotomy at maturity (When
physis is closed)
 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.
 SURGERY
Spasmodic type :
• Hindfoot fusion for pain relief.
• Subtalar arthrodesis corrects deformity.
 SURGERY
• TENDON TRANSFERS
 TRIPPLE ARTHRODESIS
• AGE >12
• TALOCALCANEAL
• CALCANEOCUBOID
• TALONAVIULAR
DEVELOPMENTAL DYSPLASIA OF
THE HIP (DDH)
 DDH
• Very important condition as early diagnosis
and correction prevent major damage.
• All newborns are screened for DDH by
Barlow’s and Ortolani’s manoevre
• Developmental dysplasia of the hip (DDH) is a
dislocation of the hip joint that is present at
birth. The condition is found in babies or
young children.
 Causes, incidence, and risk factors
• The hip is a ball and socket joint.
• In some newborns, the acetabulum is too shallow and the femoral head may slip out
of the socket, either part of the way or completely. One or both hips may be
involved.
• The cause is unknown. Low levels of amniotic fluid in the womb during pregnancy
can increase a baby's risk of DDH. Other risk factors include:
 Being the first child
 Being female
 Breech position during pregnancy
 Family history of the disorder
 Oligohydramnios
 Genetic susceptibility
 Scandinavian descent
 Hormonal imbalanace
 Uterine malposition
 Left sided
 Ligamental laxity
 Primary acetabular dysplasia
• DDH occurs in about 1 out of 1,000 births.
 Symptoms
• There may be no symptoms. Symptoms that may occur can include:
 Leg with hip problem may appear to turn out more
 Reduced movement on the side of the body with the
dislocation
 Shorter leg on the side with the hip dislocation
 Uneven skin folds of thigh or buttocks
 Diaper difficulties
 Galezzi positiove
 Gait tip toe,trendelnberg
 lordosis
• After 3 months of age, the affected leg may turn outward or be
shorter than the other leg.
 Signs and tests
• Pediatric health care providers routinely screen all newborns and
infants for hip dysplasia. There are several methods to detect a
dislocated hip or a hip that is able to be dislocated.
• The most common method of identifying the condition is a physical
exam of the hips, which involves applying pressure while moving the
hips. The health care provider listens for any clicks, clunks, or pops.
• Ultrasound of the hip is used in younger infants to confirm the
problem. An x-ray of the hip joint may help diagnose the condition in
older infants and children.
• A hip that is truly dislocated in an infant should be detected at birth,
but some cases are mild and symptoms may not develop until after
birth, which is why multiple exams are recommended. Some mild
cases are silent and cannot be found during a physical exam.
 Treatment
• When the problem is found during the first 6 months of
life, a device or harness is used to keep the legs apart
and turned outward (frog-leg position). This device will
usually hold the hip joint in place while the child grows.
• This harness works for most infants when it is started
before age 6 months, but it is less likely to work for
older children.
• Children who do not improve, or who are diagnosed
after 6 months often need surgery. After surgery, a cast
will be placed on the child's leg for a period of time.
BETWEEN 6 MONTHS AND 18
MONTHS

• PREOP TRACTION
•
• CLOSED REDUCTION

• ADDUCTOR TENOTOMY
•
• HIP SPICA
90-110 HIP FLEXION AND 20-45
ABDUCTION
DIAGNOSED > 18 MONTHS

SURGERY!
SURGERY
 Prognosis
• If hip dysplasia is found in the first few months
of life, it can almost always be treated
successfully with a positioning device
(bracing). In a few cases, surgery is needed to
put the hip back in joint.
• Hip dysplasia that is found after early infancy
may lead to a worse outcome and may need
more complex surgery to fix the problem.
 SCREENING
• HISTORY
• INVESTIGATION
ULTRASOUND
X RAYS
• CLINICAL EXAMINATION
ORTOLANI
BARLOW
 THANK YOU!

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