Deformities.pdf

PEDIATRIC LOWER EXTREMITY DEFORMITIES Dr. Evrim Şirin Marmara University Department of Orthopaedics and Traumatology DEFORMITY - DEFINITION * Deformity is a condition in which a part of the body does not have the normal (anatomical) shape. DEFORMITY - ETIOLOGY ETIOLOGY PHYSIOLOGIC; resolves spontane...

PEDIATRIC LOWER EXTREMITY DEFORMITIES Dr. Evrim Şirin Marmara University Department of Orthopaedics and Traumatology DEFORMITY - DEFINITION * Deformity is a condition in which a part of the body does not have the normal (anatomical) shape. DEFORMITY - ETIOLOGY ETIOLOGY PHYSIOLOGIC; resolves spontaneously STRUCTURAL; usually requires treatment - Idiopathic - Congenital (DDH, PEV) - Genetic (skeletal dysplasias) - Neuromuscular (serebral palsy, spina bifida) - Metabolic (rickets, osteogenesis imperfecta) - Acquired (posttraumatic) * A combination of etiologic factors may cause a structural deformity. DEFORMITY - ETIOLOGY Congenital; congenital deformities present at birth due to combination of several factors including; genetic defects teratologic affects intrauterine forces (compression) DEFORMITY - ETIOLOGY Genetic; gen defects affect cartilage formation (skeletal dysplasias) DEFORMITY - ETIOLOGY Neuromuscular; muscular inbalance leads to deformities (cerebral palsy, spina bifida) DEFORMITY - ETIOLOGY Metabolic; metabolic imbalance affects bone formation & resorbtion (rickets, osteogenesis imperfecta, etc) DEFORMITY - ETIOLOGY Post-traumatic; growth plate injury leads to a progressive deformity Pediatric Lower Extremity Deformities Angular Deformities Rotational Deformities Pediatric Lower Extremity Deformities Complex Deformities (combination of both) Pediatric Lower Extremity Deformities * Multi-level involvement (deformity) is common. ROTATIONAL DEFORMITIES OF THE LOWER EXTREMITIES All parts of the lower extremity can be involved. Hip Internal Femoral Torsion (Femoral Anteversion) Knee Genu Varum, Genu Valgum Tibia Internal Tibial Torsion, Tibia Vara Foot Pes Planus (Flatfoot), Metatarsus Adductus, Pes Equinovarus (Clubfoot) ROTATIONAL DEFORMITIES OF THE LOWER EXTREMITIES (simply result in.....) Intoeing Outtoeing internal femoral torsion (femoral anteversion) internal tibial torsion metatarsus adductus pes equinovarus external femoral torsion external tibial torsion calcaneovalgus foot pes planus (flat foot) ROTATIONAL DEFORMITIES OF THE LOWER EXTREMITIES Diagnosis; mainly based on clinical exam foot progression angle hip rotations thigh-foot angle tibial torsion foot morphology ROTATIONAL DEFORMITIES OF THE LOWER EXTREMITIES hip rotation * depends on the degree of femoral anteversion (the angle between the long axis of the femoral neck and the femoral condyles; 10-15° normally) - increased femoral anteversion leads to internally rotated extremity and intoeing ROTATIONAL DEFORMITIES OF THE LOWER EXTREMITY thigh-foot angle * simply measures tibial torsion (the angle between the thigh and the long axis of the foot; it is in slight external rotation normally) ROTATIONAL DEFORMITIES OF THE LOWER EXTREMITY foot morphology (shape) * search for foot deformities; - metatarsus adductus - pes equinovarus - pes planus FEMORAL/TIBIAL ROTATIONAL DEFORMITIES (Internal/External Torsion) TREATMENT very rarely a treatment is required have a tendency to resolve spontaneously persistant deformity + functional or cosmetic problems may require treatment (when it is necessary) usually surgical correction - conservative tx by orthosis is not helpful FEMORAL / TIBIAL ROTATIONAL DEFORMITIES corrective-derotational osteotomies bony procedures which brings the bone (the extremity) into its anatomical position METATARSUS ADDUCTUS Most common congenital foot deformity Medial deviation of the forefoot on the hindfoot Diagnosis (+) at birth Intrauterine compression (positional abnormality) METATARSUS ADDUCTUS * Clinical examination is enough for diagnosis. The border of the foot is concave medially and convex laterally. METATARSUS ADDUCTUS TREATMENT Flexible deformity - Spontaneous resolution can be achieved without treatment. Partially flexible, nonflexible deformity - Manipulation and serial casting is the first line treatment. - Treatment should be initiated before 1 y.o. - Surgical treatment is required very rarely in older children with residual deformity. PES EQUINOVARUS (CLUBFOOT) A common congenital foot deformity Diagnosis (+) at birth Etiology; environmental and genetic factors 4 types (idiopathic, postural, neurogenic, syndromic) Requires treatment (no spontaneous correction) Bilateral involvement in %50 of cases PES EQUINOVARUS (CLUBFOOT) 4 types (idiopathic, postural, neurogenic, syndromic) idiopathic PEV neurogenic, syndromic PEV (arthrogryposis) PES EQUINOVARUS (CLUBFOOT) Complex deformity; hindfoot equinus/varus forefoot adduction invertion/cavus of the foot Dysplasia of the entire extremity; calf atrophy short & widened foot PES EQUİNOVARUS (CLUBFOOT) TREATMENT Idiopathic PEV - serial casting (currently gold standart) - followed by orthosis until 2 y.o - surgical tx is rarely required in resistant cases as soft tissue releases Neurogenic, Syndromic PEV - usually surgical tx is required PES EQUİNOVARUS (CLUBFOOT) * serial casting technique ANGULAR DEFORMITIES OF THE LOWER EXTREMITIES * Seen very commonly in children - usually physiological, occasionally structural PHYSIOLOGICAL GENU VARUM (O-bein Deformity) Seen in neonates and infants < 1 y.o Etiology; mainly intrauterine compression Spontaneous resolution by independent walking by the age of 2 Differential diagnosis includes pathological genu varum (Blount’s diseae), metabolic bone disease, skeletal displasias PATHOLOGICAL GENU VARUM (Tibia Vara, Blount’s Disease) * Abnormality in the medial site of proximal tibial growth plate leads a progressive varus deformity - Etiology unknonwn - % 50 bilateral - Usually requires treatment PATHOLOGICAL GENU VARUM (Tibia Vara, Blount’s Disease) TREATMENT In children younger than 3 y.o - Mild deformities can be managed by orthoses - Moderate to severe deformities usually require surgical correction (corrective valgus osteotomi) In older children with resistant deformities usually surgical correction is required. PES PLANUS (FLAT FOOT) Collapse of the medial longitudinal arch of the foot - plantar collapse of the midfoot - pronation of the foot - valgus of the hindfoot PES PLANUS (FLATFOOT) Very common and usually asymptomatic In neonates and younger children (infants just around walking age) - ligamentous laxity - fat pad on medial longitudinal arch (plantar surface of the foot) In older children - ligamentous laxity PES PLANUS (FLAT FOOT) PES PLANUS (FLATFOOT) FLEXIBLE PES PLANUS - Usually asymptomatic - Medial longitudinal arch is (+) on tiptoe walking - Subtalar motion is normal RIGID PES PLANUS - Usually painful - Medial longitudinal arch is (-) on tiptoe walking - Subtalar motion is limited. Jack test PES PLANUS (FLATFOOT) flexible, asymptomatic pes planus - tx is not required - shoe modifications, inserts do not affect natural history flexibl pes planus + activity induced pain - generalized foot pain (patient can not localize the pain) - shoe inserts can be used to decrease pain flexibl pes planus + pain with weight-bearing - usually achilles tendon is thight / streching exercises - occasionally casting PES PLANUS (FLATFOOT) SURGICAL TREATMENT Flexible pes planus; very rarely is required PES PLANUS (FLATFOOT) SURGICAL TREATMENT Rigid pes planus; frequently is required based on the underlying pathology Thank You