Week 3 - D - Limb development and variations - genu valgum/varum, in toeing, flat-feet, curly toes

Question 1

Describe the development of the alignment of childrens knees from: * Birth –> * Around 14 months –> * Around the age of 3 –> * Around the age of 7-9

Answer 1

Children at birth norrmally have varus knees (bow legs) They become neutrally aligned around 14 months Progressing to 10-15 degrees valgus at 3 (knock knees) Gradullay regressing to the physiological valgus of 6 degrees by age 7-9

Question 2

For distances between knees and feet/ankles: * What does a valgus deformity at the knee result in? * What does a varus deformtiy at the knee result in?

Answer 2

Valgus deformity at the knee results in a more knock knee appearance with a larger gap than normal between the feet/ankles Varus deformity at the knee results in a large gap at the knees

Question 3

Are knees naturally varised or valgised? The majority of cases of bow legs (varus) or knock knees (valgus) will resolve by the age of 10 * If there is excessive genu varum or valgum after the age of 10, what may have to be done? * What classifies as excessive?

Answer 3

Knees are naturally valgised physiologically around 6 degrees If there is excessive genu varum or valgum after the age of 10, surgery may be required Ecessive genu varum or valgum is where alignment is considered outide the normal rnage (+/- 6 degrees from mean value for age)

Question 4

Excessive genu varum may be due to a growth disorder of the medial proximal tibial physis known as what? What does it cause?

Answer 4

Blount’s disease is a condition where there is a growth disorder of the medial proximal tibial physis which results in marked and peristing varus deformity beyond 4-5 years of age as the lower leg angles inwards

Question 5

If Blount’s disease is severe, how may it be treated?

Answer 5

It may have to be treated using surgical correction by osteotomy An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment.

Question 6

What are some pathological causes of genu varus? What are persistent bow legs at risk of early onset of?

Answer 6

Patholgocial causes of genu varus * Rickets * Tumour (Osteochondroma - benign tumour) * Traumatic physeal injury * Skeletal dysplasia - achondroplasia most common Persistent bow legs are at risk of early onset medial compartment osteoarthritis.

Question 7

What are some pathological causes of genu valgum?

Answer 7

Rickets Tumours (endochondromas) Trauma Neurofibromatosis

Question 8

What is in-toeing? When is it exaggerated?

Answer 8

In0toeing refers to a child who, when walking and standing will have feet that point towards the midline It is exaggerated when running

Question 9

In-toeing can be caused by in-turning at the level of the hips, tibias or feet. What are the three main causes of in-toeing? Which is a normal variation and should be ignored?

Answer 9

Three main causes of in-toeing * Femoral neck anteversion * Internal tibial torsion * Forefoot adduction Internal tibial torsion is a normal variation and should be ignored

Question 10

What is femoral neck anteversion?

Answer 10

Femoral anteversion is the anterior inclination of the femoral neck and head in relation to the shaft of the femur. Excessive femoral neck anteversion can give the appearance of in-toeing

Question 11

What else apart from in-toeing can increased femoral neck anteversion cause?

Answer 11

Excess femoral neck anteversion can give the appearance of in‐toeing (as well as knock knees).

Question 12

What is forefoot adduction?

Answer 12

Forefoot adduction is where there is adduction of the metastarsal bones at the tarsometarsal joints

Question 13

What is done to treat both femoral neck anteversion and forefoot adduction?

Answer 13

Surgery is debated in both conditions Both may resolve with time

Question 14

Do flat feet reflect underlying pathology?

Answer 14

Flat feet are part of normal variation and usually do not reflect underlying pathology. At birth all feet are flat, as we begin to walk and the muscles develop the arch will also develop. Some children continue to have flat feet which persist into adulthood without any functional problem.

Question 15

What are the two types of flat feet and how do you determine between the two?

Answer 15

The key is to determine if the flat feet are mobile or fixed JACK’s TEST determines Mobile/flexible flat feet are those where the flattened medial arch forms with dorsiflexion of the great toe Fixed flat feet’s medial longitudinal arch does not reappear with dorsiflexion of the big toe

Question 16

What may flexible flat footedness be due to?

Answer 16

Flexible flat footedness may be related to ligamentous laxity, may be familial or may be idiopathic. Flexible flat-footedness in children is a normal variant

Question 17

In the rigid type of flat footedness the arch remains flat regardless of load or great toe dorsiflexion. What type of underlying bony abnormality can cause this?

Answer 17

Tarsal coalition - where the bones of the hindfoot have an abnormal bony, fibrous or cartilaginous connection - can cause painful flat feet

Question 18

How is tarsal coalition treated?

Answer 18

Tarsal coalation may require surgery

Question 19

Minor overlapping of the toes and curling of toes is common What is the most common toe to be affected by this?

Answer 19

The most common toe to be affected by minor overlapping and curling of the toes is the fifth toe

Question 20

Is any treatment required for curling of the toes?

Answer 20

most will correct without intervention but they can occasionally cause discomfort in shoes and persistent cases in adolescence may require surgical correction.