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Paediatric Knee And Foot Problem

  1. Traumatic Dislocation Of Distal Femoral Epiphysis
    In childhood or adolescent equivalent of a supracondylar femur fracture, the lower femur epiphysis may be displaced. (1) to one side (usually laterally) by valgus force or (2) forwards i.e. anteriorlyQ by hyperextension injury. Nearly 70% of femur’s length is derived from the distal physis, so early arrest can present a major problem.
  2. Congenital Dislocation Of Knee
    1. Etiology & Pathology
      1. Abnormal fetal position i.e. feet become locked beneath the mandible or the axilla and cause hyperextesion of knees.
      2. Congenital absence of cruciate ligament & fibrosis of quadriceps & fascia lata.
      3. Quadriceps is atrophic along with the patella and has fibrous adhesion to the femur.
      4. Proximal end of tibia is displaced anteriorly & laterally on femur
      5. Patella is small or absent & cruciate ligament is long or absent.

Description: F9

  1. Clinical Features
    1. Congenital hyper extension (genu recurvatum,) is the most common presentation
    2. Hyper extension, often to such a degree that the foot can easily be placed against the baby’s face
    3. Clinical appearance is alarming & has been described as “knees on back wards”
    4. In most cases reduction of deformity is possible but the knees cannot be brought into flexion.   
  2. Associated Disorders
    1. Larsen’s syndrome
    2. Ehler’s Danlos syndrome
    3. Streeter’s syndrome
    4. Myelodysplasia
    5. Arthrogryposis
    6. DDH (ipsilateral)
    7. CTEV
  1. Genu valgum
    1. Fractures of the lateral condyles of tibia &/or femur and damage to the epiphyseal plate of femur and tibia (on lateral side) results in genu valgum (arrest of growth on lateral side)
    2. The commonest cause of genu valgum (knock knee) is idopathic > rickets.
Genu Valgum (Knock Knee)

It is abnormal approximation of knees with abnormally divergent ankles. It can be estimated by measuring the distance between the medial malleolis, when the knees are touching with the patella facing forwards; it is usually <8cm. Valgus alignment of lower extremities is normal in child between 2 — 8 years of age (Known as physiological valgus & is maximum between 2 -4 years)  


  1. Idiopathic (Physiological = most common).
  2. Post traumatic
    1. Fractures of lateral condyles of femur or tibia.
    2. Damage of lateral side of epiphysis of lower femur or upper tibia
    3. Proximal tibial metaphyseal fractures with out or with associated fracture of fibula (teathering of lateral physis by intact fibula or iliotibial band).
  3. Post infection damage of lateral side of upper tibial or lower femoral epiphysis
  4. Neoplastic cause - growth disparity at epiphysis plate
    1. Osteochondroma / chondroblastoma of proximal fibula (i.e. lateral side)
    2. Multiple heriditary exostosis
    3. Asymmetrical or U/L valgus may be secondary to tumor like conditions such as fibrous dysplasia or enchondromatosis (ollier’s disease).
    4. Excision of proximal medial tibial exostosis (Cozen’s fracture phenomenon).
    5. Metabolic bone disease
    6. Rickets (mostly renal osteodystrophy type is most likely to produce valgus as it is acquired in physiological valgus age group)
  5. Spondyloepiphyseal and metaphyseal dysplasias.
  6. Rheumatoid arthritis, osteoarthritis of lateral compartment of knee, charcot’s disease & paralytic disease are other causes seen in adults. 


  1. After 8 years age, correction of excessive physiological genu valgum may be indicated when there is gait disturbence, difficulty running, knee discomfort, patellar malalignment, evidence of ligamentous instability or excessive cosmetic concern.
  2. In children who have significant growth remaining (boys <12 years or girls <10 years), reversible or transient hemiepiphysiodesis by staples etc is done, because correction can be obtained soon after the deformity is diagnosed rather than delaying the permanent hemiepiphysiodesis until near maturity.
  3. Corrective osteotomy for excessive genu valgus is appropriate when the patient present near or after skeletal maturity, too late for correction to be obtained by hemiepiphysiodesis. It is mostly close wedge osteotomy in the distal femur.
  1. Genu Varum (Bow-Legs)
  1. Knee are abnormally divergent & ankles approximated. B/L bow legs can be estimated by measuring the distance between the medial malleoli when heels are touching; it should be <6cm.
  2. A normal children show maximum varus at 6 months to 1 year of age, neutral alignment by 1-1/2 to 2 years of age, maximum genu valgum (8°) at 4 years of age, and a gradual decrease of genu valgum to 6° by 11 years of age.
  3. The presence of genu varum after 2 years of age can be considered abnormal, as spontaneous resolution of the varus to neutral tibio femoral alignment by 2 years of age and to adult valgus alignment after 3 years of age is well documented.
  4. The causes of genu varum are similar to genu valgum except that the defective growth is on the medial side.
    Two important causes are discusied below:  
    1. Physiological genu varum, which remains the most common etiology, even in a deformity that is slow to resolve & appears to be pathological. It is a deformity with tibio femoral angle of at least 10 degrees of varus, a radiologically normal appearing growth plate, medial bowing of the proximal tibia and often of the distal femur. The legs of most newborns are bowed, with 10-15 degrees of varus angulation. When the infant begins to stand & walk the bowing may appear more prominent and often appears to involve both the tibia & distal femur. Radiograph may be indicated if the varus deformity persists beyond 2 years of age or progresses. Non resolving, assymmetrical deformity is the main indication for radiographs.
    2. Tibia vara is defined as growth retardation at the medial aspect of proximal tibial epiphysis & physis usually resulting in progressive bow leg. Two forms of deformity are  
  1. Infantile tibia vara (Blount’s disease) in which patient is <3 years old at the onset of condition (more common). It is characterized by abrupt angulation just below the proximal physis, an irregular physeal line, a wedge shaped epiphysis, and a beak like medial metaphysis. Apparent lateral subluxation of proximal tibia is often present.
  2. Late onset tibia vara includes Juvenile form occuring between 4 & 10 years of age and adolescent form occuring after 10 years of age.
    1. Non physiological causes of genu varum, include skeletal dysplasia (eg. metaphyseal chondrodysplasia, spondyloepiphvseal dysplasia, multiple epiphyseal dysplasia, achondroplasia), metabolic diseases (eg. renal osteodvstrophv, vit D resistant rickets), post traumatic deformity, post infectious sequelae, and proximal focal fibrocartilagenous dysplasia. In patients with familial hypophospatemic rickets, the bone disease is active during early infancy, when physiological varus is present
    2. If the child is younger than 3 years of age, and the lesion is no greater than lagenskiold stage II, orthotic treatment (HKAFOs i.e. hip knee ankle foot orthosis, KAFOs, medial upright elastic Blount’s brace) especially if there is only unilateral involvement
    3. Full time orthotic treatment (i.e. 23 hours a day) is traditional, so that the knee is fully protected during the day, when it is maximum exposed to varus forces during weight bearing & so that the appropriate valgus force continues to be applied at night time
    4. Valgus correction should be increased by bending the medial upright every 2 months until standing radiographs show at least neutral mechanical axis. Brace therapy is not appropriate for children older than 3 years. A maximum trial of 1 year of orthotic treatment to correct the varus deformity is recommended. Thus if correction is not achieved with in this time frame in a child younger than 3 years, definitive osteotomy can be still be performed.
    5. Surgical overcorrection of mechanical axis to at least 5 degrees valgus, with lateral translation of distal osteotomy fragment achieved by 4 years of age is believed to be optimal. The risk of delaying corrective osteotomy (even few months) past the critical age of 4 years can result in failure to achieve permanent reversal of the inhibition of proximal medial physis.
    6. High tibial osteotomy just distal to the patellar tendon insertion with fibular osteotomy in proximal third diaphysis is recommended.  

Rocker Bottom Foot

  1. Rocker bottom foot, is a foot with a convex plantar surface with a apex of convexity at the talar head.
  2. The Achilles tendon is contracted and peroneal & anterior tibialis tendons are tight. The navicular is palpable as it lies dorsally on the talar neck where it abuts the anterior tibial surface at the front of ankle joint.
  3. Talus is vertical so that its head forms the most prominent part of the sole. The fore foot is deviated outward & dorsally. It may be produced by
    1. Congenital vertical talus (congenital convex pes valgus or teratological dorsolateral dislocation of talocalenaeo- navicular joint) which may be present alone or more commonly associated with myelomeningocele, arthrogryposis, prune belly syndrome, spinal muscular atrophy, neurofibromatosis, CDH, and with trisomy 13 and 18.
    2. Oblique talus
    3. Improper correction of CTEV i.e. forceflul correction of equines by dorsiflexion before adduction, varus and inversion may actually cause movement at mid tarsal joint (not at ankle joint) producing rocker bottom foot.
    4. Over correction of CTEV
    5. Grice procedure is extraarticular arthrodesis of subtalar (tab- calcaneal) joint by bone. It is done in children older than 3 years of age with congenital vertical talus to help effect & stabilize reduction. 

CTEV-congenital talipes euino varus




Talipes is a generic term for foot deformity that centers around the talus (Talipes = talus & pes = foot). Equinus implies that the foot is flexed in the plantar direction. In its most characteristic form there are usually said to be four elements of deformity —flexion of ankle, inversion of foot, adduction of fore foot and medial rotation of tibia. In India the most common congenital anomaly is CTEV where as in western countries DDH is the commonest.

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