Paediatric Leg and Foot (Non-Trauma)

Definition of terms

Genu Valgum

Genu valgum is aka ‘knock knees’. It is normal in children aged 2-6 years and is always abnormal in adolescents. It can be unilateral or bilateral. Diagnosis is clinical, but laboratory tests for rickets can be obtained

• Causes
  • Vitamin D-resistant rickets
  • Idiopathic
• Investiagtions
  • Screen for rickets
  • Leg X-ray: to document severity and progression
• How do you determine the severity of Genu Valgum?
  • Using the Q-angle of the knee (a knocked knee > 20 degrees)
• Operative treatment
  • Osteotomy is the only effective management

Genu Varum

Genu varum is aka ‘bow leg’. It may be unilateral or bilateral. It is normal for children aged 3 – 4 years.

• Causes of genu varum
  • Blount’s disease (idiopathic cause)
  • Rickets
  • Hypophosphatemic rickets
• Investigations
  • Screen for rickets
  • X-ray of the leg: for severity and presence of bone demineralization (rickets)
• Treatment
  • Treat underlying cause (rickets or hypophosphatemic rickets)
  • Surgery

Blount’s disease (Tibia Varus)

Blunts disease is a developmental disease involving disordered growth of the proximal tibia. It presents as genu varum persisting past the normal physiological period of varum (aged 3 – 4 years). It is common in obese children and is the most common cause of pathological genu varus.

• Signs and symptoms
  • Obvious genu varus
  • Internal rotation of the foot and leg length discrepancy (shorter on the affected side)
• Treatment
  • Osteotomy

Congenital Talipes Equinovarus (CTEV/Club Foot)

Congenital talipes equinovarus (CTEV) is a common congenital anomaly foot/ankle in which there is internal rotation, plantarflexion and adduction of the foot. The cause is idiopathic, but a combination of congenital and environmental factors play a role. It is more common in those with a family history of clubfoot. The most important pathology in clubfoot is medial displacement of the navicular bone on the talus. Shortening of tendons and ligaments of the inner foot secondary to the bony malalignment ****creates the classical positioning of the foot and ankle. It has a typical presentation and is easily identifiable at birth. Diagnosis is clinical.

Occurs in 1 per 1000 births (very common. Affects males more than females (2:1). 80-90% of clubfoot occurs in low- and middle-income countrieas (incidence is 2-3 in 1000 births in southern and eastern Africa). 50% of cases are bilateral.

Pathoanatomy of clubfoot (CAVE)

• Associated conditions
  • Edward syndrome (47, +18)
  • Ehlers-Danlos
  • Arthrogryposis
  • Tibia hemimelia
  • Amniotic band syndrome (Streeter dysplasia, upper extremity and hand anomalies are also common)
  • Pierre Robin syndrome
  • Opitz syndrome
  • Larsen syndrome
  • Myelodysplasia
• Pathophysiology
  • Bony deformity
    • Medially displaced navicular and cuboid on the talus
    • Medially and plantarly deviated talar neck
    • Calcaneus in varus and rotated medially around talus
  • Muscle contracture
    • Cavus due to tight intrinsics, FHL and FDL
    • Adductus of forefoot due to tight tibialis posterior
    • Varus due to tight tendoachilles, tibialis posterior, and tibialis anterior
    • Equinus due to tight tendoachilles
• Physical examination
  • Foot is plantarflexed, internally rotated and adducted
  • Medial crease
  • Posterior crease
  • Empty heel
  • Ankle dorsiflexion
  • Always associated with permanent decrease in calf circumference related to fibrosis of cslf musculature
• Conservative treatment
  • Ponsetti casting: weekly manual manipulation and casting starting at 2 weeks of age to correct the cavus, adduction and varus
    • At 1 week intervals for the first month then 1-2 week intervals thereafter
    • Started early because the younger the child is the more lax their ligaments
    • Corrected in this order : cavus → adduction → varus
    • After correction achilles tenotomy is performed to correct the equinus
  • French method: daily physical therapy, manipulation and splinting
  • Percutaneous tenotomy of the Achilles tendon to correct the equinus after casting
  • Abduction bracing (orthosis) using a Denis Browne bar/splint worn at night until at least 4 years old
• Operative treatment of recurrent or complex cases (due to teratogenic clubfoot or decreased brace compliance)
  • Posterior-medial release (Turco’s procedure): for 1 – 3 years of age
  • Tibialis anterior tendon transfer
  • Midfoot osteotomies
  • Talectomy: salvage procedure for severe, rigid and recurrent clubfoot
  • Triple arthrodesis: for > 10 years old. Fusion of the talonavecular, subtalar and calcaneo-cuboid joint. Rarely done. Contraindicated in insensate feet
• Complications of CTEV
  • Deformity relapse
  • Rocker bottom deformity (due to overcorrection)
  • Dynamic supination
  • Pes planus (from overcorrection)
  • Undercorrection
  • Intoeing gait (due to internal tibial torsion and/or internal rotation of the talus within the mortise)
  • Osteonecrosis of talus

Osgood-Schlatter Disease (Apophysitis of the tibial tubercle)

Osgood-Schlatter disease is apophysitis of the tibial tubercle casued by repetitive microtrauma at the insertion point of the patellar tendon in the tibial tuberosity. It is common in athletically active adolescents. This condition is self-limiting.

• Signs and symptoms
  • Pain at the patellar ligament insertion on the tubercle apophysis (insertion growth plate
• Investigations
  • X-ray of the knee joint:
    • Widening of the apophysis
    • Calcified ossicles within the patellar dendon
    • Soft tissue swelling at the insertion
• Treatment
  • Activity modification until symptoms resolve or the patient reaches skeletal maturity

Sever’s Disease (Calcaneal Apophysitis)

Sever’s disease is apophysitis of the calcaneus. It may be associated with repetitive microtrauma of the heel. It is self-limiting.

• Signs and symptoms
  • Posterior heel pain
    • Aggravated by running and jumping
• Investigations
  • X-ray of the foot
• Treatment
  • Activity modification or rest