angular & torsional deformities of the lower limb
TRANSCRIPT
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ANGULAR AND TORSIONAL DEFORMITIES IN LOWER LIMB
CLINICAL AND RADIOLOGICAL ASSESSMENT
Dr T.S. GOPAKUMAR
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EVOLUTION OF ALIGNMENT IN THE LOWER LIMBS
Torsion
Fetus MM behind LM Birth same level 1 year LM behind MM Adult 20 degrees External torsion
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Evolution of alignment in the lower limbs
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Every change in the form and function
of the bones or function alone is followed
by certain definite changes in the external
configurations in accordance with
mathematical laws.
WOLFF LAW
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HEUTER VOLKMANN LAW (1862)
Pressure inhibit growth and decreased
pressure accelerate the growth of the physis
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ASSESSMENT OF ANGULAR DEFORMITY
HistoryNutritional deficiencyRenal diseasesMuscle weaknessGastrointestinal problemsFamily history
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ASSESSMENT OF ANGULAR DEFORMITY
StatureUpper segment lower segment ratioFaciesTeethMetaphyseal thickeningHandNailsChanges of ricketsProximal muscle weakness
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CAUSES OF GENU VARUM
Metabolic Bone DiseaseNutritional RicketsRenal tubular ricketsRenal Glomerular ricketsRenal Tubular acidosis
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Bonedysplasia
AchondroplasiaMEDOlliers diseaseSED
Congenital tibia vara
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Assymetric growth arrest
Blount’s diseaseTraumaInfectionTumor
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Physiological genu varum Bow legMedial tibial torsion
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Distance between the femoral condylesLateral thigh leg angleFoot normal / postural MT varusFoot progression angleLateral thrust indicate progressionLigamentous stabilityTorsional profile
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X ray UnnecessaryTibia angulated medially at the jn. Of proximal and middle thirdFemur angulated in the distal thirdMedial cortex of tibia and femur thickened and sclerosedEpiphysis,Physis and metaphysis have normal appearanceSymmetrical involvementMetaphyseo diaphyseal angle < 11 degrees
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TREATMENT Spontaneous regression Orthopaedic shoes and Orthosis Osteotomy
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Blount’s disease
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TIBIA VARA (BLOUNT’S disease)Growth defect in the proximal medial tibial epiphysis Infantile <3 yearsJuvenile 3 – 10 yearsAdolescent > 10 years Manifest 18 – 24 yearsObese childrenOften assymetricalProgressive varus deformityLateral thrust on standingSiffert Katz sign
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RADIOGRAPHIC FEATURES
Varus angulation at epiphseo
metaphysealjn
Widened and irregular physeal line medially
Medially sloping and irregularly ossified
epiphysis
Prominent beaking of medial metaphysis
Lateral subluxation of proximal tibia
Normal knee radiograph in a toddler does
not exclude Blount’s
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Tibiofemoral angle Metaphyseo diaphyseal angle Epiphyseo metaphyseal angle Langenskiold classification
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Metaphysio diaphyseal angleTibio femoral angle
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Epiphysio metaphyseal angle
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Physiological genu varum Blounts diseaseInvovement Symmetrical Often assymetricalSite of angulation prox &middle third Proximal metphysisFemur Bowed medially Normal except lateLateral thrust Absent Often presentMeta Dia angle < 11 Greater than 11Upper tib Metaphysis Normal Irregular rarifactionUpper tib Epiphysis Normal Sloping Upper tib Physis Normal Narrowed mediallyLateral Tib Cortex Gentle curve Straight Med Tib Cortex Gentle curve Sharp angulation
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ADOLESCENT TIBIA VARA 8 Years Males Obese Often Unilateral Black Africans Tibia vara Internal tibial torsion
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X RAY
Shape of epiphysis normalLack of beaking of medial tibial metaphysisWidening of medial tibial epiphyseal plateWidening of lateral distal femoral physis
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Achondroplasia
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Mucopolysaccaridosis - Hurler
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Rickets
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Biochemical investigations
S. CalciumS. PhosphorusS. Alkaline phosphatase
Renal function tests
Urine pHGlucoseAmino acids24 hr urine calcium24 hr urine phosphorus
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X-ray
Epiphysissmall fragmented
Physiswide
Metaphysiscuppingflaring
Diaphysisthinning of cortex
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Post infective genu varum
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GENU VALGUMAwkward gaitEasy fatigue due to swinging of legsShoes collapse medially due to pronated feetCalf and leg painPatellar mal alignmentObesity due to inactivityEarly degenerative arthritis
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ASSESSMENT
Inter malleolar distanceLateral tibiofemoral angleQ anglePatellar stabilityTibial torsionFlat foot
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CAUSES OF GENU VALGUM Metabolic Bone Disease
Nutritional RicketsRenal tubular ricketsRenal Glomerular ricketsRenal Tubular acidosis
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Assymetric Growth Arrest
TraumaInfectionTumorPrimary tibia valga
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Bone Dysplasia
MEDSEDChondroectodermal dysplasiaMultiple hereditary exostosisOllier’s disease
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Endocrine Turners syndrome Congenital
Congenital def of fibula Inflammatory
Rh arthritisTuberculosis
Paralytic Polio ITB contracture
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Physiological genu valgum
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Ellis van Creveld syndrome
Pyknodysostosis
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Osteo fibrous displasiaOsteoarthritis
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Turner syndromeHemophilia
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TREATMENT
ReassuranceStretching of ITBShoe modification to avoid foot strainKnock knee orthosisEpiphyseal staplingEpiphyseodesisOsteotomyIlizarovHemichondrodiactasis
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Genu Recurvatum
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TORSIONTwisting of long bone in the longitudinal axis Internal tibial torsion
External tibial torsion
Femoral antetorsion
Femoral retrotorsion
Tibial vs Tibiofemoral torsion
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CAUSES OF TOEING IN GAIT
Metatarsus varusCTEVPronated feet Tibia varaMedial tibial torsionGenu valgum (shift center of gravity medially) Congenital tibial deficiency Abnormal femoral antetorsionSpasticity of medial rotatorsAcetabular anteversion
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TOE OUT GAIT
Talipes calcaneovalgusPes valgusTriceps surae contracture Lateral tibial torsionCong absence of tibiaAbnormal femoral retroversionParalysis of medial rotatorsAcetabular retroversion
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Rotational Profile (Staheli) 1. Foot progression angle
2. Medial hip rotation in extension
3. Lateral hip rotation in extension
4. Thigh foot angle
5. Angle of the trans malleolar axis
6. Configuration of the foot
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1. Foot progression angle
Normal average + 10-15 degrees
Compensatory tibial torsion may make FPA normal even with excessive femoral
torsion
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Medial and lateral hip rotation in extension Medial 40 –60 50 more in females Lateral 25- 65 45 equal in both sexes
Femoral anteversion (Staheli) >90 IR 0 ER severe 80- 90 IR 0-10 ER moderate 70- 80 IR 10- 20 ER mild
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Thigh foot angle
Patient prone
Knee flexed 90 degrees
Ankle neutral
Angle between the long axis of foot and long axis of the thigh
Assessment of tibial torsion
Normal +10
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Angle of transmalleolar axisPatient prone
Knee flexed 90 degrees
Ankle neutral
Line joining the center point of medial and lateral malleolus are marked on sole of foot
Perpendicular to trans malleolar axis
Thigh axis line
Mean +15
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Foot deformities
Metatarsus varus in toeing Calcaneovalgus out toeingPlanovalgus
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Femoral torsion 1 year 40 degrees
2 years 30 degrees (Reduces 1-2 degrees /year)
10 years 20 degrees 15 years 16 degrees Adult 15 +/- 10
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Femoral torsionClinical features In toeing gaitExaggerated IR in extension of the hipLimitation of ERER of hip increased in 90 degree flexion of the hip Adaptive changesHind foot valgusExternal tibial torsion
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Effect
Cosmetic Torsional mal alignment
Patellofemoral problems
Femoral Torsion
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Femoral Torsion Assessment Ryder method
Prone
GT palpated
Leg is laterally rotated till GT is most prominent
The degree of rotation from neutral is the degree of anteversion
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Femoral Torsion Assessment
X ray
CT
MRI
USG
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Femoral Torsion
Treatment
ReassuranceNo role for shoe modificationsOrthosis with twister cables has no roleDB splint harmfulAvoid reverse tailors position while sitting.Encourage cross leg sitting
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Surgery Child more than 9 years
Measured anteversion > 45 degrees(CT/MRI)
Clinically severe (IR>90, ER 0)
Lateral tibial torsion <35
Functional and cosmetic disability Does not increase incidence of OA of hip/ knee
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Surgery
Derotational Osteotomy
Trochanteric
Supramalleolar
Middiaphyseal
Ilizarov
How much to rotate ?
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TIBIAL TORSION
Rotational profile (Staheli)
1. Foot progression angle2. Medial hip rotation in extension3. Lateral hip rotation in extension4. Thigh foot angle5. Angle of the trans malleolar axis6. Configuration of the foot
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Xray Nachlas method Hutter and Scott method Rosen and sandick method
CT
USG
TIBIAL TORSION
Assessment
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MEDIAL TIBIAL TORSION
Idiopathic
Cong metatarsus varus
Genu varum
Femoral anteversion
Familial
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CLINICAL PRESENTATION
Intoeing gait
Bow legs
Kites rotation test
Staheli’s torsion profile
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LATERAL TIBIAL TORSION
Contracture of IT band
Idiopathic
Congenital
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Patella point laterally Feet point outwards Axis medial to 2nd MT LM posterior to MM Knock knee Ober test ITB IR of hip restricted Femoral antetorsion ER of hip restricted Triceps surae contracture cause toeing out gait
CLINICAL PRESENTATION
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External Tibial Torsion
Does not correct with growth
Contracted ITB /TA
DB splint
Osteotomy
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Internal Tibial Torsion Spontaneous correction DB splints Corrective casts Osteotomy severe deformity above 8 years
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Thank You