DEFORMITIES

OF
THE LOWER LIMB
Dr.Tehreem Nasir
CDK
CONGENITAL HYPEREXTENSION & DISLOCATION OF THE KNEE JOINT
 Congenital
Hyperextension &
Dislocation of the knee
Joint
 ○ 50% of the patients with congenital knee dislocation will have
hip dysplasia affecting one or both hips
● Structural Components
○ Anterior capsule of the knee and quadriceps mechanism are
contracted.
○ Intra-articular adhesions
○ Hypoplasia or absence of the patella.
○ Fibrosis and loss of bulk of the muscle
○ Lateral displacement of the patella.
 Clinical Presentation
● Clinical presentation is divided into three grades
according to severity:
○ Grade 1, congenital hyperextension
○ Grade 2, congenital hyperextension with
anterior subluxation of tibia on the femur
○ Grade 3, congenital hyperextension with
anterior dislocation of the tibia on the femur.

Presents with hyperextended

knee at birth
 Treatment
● Depends upon: ● Newborn with mild-to-moderate
○ Severity of subluxation or dislocation hyperextension or subluxation
○ The age of the patient. ○ Excellent results at 5-year Follow up
● Non-operative treatment: ○ In non-responders → skeletal traction for
○ Reduction manual or with casting correction is an option.
■ Indications:
● Most cases can be treated non- ● Operative Treatment:
operatively ● Surgical soft tissue release and correction
● If both knee and hip dislocated, ○ Indications:
then treat knee first. ■ If failure to gain 30 degrees of flexion
■ Technique: after 3 months of casting
● Long leg knee casting on weekly ● .
basis
CDH
CONGENITAL/DEVELOPMENTAL DYSPLASIA OF THE HIP
 Congenital/Developmental Dysplasia of the Hip
 What is the dislocation?
 Femoral head is not in contact with
acetabulum
 Dysplastic changes in acetabulum

 It is a lost of relationships between hip joint

components.
 Occurs in neonatal period.
 Incidence of true hip dislocation in 2-5/1000
live births.
Clasification
Dysplasia
Typical
Subluxation
Developmental (Congenital)
Dysplasia of the Hip Dislocation

Teratologic
(Teratology is the science that studies the causes,
mechanisms, and patterns of abnormal development)
 Primary Prevention
 To avoid hold the baby by the ankles.
 To avoid extraction of the newborn with traction of groins for tights.
 To avoid dressing the newborn with adduction of the hips.
 Always check the hips of babies in each visit to pediatrician
 Child Treatment Methods
 Hip Abduction Braces
 Pavlik Harness. This is a specially designed harness to gently position your baby’s hips in a
well aligned and secure position.
 Traction
 Closed reduction
 Open reduction
 Pelvic osteotomy
 Femoral osteotomy
COXA VARA
 Coxa Vara
 Coxa Vara
 Varus deformity of femoral neck
 Angle between femoral neck and shaft being
less than 110-120o

• Normal angle is between 135-145o

Coxa Vara Types
Etiology 1. Congenital:
• Caused by embryonic limb bud abnormality
2. Developmental:
❑ Femoral neck fractures in children are associated • Developmental deformity of proximal femur
with coxa vara(8%) and coxa valga (3.2%) • Goes unnoticed until walking age
It is caused by • Presents as abnormal gait or leg length difference
❑ Premature epiphyseal closure 3. Acquired:
❑ Loss of reduction after initial fracture reduction or Caused by underlying condition such as
implant failure in an unstable fracture fibrous dysplasia, rickets or traumatic
❑ Incidence can be decreased by internal fixation proximal femoral epiphyseal plate
using pins and screws closure.
 Clinical Features
 Painless abnormal gait
 Trendlenberg limp (Unilateral coxa vara)
Diagnosis:
 Waddling gait (Bilateral coxa vera) • X ray pelvis
 Limb length discrepancy
 Prominent greater trochanter
• MRI
 Limitation of abduction and internal rotation of • CT scan
hip
 Femoral retroversion

Management:
Correction osteotomies and fixation
Indications of surgery
▪Neck to shaft angle less than 90 o
▪Progressive deformity
COXA VALGA
Coxa Valga
 Valgus deformity of femoral neck
o
 Femoral neck shaft angle greater than 139

• Normal angle is between 135-145o

• Infants are born with approximately 150o coxa valga which gradually drops

to adult normal of 115-120o by age 8 years

Coxa Valga
Types
 Congenital
 Acquired
 True
 Occurs after arrest of greater trochanter epiphysis
or neck cartilage following surgical procedures
 Apparent
 Due to femoral antetorsion
 Combination
ANTEVERSION
 Anteversion/Retroversion of Lower Limb

Femoral Angle:
❑ Femur neck is normally anteverted with respect to rest of the femur
❑ Normal femoral anteversion is 15 -20o
 Femoral Anteversion
 A developmental abnormality Femoral anteversion is characterized
by
 Children are normally born with 31-40o femoral • Increased anteversion of the
anteversion femoral neck relative to the femur
• Compensatory internal rotation of
 Gradually decreases the femur
• Lower extremity in-toeing
 Parents might notice children with toes turned inwards or
increased incidence of falling
 Seen in early childhood (3-6 years)
 Twice as frequent in girls than boys
 Often bilateral
 May be hereditary (Due to intrauterine mal-positioning)
 Symptoms Diagnosis
• Intoeing gait
• Sits in the W-position • Radiographs
• Knee pain when associated with tibial torsion • CT
• Functional limitations in sports and activities of daily
living • MRI

 Treatment
• Nonoperative
 Observation and parental reassurance
 Most cases usually resolve spontaneously by age 10
• Operative
 Derotational femoral osteotomy
 Indicated if < 10° of external rotation on examination in an older child (>8-10 yrs)
RETROVERSION
 Femoral Retroversion Causes
 Primarily caused by in-utero
 Head and neck of the femur are angled less position.
than the average anteversion angle along  Tightness of the muscles of
the frontal plane of the body.(femoral neck the hip
angle is less than average range)  Rarely caused by bone
deformity in which there is
 Caused by contracture of the external
an actual external twist of the
rotator muscles of the hip lower portion of femur
 Becomes apparent as the child starts to relative to its upper portion
stand between 6 and 9 months.
PRESENTATIONandSym Treatment:
• Entire extremity appears to be • Attempt to Stretch the muscle group in
externally positioned
• Child appears unsteady or the hip to improve internal rotation.
imbalanced when he/she starts
to walk • Splinting of the legs, especially at night to
• Usually late walker stretch the external rotators and take
• Associated with flatfeet
• Runs very poorly. stress off the internal rotators.
• Poor overall balance. • Exercises to help improve strength to the
• Lacks a desire to participate in
sports or any type of activity. adductor muscles
• Associated with poor
coordination. • Place the leg in a Cast to stretch the
ligaments and muscles around the knee
GENU VARUM
  Femoro-tibial alignment changes with growth

 When does femoro-tibial alignment become pathological?

1. Genu varum
2. Genu valgum
3. Genu recurvatum
 Genu Varum
 Pathologic if:  Causes:
 >18mo without signs of 
resolution
 Unilateral
 Progressive Angulation
 Pain or limp Ligament Laxity
 Underlying medical
diagnoses
 Rickets
 Renal failure
Congenital Pseudoarthrosis Coxa Vara
 Presentation
 Gait
 Stability
 Symmetry

 Treatment:
Non-operative
◼ Brace treatment
 Outcomes Of Treatment
◼ bracing must continue for
◼ Improved outcomes if unilateral
approximately 2 years for
◼ Poor results associated
resolution of bony changes with obesity and bilaterality
Indications ◼ If successful, improvement should occur
within 1 year
◼ Children < 3 years
GENU VALGUM
 Genu Valgum

 Inter-malleolar separation under 3 inches is normal at any age.

 Periodic observation and measurement if less than 3.5 inches

 Pathologic if:
 Intermalleolar distance >8cm (3 inches) >10yo
 Unilateral, Short stature
 Progressive
 Underlying medical diagnosis
◼ Rickets
◼ Renal failure
 Causes Treatment
 Developmental
 No evidence that shoe modification, splints,
 Syndromes e.g Rickets (Alk Phos
raised, with x-ray changes) or exercises affect condition
 Genetic disorders  Surgical options:
 Nutritional conditions e.gVitamin  Not indicated if intermalleolar distance
C deficiency
less than 6cm
 Autoimmune e.g RA
 Corrective osteotomy at maturity.
 Degenerative e.g OA
◼ Generally reserved for skeletally mature
patients
GENU RECURVATUM
 Genu Recurvatum
 Backward bending of the knee
 Up to 5° of genu recurvatum is sometimes seen in women with lax ligaments and is
usually generalized
 Popliteal fossa is convex instead of concave
 Causes
 Congenital
 Symptoms:
 Quadriceps contracture is the  Pain in medial tibiofemoral
 Most common cause in acquired cases joint and referred to
 Two varieties posterolateral ligaments
 Congenital  Hyperextended position of
 Post-injection contracture of infancy and childhood knee
 Neurological disorders: Polio, cerebral palsy, etc.
 Malunited fractures around the knee

 Radiographs:
X-ray of the knee
◼ Knee appears dislocated
backwards
Treatment
 Orthotics
 Surgery
 Treatment of choice
 Indicated in
 Established contractures
 Dislocation of patella
 Early recognition and
prevention through passive
exercises while the child is
receiving injections
TALIPESCALCANEOUS EQINES/
TALIPESCALCANEOUS VARUS/
TALIPESCALCANEOUS VALGUS
PES PLANUS/PES CAVUS
Anatomy of Arches of Foot

1) Two longitudinal
arches
a) Medial
b) Lateral

2) Transverse arches
a) Anterior
b) Posterior
Pes Planus Or Flat Foot Pes cavus or claw foot
 Flatfoot/pes planus) is a condition in  Pes cavus/claw foot also known as high
which the longitudinal arch in the foot, which arch, is a human foot type in which the sole of
runs lengthwise along the sole of the foot, has the foot is distinctly hollow when bearing
not developed normally and is lowered or weight. That is, there is a fixed plantar flexion
flattened out. One foot or both feet may be of the foot.
affected.
 Use of Arches of foot
✓Supports body weight in upright posture
✓Acts as a lever to propel the body forwards in walking , running and jumping
✓Acts as a shock absorber
✓Concavity of arches protects the soft tissues of the sole against pressure.
 Treatment
a) Arthrodesis (uniting two bones at a joint)
b) Wedge osteotomy
  Orthotic
Treatment  Conservative

 Surgery indicated if;

1) Painful condition
2) Failure to respond to orthotic control
3) Ulceration
4) Excessive shoe wear

 Surgical treatment
✓Arthrodesis
✓Foot plasty
✓Osteotomy
HALLUX VALGUS/HALLIX VARUS
Hallux Valgus/Hallix Varus
Hallux Valgus

 Lateral deviation of the great toe and medial

deviation of the first metatarsal
 Progressive subluxation of the first
metatarsophalangeal joint.
Pathophysiology
 Intrinsic conditions/hereditary
 Footware
 Female gender
 4th to 6th decade
 Rheumatoid arthritis
Clinical Presentation
• Pain
• Pressure from footware
• Irritation of skin
• Breakdown of skin
Hallux Varus
 Hallux Varus is a deformity of
the great toe
joint where the hallux is deviated
medially
(towards the midline of the body) away
from
the first metatarsal bone.
 The hallux usually moves in the
transverse plane.
Varus & Valgus Deformities
 The adductor hallucis exerts a valgus force on the joint,
while the abductor exerts a varus force.
 Once the toe is rotated out of a neutral position, those
varus and valgus forces become deforming forces.
 Treatment Options:
 As is usually the case, non-operative treatment should be
attempted before surgery.
 Options include orthotics, splints, and tapings.
 Generally, treatment should begin as early as possible.
HALLUX RIGIDUS/HAMMER TOE
Hallux Rigidus
✓ Hallux refers to the Stiff Big toe,
while rigidus indicates that the toe is rigid and cannot
move.
 Hallux Rigidus is a disorder of the joint located at
the base of the big toe.
Signs & Symptoms
✓Pain and stiffness in the joint at the base of the big toe
during use (walking, standing, bending, etc.)
✓Difficulty with certain activities (running, squatting)
✓Swelling and inflammation around the joint
 Hammer Toe
✓A Hammer toe or Contracted toe is a deformity of the muscles and
ligaments of the proximal interphalangeal joint of the second, third, or
fourth toe causing it to be bent, resembling a hammer.
Causes Treatment
✓ Poorly fitting shoes • Physical therapy
✓ High heels • Spacious toe boxes
✓ Short or narrow shoes • Feet rest
✓ Osteoarthritis
• Brace application
✓ Rheumatoid arthritis
• Corrective surgery
THANK YOU
Dr.Tehreem Nasir
MBBS, RMP