DEFORMITIES

OF
LOWER LIMB
 Classification of Deformities
Deformities can be classified under according to
the cause :
• Congenital
• Developmental
• Metabolic
• Neoplastic
• Infective
• Inflammatory
• Degenerative
• Traumatic & miscellaneous
 Deformities Involving the Hip
• Developmental dysplasia of hip (DDH)
• Coxa plana
• Coxa valga
• Coxa vara
• Acquired dislocation of the hip
• Acetabular dysplasia & subluxation of hip
• Femoral anteversion
• Proximal femoral focal deficiency
• Irritable hip
 Deformities Involving the Knee,
Foot & Toes
• Deformity of Knee • Deformity of Great Toe
-Genu Varum -Hallux Valgus
-Genu Valgum -Hallux Rigidus
-Genu Recurvatum
• Deformities of Lesser Toes
• Deformity of Foot -Hammer–toe
-Pes cavus -Claw-toe
-Mallet-toe
 Developmental Dysplasia of Hip
(DDH)
• Previously known as Congenital Dislocation of Hip
• Spectrum disorder :
–Frank dislocation during neonatal
–Subluxation/ partial displacement
–Shallow acetabulum without actual displacement
• Females to males ratio = 7 is to1
 Developmental Dysplasia of Hip
Aetiology of DDH :
• Genetic factors
• Hormonal changes in pregnancy :
maternal relaxin released in pregnancy,
transmitted to fetus, causing ligamental laxity
• Intrauterine malposition, esp breech position with
extended legs favouring dislocation
• Postnatal way of carrying the baby
carrying with hips & knees fully extended
 Developmental Dysplasia of Hip
Pathology of DDH :
• Acetabulum shallowed (saucer shaped instead of
cup), roof slooped too deeply
• Femoral head slides out posteriorly & rides upwards
• Joint capsule stretched, remains intact
• Fibrocartilaginous labrum folded into cavity, thus
preventing reduction
• Retarded maturation of acetabulum & femoral
epiphysis
• Femoral head anteverted
• Ligamentum teres hypertrophied
• Muscle around hip, esp adductors adaptively
shorten
 Developmental Dysplasia of Hip
Early Presentation of DDH :
DDH should ideally be diagnosed at birth
1) Ortolani’s test
– Femur elevation & abduction to relocate hip
– A test of reducibility of dislocated hip
2) Barlow’s test
– Femur adduction & depression to dislocate hip
– A test of dislocatability of unstable hip
Developmental Dysplasia of Hip
 Developmental Dysplasia of Hip
Late Presentation of DDH :
Ideally, should re-examine baby at 6m, 12m & 18m
• Limited hip abduction & delay in walking
• Higher buttock fold on affected side & asymmetry of
thigh folds
• Ortolani positive
• Trendelenburg test positive
(when stand on affected
side, ASIS on normal side
dips down)
 Developmental Dysplasia of Hip
• Galeazzi’s sign (lowering of knee at affected side in
a supine position with knee & hip flexed)
 Developmental Dysplasia of Hip
Special Tests in DDH :
• Telescopy positive (up & down piston movement of
examiner’s finger at greater trochanter)
• Trendelenburg gait
(body lurch to affected
side when bear weight,
in unilateral DDH)
• Waddling gait
(alternating lurch on
both sides, in bilateral DDH)
 Developmental Dysplasia of Hip
X-ray Features of DDH :
• Shallow acetabular socket
• Acetabular roof slopes upwards
• Underdeveloped ossification centre of femoral head
• Displaced femoral head

0
 Developmental Dysplasia of Hip
Principles of Management in DDH :
• Achieve reduction of head into acetabulum
• Maintained hip becomes clinically stable by close
reduction
• If reduction is delayed more than 2 years,
acetabular remodelling will not occur
• Thus, do not attempt for close reduction as forceful
reduction can cause avascular necrosis of bone
• Open reduction is done in this case
 Developmental Dysplasia of Hip
Treatment of DDH :
If the child is less than 6 months old :
• Double napkins/ abduction pillow between legs for
hip instability, first 6 weeks; then re-examine
• Formal abduction splintage for persistent hip
instability
• If double napkins fail,
Pavlik Harness
can be used for
three to nine months;
keeps the hip in flexion
& abduction
 Developmental Dysplasia of Hip
Treatment of DDH :
If the child is between 6 months to 6 years old with
persistent dislocation :
• Closed reduction
• Splintage/ traction after reduction
• Open reduction
 Developmental Dysplasia of Hip
Treatment of DDH :
If the child is more than 6 years old with
persistent unilateral hip dislocation :
• Open reduction
• Corrective osteotomy of femur/ innominate
osteotomy of pelvis if necessary
• In older children, no intervention as to avoid
avascular necrosis
• Reconstructive surgery if develop pain & abnormal
function
 Developmental Dysplasia of Hip
Treatment of DDH :
If the child is more than 6 years old with
persistent bilateral hip dislocation :
• Hard to maintain symmetry of both sides during
operation
• Thus, better with no surgical intervention until
develop pain & abnormal function
• Hip replacement if severe disability
 Acquired Dislocation of Hip
Dislocation after first year of life can be due to :
3 causes :
• Pyogenic arthritis
• Muscle imbalance
• Trauma
Dislocation following sepsis :
• Osteomyelitis of femoral head causes enzymatic
digestion of articular cartilage
• Septic arthritis causes partial/ complete dissolution
of femoral head & dislocation of hip (Tom Smith
dislocation)
• Treated by traction initially, followed by open
reduction if indicated, varus osteotomy &
reconstructive surgery if necessary
 Acquired Dislocation of Hip
Dislocation due to muscle imbalance :
• Unbalanced paralysis in childhood (could be due to
cerebral palsy, myelomeningocele, poliomyelitis) 
hip adductors stronger the abductors  femoral
neck becomes valgus & hip may be dislocated
• Treatment is similar to late DDH
• Muscle rebalancing operation if necessary
3. Trauma dislocation :
• Treatment by closed reduction is essential
(Open reduction if indicated)
 Coxa Vara
• Femoral neck shaft angle less than 120 deg
(normal : 160 deg at birth, 125 deg in adults)
• Bilateral in 1/3 cases
• 2 types :
congenital
& acquired
 Congenital Coxa Vara
• Rare disorder
• Due to defect of endochondrial ossification in
medial
of femoral neck when child starts to crawl & stand
• Thus bending of femoral neck & causing stress
fracture if continue bearing weight
• Finally, collapses & become varus, with shortening
or bowing of femoral shaft
 Acquired Coxa Vara
• At any age
• Causes :
– Osteochondral dystrophies
– Rickets
– Following severe grades of slipped femoral
epiphysis
– Adult osteomalacia
– Malunion/ non-union of femoral neck fracture
causing varus deformity of femoral neck
 Coxa Vara
Clinical Features of Coxa Vara :
• Painless limp in child who has just started walking,
might have waddling gait
• Leg shortening in severe case
• Limited abduction & internal rotation
 Coxa Vara
X-ray Findings of Coxa Vara :
• Physeal line too vertical
• Separate triangular fragment of bone in inferior
portion of metaphysis (Fairbank’s triangle) which is
an ossification defect
 Coxa Vara
Treatment of Coxa Vara :
• Based on Hilgenreiner’s angle (between
Hilgenreiner’s line & line through proximal femoral
epiphysis)
• Normal angle is less than 25 degrees
1. If less than 45 degrees, will correct spontaneously
2. If 45 to 60 deg :
close observation
3. If more than 60 deg :
surgery
 Perthes’ Disease (Coxa Plana)
Definition of Perthes’ Disease of Hip :
• A non-inflammatory deformity characterized by
necrosis of femoral head
• Presents in 4 to 8 year old
• 1:10000
• Delayed skeletal maturity
• Boys more common
 Perthes’ Disease (Coxa Plana)
Clinical Features of Perthes’ Disease of Hip :
• Pain
• Effusion (from synovitis)
• Limp
• Decreased hip range
of movements
(esp internal rotation
& abduction)
• Trendelenburg gait
 Perthes’ Disease (Coxa Plana)
Pathogenesis of Perthes’ Disease of Hip :
• Up to 4 months old, femoral head has 3 supplies :
– Metaphyseal vessel which penetrate growth disc
– Lateral epiphyseal vessels which run in retinacula
– Scanty vessels which run in ligamentum teres
• Metaphyseal supply gradually declines & disappear
by 4 years old
• Lateral epiphyseal head supply entirely during 4 to
7 years old
• Ligamentum teres supply starts develop at 7 years
old, but vessels in reticunala are susceptible to
stretching & effusion pressure
 Perthes’ Disease (Coxa Plana)
Pathology of Perthes’ Disease of Hip :
• Process takes 2 to 4 years to complete & has 3
stages :
Stage 1 : Bone Death :
• Following more than one episode of ischaemia
• Thus, part of femoral head dies
• Still looks normal in X-ray, but femoral head stops
enlarging
Stage 2 : Revascularization & Repair :
• New vessels enter area & new bone laid down on
dead trabeculae
• Thus, appears to have increased density on X-ray
• Bony architecture can be restored if only part of
epiphysis is involved or repair process is rapid
 Perthes’ Disease (Coxa Plana)
Stage 3 : Distortion & Remodelling :
• Epiphysis collapsed & subsequent growth at head
& neck will be distorted if
– Lateral part of bony epiphysis is damaged
– Repair process slow
• Thus, epiphysis ends up flattened (coxa plana)
• Femoral head incompletely covered by acetabulum
& irregular shape of head predispose to
degenerative arthritis in later life
 Perthes’ Disease (Coxa Plana)
X-ray Findings of Perthes’ Disease of Hip :
• Increased density of bony epiphysis
• Apparent widening of joint space
• Flattening, fragmentation, lateral displacement of
epiphysis
• Rarefaction &
broadening of
metaphysis
• Flattening of
femoral head
 Perthes’ Disease (Coxa Plana)
Management of Perthes’ Disease of Hip :
Early symptoms :
• Activity limitation
• Anti-inflammatory drugs
• Bed rest & traction if pain
Late symptoms :
• Containment needed : to keep the femoral head well
seated within acetabulum for revascularisation, by
holding hips widely abducted in plaster or splint for 1
year
• Varus osteotomy of femur or innominate osteotomy
of pelvis only if necessary
 Perthes’ Disease (Coxa Plana)
Treatment of Perthes’ Disease of Hip :
• Based on Hilgenreiner’s angle
(between Hilgenreiner’s line & line through proximal
femoral epiphysis)
• Normal angle is less than 25 degrees
1. If less than 45 degrees, will correct spontaneously
2. If 45 to 60 deg :
close observation
3. If more than 60 deg :
surgery
 Perthes’ Disease (Coxa Plana)
Prognosis of Perthes’ Disease of Hip :
Depends on :
• Bone age
• Radiographic appearance during fragmentation
phase (Lateral pillar classification) :
A : normal height of lateral pillar maintained
B : greater than 50% of lateral pillar maintained
C : less than 50% of lateral pillar maintained
 Genu Varum
Definition of Genu Varum : (Bow-legged)
• Knee angled inward, bent or twisted inward
• A deformity marked by medial angulation of the leg
in relation to the thigh, an outward bowing of the
legs, giving the appearance of a bow
 Genu Varum
Causes of Genu Varum :
• Physiological : There is gradual spontaneous
correction to zero degrees at one & one-half to two
years of age
• Pathological :
 Blount’s disease/ tibia vara (MC)
 Rickets
 Metaphyseal dysplasia
 Osteochondromatosis
 Fibrous dysplasia
 Multiple epiphyseal dysplasia
 Osteomyelitis
Genu Varum
 Genu Varum
• Pathologic bow leg deformities may produce serious
problems
• Factors suggestive of pathologic conditions include
– failure of genu varum to correct by age two years
– increasing deformity
– unilateral bowleg
– marked lateral thrust
with weight bearing
 Genu Varum
Clinical Assessment of Genu Varum :
• Bilateral genu varum can
be recorded by measuring
the distance between the
knees with the legs straight
& the medial malleoli just
touching; the intercondylar
distance should be less
than 6 cm
Blood tests can be done
to rule out rickets
 Genu Varum
X-ray Findings of Genu Varum :
• X–rays on standing position
angle created by
the intersection of
a line through the
transverse plane
of the proximal
tibial metaphysis
with a line
perpendicular to
the long axis of
the tibial diaphysis
 Genu Varum
Treatment of Genu Varum :
• Treatment is unnecessary, but the parents should be
reassured & the child should be seen at intervals of
6 months to record the progress
• Operative correction is indicated when the deformity
is still marked by the age of 10
• This is done by stapling one side of the physis to
slow growth on that side (epiphyseodesis)
 Blount’s Disease
• Due to disturbance of the medial aspect of the
proximal tibial growth plate
• Most prevalent in blacks
• The infantile form is usually bilateral, progressive,
& associated with significant internal tibial torsion
• Most often it is seen in obese children of short
stature who started walking early
• The juvenile form is usually unilateral, less
deforming & without internal tibial torsion
• Diagnosis can be made by measuring the
metaphyseal-diaphyseal angle on a standing x-ray :
if this angle exceeds 11 degrees, most often the
varus deformity will be progressive & represents
Blount's Disease
Genu Varum vs Blount’s Disease
• Genu Varum : involves both the femur & the tibia
• Blount's Disease : affects only the tibia with no
femur involvement
 Genu Valgum
Definition of Genu Valgum : ("knock-knees“)
• A condition where the knees angle in & touch one
another when the legs are straightened.
 Genu Valgum
• Individuals with severe valgus deformities are
typically unable to touch their feet together while
simultaneously straightening the legs
• Mild genu valgum is relatively common in children
up to two years of age & is often corrected naturally
as child grows up
• However, the condition may continue or worsen with
age, particularly when it is the result of a disease,
such as rickets or obesity
• Idiopathic genu valgum that is congenital or
has no known cause
 Genu Valgum
Diagnosis of Genu Valgum :
 Genu Valgum
Diagnosis of Genu Valgum :
Measuring the Q Angle
(Quadriceps Angle):
• The Q angle is formed by
the line drawn from the
ASIS to the centre of the
patella & the line drawn
from the centre of the
patella to the tibial
tuberosity
• Normal male : 14 deg.
• Normal female : 17 deg.
 Genu Valgum
Treatment of Genu Valgum :
• Generally, there is no known cure for knock knees
post-childhood
• If the condition persists or worsens into late
childhood & adulthood, a corrective osteotomy may
be recommended to straighten the legs
• Adults with uncorrected genu valgum are typically
prone to injury & chronic knee problems such as
chondromalacia & osteoarthritis
• In some cases, total knee replacement surgery may
be required later in life to relieve pain &
complications resulting from severe genu valgum
 Genu Recurvatum
Definition : Excessive hyperextension of knee
Normal : 5 to10 degrees of hyperextension at the knee
Causes :
• Congenital
• Ligament laxity
• hypotonia as in rickets
• post-poliomyelitis
• neuropathic joint
Treatment : Depends on cause
• Soft tissue : Quadriceps spasticity or fibrosis
• Bone :
- congenital
- post-traumatic
• Both
Congenital Talipes Equino Varus
(CTEV or “Clubfoot”)
• Talipes talus

• Equino horse
• Equinuus horse hoof
• Varus

• Adduction & inversion

Congenital Talipes Equino Varus
(CTEV)
Congenital Talipes Equino Varus
• Common in Maoris (New Zealand) & Asians
• More common in males, M : F = 2 : 1
• Bilateral in 30 to 50% of cases
Aetiology of CTEV :
• Genetic : multi-factorial inheritance
• Mal-position of the foetal foot
– Increased content in uterus
– Decreased volume of uterus
eg. fibroid uterus
• Neuromuscular defect
 Congenital Talipes Equino Varus
Classification of CTEV :
1. Idiopathic :
• Postural (extrinsic)
–Intra uterine moulding
• Rigid (intrinsic)
–Abnormal development
2. Neurogenic :
• With spina bifida
–sensory loss present
• With arthrogryposis
 Congenital Talipes Equino Varus
Pathology of CTEV :
Contracture of muscle / tendon :
• Tendoachilles
Contracture of capsule :
• Posterior capsule of ankle
• Medial capsule of subtalar joint
• Medial & inferior capsule of talonavicular joint
Contracture of ligaments :
• Plantar ligament
• Deltoid ligament
• Spring ligament (plantar calcaneo-navicular ligament)
 Congenital Talipes Equino Varus
Deformities in fore-foot & hind-foot
Classification of Deformities :
Mild : deformity can be corrected passively to
beyond neutral
Moderate : deformity can be corrected passively to
neutral
Severe : deformity cannot be passively corrected
 Congenital Talipes Equino Varus
Clinical Features of CTEV :
Typical deformities include :
• Heel is raised & small
• Foot is inverted
• Medial malleolus less prominent
• Arch of the foot increased as in cavus
• Lateral border of foot is convex
• Medial border is concave
• Foot cannot be pushed through
normal range of dorsiflexion
and eversion
 Congenital Talipes Equino Varus
Clinical Features of CTEV :
• In unilateral cases affected foot is smaller
• Muscles of leg are under-developed
• When presented late : callosity on lateral aspect of
foot & malleolus
Congenital Talipes Equino Varus
Treatment of CTEV :
Started as soon as possible : becomes rigid with time
Infants less than 6 months old : Principles
1. Correct one deformity at a time
2. Correction by manipulation without anaesthesia
3. No force to be applied during manipulation
4. Deformity corrected in a particular sequence
5. Above knee plaster case to be applied with knee
in 90 deg flexion & foot in sequentially corrected
position after manipulation
6. The foot is reassessed clinically & radiologically
 Congenital Talipes Equino Varus
Treatment of CTEV :
Treatment for infants less than 6 months old :
• Kite’s manipulation & serial cast application
• Fore-foot adduction
• Hind foot varus
• Forefoot & hind-foot equinus
Break in mid-tarsal joint :
Rocker - bottom deformity
 Congenital Talipes Equino Varus
Treatment of CTEV :
Treatment for infants less than 6 months old :
• If correction satisfactory : Dennis-Brown splint until
1 year old, later club-foot shoes till skeletal maturity
• If correction unsatisfactory : posterio-medial soft
tissue release operation
 Congenital Talipes Equino Varus
Treatment of CTEV :
Treatment for infants over 6 months old :
Mild deformity : Conservative management
Moderate to severe deformities :
• Surgical release of the soft tissue by
postero-medial soft tissue release
• Contracted soft tissues are either lengthened or
divided, Tendoachillis & tibialis posterior lengthened
by Z-plasty
 Congenital Talipes Equino Varus
Treatment of CTEV :
Post operatively :
• Plaster cast applied, split post-operatively if oedema
• Cast reinforced, child discharged in 5 days if afebrile
• Sutures removed at 14 days
• Cast reapplied in operation theatre under anesthesia
• Cast retained for 6 weeks
• Cast removed , Dennis-Brown splint measured for &
cast reapplied
• Dennis-Brown splint applied at end of 3 months
 Congenital Talipes Equino Varus
Dennis-Brown Splint :
• Dynamic splint
• Used in children less than 1 year old, till child walks
• Cannot be used beyond this age as the splint will
not allow walking
• Used for maintenance of corrected position of the
foot
• Not used for correcting
the deformity
• Shoes placed in 20 deg
external rotation
 Congenital Talipes Equino Varus
Treatment of CTEV :
Treatment for children over 4 years old :
• In addition to soft tissue release, bony surgery may
be required
• Bony surgery also needed in case of relapse or
recurrence of deformity
Evan’s Procedure : calcaneo-cuboid fusion, wedge of
bone removed to correct forefoot adduction &
inversion, decrease growth on lateral side & allow
medial side to grow
Dwyer’s Procedure : Lateral wedge is removed from
calcaneum to correct hind-foot varus
 Congenital Talipes Equino Varus
Treatment of CTEV :
Treatment for children after skeletal maturity :
Triple Arthrodesis :
• Fusion of three joints done after removal of suitable
wedges to correct deformities
Talo-navicular
Calcaneo-cuboid
Subtalar joint
Neglected CTEV
• Illizarov’s method
is an option
 Pes Cavus (High Arched Foot)
• Arch is higher than normal with clawing of the toes
• Seen in neurological disorders where the intrinsic
muscles are weak or paralysed suggest that all
forms of pes cavus are due to some type of muscle
imbalance
 Pes Planus (Flat Foot)
• Child will have flat feet when born & develop an arch
as he grows up with weight bearing & walking
• In adults : may be due to abnormal ligamentous
laxity, tarsal deformities, disorders of the tibialis
posterior tendon, post-traumatic deformity,
degenerative arthritis, neuropathy & conditions
resulting in muscular imbalance
Treatment for Pes Planus :
• Functional Foot Orthosis
• Physiotherapy
• Surgery
Pes Planus
 Hallux Valgus
• In those who have never worn shoes, big toe is in
line with the first metatarsus, retaining the slightly
fan-shaped appearance of the forefoot
• In those who habitually wear shoes, the hallus
assumes a valgus
position & is only
referred as
hallus valgus
when the angulation
if excessive
 Hallux Valgus
• Metatarsus primus varus may be :
congenital
loss of muscle tone in forefoot in the elderly
common in rheumatoid arthritis
• Lateral deviation & rotation of hallux, together with
hypertrophy (exostosis) of medial part of metartasal
head & overlying bursa which together form a
prominent bump or (‘bunion’) on the medial side
• Lateral deviation of hallux may lead to overcrowding
& sometimes overriding of lateral toes
 Hallux Valgus
Clinical Features of Hallus Valgus :
• Common in women 50-70
• Usually bilateral
• Those with strong family history tendency appears
during late adolescence
• Often there is no symptom
• If pain present may be due to :
shoe pressure on large or an inflamed bunion
splaying of forefoot & muscle strain (metatarsalgia)
associated deformities of the lesser toes
secondary osteoarthritis of first metatarso-
phalangeal joint
 Hallux Valgus
X-ray Findings of Hallus Valgus :
• Standing position to show degree of first
metatarsus & hallux angulation
• The first metatarsal-phalangeal joint may be
subluxated or it may look osteoarthritic
 Hallux Valgus
Treatment of Hallus Valgus :
In adolescence : conservative due to high recurrence
rate (20 to 40%)
• wear shoes with deep toe-boxes, soft upper & lower
heels
• if deformity progresses, then corrective osteotomy
In adults :
• Excision of bunion
• Metatarsal osteotomy & soft tissue rebalancing
• If first metatarso-phalangeal joint is frankly
osteoarthritic, arthrodesis of joint may be a better
option
 Hammer-toe
• Isolated flexion deformity of proximal interphalangeal
joint with hyperextension of metatarso-phalangeal
joint of second or third toe
• Distal interphalangeal joint is straight or pulled into
hyperextension
• May produce a painful corn
on dorsally projecting
PIP jt when wearing
covered shoes
 Hammer-toe
Causes of Hammer-toe :
• Wearing poorly-fit shoes that can force the toe into a
bent position as in high-heeled shoes
• Toes bent for long time cause intrinsic muscles to
shorten
• Can also be seen in
diabetes mellitus,
osteoarthritis,
rheumatoid arthritis,
stroke,
Charcot-Marie-Tooth disease
 Hammer-toe
Treatment of Hammer-toe :
• Operative correction is indicated for pain or for
difficulty with wearing shoes
• Toe is shortened & straightened by excising the joint
then fusing the proximal & middle phalanges
• Alternative treatment is to fix toe in straight position
with Kirschner wire
 Claw-toe
• All toes can be affected to greater or lesser degree
• Metatarso-phalangeal joints are hyperextended &
interphalangeal joints are flexed
• If all toes are involved, maybe associated with pes
cavus or some other cause of intrinsic muscle
insufficiency
 Claw-toe
Clinical Features of Claw-toe :
• Pain in forefoot & under metatarsal heads
• Bilateral
• Restricted walking
• Initially, the joints are mobile & can be passively
corrected; later deformities become fixed &
metatarso-phalangeal joints subluxed or dislocated
• Painful corns & callosities develop
• In very severe cases, skin ulcerates at press sites
 Claw-toe
Treatment of Claw-toe :
• If toe can be passively straightened, may obtain
relief by wearing a metatarsal support
• If toe cannot be passively straightened, dynamic
correction is achieved by transferring long toe flexor
to extensor
• If fixed deformity, either accepted & accommodated
by special footwear or treated by interphalangeal
joint arthrodesis combined with tendon transfer
 Mallet-toe
• Detached or avulsed insertion of extensor tendon
to distal interphalangeal joint of toe
Hammer-toe, Claw Toe
& Mallet Toe