ANGULAR AND TORSIONAL DEFORMITIES IN LOWER LIMB

CLINICAL AND RADIOLOGICAL ASSESSMENT

Dr T.S. GOPAKUMAR

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

Evolution of alignment in the lower limbs

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

HEUTER VOLKMANN LAW (1862)

Pressure inhibit growth and decreased

pressure accelerate the growth of the physis

ASSESSMENT OF ANGULAR DEFORMITY

HistoryNutritional deficiencyRenal diseasesMuscle weaknessGastrointestinal problemsFamily history

ASSESSMENT OF ANGULAR DEFORMITY

StatureUpper segment lower segment ratioFaciesTeethMetaphyseal thickeningHandNailsChanges of ricketsProximal muscle weakness

CAUSES OF GENU VARUM 

Metabolic Bone DiseaseNutritional RicketsRenal tubular ricketsRenal Glomerular ricketsRenal Tubular acidosis

 

Bonedysplasia 

AchondroplasiaMEDOlliers diseaseSED

  Congenital tibia vara

Assymetric growth arrest 

Blount’s diseaseTraumaInfectionTumor

 

Physiological genu varum Bow legMedial tibial torsion

Distance between the femoral condylesLateral thigh leg angleFoot normal / postural MT varusFoot progression angleLateral thrust indicate progressionLigamentous stabilityTorsional profile

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

TREATMENT Spontaneous regression Orthopaedic shoes and Orthosis Osteotomy

Blount’s disease

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

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

Tibiofemoral angle Metaphyseo diaphyseal angle Epiphyseo metaphyseal angle Langenskiold classification

Metaphysio diaphyseal angleTibio femoral angle

Epiphysio metaphyseal angle

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 

ADOLESCENT TIBIA VARA      8 Years     Males     Obese     Often Unilateral     Black Africans     Tibia vara     Internal tibial torsion

X RAY

Shape of epiphysis normalLack of beaking of medial tibial metaphysisWidening of medial tibial epiphyseal plateWidening of lateral distal femoral physis

Achondroplasia

Mucopolysaccaridosis - Hurler

Rickets

Biochemical investigations

S. CalciumS. PhosphorusS. Alkaline phosphatase

Renal function tests

Urine pHGlucoseAmino acids24 hr urine calcium24 hr urine phosphorus

X-ray

Epiphysissmall fragmented

Physiswide

Metaphysiscuppingflaring

Diaphysisthinning of cortex

Post infective genu varum

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

ASSESSMENT

Inter malleolar distanceLateral tibiofemoral angleQ anglePatellar stabilityTibial torsionFlat foot

CAUSES OF GENU VALGUM Metabolic Bone Disease 

Nutritional RicketsRenal tubular ricketsRenal Glomerular ricketsRenal Tubular acidosis

Assymetric Growth Arrest 

TraumaInfectionTumorPrimary tibia valga

Bone Dysplasia 

MEDSEDChondroectodermal dysplasiaMultiple hereditary exostosisOllier’s disease

Endocrine Turners syndrome Congenital

Congenital def of fibula Inflammatory

Rh arthritisTuberculosis

 Paralytic  Polio ITB contracture 

Physiological genu valgum

Ellis van Creveld syndrome

Pyknodysostosis

Osteo fibrous displasiaOsteoarthritis

Turner syndromeHemophilia

TREATMENT 

ReassuranceStretching of ITBShoe modification to avoid foot strainKnock knee orthosisEpiphyseal staplingEpiphyseodesisOsteotomyIlizarovHemichondrodiactasis

Genu Recurvatum

TORSIONTwisting of long bone in the longitudinal axis Internal tibial torsion

External tibial torsion

Femoral antetorsion

Femoral retrotorsion

Tibial vs Tibiofemoral torsion

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

TOE OUT GAIT

Talipes calcaneovalgusPes valgusTriceps surae contracture Lateral tibial torsionCong absence of tibiaAbnormal femoral retroversionParalysis of medial rotatorsAcetabular retroversion

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

1. Foot progression angle 

Normal average + 10-15 degrees

Compensatory tibial torsion may make FPA normal even with excessive femoral

torsion 

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

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

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

Foot deformities

Metatarsus varus in toeing Calcaneovalgus out toeingPlanovalgus

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

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

Effect

Cosmetic Torsional mal alignment

Patellofemoral problems 

Femoral Torsion

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

Femoral Torsion Assessment  

X ray

CT

MRI

USG

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

 

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

Surgery

Derotational Osteotomy

Trochanteric

Supramalleolar

Middiaphyseal

Ilizarov

How much to rotate ?

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

Xray Nachlas method Hutter and Scott method Rosen and sandick method

CT

USG

TIBIAL TORSION

Assessment

MEDIAL TIBIAL TORSION

Idiopathic

Cong metatarsus varus

Genu varum

Femoral anteversion

Familial 

CLINICAL PRESENTATION

Intoeing gait

Bow legs

Kites rotation test

Staheli’s torsion profile 

LATERAL TIBIAL TORSION 

Contracture of IT band

Idiopathic

Congenital

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

External Tibial Torsion

Does not correct with growth

Contracted ITB /TA

DB splint

Osteotomy 

Internal Tibial Torsion Spontaneous correction DB splints Corrective casts Osteotomy severe deformity above 8 years 

Thank You