Knee and Foot Deformities in pediatrics.pdf

Physiotherapy for pediatrics

1. Congenital Knee and
Foot Deformities
Dr. Radwa Said

2. Congenital Knee
Deformities

3. Classification
Malalignment
(angular) knee
deformities
Genu varum &
Genu valgum
Tibiofemoral
angle
Intercondylar &
Intermalleolar
distances
Genu recurvatum
Rotational
deformities
Tibial torsion
Thigh-foot angleFoot progression
angle
Femoral
anteversion/retrov
ersion
Femoral angleCraig’s test

4. Genu varum & Genu valgum

7. Physiologic angular knee
deformities
Pathologic angular knee
deformities
Evaluation-Symmetrical
-Mild –moderate
-Regressive
-Generalized
-Expected for age
-Asymmetrical
-Severe
-Progressive
-Localized
-Notexpectedforage
Causes-Normal–forage
-Exaggerated
§Overweight
§Earlywt.bearing
§Useofwalker?
-Rickets
-Endocrine disturbance
-Metabolic disease
-Injury to epiphyseal plate
(Infection / Trauma)
-Idiopathic

8. Angulation assessment

9. -Mean IC distance is
0.2 cm at 1 -10 years
of age.
-The greatest IM
distances of 2.5 cm
and 2.2 cm were
noted between the
ages of 2 and 4 years.

10. Management
–Most children with knock knees and
bowlegs do not require any
treatment.
–Bracing, connective bars and
orthotics might be prescribed in
some cases.
–Surgical osteotomy may be
considered in severe, non-resolving cases.

11. Genu Recutrvatum
1. Dynamic knee recurvatum is defined
as hyperextension of the knee during
the stance period of the gait cycle and
this impairment is neurologically based.
–-quadriceps weakness
–-ankle planter flexor spasticity
–-heel cord contracture
–-quadriceps spasticity
–-gastrosoleusweakness
2. The structural genu recurvatum can
be congenital due to abnormal intra-
uterine posture.

12. Causes
–A defined disorder of the connective tissues
–Laxity of the knee ligaments
–Ligament and joint capsule injuries
–Irregular alignment of the femur and tibia
–Lower limb discrepancy
–Congenital defect
Management
–Knee support/brace as the Swedish knee cage or ground
reaction force orthosis.
–Strengthening exercise to weak muscles.
–Kinesiotaping.
–Tendon transfer operations in severe cases.
Complications
–Popliteal pain
–Instability
–Decreased mobility
–Increased risk of ACL
injury

13. Tibial Torsion
–-Toe-in and Toe-out
–-Normally, lateral rotation
of the tibia increases from 5°
at birth to 15°at maturity.
–-Surgical management is
avoided until > 10 years.
–-If untreated =
patellofemoral syndrome

14. Thigh-foot angle
Foot progression angle

15. Femoral
Anteversion/
Retroversion
–It is more common in girls.
–The normal angle at birth is 30-40 degrees anteversion.
–The most common onset age is 3-5 years.

16. Femoral AnteversionFemoral Retroversion
Clinical signs-Standing appearance: “kissing patellae”
-Clumsy gait and awkward running
appearance “egg-beater”
-In-toeing feet “pigeon-toed”
-Inverted W sitting position
-Out-toeing “Charlie Chaplin walk”
-Hip internal rotation decreased
-Hip external rotation increased
Causes-Infants: congenital hip dysplasia, cerebral
palsyor other neuromuscular disorder
-Toddlers: Legg-Calve-Perthes disease
-Teen and pre-teen: slipped capital femoral
epiphysis
-Typically related to hip contracture
from intrauterine positioning
Complications-Chondromalacia patellae (patellofemoral
syndrome)
-Slipped capital femoral
epiphysis(if persists >age 8 years
old)
-Legstress fracture

17. -Normalhip:Femoralheadisslightlyanteriortofemoralneck.
-Antevertedhip:Femoralheadissignificantlyanteriortofemoralneck.
§Associatedwithtoeing-in.
§Increasedrangeforhipinternalrotationwhilethereislimitedexternal
rotation.
-Retrovertedhip:
§Femoralheadisposteriortofemoralneck.
§Associatedwithtoeing-out
§Increasedrangeforhipexternalrotationwhilethereislimitedinternal
rotation.

18. Craig’s test
51o-70o38o-56o

19. –Spontaneously resolves to normal range in 80% of the cases by the age of 8 years.
–Avoid non-helpful measures
–Shoe modifications
–Night splints
–Dennis-Browne splint
–Twister cables
–Passivestretching exercises
–Femoral rotational osteotomy indications
–Comorbid neuromuscular disease (e.g.cerebral palsy)
–Severe functionaldisabilityat age > 8 (0.1% of cases)
–Femoral anteversion >50 degrees
–Internal rotation >80 degrees
Management:

20. Congenital Foot
Deformities

21. FeatureNewbornAdult
Arch Flatter, less defined Well defined
Typical ROM Greater ROMLesser ROM
End Point of ROMSoft, difficult to
appreciate
Firm, well defined
Amount of subcutaneous
fat tissue
Greater Lesser
Differences between newborn and adult foot

22. Types:
•Bleck’s test for flexibility
•Bleck’stest for appearance (Heel bisector method)
•V-finger test
Metatarsus adductus
Clubfoot –Talipes equinovarus
Talipes Calcaneovalgus
Flatfoot

23. Metatarsus
Adductus
–1-2:1000 live births
–It is a transverse plane deformity
–Deformity in Lisfranc's (tarsometatarsal) joints.
–The forefoot is adducted with respect to the hindfoot.
–Described as bean/kidney shaped.

24. Causes
–unknown.
–family history.
–intrauterine positioning.
–sleeping position of the baby (on stomach).
–Absence of a medial cuneiform/ abnormal growth of medial cuneiform
–Abnormal muscle position
–Arrest of normal ontologicrotation of the foot

25. Bleck’stest for appearance (Heel bisector method)

26. V-Finger TestBleck’stest for flexibility

27. TypePresentationTreatment
IFlexible, with abduction
beyond the midline of the
heel bisector
Actively corrects with
stroking or tickling the lateral
foot
IIPartly flexible, with abduction
only to the midline
Corrects only with passive
stretching
IIIInflexible, rigid with no
abduction possible
Cannot be passively
corrected (Casts or Surgery
Bleck’stest for metatarsus adductusfor flexibility

28. Reverse last shoes
Wheaton ankle foot orthosis
Bebax‘‘boot’

29. Clubfoot
–AKA Congenital Talipes Equinovarus
–Malalignment of soft and bony structures.
–Soles of the feet face each other.

30. Main Four clubfoot deformities:
1. Cavusin the midfoot
2. Forefoot Adductusmovement
3. Varusof the hindfoot
4. Equinus
1
2
3
4

31. Causes of
Clubfoot
1. Idiopathic clubfoot
–the most common type of clubfoot and is
present at birth.
–1:1000 babies, with half involving only one foot.
–boys:girls= 2:1
2. Neurogenic clubfoot
3. Syndromic clubfoot
–arthrogryposis, constriction band syndrome,
tibial hemimelia and diastrophic dwarfism.

32. Signs and
Symptoms
–Heel inversion with internal rotation
–Kidneyshape: medial foot concave, lateral
foot convex and footinverted.
–Plantar flexion with inability of dorsiflexion
–Very tight heel cord.
–Leg internal rotation.
–Muscular changes:
–Muscle weakness due to the continuous
stretch mainly for the proneustertius.
–Muscle tightness due to their continuous
contraction mainly for the tibialis posterior.

33. X-ray of clubfoot:

34. Treatment
–Ponseti method:
–Casting
–Achilles tendon release
–Bracing: Dennis-Browne splint
–French method: (Daily for 2 months-3/week for 4 months)
–Realignment
–Taping
–Log-term home exercises
–Night splinting
–Surgery

35. Talipes Calcaneovalgus
–Due to malpositioningintrauterine
–The forefoot is abducted and dorsiflexed, and
the heel with calcaneus valgus
–The bones are normal
–The foot evertors and dorsiflexors may be
tight (mainly the proneustertius)
–The foot invertors and plantarflexorsmay be
stretched and/or weak (mainly the tibialis
posterior).

36. Treatment:
–Mostly resolves spontaneously in the
first year of walking.
–Gentle stretching by caregivers.
–If persists:
–Exercises (stretching and
strengthening)
–Corrective shoes
–Splinting:
–Firm, high-top lace up shoes
–Retention taping
–Molded AFO
–Serial casting in severe deformity

37. Flatfoot
–Structural problem
–The toddler may pronate the foot for
stability
–Variant of ligamentous laxity (no treatment)
–Also called:
–Pes planovalgus
–Fallen arches
–Pronation of feet
–Pes planus

38. –It can be:
Flexible:
conservative ttt
Rigid: (rare in
children ) Surgical
intervention

39. Treatment
1. Conservative mainly for flexible
flatfoot
–Stretching exercises (Achilles tendon)
–Proper shoe wear
–Arch supports (orthotic devices):
–Medial wedge.
–UCBL orthosis.
–Heel seat cup with or without medial
posting.

41. 2. Surgery mainly for rigid flatfoot
–Types:
–Tendon repair
–Fusejoints
–Postoperative treatment according
to the type of surgery:
–Strengthening exercises
–Stretching exercises for foot muscles.
–Mobilization.