Paediatric Lower Limb Deformity

Likely Pathologic Varus

  • Unilateral
  • Severe
    • 2SD outside selenius curve
  • IM distance >15 cm at 5 years
  • Varus present over 2 years old
  • Obese child
  • Wider developmental abnormality evident

Likely Pathologic Valgus

  • Unilateral
  • Severe
    • IM distance >10cm at 10 years
  • Progressive deformity

Genu Varus Causes

  • Blount’s Disease
  • Rickets (all types)
  • Achondroplasia
  • Tibial Hemimelia
  • Osteogenesis Imperfecta

Genu valgus causes

  • Morquio Syndrome

  • Multiple Epiphyseal Dysplasia (MED)

  • Cozen’s fracture

  • Hypophosphataemic Rickets

  • Physiologic

Both

  • Multiple hereditary osteochondromatosis
  • Infection
  • Trauma

Blount’s Disease

Epidemiology

  • Most common paediatric cause of tibia vara

Aetiology

  • Obesity – overload on medial tibial physis restricts growth
  • There is varus but also internal rotation deformity

Classification

  • Infantile or Adolescent
    • Infantile is more aggressive with worse outcomes.
  • Langenskiöld Classification
    • 6 stages based on the appearance of the medial physis
    • Grade 1 & 2 are mild
    • Grade 5 & 6 are severe with joint depression

Evaluation

  • Differentiate between physiologic bowing and Blount’s:
    • Physiologic bowing:
      • Milder
      • Spread across whole tibia, not at physis
      • Will not progress
      • Will not cause pain
      • Always bilateral

Investigations

  • X-Ray if:
    • Progressive bowing
    • Walking age child with >20-degree varus
    • Short stature or family history of metabolic bone disease

Management

  • Primary Aim: Restore mechanical axis
  • Secondary Aims:
    • Elevate joint depression
    • Equalize limb lengths
    • Prevent complications (e.g., compartment syndrome)
  • Non-Operative:
    • Grade 1 or 2 initially
    • Appropriate for <4 years if not severe
  • Operative:
    • Osteotomy (Infantile: Long oblique; Adolescent: Dome or medial opening wedge)

Genu Valgum

Causes

  • Physiologic
  • Obesity
  • Cozen’s fracture
  • Hypophosphataemic rickets
  • Multiple Epiphyseal Dysplasia
  • Tumour
  • Infection

Management

  • Non-Operative:
    • Reassure and observe if physiologic and asymptomatic
  • Surgical:
    • Guided Growth: Lateral physis tethering (8-plate or staples)
    • Hemiepiphysiodesis: Permanent correction
    • Osteotomy: For older children or residual deformity

Tibial Bowing

Types

  • Posteromedial Bowing
    • Physiologic; resolves spontaneously
    • Complication: Leg length discrepancy
  • Anterolateral Bowing
    • Associated with congenital pseudoarthrosis of the tibia
    • Management: Nailing, Ilizarov, or amputation if severe
  • Anteromedial Bowing
    • Associated with fibula hemimelia

Paediatric Limb Length Discrepancy

Aetiology

  • Congenital or Acquired:
    • Dwarfism, neuromuscular, PFFD, infection, trauma, etc.

Management

  • <2 cm: No treatment or shoe raise
  • 2–5 cm: Epiphysiodesis or lengthening
  • 5–15 cm: Lengthening or amputation
  • >15 cm: Amputation and prosthetics preferred

Paediatric Rotational Abnormalities

Femoral Torsion

  • Normal Variants:
    • Anteversion reduces from 40° at birth to 15° at skeletal maturity
  • Management:
    • Reassurance for physiologic cases
    • Surgical rotational osteotomy if severe

Tibial Torsion

  • Aetiology:
    • Packaging disorder or neuromuscular
  • Management:
    • Resolves spontaneously; surgery if symptomatic in children >10 years

Children with persistent varus after walking age should be investigated

Selenius curve: Joseph B, Nayagam S, Loder R, Torode I (2009) Paediatric Orthopaedics: a System of Decision Making

Back to top