Parents frequently seek medical adv...

Parents frequently seek medical advice about lower extremity appearance in their children. In principally cases, the complaint is a variation of normal produce and development, and the puzzle resolves without treatment as the child improves Common variations include rotational point in disputes (intoeing, out-toeing) and angular vexed questions (genu varum [bowlegs], genu valgum [knock-knees]).

The normal range of rotation of the twelve inches leg, and hip includes measurements that fall within sum of two units standard deviations of the mean. A variation becomes a deformity when the amount of deviation from normal for that particular age is more than pair standard deviations. For example, normal external hip rotation for a five-year-old child is between 30 and 65 steps Those with hip rotation values outside this range are said to have a deformity. A careful history and physical examination are all that are necessary to determine whether a complaint requires further evaluation. History and Physical Examination

Table 1 defines orthopedic terminology used in the history, examination, and diagnosis. Table 2 (12) includes important aspects to obtain when evaluating a child with a lower extremity problem

Physical examination should include assessment of height and weight. Normal size for age makes pathologic conditions (eg hypophosphatemic rickets, metabolic bone disease) unlikely. (34) The spine should be examined for scoliosis, hairy patches, or sinus openings. A neurologic examination should be done to direction out neuromuscular disorders. (1,5) The lower extremities should be examined for Trendelenburg's Sign (Figure 1) and leg continuance discrepancy to rule out hip dysplasia. (145) The range of motion of the hips, knee and ankles should be determined. Evidence of joint laxity (Figure 2) that mimics the appearance of a torsional/angular deformity should be checked. The majority of children les than three years of age will have all the findings. Therefore, these characteristics become more meaningful as children improve older.

Presence or absence of flat feet should be determined. The lateral border of the lower extremity should be checked; if it is curv inwardly, the child has metatarsus adductus. Normal ankle dorsiflexion above the neutral position (Figure 3) should be checked to determine if the lower extremity deformity is flexible. (4)

Torsional Profile

Torsional profile is a composite of measurements of the lower extremities. (6) It differentiates thigh, leg and lower part variations as the anatomic basis of a torsional abnormality. It also documents the severity of the abnormality. Rotational riddles should be clinically evaluated and the findings compared with normal values. Figure 4 describes normal values and values with sum of two units standard deviations for three of the four elements of the torsional profile, which are the bottom progression angle, forefoot alignment, hip rotation, and thigh-foot angle.

twelve inches Progression Angle. Also known as gait angle, this is the angle made by the agency of the foot with respect to a straight line plott in the direction the child is walking. (7) The child's feet can be dusted with chalk prior to walking in succession a long strip of paper toward his or her parents. (6) The angle can then be measured. A plus sign denotes an out-toeing angle, and a minus sign denotes an intoeing angle. bottom progression angle can be normal in children with combined torsional deformity (eg medial femoral torsion compensated through lateral tibial torsion). (4)

Forefoot Alignment. Metatarsus adductus exists if the single of the foot is adducted (deviates medially) and if the lateral border is "C" shaped.

Hip Rotation. The range of internal and external rotation of the hips should be measured with the child lying flat and knees flexed to 90 standings Internal rotation is determined on fully abducting the legs. External rotation is determined at fully adducting the legs. The grades of internal and external rotation are generally equal, about 45 qualitys In children with excess femoral anteversion, the femoral neck axis is rotated anteriorly in relation to the frontal plane of the femoral condyle The internal rotation will far exce external rotation, while the opposite is authentic in femoral retroversion.

Thigh-Foot Angle. The angle between the axis of the lower part and the axis of the thigh should be measured with the child inclining and knees flexed to 90 standings Intoeing angles are given negative values while out-toeing angles are given positive values. The angle describes the grade of tibial torsion. Each leg should be measured because the puzzle may be unilateral or the leg may differ in extent of torsion. (5) Normally, the lower part axis out-toes 10 degrees relative to the thigh axis. If the paw turns in relative to the thigh axis, the child has internal tibial torsion. (7)

Additional Measurements

In addition to the torsional profile standard for bowlegs and knock-knees, angulation should be quantified by means of measuring the intercondylar or intermalleolar distance (Figure 5) (3) Standard values for these measurements are shown in Figure 6 Intercondylar measures the step of genu varum and is the distance between the medial femoral condyle when the lower extremities are positioned with the medial malleoli touching. The intermalleolar measurement quantifies genu valgum and is the distance between the medial malleoli with the medial femoral condyle touching. Intermalleolar and intercondylar have the disadvantage of being relative measurements that are affected on the child's size. Measuring the femoral tibial angle with a goniometer is a more accurate way to quantify angulation. However, obtaining reliable goniometric measure forward a child is often a challenge. A chart from Salenius and Vankka can be used for that meaning (8)