Characteristic radiographic findings of congenital coxa vara. (A) Decreased neck shaft angle.

(B) Smaller and flatter femoral head. (C) More vertical orientation of physeal plate. (D) Coxa brevis. (E) Abnormal bony fragment inferolateral to physeal plate and contained in inverted Y-shaped lucency.

Pathology Under normal conditions, the femoral neck develops as an upward and medial growth of the diaphysis. Fusion of the epiphysis occurs between seventeen and nineteen years of age. A diaphyseal spur grows medially under the femoral head, causing the epiphyseal plate to become horizontal, supporting the head from below. In congenital coxa vara the cartilage of this spur does not ossify normally, and a more vertical epiphyseal plate results (Fig. 1). A cartilaginous plate is often seen extending into the metaphysis,

giving rise to the formation of a separate bone fragment (Fig. 4). This fragment of bone corresponds to the normal supporting ledge for the femoral capital epiphysis. Rather than actually originating from the metaphysis, it is possible that this fragment represents a separate ossification center. Occasionally an irregular mixture of bone fragments, cartilage, and fibrous tissue is found in the metaphysis beneath the deformed epiphyseal plate. The capital epiphysis is displaced downward in relation to the trochanters, but retains its normal shape. The shearing forces concomitant with weight-bearing act upon the deformed femoral neck to produce coxa vara.

Barr (3) removed material from the midcervical region of the femur. Histologically, it showed abnormal enchondral ossification, islands of disintegrated cartilage, and some bone atrophy. Nowhere was there marked evidence of bone formation, nor was there evidence of repair.