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Bowing

Parents of children who have bowed legs often want to know if the child's legs are
abnormal. To help answer that question, here are some basic facts about bowing.
This section will give you an idea of what the physician is thinking about when he
or she is examining your child.
First, bowing or the technical term genu varum (genu = knee, varus / varum =
angles in) is a part of the normal development of a child. The role of the physician
is to determine if the bowing is physiologic (part of normal development) or
pathologic (due to some disease process). Physiologic bowing will improve as the
child grows without treatment, while pathologic bowing will tend to worsen over
time without treatment. The bowing can arise from the lower portion of the femur
near the knee, the knee joint itself, the upper shin bone near the knee, or a
combination of these areas.
Normally, an infant is born with bowed legs. Over time, the leg alignment will
correct and usually straightens out by about eighteen months of age. By the time
the child is three to four years old, he or she will normally develop a knock-kneed
alignment. The technical term for this is genu valgum (valgus/valgum = angles
out) . This genu valgum will then correct somewhat by the age of five to six years
old, leaving the normal adult alignment of slight genu valgum (slight knockkneed).
Listed above are the mean ages for these changes to occur so half of the children
will correct their bowing earlier and half will correct it later. Occasionally, the
bowing never fully corrects. That is why some adults have bowed legs. So you
can see, there is a wide range of normal when looking at bowed legs. Physiologic
bowing does not require any treatment other than observation for correction as the
child grows.
Internal tibial torsion (inward twist of the tibia caused by intrauterine
positioning), also called medial tibial torsion, can complicate matters by making
the bowing appear worse than it really is, as we see the side of the knee relative to
the foot rather than the front. Correction of the torsion will make the legs appear
straighter. Fortunately, internal tibial torsion tends to correct itself without
treatment up until the age of four to six years, thereby correcting the visual bowing
also.

Adults will not correct bowed bones by diet. then altered further by the kidney. no correction. is really a family of entities. In the older sense. Two of the more common diseases known to cause bowing are Rickets and Blount's disease. Because of this. Dietary supplementation of Vitamin D has gone a long way toward abolishing dietary rickets. and eventually (when x-ray allowed) noted to be associated with widened growth plates which did not fully calcify . No growth. . a child with bowing of bones. The body uses several mechanisms to keep the two at a certain level.either by the Ca++ or by the PO4= then the syndrome may manifest. When that is off . altered by the liver. the hereditary forms of rickets are more commonly seen. Caught early. The substance in the diet must first be absorbed. However. Rickets: Rickets is a generalized skeletal disease involving Vitamin D metabolism. Dietary change would do little. A dominant defective gene disabled her ability to activate the vitamin D form found in food. rickets. So older usage's run counter to current more precise etiologic (based on cause) uses of the term. in today's terminology. Calcium as Ca ++ interacts with Phosphate as PO4= such that at a certain concentration. Dietary deficiency of Vitamin D is the most familiar (to the public) form of rickets. then changed again in the skin by sunlight before it is in the active form. while there is lots of growth remaining. a rickets syndrome may be seen. a build it yourself kit for what is often called "active vitamin-D". The little girl on the right has a genetic form of rickets seen only in the females of her family (four generations). then dietary vitamin D will be no more active than sand or jelly beans. often irritable. if any of the needed bodily steps are not functional. Vitamin D in the diet isn't really an active agent.Many disease processes effecting bone growth cause pathologic bowing. Therefore.that was called rickets. corrected growth can undo deformations which have not gone too far. but it still occasionally seen in less developed countries and in circumstances of dietary peculiarity. even with a normal intake of "vitamin-D". Vitamin D is vital for bone mineralization. Although this vitamin is important it does not act alone. If any of those steps is faulty. but rather a precursor. The term 'rickets' predates the later and current notions of the actual causal chemistry. Rickets causes a distinctive cupping and widening of the growth plates which can be recognized on a plain x-ray along with other characteristic findings. the calcium can precipitate. Correction by supplements is from corrected growth. with thickened ends of bones (including ribs).

If that something is defective. it is not uncommon that a so called something defect actually involves more than the something that names it. and interestingly. Odd metabolic work around tricks are required when this occurs. The complexity of the treatment of rickets varies with the complexity of the curvatures. require surgical correction. by giving her a processed already activated form of vitamin D which gets around her inherited bodily inability to activate it. metabolic echoes. but extreme cases. such as the one above. that is there is no deficiency of the vitamin or the activated form. The outside part of the growth plate continues to grow normally. Her younger sister with similar findings behaved in exactly the same manner.At an early time. as deep biochemical alterations often have broad. On the left we see an extreme form of rickets with multiple tiny fractures caused by a defect in the mechanism which uses vitamin D. If the activated form of the vitamin fails to alter the course of things then rather than blame the key (vitamin D) we need to suspect the lock. four generations in this girl bearing family managed to dodge this outcome. . In genetic disorders. her deformities went away. The girls treated early have statures greater then mother. Active vitamin supplementation will not undo deformities if they are addressed too late for remaining corrective growth to get the job done. This form of rickets has interaction with zinc. then it gets even more difficult to get around. Blount's Disease: Blount's disease affects the inner edge of the upper shin bone at the knee growth plate (epiphyseal plate . leading to progressive bowing.runs horizontally across the knee). grandmother and great grandmother by age 8. Most cases are treated with medicine alone. Hormones or vitamins work like keys by fitting into something that responds. magnesium. growth hormone. Although boys in alternate generations could also land this particular gene defect. causing it to decrease its rate of growth in the portion of the growth plate that is closest to the leg's inseam.

The growth plates are checked for any abnormality. the osteotomy must correct the bowing and twist (tibial torsion) at the same time. Depending on how crushed the growth plate is. We have had good results bracing children as young as two years old. Angle measurements about the proximal tibia as well as between the tibia and femur are made. This is the best prognosticator for progression. There is infantile Blount's. Tibial osteotomy (tibia = shin bone. is aimed dead straight ahead. Many will wait and "see how it goes". But there is an important detail to be aware of when taking these x-rays. X-rays are helpful for diagnosing Blount's disease as well. the bowing may recur after surgery. yet the ankle is directed toward the child's right.Blount's disease affects two different age groups. In a special parallax-free three exposure x-ray of the full leg from hip to ankle. If infantile Blount's is diagnosed early enough. If that line passes outside the bone of the knee. treatment will require a tibial osteotomy (surgery of the tibia) to straighten the lower extremity. The left knee. and let the most effective bracing period go right by. Bracing also attempts to correct both deformities at the same time. then the angulation will worsen with time and not self-correct. such as is seen in rickets and other diseases. tome = to cut) is also part of the treatment for the adolescent. There are many different techniques for performing the osteotomy. Usually an anterior -posterior (AP) view of the lower extremity is obtained with the knee pointed straight ahead (ignoring the foot direction). seen in teenagers. No matter what technique is chosen. Usually by the age of three.see above picture). In both groups. which will help determine if Blount's disease is present. a line from the center of the hip joint to the center of the ankle joint is drawn as discussed above. This line is the weight bearing line of the lower extremity. If it passes completely beyond the knee joint substance. osteo = bone. with the knee carefully aimed straight ahead . We have seen no such reversals in that subset of children. then whenever weight is placed on the leg it is . the children tend to be overweight for their age. and adolescent Blount's. above. bracing can be instituted. This bowing deformity is always associated with internal tibial torsion (an inward direction of the ankle and foot relative to the direction of the knee . seen in young children. a line through hip and ankle centers ought to pass through knee center. We prefer to brace as bracing early not only works better but heads off the addition damage to the inner growth plate caused by the angular mechanical (nut cracker) compression caused by the bowed leg. Importantly.

This will tend to make the bowing worse over time. The leverage amplifies the forces. damaging the growth plate.passed from the hip to the ankle levered through the very medial part of the knee. and is an indication for treatment of the bowing. .