Bow Legs, Knock Knees and

Other Normal Variants

Dr David Bade
Director of Orthopaedics
Lady Cilento Children’s Hospital
 Normal Variants
• Symmetrical
• Improve with growth
• Large range of ‘normal’
• Coronal, axial/rotational planes in the lower
limb
• Most common referral to general paediatric
orthopaedic
• PARENTAL ANXIETY
CORONAL PLANE ISSUES
 Knee Varus/Valgus
• Femoro-tibial alignment changes with growth
Maximum varus <18mo

Tachdjian’s 5th Ed
Neutral by 2yo
Max valgus
4yo
Adult
alignment by
10 yo
 When does femoro-tibial alignment
become pathological?
1. Genu varum
2. Genu valgum
 1. Genu Varum
• Pathologic if:
– >18mo without signs of resolution
– Unilateral
– Progressive
– Pain
– Underlying medical diagnoses
• Rickets
• Renal failure
 1. Genu Varum
• What not to miss?
1. Infantile tibia vara (progressive proximal tibial
varus deformity)
• Treatment should begin <4yo
2. Underlying medical diagnoses
• Rickets
• Renal failure
 2. Genu Valgum
• Pathologic if:
– Intermalleolar distance >8cm >10yo
– Unilateral
– Progressive
– Underlying medical diagnosis
• Rickets
• Renal failure
 2. Genu Valgum
• What not to miss?
– Cozen phenomenon
• Progressive (and generally self-limiting) genu valgum
after proximal tibial metaphyseal greenstick with intact
lateral cortex
 Treatment
• 8 plates
– Require referral prior to 12 F or 14 M (guided
growth requires >/= 2 years of growth remaining
for maximal effectiveness)
• Osteotomies
– Generally reserved for skeletally mature patients
ROTATIONAL ISSUES
 “Intoer/Outtoer”
• Foot progression angle refers to angle foot
makes with straight line on floor

– Intoers have an internal foot progression angle

– Outtoers have an external foot progression angle

Why does a patient in- or outtoe?
 Rotational Profile
• Method of determining the cause for in- or
outtoeing
• Three components
1. Comparison of internal and external rotation
(hip)
2. Thigh-foot angle (or transmalleolar axis)
3. Heel bisector
 Rotational Profile
• Place patient prone, knees flexed to 90
• Check:
1. Heel Bisector (N = 2/3)
2. Thigh-foot Angle (N -5 IR – 20 ER)
2. Transmalleolar Axis (N -10 IR – 15 ER)
3. Hip Rotation (compare IR with ER)
 Intoeing
• Three etiologies:
1. Femur
2. Tibia
3. Foot
 Femur
• Femoral anteversion

– IR > ER

– Pathologic if persists >10yo

• Normal adult anteversion ~15 degrees
 Tibia
• Internal tibial torsion

– Thigh-foot angle < -15

– Pathologic if persists >8yo

• Normal adult torsion -5 IR – 30 ER
 Foot
• Metatarsus adductus

– Heel bisector > 3

– Pathological
• Associated with DDH
• Screen for DDH with U/S if <6mo and XR if > 6mo
 Outtoeing
• Three etiologies:
1. Femur
2. Tibia
3. Foot
 Femur
• Femoral retroversion

– ER > IR
– Normal adult anteversion 15

– Pathologic if
• Unilateral
• Progressive
• Associated with groin/thigh/knee pain (SUFE)
 Tibia
• External tibial torsion

– Thigh-foot angle > 30 ER

– The most common normal variant not to correct

– Pathologic if
• Unilateral
• Progressive
 Foot
• Forefoot abduction

– Heel bisector intersects medial to 2/3

– Pathologic if
• Progressive
• Associated with rigid flatfoot
 What needs treatment?
• Controversial!

• Considerations
– Functional limitations
– Pain/ Falls
– Cosmesis
– MTA
• straight- or reverse-last boots (non-operative, low risk)
 What treatment is available?
• No successful non-operative therapy

• Operative
– Femoral or tibial derotation osteotomies
PESKY FEET
 Flatfeet
• Arch develops until 8yo

• Two varieties
1. Flexible
2. Rigid
 Which is it, flexible or rigid?
• Heel rise
• Jack’s test
Normal hindfoot valgus ~5-10 degrees
 Flexible flatfeet regain arch and
convert to heel varus with heel rise
Flexible flatfeet regain arch with first toe
dorsiflexion (Jack’s test)
 Flexible Flatfeet
• Treatment
– ONLY if painful
• Semirigid medial longitudinal arch support orthotic
 What if the arch does not
reconstitute?
• Rigid flatfeet
 Rigid Flatfeet
• Differential diagnosis

1. Tarsal coalition

2. Congenital vertical talus

 1. Tarsal Coalition
• Abnormal connection between two tarsal
bones
– Fibrous/cartilagenous/bony

• Investigations:
– XR
– +/- CT or MRI
 Treatment
• Immobilization
• Orthotic
• Surgical excision
 2. Congenital Vertical Talus
• Dorsal dislocation of navicular onto talar head
– “rocker bottom” foot
 Summary
1. Genu Varum
– Beware >2yo progressive +/- unilateral
2. Genu Valgum
– Beware intramalleolar distance >8cm at 10yo
3. Intoeing
– Beware DDH in MTA
4. Outtoeing
– Beware SUFE
5. Flatfeet
– Beware the rigid flatfoot
 OPSC at LCCH
• Orthopaedic Physiotherapy Screening Clinic
• Review all normal variant referrals to LCCH
• Doesn’t delay orthopaedic review or
intervention
• Allows earlier review in less hectic clinics
Simple Fracture Management