Angular deformities of the lower limb in children.

Abstract

Angular deformities of the lower limbs are common during childhood. In most cases this represents a variation in the normal growth pattern and is an entirely benign condition. Presence of symmetrical deformities and absence of symptoms, joint stiffness, systemic disorders or syndromes indicates a benign condition with excellent long-term outcome. In contrast, deformities which are asymmetrical and associated with pain, joint stiffness, systemic disorders or syndromes may indicate a serious underlying cause and require treatment.Little is known about the relationship between sport participation and body adaptations during growth. Intense soccer participation increases the degree of genu varum in males from the age of 16. Since, according to some investigations, genu varum predisposes individuals to more injuries, efforts to reduce the development of genu varum in soccer players are warranted. In this article major topics of angular deformities of the knees in pediatric population are practically reviewed.

Full text

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© 2010 by Sports Medicine Research Center, Tehran University of Medical Sciences, All rights reserved. 
REVIW ARTICLE
46
Angular Deformities of the Lower Limb in Children
Ramin Espandar *1, MD; Seyed Mohammad-Javad Mortazavi 2, MD; Taghi Baghdadi 1, MD
1. Department of Orthopedic
Surgery, Tehran University of
Medical Sciences, Tehran, IR
Iran
2. Sports Medicine Research
Center, Tehran University of
Medical Sciences, Tehran, IR
Iran
* Corresponding Author;
Address: Sports Medicine Research
Center, No 7, Al-e-Ahmad Highway,
Tehran, IR Iran
E-mail: espandarmd@tums.ac.ir

Received: Feb 06, 2009
Final Revision: Jul 11, 2009
Accepted: Aug 25, 2009
Key Words: Genu varum; Genu
valgum; Angular deformity of the
limbs; Children; Sport




ABSTRACT
Angular deformities of the lower limbs are common during childhood.
In most cases this represents a variation in the normal growth pattern
and is an entirely benign condition. Presence of symmetrical
deformities and absence of symptoms, joint stiffness, systemic
disorders or syndromes indicates a benign condition with excellent
long-term outcome. In contrast, deformities which are asymmetrical
and associated with pain, joint stiffness, systemic disorders or
syndromes may indicate a serious underlying cause and require
treatment.
Little is known about the relationship between sport participation
and body adaptations during growth. Intense soccer participation
increases the degree of genu varum in males from the age of 16. Since,
according to some investigations, genu varum predisposes individuals
to more injuries, efforts to reduce the development of genu varum in
soccer players are warranted. In this article major topics of angular
deformities of the knees in pediatric population are practically
reviewed.
Asian Journal of Sports Medicine, Vol 1 (No 1), March 2010, Pages: 46-53
INTRODUCTION
lthough from clinical experiences an association
between intense sports activities like soccer
players and genu varum seems evident, today no
scientific data regarding this association are available.
Chantraine [1] hypothesized that the high amount of
stress and strain imposed on a joint during growth and
adolescence through intensive practice of a sport may
contribute to a growth deformity. This possibility is
pertinent, but not yet investigated for the development
of genu varum and playing soccer. However, several
studies showed that the presence of genu varum
predisposes an individual to various injuries. For
example, genu varum has been associated with the
deterioration of the articular cartilage in the knee’s
medial tibiofemoral compartment
experimentally induced osteoarthritis and as a risk
factor for osteoarthritis in a patient cohort [2-4].The
presence of genu varum alters the forces at the knee so
that the line of force shifts farther medially from the
knee joint center intensifying the medial compartment
load and creating a medial joint reaction force that is
nearly three and a half times that of the lateral
both to
A

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Angular Deformities of the Lower Limb
47
compartment [5]. In addition to the development of tibio
femoral osteoarthritis, the presence of genu varum
seems also to predispose subjects to the occurrence of
injuries at the patellofemoral joint. Several studies have
identified the presence of genu varum as a risk factor
for the development of the patellofemoral pain
syndrome in athletes [6-10].
Since the knee malalignment is important in athletes,
the development of normal tibiofemoral angle and
common angular deformities in children and
adolescents are explained in this article.
NATURAL HISTORY
Genu varum (bow legs) and medial tibial torsion are
normal in newborn and infants and maximal varus is
present at 6 to 12 months of age. With normal growth,
the lower limbs gradually straighten with a zero
tibiofemoral angle by 18 to 24 months of age (when the
infant begins to stand and walk). With further normal
development, knees gradually drift into valgus (knock-
knee). This valgus deformity is maximal at around age
3-4 years with an average lateral tibiofemoral angle of
12 degrees [11]. Finally the genu valgum spontaneously
correct by the age of 7 years to that of the adult
alignment of the lower limbs of 8 degrees of valgus in
the female and 7 degrees in the male. The greater
degree of valgus in females may be due to their wider
pelvis.
Extrinsic and intrinsic factors may interfere with
this normal angular alignment of the lower limbs.
PERSISTENT GENU VARUM IN THE
OLDER CHILD
Bowlegs after 2 years of age are considered abnormal.
It may be due to persistence of severe physiologic
bowlegs (the most common etiology), a pathologic
condition, or a growth disorder.
Assessment
History: Family history of bowlegs or other limb
deformities and the presence of short stature may
indicate the possibility of bone dysplasia or a
generalized growth disorder. Physiologic genu varum
improves with growth, whereas pathologic bowing of
the legs increases with skeletal growth; therefore it
seems important to ask the parents about:
1. When they first noticed the deformity in the child.
2. Were the legs bowed at birth and in infancy, or did
the bowlegs develop later on when the child started
walking?
3. Is the deformity improving, staying the same, or
increasing in severity?
4. When did the child begin to stand and walk?
Children with tibia vara (Blount’s disease) are early
walkers. Inquire as to the previous treatment and
response to it.
Etiologic factors: The physician should be aware of
the dietary and vitamin intake of the patient [12] and
also should consider any allergy to milk, history of
trauma or infections and inquire the possibility of
exogenous metal intoxication, specifically lead and
fluoride [13].
Examination: Short stature suggests the possibility of
vitamin D refractory (hypophosphatemic) rickets [14] or
bone dysplasia, such as achondroplasia or metaphyseal
dysplasia [15].
In stance and supine the physician should measure
the distance between the femoral condyles at the joint
level with the ankles just touching each other. Ruling
out the deformity of the feet especially pes or
metatarsus varus or valgus which may represent
torsional deformity of the limb is mandatory [16].
The site of varus angulation should be determined.
In physiologic genu varum there is a gentle curve
involving both the thigh and the leg with more
pronounced bowing in the lower third of the femur and
at the juncture of the middle and upper thirds of the
tibia [17]; whereas in ligamentus hyperlaxity it is at the
knee joint. In Blount’s disease it is commonly at the
proximal tibial metaphysis with an acute medial
angulation immediately below the knee and in the
congenital familial form of tibia vara it is at the lower
tibia at the junction of the middle and the lower thirds

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48
[18]. In the very rare distal femoral vara the site of
angulation is in the distal femoral metaphysis. When
the lower tibiae are the sites of varus angulation, the
upper tibial segment is straight and the lower segment
angulated.
Next, inspect the gait and determine the foot
progression angle; in genu varum the foot progression
angle may be medial or normal. When laxity and
incompetence of the lateral collateral ligament of the
knee are present, the fibular head and upper tibia shift
laterally during gait; whereas, in physiologic bowlegs
there is no such lateral thrust [19].
It is important to assess symmetry of involvement.
In physiologic genu varum and congenital tibia vara it
is usually bilateral and symmetric, whereas in Blount’s
disease it may be unilateral or bilateral, and when both
tibiae are involved, the degree of affection is often
asymmetric.
Measure both the actual and apparent limb lengths.
In Blount’s disease and in congenital longitudinal
deficiency of the tibia
severely affected limb is shorter than the contralateral
one; in physiologic genu varum the lower limb lengths
are even.
In the medially bowed leg, determine the level of
the proximal fibula in relation to that of the tibia.
Normally the upper border of the proximal fibular
epiphysis is in line with the upper tibial growth plate –
well inferior to the joint horizontal orientation line;
whereas Blount’s disease, congenital longitudinal
deficiency of the tibia, and achondroplasia demonstrate
relative overgrowth of the fibula, and the fibular
epiphysis is more proximal, near the joint line [21].
Palpate the epiphysis of the long bones at the
ankles, knees, and wrists. In rickets (vitamin D
refractory or vitamin deficiency) they are enlarged.
Inspect the thoracic cage. Is there a “rachitic rosary” of
the ribs, pectus carinatum deformity, or Harrison’s
groove?
Imaging: Take radiograms when:
1. A child is 3 years and older and the varus deformity
is not improving or is getting worse,
2. The medial bowing is unilateral or asymmetric,
3. The site of varus angulation is acute in the proximal
tibial metaphysis immediately below the knee,
[20], the involved or more
4. The possibility of a pathologic condition is
suggested by other clinical findings. The clinical
stigmata suggesting pathologic genu varum are
short stature (bone dysplasia), enlarged epiphysis
and physis (rickets), history of trauma or infection
(meningococcemia) [22], short tibia and relatively
long fibula, and history of possible metal
intoxication (lead or fluoride).
Standing long films (AP and lateral) should be made
to include the hips, knees, and ankles. Proper
positioning is important – knees straight and patella
facing forward.
The growth plates of the distal femur and proximal
and distal tibia should be considered carefully. In
physiologic genu varum they are normal. In rickets the
physes are markedly thickened, the physeal borders of
the epiphyses are frayed with a brush-like pattern of the
bone trabeculae, the epiphyses are enlarged, the bone
trabeculae are coarse, and the cortices of the diaphyses
of the femurs and tibiae show decreased bone density
[23].
Then, the epiphyses, metaphyses, and diaphyses
should be inspected. In physiologic genu varum the
bone seems normal without any sign of bone dysplasia.
The medial bowing of the lower limb is a gentle curve,
taking place at the junction of the middle and the
proximal thirds of the tibiae and the distal thirds of the
femurs. The horizontal joint lines of both the knee and
ankle are tilted medially.
Measure the metaphyseal-diaphyseal angle. In the
physiologic genu varum it is less than 11 degrees,
whereas in tibia vara it is greater than 11 degrees [24].
List of conditions that cause pathologic tibia vara is
given in Table 1.
Treatment
In physiologic genu varum education and assurance of
the parents is important and just follow its natural
course by reassessing the child in 6 months. Orthopedic
shoes are not effective in its prevention or management
[25].
Metabolic deformities such as rickets could simply
be corrected with medical treatment, i.e. calcium and
vitamin D supplements.
When severe genu varum is associated with severe
medial tibial torsion and the metaphyseal-diaphyseal

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Table 1 – Skeletal affections that present as bowlegs
1. Apparent genu varum
2. Physiologic genu varum
3. Congenital familial tibia vara
4. Tibia vara (Blount’s disease)
5. Asymmetric growth arrest of medial part of distal femur and proximal tibia due to infection,
fracture, or tumor
6. Rickets – vitamin D deficiency or refractory (hypophosphatemia)
7. Bone dysplasia, such as achondroplasia and metaphyseal dysplasia
8. Fibrocartilagenous dysplasia
9. Congenital longitudinal deficiency of the tibia with relative overgrowth of the fibula
10. Lead or fluoride intoxication

angle is 11 degrees or greater, a Denis Browne splint is
prescribed with the feet (shoes) rotated laterally and
with an 8 to 10-inch bar between the shoes. This is
ordinarily worn only at night for a period not more than
3 to 6 months in order to correct excessive medial tibial
torsion [26].
In the adolescent with severe genu varum with
marked malalignment of the mechanical axis of the
lower limbs, occasionally osteotomy of the tibia or
hemiepiphysiodesis of the distal femur and/or proximal
tibial physis is indicated to correct the deformity [27]. It
is difficult to calculate
hemiepiphysiodesis. Stapling is preferred by some
authors [28].
the exact age for
PERSISTENT EXAGGERATED GENU
VALGUM IN THE OLDER CHILD AND
ADOLESCENT
Exaggerated genu valgum up to 7 years of age is
physiologic and not pathologic [29]. The problem is the
adolescent or the child over 8 years of age who present
with moderate to severe knock-knees. The patient
complains of pain in the thigh and/or calf and easy
fatigability, the child walks with his knees rubbing
together, feet apart and one leg swinging around the
other. Frequently, parents are concerned with this form
of gait. Due to malalignment and an increased Q angle
of the quadriceps extensor mechanism, the patella
subluxates laterally; hence, the patellofemural joint
seems to be unstable. The shoes shows medial collapse
of the upper parts and it is the result of abnormal
weight-bearing forces on the ankle and foot [30]. The
parents seek active treatment and commonly believe
that the deformity will result degenerative, crippling
arthritis of the knee [31]. In order to manage the problem
properly, first we should determine the cause of
abnormal genu valgum by careful history taking,
physical examination, and appropriate imaging studies.
The various causes of genu valgum are listed in Table
2.
Assessment
History: The presence of positive family history and
short stature in other members of the family will
suggest the presence of bone dysplasia, such as
multiple epiphyseal dysplasia, multiple metaphyseal
dysplasia, multiple enchondromatosis
disease), multiple hereditary exostosis, Ellis Van
Creveld syndrome
History of swollen and hot knees indicates rheumatoid
arthritis [34]. With increased circulation in the knee the
tibia overgrows relative to the fibula. In congenital
(Ollier’s
[32], or Morquio’s disease
[33].

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Table 2 – Various causes of genu valgum
1. Developmental – physiologic, no intrinsic bone disease or congenital anomaly
2. Congenital – due to longitudinal deficiency of the fibula
3. Iliotibial band contracture
4. Trauma
a. Malunion of fracture
b. Growth stimulation by greenstick fracture of the proximal tibial metaphysic
c. Asymmetric growth arrest due to fracture-separation involving the lateral segment of the upper tibial physis or
distal femoral physis
5. Infection – causing asymmetric growth disturbance
6. Arthritis of knee – rheumatoid, hemophylia
7. Bone dysplasia – Morquio’s syndrome, Ellis-Van Creveld syndrome, Ollier’s disease(multiple
enchondromatosis), multiple hereditary exostosis, metaphyseal dysplasia, multiple epiphyseal dysplasia
8. Osteogenesis imperfecta
9. Metabolic bone disease, particularly

longitudinal deficiency of the fibula, genu valgum is
common [35].
Examination: For assessment of short stature and bony
dysplasia the standing and sitting height of the patient
should be measured [36]. Inspect the alignment of the
lower limb in stance. Measure the degree of genu
valgum with a goniometer on the lateral side of the
thigh-leg, the distance between the medial maleolli
with the knee just touching. Genu requrvatum, if
present, causes an apparent increase in the degree of
deformity [37].
Asymmetry or unilateral involvement of the knee is
suggestive of pathologic genu valgum. In walking,
there is protective toeing-in to shift the foot medially so
that the center of gravity falls in the center of the foot
[38].
Ligamentous laxity may be the cause of knock-knees;
therefore one should determine the stability of the
collateral and cruciate ligaments of the knee.
The site of valgus angulation should be determined.
Tibia valga, or greenstick fracture of the medial part of
the proximal tibial metaphysic cause genu valgum at
the proximal tibia [39] whereas in ligamentus hyper-
laxity, congenital longitudinal deficiency of the fibula,
or rheumatoid arthritis of the knee, it is at the knee and
in metabolic bone disease and bone dysplasia at the
distal femur or in both femur and the tibia. Tibia valga
is usually associated with excessive lateral tibiofibular
torsion thus the degree of tibial torsion should be
assessed [40].
Iliotibial band contracture may cause tibia valga and its
presence should be ruled out by an Ober test (41).
Exostosis and lower limb length inequality should be
assessed by careful palpation of the epiphysis and
metaphysis and limb
respectively (42).
Imaging findings: In developmental genu valgum the
epiphysis, physis, and metaphysis are normal. The
horizontal axis of the knees and ankles is tilted
laterally. No intrinsic bone disease is present.
In pathologic genu valgum the radiographic features
are usually characteristic, and diagnosis is readily
made. When an osseous bridge across the lateral physis
of the distal femur and proximal tibia is suspected,
MRI should be performed. Bone age should be
determined if a hemiepiphysiodesis is being planned
[43].

Treatment
Special shoes are ineffective in prevention or treatment
of genu valgum. If the feet are in valgus and foot strain
is a complaint, foot orthotics, such as University of
length measurements,

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California Biomechanics Laboratory (UCBL) orthotics,
are appropriate to support the foot. They do not correct
the genu valgum but relieve foot strain, easy
fatigability, and foot-calf pain [44]. When the iliotibial
band is contracted, passive stretching exercises for its
stretching should be done. This may relief valgus
deforming force of the knee.
The role of orthotics to control or correct genu valgum
has not been proven and is controversial. Some authors
do not recommend them. According to the body of
literature, the only indication for a Knee Ankle Foot
Orthosis (KAFO) is to support the knee ligaments and
prevent them from overstretching. It is used in
pathologic genu valgum.
In the adolescent with severe genu valgum and marked
mechanical axis deviation, surgical correction is
indicated. Two methods of surgical management are
available:
1. Hemiepiphysiodesis is done by stapling or fusing
the medial part of the distal femoral and/or proximal
tibial growth plates. Appropriate time is crucial.
Despite all precautions, one may end up with
overcorrection or undercorrection. Some authors
prefer stapling over epiphysiodesis because it allows
a certain amount of flexibility of timing [45].
2. Osteotomy of the distal femur and proximal tibia is
performed in the skeletally mature patient.
Neurovascular structures, particularly the common
peroneal nerve and tibial vessels, are at definite risk
for injury. Gradual correction with an external
fixator lessens the degree of neurovascular change
[46-48].
CONCLUSION
Angular deformities of the lower limbs are common
during childhood and usually make serious concern for
the parents. Most commonly these deformities
represent normal variations of the growth and
development of the child and needs no treatment
except for observation and reassurance of the parents.
Despite of the benign nature of physiologic or
exaggerated physiologic genu varum and genu valgum,
most of the pathologic causes need proper management
by an orthopedic surgeon; hence, the importance of
careful evaluation of the patients and determination of
these pathologic causes is evident.
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