Hallux varus

It is medial deviation of big of big toe from the midline of foot.

Hallux varus

Causes:

o   Congenital

o   Trauma

o   Sometime Bunion surgery (swelling of joint between great toe and 1^st metatarso - pharyngeal joint)

Clinical features:

o   Deformity

o   Pain

o   Decrease ROM

o   Problems with shoe wear

o   Clawing of great toe

Management:

Depends on severity, if deformity is mild and the toe remain flexible, no treatment is required.

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Genu Valgum

It is also called knock knees. It is a condition in which the knee angle is in and they touch each other when the legs are straightened. Females have a wider pelvis than males and relatively shorter length of thigh bone and as a result have a greater static genu valgum than men. Individuals with severe Valgus deformity are typically unable to touch their feet together while simultaneously straightening the legs. Valgus actually mean bent outwards. But here the distal portion bends outwards and the proximal portion seems bend inwards.

Causes:

         i.            Idiopathic

       ii.            Congenital

      iii.            Osteogenesis imperfecta

     iv.            Rickets

Diagnosis:

·         X – rays

·         Clinical examination

Management:

Medical treatment for Rickets is optimum vitamin D, for Osteogenesis imperfecta is Bisphosphonates.

Surgical options:

Osteotomy using extaperiosteal two holes plate for 12 month, sometimes repeated osteotomies might be required.

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Genu vara

It is also called bow legs. There is a medical angulation of leg in relation to thigh. There is outward curvature of femur and up to the age of 3 – 4 years children have a degree of varus normally.

Causes:

1.       Rickets

2.       Infections

3.       Tumor

4.       Trauma

Genu varum

Management:

·         One should always identify the cause and if possible should be treated.

·         Surgical osteotomy (Multi – disciplinary team)

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Proximal Femoral deficiency

Basically there is proximal femoral deficiency, the proximal femur is partially absent and the entire limb is shortened.

Frequency:

Incidence ranges from one case per fifty thousand to one case per two Lac populations.

Etiology:

·         No exact known cause

·         Injury to neural crest cells (embryonic cells of spinal cord and brain)

·         Defect in proliferation and maturation of chondrocytes in proximal growth plate due to anorexia, ischemia, irradiation, bacterial, viral infection, toxins, hormones, mechanical injury, thermal injury, thalidomide (anticancer drugs). No genetic etiology. There is associated high incidence of other anomalies like fibula deficiency, Valgus feet, cleft palate, and club foot.

AITKEN classification of proximal femoral deficiency:

AITKEN divided it into the following four categories.

Class A:

Femoral head is often absent

Class B:

Femoral head is absent + proximal femur

Class C:

Absent femoral head dysplastic acetabulum, tronchanter doesn’t develop.

Class D:

Severe shortened shaft, No acetabulum present

Proximal Femoral deficiency

Remember in the 1^st two categories ossification may occur

Diagnosis:

Radiographic studies

Management:

·         Prosthesis (head of femur)

• Treatment is delayed in child after 3 years.

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Coxa valga

Normally the angle between the head of femur and shaft is 120° - 135°. An angle above 135° is coxa valga.

Causes:

1)      Skeletal disease (Osteomyelitis, Paget’s disease, Osteogenesis Imperfecta)

2)      Spasticity of adductor muscles of hip

3)      Cerebral palsy (a disorder of movement and or posture as a result of permanent damage to the developing brain. This damage may occur before, during, or immediately after the delivery and has many causes)

4)      Spinal dystrophism (Spina bifida)

5)      Poliomyelitis (an infectious virus disease affecting the CNS. The virus responsible is RNA, transmission through orofaecal, and 90 – 95% polio affected people will not develop polio disease)

Management:

Non surgical:

a.      Physiotherapy:

Aim is stretching the spastic agonist muscles.

b.      Orthotic devices:

These help in maintaining adequate positioning

Surgical:

Valgus osteotomy

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Coxa vara

Normally the angle between the head of femur and shaft is 120° - 135°. An angle below 120° is coxa vara.

Causes:

1)   Trauma

2)   Congenital

3)      Paget’s disease (also known as osteitis deformans ,a chronic disease of bones, occurring in the elderly and most frequently affecting the skull, backbone, pelvis, and long bones. There is 1% risk to develop osteosarcoma. Treatment is with bisphosphonates or calcitonin)

4)      Perthes disease (avascular necrosis, decrease supply to the epiphyseal plate of femur or necrosis of head of femur due to interruption of its blood supply)

5)      Osteomyelitis (inflammation of bone due to infection)

6)      Osteogenesis imperfecta (fragilitas ossium is a congenital disorder in which the bones are usually brittle and fragile. No treatment, there is abnormal; collagen type I, type II, type III, and type IV. Patient involving type I, IV live normal, with type II die early and with type III has severe disease.)

7)   Tumors

Symptoms:

In unilateral condition the limb may be small. There will be gait problem.

Diagnosis:

Radiological:

o   X – rays

o   MRI/CT scan

Treatment:

·         Varus Osteotomy

·         Hip dynamic screws

·         One should identify causes and if possible should be treated

·         Physiotherapy

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Intoeing

In this condition the front half of the foot is deviated inwards contrary to Talipes Equinovarus which is deviation at the ankle. In this condition the ankle is spared.

Intoeing between the ages of one and two ears is usually a result of an abnormal in alignment of upper (thigh) and lower leg. While Intoeing developing around 18 months may be the result of abnormality in pelvis and hip.

Intoeing

Causes of intoeing:

1)      Neurological abnormality (Cerebral Palsy, Multiple Sclerosis, Polio etc)

2)     Metatarsus adductus (A foot deformity in which the bones in the front half of the foot bend or turn in toward the body)

3)      Hallux Varus (medial deviation of the great toe)

4)      Club foot

5)      Pes cavis (high instep arch)

All of these exhibit intoeing between the ages of 1 to 2 years. The abnormality is in alignment of upper and lower leg.

Management:

Casting:

·         Applied at 6 months beneficial up to 2 years

·         Success rate drops dramatically after age of two years

Surgery:

·         Ligaments released

·         Metatarsal Osteotomy

Physiotherapy

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Talipes Equinovarus (Clubbed foot)

It is a congenital deformity involving one or both feet. The affected foot appears rotated internally at ankle. The person appears to walk on their ankles. Approximately 50% are bilateral. It occurs commonly in female i.e. 2:1

Causes:

·         Edward syndrome (extra chromosome on 13 number)

·         Ehlers danlos syndrome (disorder of connective tissue involving deficient or abnormal collagen)

Management:

a.    Tenotomy:

Need in 80% cases

b.    Anterior tibial tendon transfer:

The tendon is moved from first toe to 3^rd in order to release inward traction on foot.

c.    Ponsiti method:

It is a conservative approach in which serial cast applied over 4 weeks then Mini incision in Achilles tendon.

Physiotherapy

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Flat feet (Pes Planus)(Fallen Arch):

The arch of the foot collapses, the entire sole coming into complete or near complete contact with ground. In 20 – 30 % of the population, the arch never develops unilaterally or bilaterally. Children usually have flat feet but as they grow it will correct by itself.

Management:

·         Most of the cases don’t require treatment

·         Arch support (orthotic)

·         Surgery: It is the last resort. It is also costly and time consuming.

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