Knee Deformities in pediatrics

FUNCTIONAL ANATOMY

• The knee is a part of a kinetic chain that is greatly affected by the linked
segments from the proximal and distal
joints.
• Looking at the knee region specifically, the tibia and femur make up the
tibiofemoral joint, and the patella and femur make up the patellofemoral joint. The
fibula is also noted as it is the attachment site of the biceps femoris, which crosses
and affects the knee.

REVIEW OF KNEE FUNCTIONAL ANATOMY

• Proximally, the femur and the pelvis make up the iliofemoral joint, and the
sacrum and pelvis make up the sacroiliac joint. Collectively, these structures
anchor the proximal myofascial tissues. These bones and joints are of importance
in corrective exercise because they will also have a functional impact on the
arthrokinematics of the knee.

REVIEW OF KNEE FUNCTIONAL ANATOMY

• Distally, the tibia and fibula help form the talocrural (ankle) joint Collectively,
these structures anchor the distal myofascial tissues of the knee. These bones and
joints are of importance in corrective exercise because they will also have a
functional impact on the arthrokinematics of the knee.
KEY MUSCLES ASSOCIATED WITH THE KNEE

• Gastrocnemius/soleus.
• Adductor complex.
• Medial and lateral hamstring complex.
• Tensor fascia latae/IT-band.
• Quadriceps.
• Gluteus medius and maximus.

Normal Development

The term Genu Valgus and Genu Varus describes the relationship of the tibia with
respect to the femur.
Genu Valgus indicates abduction of the tibia at the knee while Genu Varus
indicates adduction of the tibia at the knee.

Normal Development
• Following birth and through the childhood the normal pattern of development is
to progress from position of varus to one of the valgus and then return to near
neutral by adolescence.

Normal Development
In the Newborn : The average angle of the varus is 17 degree.
At 1 year : The angle of varus decrease to average 9 degree.
At 2 year: An average 2 degree of valgus.
At 3 years of age :when the child is walking the average angle of valgus is 11
degree.
At 13 year of age :angle of valgus reduce to 6 degree.
Angular Deformities Evaluation:

Should differentiate between “physiologic” and “pathologic”deformities

Physiologic Pathologic
Symmetrical Asymmetrical
Mild – moderate - Severe
Regressive Progressive
Generalized Localized
Expected for age Not expected for age

Angular Deformities Causes

Physiologic Pathologic
Normal – for age - Rickets
Exaggerated : - Endocrine disturbance
Overweight -Metabolic disease
Early wt. bearing - Injury to Epiphyses Plate
Infection / Trauma
- Use of walker? -Idiopathic

Symmetrical deformity
Asymmetrical Deformity

KNEE DEFORMITIES
• There are 3 types of deformities:
1) Genu Varum.
2) Genu Valgum .
3) Genu recarvatum.

Angular Deformities Nomenclature

1)Genu varum
• Genu varum (also called bow leggedness, bendiness, bandy-leg, and tibia vara), is
a physical deformity marked by (outward) bowing of the lower leg in relation to
the thigh, giving the appearance of an archer's bow.Usually, medial angulation of
both femur and tibia is involved.
Angular Deformities Evaluation
Measure Angulation( standing / supine ):
in bowlegs / genu varum Inter-condylar distance

Angular Deformities Evaluation

Measure Angulation Use Goniometry
Measures Tibiofemoral angle : medial angle formed between femoral and tibial
longitudinal axes
Normally : 5-7 degree

Angular Deformities Evaluation

Investigations / Radiological
X-ray when severe or possibly pathologic
• Standing AP film
• long film ( hips to ankles ) with patellae directed forwards
• Look for diseases :
• Rickets / Tibia vara (Blount’s) / Epiphyseal injury..
• Measure angles.
1)Genu varum Treatment

• No treatment is required for idiopathic presentation as it is a normal anatomical

variant in young children. Treatment is indicated when it persists beyond 3 and a
half years old.

• Pathological Genu Varum: Treatment

options for pathological cases may include:
• Bracing: Wearing braces can help guide the bones to grow straighter.
• Physical Therapy: Exercises can help strengthen the muscles around the knee and
improve joint function.
• Surgery: In severe cases, surgery may be necessary to correct the bowing of the
leg bones.
• In the case of unilateral presentation or progressive worsening of the curvature,
when caused by rickets, the most important thing is to treat the underlying disease.
• At the same time instructing the care-giver never to place the child on its feet .
• Matters can be hastened somewhat by applying splints.

Pathologic Genu Varum Tibia Vara (Blount Disease)

• Idiopathic tibia Vara, or Blount disease, is the most common pathologic disorder
producing a progressive genu varum deformity. It is characterized by abnormal
growth of the medial aspect of the proximal tibial epiphysis, resulting in a
progressive varus angulation below the knee.
There are two types of Blount's disease:

• The first type is Infantile: this means that children under four are diagnosed with
this disease. Blount's disease in this age is very risky because sometimes it is not
detected, and it passes to the second type of Blount's disease.
• The second type of Blount's disease is found mostly in older children and in
teenagers,sometimes in one leg and sometimes in both; the patient's age determines
how severe the diagnosis is.

Pathologic Genu Varum Tibia Vara (Blount Disease)Treatment

• Treatment for children with Blount's disease is typically braces but surgery may
also be necessary,especially for teenagers. The operation consists of removing a
piece of tibia, breaking the fibula and straightening out the bone; there is also a
choice of elongating the legs. If not treated early enough, the condition worsens
quickly

2)Genu valgum

• Genu valgum, commonly called"knock-knee", is a condition in which the knees

angle in and touch one another when the legs are straightened.
• Individuals with severe valgus deformities are typically unable to touch their feet
together while simultaneously straightening the legs.

• The term originates from the Latin genu, "knee",and valgus which actually means
bent outwards, but in this case, it is used to describe the distal portion of the knee
joint which bends outwards and thus the proximal portion seems to be bent inwards.

• Mild genu valgum is diagnosed when a person standing upright shows the knees
touching. It can be seen in children from ages 2 to 5 and is often corrected
naturally as children grow. However, the condition may continue or worsen with
age, particularly when it is the result of a disease, such as rickets or obesity .
Angular Deformities Evaluation
Measure Angulation( standing / supine ):
in knock knees /genu valgum : Inter- malleolar distance

2)Genu valgum Treatment

It is normal for children to have knock knees between the ages of two and five
years of age, and almost all of them resolve as the child grows older.
If symptoms are prolonged and pronounced or hereditary, doctors often use
orthotic shoes or leg braces at night to gently move a child's leg back into position.

• If the conditions persists and worsens later in life, surgery may be required to
relieve pain and complications result in from severe or hereditary genu valgum.
Available surgical procedures include adjustments to the lower femur and total
knee replacement (TKR).
• Weight loss and substitution of high-impact for low-impact exercise can help
slow progression of the condition. With every step, the patient's weight places a
distortion on the knee toward a knocked knee position, and the effect is increased
with increased weight.

• Physical therapy is generally of benefit to people with knock knees. To

correct knock knees, the entire leg must be treated, especially:
1) Activating and developing the arches of the feet,
2) Waking up the outer leg muscles (abductors),
3) Stretching of tight muscles and strengthening of weak muscles.

• Rarely, the bone malformation underlying knock knees can be traced to a lack of
nutrition necessary for bone growth, which can cause conditions such as rickets
(lack of bone nutrients,especially dietary vitamin D and calcium), or scurvy (lack
of vitamin C).
The correction ofthe underlying vitamin deficiency may restore a more normal
progression of bone growth.

3)Genu Recurvatum
• Genu recurvatum is a deformity in the knee joint, so that the knee bends
backwards. In this deformity, excessive extension occurs in the tibiofemoral joint.
• Genu recurvatum is also called knee hyperextension and back knee. This
deformity is more common in people with familial ligamentous laxity.
• Hyperextension of the knee may be mild, moderate or severe.
• The normal range of motion (ROM) of the knee jointis from 0 to 135 degrees in
an adult. Full knee extension should be no more than 10 degrees. In genu
recurvatum (back knee), normal extension is increased. The development of genu
recurvatum may lead to knee pain and knee osteoarthritis.

The most important factors of knee stability includes

1) Ligaments of the knee: The knee joint is stabilized by four main ligaments:
• Anterior cruciate ligament (ACL). The ACL has an important role in stabilization
of knee extension movement by preventing the knee from hyperextending.
• Posterior cruciate ligament (PCL)
• Medial collateral ligament (MCL)
• Lateral collateral ligament (LCL)

2) Joint capsule or articular capsule (especially posterior knee capsule).

3) Quadriceps femoris muscle.
4) Appropriate alignment of the femur and tibia (especially in knee extension
position )
3)Genu recurvatum Causes

-Inherent laxity of the knee ligaments.

-Weakness of biceps femoris muscle.
-Instability of the knee joint due to ligaments and joint capsule injuries.
-Inappropriate alignment of the tibia and femur.
-Malunion of the bones around the knee.
-Weakness in the hip extensor muscles.
-Gastrocnemius muscle weakness (in standing position).
-Upper motor neuron lesion (for example, hemiplegia as the result of a
cerebrovascular accident).
-Lower motor neuron lesion (for example, in post-polio syndrome).
-Lower limb length discrepancy.
-Congenital genu recurvatum.
-Cerebral palsy.
-Multiple sclerosis.
-Muscular dystrophy.
-Popliteus muscle weakness.

3)Genu recurvatum Evaluation

➢Non weight bearing test:

• Supine lying position and therapist sit on the affected side, upper hand above the
knee, lower hand above the ankle, upper hand make slight pressure downward and
the lower hand make slight SLR.
• +ve sign: The knee joint has a C- shape as the therapist look from the lateral view
during SLR.

➢Weight bearing test:

• Standing on the tested side and the therapist observe the knee from lateral view.
• +ve sign: The knee joint has a C- shape from lateral view.

3)Genu recurvatum Treatment

• Use of appropriate assistive devices such as orthosis
• Conservative treatment:
➢ Exercise to regain muscle balance
➢Stretch the contracted part
• Surgical treatment