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Guide: Dr. Jaswinder Sir
Presenter: Shubhanshu Ranjan Singh
 6 y old boy of Vitamin D Deficiency B/L Genu
Valgum having Tibiofemoral angle 16 degree
Intermalleolar distance of 11cm, Q angle of
15 degree with 0-140 ROM of knee joint
Bilaterally, Flexion test- femur deformity,
Blood Inv-ALP-317/S. Calcium 8.7/S. PO4- 5.2
Rasied eosinophils
More Medial
 Varun Kumar 6y/ M from Patna
 Gait- Adduction, patella centralised knee touching
knee
 C/O abonormal walking/ future concern
 Deformity first notice by her mother in 2019 and
progessive in nature for which patient got treatment
that time locally for 2 years and deformity get fixed.
 History of vitamin D deficiency (no previous record)
for which he took one weekly sachet and calcium
syrup
 No history of trauma/ infection/swelling/ burning
and pain in micturation/depression in between
thorax and abdomen
 Birth history- mother didn’t took iron and
calcium tablet during pregnancy, rest
uneventful and normal
 Developmental milestones attend
appropiately at his age group
 Family History- Mother h/o hypothyroidism
since 9 years on medication
 2019 diagnosed with vitamin D deficiency
for which she took tab calcium and vit d
sachet
 At age of 1 year left mid upper limb burn scar
mark present
6 y/ M, FTNVD, C/o abnormal walking and
future concern of progression Mother noticed
deformity @ age 3 years age
Deformity progressive
No h/o trauma, infection or any swelling
F/H Mother hypothyroidsm since 9 years
 Height 115
 Weight 25
 General Exam- good nutrition, no skin lesion,
no polydactyly, no short stature spinal deformity
(for Rickets/ skeletal dysplasia/multiple hereditary
exostosis)
Gait- Adduction, Knee touch each other wide space ankle
(circumduction gait)
B/L Genu valgus no patellofemoral instability
ROM normal
 Valgum Alignment – Inward angulation of
extremity in coronal plane (Distal deviate
lateral wrt proximal)
 Valgum called be deformity
depends on
 Age
 Degree of Valgus – 7 degree normal upto 7
year
 Physiological- knock knee, apparent
(ligamentous laxity, rotational deformity, fat
thigh)
 Pathological- Idiopathic, trauma (malunion,
physeal arrest, metaphyseal tibial fracture, )
tumor, tumor like conditions (fibrous dysplesis,
enchondromatosis, MHE), Infection,
 Metabolic (Rickets, renal osteodystrophy)
 Inflammatory- RA
 Syndrome – Ellis Van Creveld syndrome
 Polio, Cerebral palsy
 Skeletal dysplasia- focal fibrocartilaginous
dysplasia, Osteogenic imperfecta
 Assymetric Involvement
 Short stature
 Limb length discrepancy
 Supine knee flexed touching each other both
feet medial malleoli approximated
 If defomity resolve than its femur otherwise
in tibia
 Tibio femoral angle- Clinical radiological
 Intermaleolar distance- Bet medial malleoli
<5/5-10/>10
standing erect wirth hips knee fully extended
and neutral rotation with patella both knee
touching each other
Marking ASIS, centre of patella centre of ankle,
malleoli
 Goniometer ?
 Rotational Profile Assesment
Foot Progression angle
Thigh foot angle
Medial hip rotation 70
Lateral hip rotation 30
Sole of foot (straight)
?femoral anteversion/ tibial torsion
 FPA-line of progession vs foot 10-15
external N
 Thigh foot axis- 20 IR +, ER –
 Apex @ Patella b/w ligamentum patellae and
extension of quadriceps resultant distally
 Patellar instability or not
 Measure – Standing/ Supine 30 flexed(patella
fixed into femoral condyle)(8-10M/15F)
 For ligamentous laxity
 Center of rotation of angulation- Apex of
deformity where osteotomy done in
orthoscanogram drawn.
 Imaging – Full length Xray of bilateral Lower
limbs, xray of wrist, knee
 Lab- Ca/P/PO4/S. VitD/ALP,CBC,ESR, PTYH U.
Ca/P
 Treatment-
Observation – Physiological
Acute Correction-Corrective Osteotomy
Gradual Correction-Guided growth
modulation/ six axis correction device or
ilizarov
 Mechanical Axis deviation ???? Stevans Zones
 Xray Wrist – Metapyseal splaying
/cupping/fraying/osteopenia/ Epiphyseal
thininng
 X-ray Ankle
 In our patient growth potential remaining
So,Guided growth modulation
Figure of 8 plate 16mm applied B/L
Now this is standard treatment for skeletally
immature
Removal?
 Iliotibial band contracture
Hip- abduction/ apparent lenthening/ true
shortening
ANKLE/FOOT- talipes equino varus
Leg- external tibial torsion
Knee- flexion contracture/ genu valgum
Hip- flexion/abduction/ER
Pelvic- pelvic obliquity
Spine- lumber lordosis/ scoliosis