JOSEPH BOGDAN, M.D., Resident, Orthopaedic Surgery
ROBERT P. STANTON, M.D., Attending, Pediatric Orthopaedic Surgery
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
A three year old white male sustained a fracture of the left proximal tibia while jumping off a chair. The minimally displaced fracture was located in the proximal. Treatment consisted of a long leg cast for six weeks. Upon removal of the cast a slight valgus deformity was noted.
Four months after the fracture, progressive valgus deformity was noted and the patient was referred to the duPont Institute for evaluation. Examination revealed full range of motion of the left knee with 20 degrees of genu valgum on left and 10 degrees on the right.
Diagnosis: Post Traumatic Tibia Valga
Plan: Continued observation and parental instruction.
X-ray Set 1. 10 Months post Fracture, Right 8* Left 19* Mechanical axis
X-ray Set 2. 16 Months post Fracture, Right 8* Left 26* Mechanical axis, Left 34* Femoral Tibial Angle.
At this time the child was experiencing significant pain and inability to ambulate. He was treated with varus producing closing wedge osteotomy of the proximal tibia with neutral alignment
X-Ray Set 3. Post-Op, Neutral alignment
X-Ray Set 4. 3 Months post Surgery , Left 6* Mechanical axis
X-Ray Set 5. 9 Months post Surgery Left 10* Mechanical axis
Fractures of the proximal tibial metaphysis initially appear innocuous, but can develop an undesirable valgus deformity. Cozen(2) described four cases of valgus deformity after fracture in 1953. Since then numerous reports and hypotheses have been presented. Fractures in this region are relatively rare with a reported incidence according to Skak(8) of five to six per 100,000.
The proposed causes of progressive valgus deformity include:
Zoints and MacEwen reviewed the cases of seven children with post-traumatic tibial valga. In six of these patients spontaneous correction occurred. Although improvement was seen in the metaphyseal diaphyseal angle in all cases in which spontaneous correction occurred, compensatory overgrowth of the lateral distal physis was also seen. Valgus deformity in excess of 15 degrees is less likely to spontaneously improve according to Jackson .
TREATMENT OF RESIDUAL VALGUS DEFORMITY: