Module 69, Pediatric Orthopaedist Level

1, 2

This 2 year and 9 month old male presented for evaluation of a worsening valgus deformity of his right knee. Thirteen months ago, his mother states the patient complained of some right leg pain and a limp, unassociated with recognized trauma. The pain and limp resolved over a number of weeks. Mom has noticed a progressive cosmetic deformity of the leg without any complaints of pain or functional limitation in running or walking. At the time of the initial injury, the patient was examined by his doctor but there was no history of injury and the problem was not considered to be significant; therefore, no x-rays were performed to document the possibility of a fracture. On physical examination moderate to severe genu valgum of 25 degrees of the right knee and 5 degrees of genu valgum of the left knee was noted. The right knee had full, painless range of motion without ligamentous instability. The left iliac crest was higher than the right. There was no significant rotational deformity noted at the hip, knee or ankle. On gait examination, patient was able to walk and run without tripping or displaying a functional deficit. Standing AP films of the bilateral lower extremities revealed a tibial femoral angle of 17 degrees of the right knee(image1). At a four month follow up now 13 months after injury a progression to 27 degrees was noted(image2). Neutral alignment of the left knee was noted.

Question 69A

This is the typical rate of progression expected for this condition.

Question 69B

He is walking without a limp and not having pain therefore continued observation is the treatment of choice.

Question 69C

The most popular theory of the etiology of this condition is medial tibial over growth due to the hyperemia of the minor fracture.

Question 69D

If a corrective osteotomy is considered, it is recommended to wait 2 years following the traumatic event.

Question 69E

Epiphysiodesis is a reasonable option which the mother can be told about but should be put off for a number of years.

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