Varus and valgus of the knee joints in children (bow legs & knock knees)

Many parents worry if their child's legs are shaped like the letter "O" or "X". Most often, this is a variant of the child’s normal growth and development and corrects itself as the child grows older.

But regardless of whether the shape of the child’s legs is pathological or physiological, an examination should be carried out for each child, taking into account the collection of a detailed history and research.

Terminology

• Varus of the knee joints is a term that corresponds to an “O”-shaped deformity of the legs
• Knee valgus is a term that corresponds to an “X”-shaped deformity of the legs.

Physiological varus and valgus of the knee joints in a brother and sister

How to measure the severity of valgus and varus?

To measure varus of the knee joints, a measurement is taken between the condyles of the femurs (between the knees) with the feet brought together

To measure knee valgus, a measurement is taken between the ankles of the feet with the knees brought together.

Normal values ​​for different ages are shown in the figure below (values ​​above zero indicate the distance between the knees, below zero between the feet):

Chart of age norms of valgus and varus of the knee joints in children.

Mechanism of disease development

By the age of 2-3 years, the O-shaped legs should disappear. By this age, a slight curvature of the lower leg may remain. At the initial stage of varus curvature, the external femoral condyle increases while the internal one decreases. The interarticular space becomes different. In the inner part it narrows, in the outer part it increases. Because of this, there is pressure on the meniscus, the ligaments on the outside of the joint are stretched, and the heels are deflected inward.

A child's legs are like wheels

Over time, the disease progresses, and a compensatory reaction of the body is formed, in which the feet become deformed. In severe stages of pathology, the legs change their location inward, the hips change outward. As a result, bending at the knees is limited, gait is disrupted, and the child gets tired. The load is distributed incorrectly due to a shift in the center of gravity, posture worsens, and the spine is bent.

Tibiofemoral angle

The tibiofemoral angle (knee angle) is the angle formed by the mechanical axis of the femur intersecting the mechanical axis of the tibia. If this angle decreases, varus of the knee joint (“O” leg) occurs. As this angle increases, valgus of the knee joint (“X” leg) occurs.

In infants, the physiological development of the tibiofemoral angle goes from varus to valgus:

Tibiofemoral angle in children from 0 to 13 years.

Characteristics of the disease

O-shaped legs have a number according to the ICD classification 10 - 21.0. Wheel legs in a newborn are physiological in nature. This is due to the intrauterine development of the child, during which his legs take a forced position, slightly curved in an arc. At first, a newborn’s limbs still adhere to their usual shape. Over time, muscle tone decreases and they straighten.

On a note!

If parents notice curvature of the legs, then it is necessary to consult a pediatric orthopedist who will determine whether this is a pathology.

Causes of physiological varus and valgus

The “O” shape (varus) of the legs in children of the first year of life is the result of the intrauterine position. In the womb, your baby's legs are positioned so that the hips are flexed, outwardly rotated, and abducted, the knees are bent, and the legs are turned inward.

This combination of external rotation of the hip together with internal rotation of the leg leads to varus of the lower extremities. Varus reaches its maximum values ​​in newborns (from 12 to 15 degrees), and becomes neutral at the age of 1.5 to 2 years.

The “X” shape (valgus) of the legs in children occurs as a result of physiological changes as the child grows. By 3-4 years, maximum valgus deformity is observed (up to 12 degrees) and decreases by 5-8 years (up to 7 degrees).

What are the causes of X-shaped leg deformity in children?

Typically, valgus deformity of the knee joints between the ages of 2 and 7 years is the age norm. This position helps children maintain balance.

In more rare cases, “x-shaped” leg deformity may be associated with:

• Genetic diseases such as skeletal dysplasia or metabolic bone diseases (such as rickets)
• Impaired muscle tone, compression of the joints of the pelvis and lumbosacral spine
• Trauma to the growth plate of the tibia or femur (in this case, only one knee joint is valgus)

When should parents be concerned about knee valgus?

• If your child has varus of the knee joints and one of the following symptoms, you should consult a doctor:
• Varus deformity of the knee joints under 2 years of age and over 7 years of age
• Increased varus deformity of the knee joints over the age of 7 years
• Different leg lengths, different severity of valgus in the knee joints on the legs
• If your child limps when walking
• Knee or hip pain
• Short child height

For what pathologies is it prohibited to independently treat curvature of the legs?

Parents who have discovered an O-shaped curvature of the legs in their child should not engage in independent treatment of this pathology. In this case, the severity of the deformation processes does not matter.

This anomaly in the development of the child’s musculoskeletal system should be examined and studied by a specialized specialist. Only a pediatrician or pediatric orthopedist can formulate a correct and effective course of therapy.

It should be taken into account that successful treatment of O-shaped curvature is possible only using an integrated approach.

The shape of the child’s lower extremities should be corrected with the help of physical therapy exercises, physiotherapy, massage and properly selected orthopedic products. Self-treatment of an O-shaped curvature without the help of doctors can lead to the progression of the pathology, as well as the development of associated complications.

Hip dysplasia in children under 1 year of age

So, what is Dysplasia? This is a violation of the formation of an organ or tissue.

First, let’s look at the structure of the hip joint without pathologies:

The hip joints connect the lower limbs (thigh bones) to the pelvis. It is a classic hinge: it consists of a spherical head of the femur (1) inserted into a concave round acetabulum (2) in the pelvic bones. Both the head of the femur and the acetabulum are covered with elastic and durable cartilage (3). The joint cavity contains slippery synovial fluid (4), which reduces friction, softens shock and transfers some nutrients. The head of the femur is supplied with blood from the vascular bundle (5) passing inside the joint.

In our case, when we talk about hip dysplasia, we mean congenital underdevelopment of the acetabulum (2). The roof of the acetabulum in this case only partially covers the head of the femur. Thus, the area of ​​support of one articular surface on another is reduced, which means that the pressure per unit area of ​​the joint increases significantly. In addition, in such a joint, excessive movements are possible when walking, which over time destroys the joint, which is quite common in newborns. One of the clinical manifestations of dysplasia is dislocation of the femoral head.

There are 3 degrees of hip dysplasia (congenital hip dislocation):

1. Pre-dislocation (hip instability) - grade I dysplasia - underdevelopment of the hip joint without displacement of the femoral head relative to the acetabulum.
2. Subluxation (congenital subluxation of the femur in the hip joint) - grade II dysplasia - underdevelopment of the hip joint with partial displacement of the femoral head relative to the acetabulum.
3. Dislocation (congenital dislocation of the hip) - grade III dysplasia - underdevelopment of the hip joint with complete displacement of the femoral head relative to the glenoid cavity.

The formation of the musculoskeletal system occurs at 4-5 weeks of intrauterine development, its final formation is after the child begins to walk. At any stage of development of the musculoskeletal system, disorders are possible. The most common cause is genetic defects. This developmental defect can form as a result of infectious, endocrine diseases of the mother during pregnancy, while gynecological diseases (in this case, the presence of uterine fibroids, adhesions in the uterus, and other processes) can impede the child’s intrauterine movements. Late pregnancy, toxicosis (especially the first half of pregnancy), unbalanced nutrition of the expectant mother, lack of vitamins and minerals that contribute to the proper formation of connective tissue and mineralization of cartilage tissue can also have an impact on the development of dysplasia.

In addition, the formation of hip dislocation occurs in the last months of intrauterine life under the influence of unfavorable factors, such as: the tight position of the fetus in the uterus (with oligohydramnios, a large fetus, more often in first-time mothers), with a breech presentation of the fetus (the fetus has a reduced range of motion in the joints, especially in the hip, which interferes with the full formation of the hip joint). This pathology of newborns is five times more common in girls with a predominance of dislocation on the left side.

The success of treatment directly depends on the early examination of the child by a pediatric orthopedist. That is why a thorough examination of the newborn for congenital pathology of the hip joint is carried out in the maternity hospital. If there is even a suspicion of pathology of the hip joint, the child is sent to an orthopedist immediately after discharge from the maternity hospital. The local pediatric orthopedist should see the child for the second time at 1 month, the third time at 3 months, the fourth at 6 months, and the fifth time at 1 year or when the child begins to walk. An attentive mother (with a unilateral dislocation) can also notice some signs of hip dislocation, paying attention to the following symptoms up to a year: limited hip abduction in the child. To do this, place the baby on his back, bend his legs at the hip and knee joints at a right angle and gently spread his hips to the sides. If a joint is affected, abduction is limited to the side of the affected joint. You can also determine the restriction of movement in the position of the child on his stomach when bending his legs, as when crawling. However, we must remember that the available possibility of hip abduction up to 90° in a child decreases with age and by 9 months it reaches only 50°.

• symmetry of the subgluteal folds and skin folds on the thighs. You need to put the baby on his stomach, straighten his legs and carefully examine the symmetry of the folds: asymmetry of the folds on the hips and buttocks is not necessarily hip dysplasia, this only allows you to suspect it and examine the child in more detail.
• a slipping or “clicking” symptom, called the Marx-Ortolani symptom. When the legs are abducted, the dislocation is reduced, with a characteristic click and push, which is felt by the specialist’s hand. It should be noted that this symptom, as a rule, disappears by the 5-7th day of the child’s life, but in some children, if muscle hypotonia is present, it may persist during the first months of life.
• visually detectable shortening of the lower limb. It is clearly visible to the eye when the child is positioned on his back with his legs bent at right angles at the knee joints. You can compare the length by the location of the ankles and heels with straightened legs.
• external rotation of the lower limb. It is clearly visible when the child is sleeping. The difference in leg length is judged by the different locations of the levels of the knee joints, bent and close to the stomach.

In a child older than one year, it is easier to diagnose based on the following symptoms:

• late start of walking;
• lameness on the affected leg;
• increased lumbar lordosis;
• symptoms detected during the neonatal period appear more clearly (limited abduction, external rotation, shortening).

All of these symptoms may occur together, or only part of the symptoms may occur. At the slightest suspicion of congenital pathology of the child’s joints, it is necessary to immediately show the child to an orthopedist. The orthopedist conducts a clinical examination and, if necessary, refers the child to an ultrasound examination of the hip joints. This is a harmless examination method, however, it does not always allow a reliable assessment of the condition of the joint, because it does not provide a complete picture of the relative position of its elements. Namely, the relative position of the elements makes it possible to determine whether there are pathological changes in the joint. To a greater extent, ultrasound is suitable for screening, that is, examining all newborns in maternity hospitals for pathology of the hip joints. Unfortunately, this has not yet become widely practiced in our country. In addition, ultrasound may be useful in monitoring the effectiveness of treatment.

If dysplasia is present or suspected, the doctor may prescribe an X-ray examination of the hip joints. Radiography allows you to objectively assess the condition of the joints.

Treatment of hip dysplasia

It is important to start treatment early. With timely diagnosis and adequate treatment, joint functions are almost completely restored before 3 months of age.

If the orthopedist confirms the diagnosis of dislocation (as well as subluxation or pre-luxation) of the hip, then treatment begins immediately. It must be remembered that the treatment of congenital hip dislocation is long and complex. During this therapy, wide swaddling and special abductor splints are used, which can be removable or non-removable (1. Pavlik stirrups, 2. Freik pillow, spacer splints: 3. splint with femoral splints, 4. splint for walking, 5. splint with popliteal splints splints), plaster casts.

Treatment is aimed at keeping the hips in a position of flexion and abduction in the hip joints and improving blood supply to the hip joint area. The purpose of using these devices is to create the most favorable conditions for the development of all elements of the joint (femoral head and acetabulum). The duration of wearing a splint is determined in each case individually and can range from several months to one year. Without the permission of the orthopedist, it is strictly forbidden to put the child on his feet and remove the splints. The most important thing is not to interrupt treatment. The most optimal device from 1 month to 6-8 months is Pavlik stirrups with ankle splints or an abduction splint with popliteal splints. From 6-8 months, an abduction splint with femoral splints is prescribed, and if the orthopedic doctor allows the child to walk, an abduction splint for walking is prescribed.

Physiotherapy, massage, and physical therapy are also widely used for treatment. But it is important for parents to remember that massage and physical therapy should only be carried out by a specialist.

If conservative treatment is ineffective, surgery is performed. The essence of the operation is to realign the head of the femur and restore the anatomical conformity of the elements of the hip joint. After the operation, long-term fixation is carried out, then restorative treatment using adequate physical activity on the joints, physical therapy, massage and physiotherapy.

If congenital dislocation of the hip is not cured, then due to improper biomechanics (that is, movements), dysplastic coxarthrosis develops in the joint - a severe disabling disease of the hip joints, accompanied by pain, gait disturbance, and decreased range of motion in the joint.
Treatment for this condition can only be surgical. The later the operation is performed, the less likely it is for a full recovery. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Komarovsky's opinion

The famous pediatrician Komarovsky denies the negative impact of rickets on the musculoskeletal system. He claims that the development of the problem is influenced by a hereditary factor, kidney disease, which leads to poor absorption of minerals by the body. Komarovsky gives the following advice to parents to avoid clubfoot:

• It is important to ensure that the child receives proper nutrition and all the necessary vitamins and minerals;
• Water procedures will help relieve increased muscle tone;
• To prepare for walking, you should massage the outer and inner sides of the lower leg and foot;
• After bathing, massage your feet well with a stiff brush;
• Two feet joined together is a good exercise for the muscular system;
• Keeping the child in an upright position strengthens his legs and back;
• A fat baby needs more time before starting to walk.

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Features of treatment

As a rule, treatment for pain in the legs includes several conservative methods. Surgery is required only in cases of severe destruction of musculoskeletal tissue or accumulation of pus, as well as in certain heart pathologies. In the early stages of leg disease are treated with:

• drug therapy;
• exercise therapy;
• physiotherapy;
• massage;
• reflexology (acupuncture, biopuncture).

Complex therapy allows you to eliminate inflammatory processes and get rid of pain, normalize blood circulation, improve tissue nutrition, strengthen muscles and ligaments and provide conditions for healthy, harmonious development of the body. With timely help, even dangerous diseases, such as infectious arthritis, can be successfully treated without long-term consequences for the body. In the network of clinics “Hello!” There are all possibilities for early and accurate diagnosis of diseases that cause pain in the legs. Experienced and attentive medical staff create comfortable treatment conditions, and the development of an individual treatment plan for each patient eliminates the risk of complications.

What to do if your child’s legs hurt?

Self-administration of antibiotics and painkillers can only harm health: cause the development of secondary diseases or accelerate the progression of the underlying pathology. In case of intense or persistent pain, you should consult a pediatrician or orthopedist. A comprehensive diagnosis will help answer the question of why a child’s legs hurt:

• X-ray;
• MRI;
• CT;
• ECG;
• blood and urine tests;
• collection of intra-articular fluid (in some cases).

Please note: radiography makes it possible to detect only deformation of the joints and spine, but does not provide information about the condition of the spinal cord, nerve endings and blood vessels. Therefore, do not refuse if your doctor recommends tests such as MRI and CT: they will help to accurately determine the cause of the pain.