Menu
+38
Menu
Services
Oleg Loskutov
This article was written together with Oleg Loskutov, Candidate of Medical Sciences, President of the Association for Foot and Ankle Surgery. Contact your doctor
O-shaped legs are very common among babies. When a child with varus deformity stands with his feet together, there is a clear space between the shins and knees. This may be the result of one or both legs being curved outward. Walking often accentuates this deformity.
In most cases, O-shaped legs will begin to straighten naturally as the child grows. If the deformity has not disappeared by age 3, it may be the underlying cause of diseases such as Blount's disease or rickets.
Teenagers sometimes have an o-shaped leg deformity. In many cases, the child is significantly overweight.
What can Blount's disease be confused with?
- in a child under 2 years of age – with physiological norms;
- with rickets and rickets-like diseases, phosphate diabetes;
- in rare cases - with achondroplasia, hypochondroplasia, TAR syndrome.
When evaluating a child with suspected infantile Blount disease, teamwork is essential for success. The minimum that the orthopedist should not neglect is a consultation with an experienced pediatrician (who will prescribe a list of laboratory tests for your child). You may also need: examination by a nephrologist, endocrinologist, geneticist.
Medical examination
Your doctor will start with a thorough physical examination of your child.
If your child is under 2 years of age, is in good health, and has symmetrical arching (the same curve in both legs), then your doctor will likely say that no further testing is needed at this time.
However, if your doctor notices that one leg is more bent than the other, he or she may recommend taking an X-ray of the lower leg. An X-ray of your child's legs while standing may show signs of Blount's disease or rickets.
If your child is older than 2 1/2 years old at the first visit and has symmetrical leg bending, your doctor will likely recommend an X-ray. Your child is more likely to have Blount's disease or rickets at this age. If an X-ray shows signs of rickets, your doctor will order blood tests to confirm the presence of the disease.
Why is it important to make a correct diagnosis?
Treatment for Blount disease is, in most cases, surgical. Most children under 2 years of age have a physiological varus (O-shaped) curvature of the legs. An extreme version of this physiological curvature may be mistaken for a bilateral form of Blount's disease. This child will undergo surgery. At the same time, further growth of the child, if surgical intervention is not performed, leads to independent correction of this curvature, and surgical treatment can lead to the formation of valgus (X-shaped) deformity. If we confuse Blount's disease with rickets and rickets-like diseases, then surgical intervention may be ineffective and lead to recurrence of the deformity, because we did not compensate for the missing element (vitamin D, calcium, phosphorus, etc.). Moreover, timely therapy selected by a pediatrician may be sufficient for self-correction of the deformity as the child grows.
Rickets
Rickets
is a disease in children that affects the bones and causes bowed legs and other bone deformities. Children with rickets do not get enough calcium, phosphorus or vitamin D, which are important for healthy bone growth.
Dietary rickets is unusual in developed countries because many foods, including dairy, are fortified with vitamin D. Rickets can also be caused by a genetic abnormality that prevents vitamin D from being absorbed properly. This form of rickets can be inherited.
Should Blount's disease be treated?
In this case, there is no doubt - it is necessary. The problem is not just an aesthetic issue. If Blount's disease is not treated, then in 100% of cases the patient is doomed to arthrosis of the knee joint with early manifestations, namely, pain symptoms. We can say this with confidence, because... We have repeatedly encountered patients with the infantile form of Blount's disease who did not receive treatment at a young age, but presented at the age of 12-15 years. Most of these children already had pain symptoms that limited their daily activities.
Symptoms
The bowing of the legs is most noticeable when the child is standing and walking. The most common symptom of o-shaped legs is an awkward gait.
Babies with O-shaped legs usually have normal coordination and do not lag behind their peers in learning to walk. However, the degree of curvature can be significant and may cause concern for parents and family members.
A toes-in gait is also common in children, combined with bowed legs.
O-shaped leg curvature is usually painless. However, during adolescence, persistent deformity can lead to discomfort in the hips, knees and/or ankles due to excessive stress on the joints of the crooked legs. In addition, parents are often concerned that the child trips too often, especially if a toes-in gait is also present.
Regarding the tactics of treating Blount's disease, we fundamentally use the following algorithm in our practice.
- Child under 3 years old. Massage, unloading of the lower extremities. A number of orthopedists prefer plaster corrective bandages or their orthotic equivalent. We do not use these methods, because... From our point of view, it is important to exclude axial load on the affected limb(s), and casts do not allow this.
- For a child under 4 years old, there is confidence in the diagnosis, there are no radiological signs of synostosis (fusion) of the growth plate - hemiepiphysiodesis with figure-of-eight plates (controlled growth). Child over 4 years old, no synostosis, corrective osteotomy, osteosynthesis with wires, plaster immobilization.
- If there are radiological signs of synostosis, and the synostosis does not exceed 40-50% of the area of the growth plate, there is no significant shortening, the child is under 6-7 years old, the child is not large - curettage (resection of synostosis), corrective osteotomy, osteosynthesis with knitting needles, plaster immobilization.
- If there is significant synostosis, shortening of the lower leg, a child over 6-7 years old, we perform epiphysiodesis (closure of the functioning growth zone by drilling), osteotomy (intersection) of the lower leg bones, lengthening and correction of the deformity using transosseous osteosynthesis. A number of orthopedists prefer not to perform epiphysiodesis, but use the so-called. overcorrection (i.e. they create a valgus deformity from a varus one). We are categorically opposed to this method, because In our experience, maintaining a functioning part of the growth zone in the presence of synostosis (closure) on the other leads to a recurrence of the deformity as it grows, and a relapse occurs in the shortest possible time (6-12 months). In our practice, we strive for ideal correction and, if possible, perform “re-lengthening” of the lower leg, counting on the continued growth of the child.
Features of the disease
This term refers to pathology that is accompanied by curvature of the upper fragment of the tibia.
The result is varus deformity. Sometimes there is valgus curvature of the limbs. Por ICD-10 disease belongs to category Q68.4. The main cause of the anomaly is considered to be damage to the epiphyseal cartilage. This occurs in the area of the tibia condyles. As a rule, the internal condyle suffers. However, sometimes damage to the outside is observed.
The disease occurs at 2-3 years of age or after 6 years of age. A characteristic sign of the anomaly is deformation of the upper third part of the lower leg. To identify the disease, the doctor performs an examination and prescribes x-rays. To cope with the disease, surgery is usually performed.
Clinical manifestations
Infectious mononucleosis - symptoms and treatment
The incubation period is from 4 to 15 days, according to some sources - up to 1 month.
When infected in early childhood, the course of the disease is usually asymptomatic or minimally symptomatic and often passes under the guise of a mild acute respiratory infection.
Symptoms of infectious mononucleosis in adults
Characteristic syndromes:
- General infectious intoxication: headache, apathy or, on the contrary, agitation, sleep disturbances, general fatigue, joint and muscle pain, general weakness, loss of appetite, decreased ability to work.
- Organ damage: generalized lymphadenopathy - enlargement of lymph nodes in two or more non-contiguous areas.
- Tonsillitis (inflammation of the pharyngeal and palatine tonsils). It is the main one in the typical form of the disease.
- Hepatolienal (enlarged liver and spleen).
- Changes in hemogram (blood parameters)/mononucleosis syndrome.
- Exanthema (skin rash). Most often appears when using antibiotics.
- Pigment metabolism disorders (jaundice).
- Hospital abstinence (dependence of patients on medical institutions and the formation in them of a fear of death from the disease).
The onset of the disease is gradual, the main syndrome appears later than three days from the onset of clinical manifestations. Fever gradually appears and increases with an increase in body temperature to 38-39 ℃. The fever lasts up to three weeks or more, while the patient experiences weakness and lack of appetite. Myalgia (muscle pain) is not typical.
The lymph nodes of different groups symmetrically enlarge, mainly the posterior cervical, anterior cervical, occipital; in some patients, the axillary, elbow, inguinal, and intra-abdominal groups are also involved (mesadenitis). A characteristic feature is their low pain, soft elasticity, and absence of changes in the integumentary tissue. The increase in size persists for up to 1 month or more and often leads to significant differential diagnostic difficulties. After a certain initial period, in typical cases, acute tonsillitis develops (lacunar, ulcerative necrotic) with an abundant white or dirty gray cheesy coating, which easily crumbles, is removed with a spatula and rubbed on glass. Symptoms of infectious mononucleosis include mild sore throat.
In some cases, periorbital edema develops, manifested by bilateral transient swelling of the eyelids. Almost always there is an enlargement of the spleen, which is characterized by smoothness, elasticity, and sensitivity to palpation. Sometimes reaching large sizes, the spleen can rupture. Normalization of its value occurs no earlier than four weeks from the onset of the disease, and may take several months.
Less commonly, liver enlargement occurs, which is accompanied by disruption of its function and the development of hepatitis of varying severity (benign course) [3][4][6].
If the symptoms are misinterpreted and antibiotics of the aminopenicillin series are used, in 70-80% of cases a rash appears (can be spotted, maculopapular, bright red, with a tendency to merge, of different localization, without obvious stages of appearance).
With an adequate immune response, the course of the disease is usually benign and ends with the formation of virus carriage in the complete absence of symptoms and laboratory changes.
What “wrong” variants of the course of the disease are possible in adults?
In rare cases, the disease can develop as a “chronic mononucleosis” (with periods of exacerbations and remissions). This is possible with congenital or acquired disorders in the immune system, immunosuppressive diseases, or taking cytostatic (antitumor) drugs.
Why is the chronic form of infectious mononucleosis dangerous?
In the clinical picture of chronic mononucleosis, almost all syndromes of the acute process appear, but they do not appear so pronounced: tonsillitis, as a rule, is absent, and withdrawal syndrome comes to the fore. This condition is not an independent disease, it is a consequence of the existing underlying immunopathological process, therefore it should be considered not as mononucleosis, but as a chronic active Epstein-Barr viral infection. Therefore, examination and treatment must be approached with this perspective in mind.
The possibility of transplacental transmission of EBV during primary infection in pregnant women and the development of congenital EBV infection in a newborn has been proven. This form manifests itself in the form of multiple organ damage to internal organs; the frequency and severity of the disease depends on the timing of pregnancy [1][3][4].
Causes
The exact causes of the disease have not yet been determined. However, the risk of its development increases due to damage to the tibia in the area of the epiphyseal cartilage. Doctors believe that this deviation is associated with the following anomalies:
- chondrodysplasia;
- osteochondropathy.
The pathology may be supplemented by other congenital diseases. There is also a hypothesis regarding a hereditary predisposition to the development of the disease. In addition, the provoking factors of Blount's disease include the following:
- excess weight;
- premature onset of walking – due to the absence of the crawling stage;
- traumatic injuries of the legs in infancy;
- complex infectious diseases;
- pathologies of endocrine organs.
The provoking factor in the development of the disease is the increased load on the unprepared musculoskeletal system in combination with the anatomical features of the legs.
Another cause of the disease is considered to be a lack of vitamin D. A lack of the element in food or a violation of its absorption can affect the appearance of the mutation. As a result, this becomes the cause of the disease.
Stages of deformation
Anatomy of the lower leg
The human shin consists of two bones - the tibia (a massive bone consisting of a tubular substance) and the fibula (also consisting of a spongy substance, but somewhat smaller in size). Their surface is the site of attachment of numerous muscles and ligaments that provide movement and support. The tibia has a central location - medial, while the fibula is located on the side of it - lateral.
The tibia has a triangular shape and is attached to the femur through the knee joint. Conventionally, it can be divided into 2 parts - the proximal (upper) and distal (lower) epiphyses. In Blount's disease, the affected area is the proximal epiphysis of the tibia.
Classification of deforming epiphysitis
Depending on the age of the patient, Blount's disease is divided into forms:
- Infantile, or infantile - affects children under 3 years of age;
- Juvenile – junior preschool and school age – 4-10 years;
- Adolescent - in children aged 11 years and older, it most often occurs with damage to one lower leg.
Depending on the nature of the tibia deformity:
- X-shaped – valgus;
- O-shaped – varus.
Depending on the level of curvature:
- Potential – there is internal or external sclerosis of the tibia, in which the angle of curvature does not exceed 15°;
- Moderate – the epiphysis of the tibia is divided into segments, the angle of curvature is up to 30°;
- Progressive – the epiphysis is hypertrophied (thickened) in the middle section;
- Rapidly progressing - the growth zone of the medial section is closed, the metaphysis and epiphysis form a bone articulation between themselves - a bridge.