ppt about blounts disease

1. BLOUNTS DISEASE
Dr Imran Jan

2. Definition
It is an disorder of the proximal
medial tibial growth plate
causes progressive varus
alignment of the knees (bowed
legs) in children or adolescents .

3. synonyms
 Infantile tibia vara
 Erlacher`s disease
 Blount-barber disease
 Subepipyseal osteochondropathy
 Non rachitic bow legs
 Ostetis deformans tibia

5. BLOUNTS DISEASE
 Erlacher first description of
tibia vara and internal tibial torsion
(1922)
 Blount (1937) described tibia vara as
 “an osteochondrosis similar to coxa
plana and Madelung's deformity but
located at the medial side of the
proximal tibial epiphysis.”
 .

6.  Prevalence
<1% of all bow legs
 The infantile form is more common in girls.
 The juvenile or adolescent form is more
common in boys.
 The disorder is more common in African
American children than those of other races.

7. ETIOLOGY
 Current concept is tibia vara is
An acquired disease of the
proximal tibial metaphysis of
unknown cause
 Enchondral ossification seems
to be altered.

8. Suggested causative factors include
infection
trauma
osteonecrosis
latent form of rickets
although none of these has been proved
A combination of hereditary and
developmental factors is the most
likely cause

9.  The relationship of early walking
and obesity to Blount disease
has been clearly documented.
 Rarely seen in non ambulant
children

10. BLOUNTS DISEASE
COMPONENTS OF DEFORMITY
 Varus
 Internal torsion of tibia
 Recurvatum
 LLD
 Femoaral varus late
 MSC hypertrophy

11. PATHOLOGY
 islands of densely packed chondrocytes with
hypertr0phy
 areas of almost acellular cartilage
 Intraphyseal ossification centers
 abnormal groups of capillaries.
 Extension of noncalcified cartilaginous bars
into the proximal epiphysis and distal
metaphyses

12. CLASSIFICATON
 Infantile:
before 8 years of age
 bilateral in 60%
 Adolescent more than 8Yrs till
skeletal fusion
 1 with a cause
 2 obese , black

13. Clinical features
Bowing of legs -
progressive
Metaphyseal spike
Knee pain +/-

14. Radiology
 medial half of the epiphysis as seen on
radiographs is short, thin, and wedged
 the physis is irregular in contour and slopes
medially.

 The proximal metaphysis forms a projection
medially
 . According to Smith, however, medial
metaphyseal fragmentation is pathognomonic
for the development of a progressive tibia
vara.

15. Radiological Features
Metaphyseal
beak

17. Tibio Femoral Angle Metaphysio Diaphysial angle
(Levin and Drennen)
MD
angle

18. MDA ANGLE
 MDA < 11: normal
physiologic bowing
 MDA 11-15: equivocal
 MDA >15: Blount’s

19. Langenskiold classification
(1952)
 I - irregular metaphyseal ossification combined with medial and distal
protrusion of the metaphysis
 II, III, IV - evolves from a mild depression of the medial metaphysis to a
step-off of the medial metaphysis
 V - increased slope of medial articular surface and a cleft separating the
medial and lateral epicondyle
 VI - bony bridge across the physis
 Depending on degree of metaphysial and epiphysial changes
on radiograph – 6 progressive stages with increasing age

20. Work up findings
No specific blood marker
Tests to R/o Infection and
Rickects
CT scan in 5yrs + to detect
physeal bar

21. Differential Diagnosis
 Physiologic genu varum
 Skeletal dysplasias (Metaphysial
chondrodysplasia, SED, MED, Achondroplasia)
 Metabolic diseases (Renal OD,Vit D resistant
rickets)
 Post-traumatic deformity
 Post-infective sequelae
 Proximal focal fibrocartilaginous dysplasia

22. Treatment
 Treatment choices and
prognosis depend greatly on
the age of the patient and
radiographic stage at the time
of diagnosis

23. Rx - Orthotics
 Recommended for patients < 3 years of age and <
stage II disease
 Rainey et al recommended LOCKED KAFO that
produced a valgus force by three point pressure
 23 HRS /DAY
 Full weight bearing
 Risk for failure included ligamentous
instability, patient weight above 90th percentile and
late initiation of bracing

24. Corrective osteotomy options
Metaphyseal
Epiphyseal – metaphyseal
Intra epiphyseal
 Fibula &Bony bar resection

25. Rx – Corrective Osteotomy…
 Rab
 proximal tibial oblique
metaphyseal osteotomy in which
single plane oblique cut allows simultaneous
correction of varus and internal rotation and
permits postoperative cast wedging if necessary
to obtain appropriate position.

27. RAB’S OBLIQUE PROX. TIBIAL
OSTEOTOMY

28. Rx – Corrective Osteotomy…
Greene
 Chevron open- closing wedge osteotomy in
which opening and closing wedges can be
made so that the limb length deformity
present in moderate to severe tibia vara will
not be increased. He prefers a crescent
shaped osteotomy using one half lateral
closing wedge and using the graft medially in
an opening wedge to maintain length.

29. GREEN CHEVRON

30. Rx – Corrective Osteotomy…
 In children older than 9 years with more severe
involvement, osteotomy alone, with bony bar
resection, or with epiphysiodesis of the lateral
tibial and fibular physes may be indicated
 For older children in whom bracing and tibial
osteotomy have failed to prevent progressive
deformity, Ingram, Siffert and others have
suggested an intraepiphyseal osteotomy to
correct severe joint instability and a valgus
metaphysial osteotomy to correct the varus
angulation

31. Rx – Corrective Osteotomy…
 Schoenecker et al – elevation of medial tibial
plateau with metaphysial wedge osteotomy
 Gregosiewics – double elevating osteotomies;
intraepiphyseal and metaphyseal
 Zayer – hemicondylar tibial osteotomy through
the epiphysis into the tibial intercondylar notch
 Bell, Coogan – recommended Ilizarov’s
technique
 Uniplanar external fixator for isolated frontal one
plane deformity

32. SIFFERT’S I E OSTEOTOMY

33. ILLIZARROV’S TECHNIQUE

34. Rx in a nut shell
AGE STAGE Rx
< 2 1-11 observation
2-3 1-11 Modified locked KAFO
3-8 11-111 Oblique / chevron o-y
9 + 1v + Resection of bony / physeal bar
+osteotomy+ epiphyseal elevaton +/-lateral
tibial epiphyseodesis

35. COMPLICATIONS
Common peroneal nerve
palsy
Compartment syndrome
Anterior tibial artery
occlusion
Recurrence

36. Not yet over

37. CONGENITAL METATARSUS
ADDUCTUS
 Definition
 Metatarsus adductus is a congenital
foot deformity consists of adduction
of the forefoot in relation to the
midfoot and hindfoot presenting as
in-toeing in children.

39. Transverse crease along medial
border of foot
Widening of 1st web space

41. CONGENITAL METATARSUS ADDUCTUS
 It can occur as an isolated
anomaly or in association with
clubfoot.
 Among individuals with
metatarsus adductus, 1% to 5%
also have developmental
dysplasia of the hip or
acetabular dysplasia

42.  Metatarsus adductus may be
seen as a residual deformity in
patients previously treated
surgically or nonsurgically for
congenital clubfoot.
 This residual metatarsus adductus can be rigid, indicating fixed
positioning of the forefoot on the midfoot and hindfoot, or it can
be dynamic, caused by imbalance of the anterior tibial tendon
during gait.

43. CONGENITAL METATARSUS ADDUCTUS
 BLECK classified as
 mild
 moderate
 severe
 In the mild form, the forefoot can be clinically
abducted to the midline of the foot and beyond
 The moderate form has enough flexibility to allow
abduction of the forefoot to the midline only
 In rigid metatarsus adductus, the forefoot cannot
be abducted at all.

45. Diagnosis
Clinical and radiologic

46. Treatment
 MILD
 mild deformities resolve
 Reassurance
 Observation
 Serial stretching and casting can be tried

47.  MODERATE - SEVEREtype
 Serial stretching and casting
for 2-3 months

48. Rx SURGICAL
 INDICATIONS
 severe deformity uncorrected
by conservative treatment
 pain
 Objectionable appearance
 Difficulty in fitting shoes

49. SURGICAL OPTIONS
 Less 4 yrs of age
Tarsometatarsal capsulotomies
 (Heyman, Herndon, and Strong)
 Beyond 4 yrs of age

Multiple metatarsal osteotomies
 (Berman and Gartland)
 Medial cuneiform, lateral cuboid
double osteotomy

50. BERMAN GARTLAND
TECHNIQUE

51. DOUBLE OSTEOTOMY

52. Hold on!!!!
5 more
minutes

53. Congenital
Calcaneovalgus
foot

55. CCV foot
 Ccv presents
 Marked dorsiflexion at ankle
 Hind foot valgus
 Dorsum of foot against anterior
surface of distal leg
 Ankle ROM till neutral or lessat
birth with a dramatic

56. CCV foot - causes
Uterine packing
Oligohyraminos
Primipara
Twin/triplets

57. Ccv Foot Rx
Spontaneous recovery
with 2-3 months
Stretching advisable
Serial casting +/-
Allay parental anxiety

58. THANK YOU