Published: 17-08-2010, 17:27

Genu varum (“bowlegs”) and genu valgum (“knock-knees”)

From the 1940s to the present, “bowlegs” and “knock-knees” have enjoyed the distinction of being one of the most common complaints seen by primary care physicians and orthopedic surgeons. A far greater understanding of the natural evolution of these conditions in childhood has resulted in a dramatic reduction in the number of these cases currently seen by physicians.
Genu varum (“bowlegs”) and genu valgum (“knock-knees”)

Figure 2.3. Graph demonstrating physiologic progression of varus to valgus. SM: Skeletal Maturity.

In addressing the natural history of these two conditions in the growing child, it is important to exclude those cases associated with nutritional or vitamin D resistant rickets, Blount’s disease, skeletal chondro-osseous dysplasia, traumatic growth plate insults, infection, and neoplasm. If there is any question, a careful history coupled with radiographs taken of the knees and occasionally laboratory tests are capable of differentiating these conditions from the physiologic type of varus and valgus that will be discussed. Over the past 20 years, several articles have clearly shown that the natural history of physiologic varus and valgus follows a clear and defined pathway (Figure 2.3). From birth to roughly 18 months of age, there is a normal “varoid” stage of development in which bowed legs persist. From 24 months onward, children normally will enter a stage of increasing valgus at the knees and this generally will persist until adolescence, at which time they seem to follow a pattern of their genetic inheritance, eventually culminating into a pattern of knees that are either straight or with very minor degrees of varus or valgus. Varus and valgus at knee level is most readily measured by placing the ankles together at the medial malleoli, and measuring the number of “fingerbreadths” that can be placed between the medial femoral condyles (bowed legs or varus) (Figure 2.4).
Genu varum (“bowlegs”) and genu valgum (“knock-knees”)

Figure 2.4. The technique of measurement by finger-breadths of genu varum and genu valgum.

Knock-knee or valgus deformity is most readily measured by bringing the medial femoral condyles together and then measuring the distance between the medial malleoli with the knees in the extended position. A simple recording of the number of fingers measured on each visit will provide irrefutable evidence of the natural evolution of the angular deviation. It has also been commonly observed that youngsters who walk early (i.e., at 9–10 months of age) will commonly have more genu varum, which will tend to persist even into the second and early third year of life before spontaneous resolution into valgus occurs. An alternative method of following the process clinically is to make drawings on a sheet of paper of the contour of the knees in relationship to the ankles, and then measuring the distance between the various anatomic landmarks on a sheet of paper (Figure 2.5).
Genu varum (“bowlegs”) and genu valgum (“knock-knees”)

Figure 2.5. The technique of measurement by centimeters or inches of genu varum and genu valgum.

Historically these physiologic angular alterations have been treated by stretching, shoe adaptations, orthotics, medications, surgical epiphyseal stapling, and osteotomy of the long bones. In the absence of a known medical disease or disorder (Pearl 2.1), physiologic genu varum and genu valgum will spontaneously resolve into an acceptable degree of knee alignment by maturity. Our own extensive experience has failed to provide any cases presenting for treatment at skeletal maturity. Periodic follow-up and reassurance to ameliorate parental anxiety appears to be all that is necessary.
Pearl 2.1. Differential diagnosis of physiologic genu varum
Blount’s disease
Skeletal dysplasias
Nutritional rickets
Vit D resistant rickets
Growth plate insult
Infection
Neoplasm
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