Angular and axial deformities of the legs of children.

Age is often a determining factor in establishing a treatment program for these axial and angular problems. As can be seen, the deformities of torsion are noticeable from early life. Any tibial torsion should be treated early, but an excessive medial range of motion in the infant leg with a corresponding adequate lateral range of motion of the limb may be cautiously observed. Medial femoral torsion is a normal early finding in the infant thigh. The problem becomes evident as the child matures without the corresponding reduction in femoral torsion, leading to a persistence of fetal or infantile alignment. The gait consequences are usually noticed at 4 to 8 years of age. The angular changes generally are a delayed finding noticed in stance. The bowleg may be associated with marked tibial torsion and picked up early but the Blount's patient has been traditionally definable at 2 years of age. Levin and Drennan may hasten the time of diagnosis with their radiographic criteria. Knock-knee is an alignment disturbance noticed during the early to mid-childhood years, age 4 to 8 years. The diagnosis is important, differentiating physiologic from torsion-related deformities, and treatment, if warranted, should not be delayed. Generally the earlier these problems are discovered, the more optimistic the prognosis. Since the pediatric limb is in a constant state of transition, there will be a perpetual argument as to the need or efficacy of various approaches to the problems of knock-knee and bowleg. If observation is the treatment of choice, the percentage of cases which go on to osteotomies and epiphyseal stapling will continue. For those with axial or angular deformities, degenerative arthritis of the knee may be forthcoming. Swanson, Greene, and Allis warned of problems becoming "unphysiologic." If we consider the epiphyseal malleability, not only to deformity but to correction, we can appreciate Lenoir's comment of "every day the problem goes untreated is a golden opportunity lost forever." Early, gentle conservative therapy, using splints and casting, is an approach which should be considered in appropriate early problems.