Pediatric Limb Differences and Deformities

Washington University Orthopedics provides the best in pediatric orthopedic evaluation, diagnosis and surgical intervention for children with limb differences and deformities. Through the collaboration of our staff, including advanced nursing care, therapy and psychological intervention, our goal is to improve the function, mobility and independence of each child. Learn more below about:

Conditions we treat ⎮ Treatment options ⎮ Meet our team of specialists

Contact Us

For more information or questions, please contact our nurse educator, Melissa Eagan, RN, BSN, ONC, at 314-454-5228 or our clinical coordinator Jill Hahn, RN, BSN, CCM, at 314-692-6443. You may also email us at [email protected].

To schedule an appointment, call or visit:

Call (314) 514-3500 Schedule online appointment

Commonly Treated Conditions

Rotational Problems

Femoral anteversion
Femoral anteversion is an inward twist of the femur (thigh bone) that leads to children walking with their feet turned inward. Most people are born with femoral anteversion, but typically grow out of it by age two. Some children continue to walk in-toe, and it can slightly worsen from ages two to five. Nearly all children grow out of this by age nine or ten. There is no treatment to make children grow out of in-toeing more quickly or grow out of it at all. In-toeing can occur in children who are otherwise completely healthy or in children who have neuromuscular conditions such as cerebral palsy. After ages nine or ten, those who are still affected by tripping and gait issues can be treated by a derotational osteotomy. This procedure involves cutting the bone, untwisting it, and placing a rod inside the femur to allow the bone to heal.

Femoral retroversion
Femoral retroversion is an outward twist of the femur (thigh bone) that leads to children walking with their feet turned outward. This can be associated with hip conditions such as slipped capital femoral epiphysis or congenital coxa vara. After ages nine or ten, children who are symptomatic with tripping and gait problems that limit their activity, can be treated by a derotational osteotomy, which cuts the bone and untwists it. This technique can involve a rod, like femoral anteversion, but depends on the cause of the retroversion.

Tibial torsion (internal)
Tibial torsion is an inward twist of the tibia (larger bone in the lower leg) that leads to children walking with their feet turned inward. Many children have internal tibial torsion when they first begin walking but grow out of this by age three. Some children continue to have an inward twist, but it can continue to improve until around ages six or seven. After ages six or seven, children who continue to have internal tibial torsion can develop tripping and gait abnormalities. Children whose daily activities are limited by their symptoms can be treated by a derotational osteotomy. The technique involves cutting the tibia, untwisting it, and placing a plate on the bone to allow the bone to heal.

Tibial torsion (external)
Tibial torsion is an outward twist of the tibia (larger bone in the lower leg) that leads to children walking with their feet turned outward. Many children have internal tibial torsion when they first begin walking. Many children grow out of this by three years of age, but some children develop an outward twist. This outward twist can improve until around ages six to seven. After ages six to seven, children who continue to have external tibial torsion can develop knee pain and this can produce gait abnormalities. Children who are symptomatic with gait problems or knee pain that limits their daily activities can be treated by a derotational osteotomy. This technique involves cutting the tibia, untwisting it and placing a plate on the bone to allow the bone to heal.

Angulatory Problems

Genu valgum (knock knees)
Genu valgum is a condition where the knees bow inward, which prevents a child from standing with their ankles touching without pushing the knees together. Children are normally born with bowed legs (genu varum). The legs begin to straighten around the age of eight months and eventually become straight between the ages of 18 and 30 months. The legs then develop knock knees (genu valgum) that will increase until it reaches a peak at around age five, then straighten out around ages eight or nine. Children who have genu valgum have an increased likelihood of knee pain.

Genu varum (bowed Legs)
Genu varum is a condition where the knees bow outward, which prevents a child from being able to stand with the knees touching without pushing the ankles together. Children are normally born with bowed legs (genu varum). The legs begin to straighten around the age of eight months and eventually become straight between the ages 18 and 30 months. The legs then develop knock knees (genu valgum) that will increase until it reaches a peak at around age five, then straighten out around ages eight or nine. Children who have genu varum can have knee pain.

Tibia vara (Blount's disease)
Tibia vara, also known as Blount’s disease, is a problem with the growth plates around the knee that causes bowing of the lower extremities. This can occur in children under the age three (infantile tibia vara), ages three to seven (juvenile tibia vara) or children older than seven (adolescent tibia vara).

Physeal arrest
Physeal arrest is a problem caused by an injury to the growth plate leading to a permanent lack of growth of part or all of the growth plate. This injury can be caused by a fracture, infection, tumor, cyst or other problems. This can lead to an angulatory deformity or shortening of a limb.

Metabolic Bone Disease

Rickets
Rickets is known as a problem that affects the way the body processes calcium and incorporates calcium into the bones, and can be caused by dietary deficiencies, kidney problems or genetic metabolic issues. Children with dietary rickets have too little calcium in their diet. Kidney conditions can cause problems with how the body processes calcium and phosphorus, leading to inadequate calcium being deposited in the child’s bone. Children with genetic rickets have metabolic problems that affect how their body absorbs calcium and moves the calcium into the bone. Children with rickets have weak bones that are less dense than they should be and often have characteristic widening of the growth plates that can lead to changes in alignment of the lower extremities. Treatment includes medical care and potentially, surgical care.

Osteogenesis imperfecta (brittle bone disease)
Osteogenesis imperfecta, also known as brittle bone disease, is a problem that causes children’s bones to fracture or break easily, often after minimal injuries. There are many types of osteogenesis imperfecta with different effects on the child’s bones and varying degrees of fragility. Some lead to a few fractures during childhood while others can cause dozens of fractures. Some of these can cause problems with the child’s teeth as well.

Congenital pseudarthrosis of the tibia
Congenital pseudarthrosis of the tibia is a problem with the tibia (larger bone in the lower leg) that causes it to break or fracture easily, often when the child is an infant, and often does not heal. This leads to a pseudarthrosis or nonunion, in which the bone does not heal at all or heals only with fibrous tissue. Children with congenital pseudarthrosis often have bowing of the tibia and fibula (smaller bone in the lower leg) in an anterolateral (front and side) direction in which the bow is directed forward and outward. About half of children with congenital pseudarthrosis of the tibia have neurofibromatosis.

Limb Length Discrepancy

Physeal arrest
Physeal arrest is a problem caused by an injury to the growth plate leading to a permanent lack of growth of part or all of the growth plate. This injury can be caused by a fracture, infection, tumor, cyst or other problems. This can lead to an angulatory deformity or shortening of a limb.

Acquired limb length discrepancy (LLD)
Acquired limb length discrepancy is a condition where one limb grows more slowly or more quickly than the other because of a problem that originates or continues after birth, causing unequal limb lengths. This can be commonly due to trauma, infection, tumor, metabolic or developmental problems.

Congenital limb length discrepancy
Congenital limb length discrepancy is a condition where one limb is too long or too short, because of a problem that originated prior to birth.

Congenital short femur
Congenital short femur is a form of congenital limb length discrepancy in which the thigh and tissues around the femur (thigh bone), and the tissue around it, are shorter than normal. This is commonly associated with other conditions, including a shallow hip (acetabular dysplasia), external rotation, proximal femoral deformity and knock knee. Children with this condition often have fibular hemimelia as well, which is when a child is born with a short or missing fibula (smaller bone in the lower leg).

Proximal femoral focal deficiency
Proximal femoral focal deficiency is a form of congenital limb length discrepancy in which the thigh and tissues around the femur (thigh bone), and the tissue around it, are shorter than normal. This is typically more severe than congenital short femur and is commonly associated with other conditions, including a shallow hip (acetabular dysplasia), external rotation, proximal femoral deformity and knock knee. Children with this condition often have fibular hemimelia as well, which is when a child is born with a short or missing fibula (smaller bone in the lower leg). The disorder may affect one side or both.

Tibial hemimelia
Tibial hemimelia is a rare congenital limb length discrepancy affecting the lower leg. The tibia (larger bone in the lower leg) is primarily affected, leading to failure of all or part of the bone to form. The leg is typically shorter and may be associated with an abnormal knee or ankle. There may be a clubfoot present and the child may be missing toes or have too many toes.

Fibular hemimelia
Fibular hemimelia is a congenital limb length discrepancy affecting the lower leg. The fibula (smaller bone in the lower leg) is primarily affected leading to failure of all or part of the bone to form. The leg typically is shorter and may be associated with an abnormal knee or ankle. There may be a fusion or coalition present in the foot and the child may be missing toes.

Posteromedial bowing of the tibia
Posteromedial bowing of the tibia is a congenital limb length discrepancy affecting the lower leg. The tibia (larger bone in the lower leg) and the fibula (smaller bone in the lower leg) are both affected, leading to angulation of the lower leg with the ankle tilted outward and forward (valgus and recurvatum). The leg typically is shorter and often the angulation spontaneously resolves over the first five to eight years of life. The child is often born with a calcaneo-valgus foot deformity. This deformity typically resolves by 18 months of age with gentle stretching. Casting or bracing is almost never required.

Hemihypertrophy
Hemihypertrophy is a congenital limb length discrepancy in which the affected side of the body is larger than it should be. The limbs will typically be larger in diameter as well as longer. This is associated in a small number of patients with retroperitoneal and abdominal tumors. Ultrasounds and blood tests are typically ordered in infancy and early childhood to make sure that the child does not have one of these tumors.

Other conditions treated:

Skeletal dysplasia
Metaphyseal dysplasia
Epiphyseal dysplasia
Achondroplasia
Dysplasia epiphysealis hemimelica (Trevor's Disease)
Osteochondromatosis (multiple hereditary exostoses - MHE)

Treatment Options

Shortening of a Longer Limb

Epiphysiodesis
Epiphysiodesis is the process where the growth plates are removed with a cannulated drill and a curette. It is one way to correct limb length discrepancies by closing or removing the growth plate in the “long” limb. An epiphysiodesis is the best method to correct most discrepancies between 2 and 5 cm. The procedure is usually performed at the distal femur, the upper tibia or both.

Lengthening of a Shorter Limb

Taylor spatial frame
A Taylor spatial frame is a circular fixator composed of metal rings and six struts. It is connected to the bone with thin wires and thick pins. The computer-generated ring positions are based on measurements taken from X-rays and clinical examinations. The computer then generates a schedule of daily strut settings. The struts are turned daily to straighten or lengthen the bone. The Taylor frame stays in place until the bone is healed.

Ilizarov frame
The Ilizarov external frame is a circular fixator composed of metal and carbon rings connected by metal rods and clickers. The Ilizarov fixator is connected to the bone with thin wires and thick pins that are used to hold the bone in place.

Ellipse nail
Another lengthening procedure involves surgically inserting a PRECICE intramedullary (IM) nail that can help lengthen the bone through magnetic interaction with a remote control. The external remote controller (ERC) is a portable, handheld device that precisely lengthens the IM nail with the touch of a button. The ERC is fully customizable and can be used in a clinical setting or at home.

Truelok Hexapod (TL-HEX)
A Truelok Hexapod (TL-HEX) System is a hexapod-based 3D external frame that surgeons can
utilize to reposition bone segments. These circular and semi-circular supports have struts, wires
and pins connecting the device to the bone. The bone can be repositioned by adjusting the fixator either rapidly or gradually in precise increments. The TL-HEX combines hardware and software to correct bone deformities, which allows for adjustment simultaneously at multiple angles. After the bone has realigned or lengthened, patients will continue to wear the fixator until new bone tissue hardens and the limb strengthens.

After Surgery Care

You may shower for the first time four days after surgery. Your nurse will teach you how to care
for your pin sites. Even with the best hygiene practices, it is very common for a pin tract
infection to occur. It is usually easily treated with oral antibiotics. After the removal of the
external fixator, the pin sites will not be sutured closed but allowed to heal. They will typically
close within four to six days and small scars will form. Sometimes these scars are large and
dimpled, and other times they heal with minimal scarring.

Possible Surgical Complications

Infection: It is not unusual to get a minor pin tract infection that is treated with oral
antibiotics.
Damage to the nerves and blood vessels: This complication is very rare due to the close
monitoring of circulation, sensation and motion.
Bone not healing: This may result in not achieving the length or correction desired.
Temporary loss of motion in the affected joint: May require that the lengthening
process be slowed as well as more intense physical therapy.

Important Things to Remember

Therapy is required and extremely important. You will do therapy twice a day at home and three times a week with a therapist (once during your clinic appointment and twice with private therapist).
You must shower every day to care for pin sites.
Avoid all nonsteroidal medications such as Motrin, Advil, Aleve and Naproxen.
You may swim in a chlorinated pool.
Weekly clinic visits are necessary at first to check on your progress.

For questions or concerns, contact: Melissa Eagan, RN, BSN, ONC, Nurse Educator, at 314-454-5228, or Jill Hahn, RN, BSN, CCM, Clinical Coordinator, at 314-692-6443 or [email protected].