Blounts

Disease
Textbook Reading
Radinal Irwinsyah, Ahmad Ulil Albab, Asep M, Wan M Fikri, Dini A, Chek Natrah
Advisor: dr. Ira Nong, dr. Arnold, dr. Zuwanda

Supervisor: dr. Jainal Arifin, M.Kes, Sp.OT

DEFINITION
Progressive bow-leg deformity associated with abnormal growth of the
posteromedial part of the proximal tibia.
An irregular physeal line and a wedge-shaped epiphysis with a beak
at the medial metaphysis.

Miller MD, Brinker MR. Pediatric Orthopaedics. 3rd Ed. Review of Orthopaedics; 2006.
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
ETIOLOGY
Inherited/congenital
Developmental disorder
The children are usually overweight and start walking early.
Miller MD, Brinker MR. Pediatric Orthopaedics. 3rd Ed. Review of Orthopaedics; 2006.
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Netters Concise Orthopaedic Anatomy, 2
nd
Edition, Chapter, Leg/Knee
ANATOMY
Normal leg axis
Netters Concise Orthopaedic Anatomy, 2
nd
Edition, Chapter, Leg/Knee
Development of the tibiofemoral angle during
growth.Salenius&Vankka Graph
Normal children show
maximal varus at 6 to 12
months of age
Neutral alignment by 18 to
24 months
Maximal genu valgum at
4 years
Gradual decrease in genu
valgum age of 11 years
John Anthony Herring, MD. Chapter 22:
Disorder of the Leg. In: Tachdjian's Pediatric
Orthopaedics 4
th
edition; Elsevier Saunders;
2008
PHYSIOLOGY
Evolution of lower limb alignment from varus to valgus
to normal alignment.
Normal transition from varus alignment at 14
months to neutral position at 25 months to
valgus tibiofemoral alignment at 39 months
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Toddlers or children who are large or overweight for
their age and who walk early are most often affected.
As the child walks, the repeated stress and compression
of extra weight suppresses (slows) or stops growth of the
developing bone.
When only one side of the tibia stops growing, there are
abnormal changes in bone alignment.
Results in curvature or bowing of the bone.(O shape)
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
PATHOPHYSIOLOGY
CLASSIFICATION
There are three types of tibia varum based on the age it
begins:
infantile (less than 4 years old),
juvenile (occurs between 4and 10 years), and
adolescent (>10 years of age and older).

John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
ANAMNESIS
Infantile:
-Family history with the same disease
-history walk earlier
-developmental disorder
Juvenile/Adolescence:
-chief complain pain and tenderness over medial prominence of proximal tibia.
-change in gait
-History of infection or trauma in growth plate.
-Rapid weight gain
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
PHYSICAL EXAMINATION
Head to toe
Look: varus deformity of the knee,
internal rotasi of tibia, hyperextension
knee.
Feel : intercondyle space, Q angle,
general laxity, head of fibula protuded
Move : change in gait (lateral trust
gait/intoeing gait)


Hallmark is genuvarum
deformity
Flat foot and valgus
Obesity
Limb length discrepancy
secondary to deformity

John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
CLINICAL FEATURES
Infantile
Non-tender bony prominence or "beak" may be
palpable over medial tibial condyle
Excessive medial tibial torsion
Pronated feet
Shortening of involved leg
Juvenile/adolescent
Obesity
Gait characterized by painless varus thrust in stance phase
Pain & tenderness over medial prominence of proximal tibia
Mild medial knee ligamentous laxity
Shortening of involved leg up to 3-4 cm
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Physical Appearance
Blounts Disease is characterized the deformity as an abrupt angulation just below the proximal physis
Netters Concise Orthopaedic Anatomy, 2
nd
Edition, Chapter, Leg/Knee
Langenskiold classification
based on the degree of
metaphyseal-epiphyseal changes
RADIOGRAPHIC FINDINGS
Abrupt angulation at the epiphyseal
metaphyseal junction and medial
metaphyseal radiolucency and
beaking.
Tibiofemoral angle
(TFA) >20
Tibial metaphyseal
diaphyseal angle
(MDA) > 11
John Anthony Herring, MD. Chapter 22:
Disorder of the Leg. In: Tachdjian's Pediatric
Orthopaedics 4
th
edition; Elsevier Saunders;
2008
Treatment
Stage I
Child is younger than 3 years of age and the lesion is no greater than
Langenskild stage II, orthotic treatment is recommended such as
braces.
Length of time that the orthosis is worn during a 23-hour period vary.
Early brace treatment appears to be effective in stage I or II disease up
through 36 months of age.
Brace therapy is not generally appropriate for children older than 3
years.
Knee-Ankle-Foot Orthosis (KAFO) that produced a valgus force by three-
point pressure.

John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Stage II
Surgical treatment in the early stages is crucial to
achieve permanent and lasting correction.
Surgical overcorrection of the mechanical axis to at
least 5 degrees of valgus by 4 years of age, along
with lateral translation of the distal osteotomy
fragment.
Prophylactic fasciotomy of the anterior, lateral, and
posterior compartments is recommended.
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
STAGE III
Stage III lesions can respond to
corrective osteotomy alone in
patients > 4 years.
Neither observation nor orthotic
treatment is recommended
beyond this age, especially if the
deformity exceeds 10 degrees of
femorotibial varus.

John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Stage IV-V
Lesions greater than stage III
cannot be definitively
corrected by simple
mechanical realignment.
Repeated osteotomies
Alternatively, some form of
lateral epiphysiodesis.
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Radiographic
appearance after
bilateral upper
tibial osteotomies.
The mechanical
axis is
overcorrected to
12 degrees valgus
on the left
Stage VI
If the patient has less than 2 years
of growth remaining and a
relatively normal joint surface,
corrective osteotomy with
complete physeal closure is a
practical.
Treatment options in patients with
more than 2 years' growth
remaining include completion of
the lateral tibial epiphysiodesis,
angular correction, and
lengthening.
A and B, Schematic correction of the medial
joint line depression by an intra-articular
osteotomy to elevate medial plateau,
combined with angular correction of tibia
vara.
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
PROGNOSIS
Depend on the age and the severity when the first
patient intervention.
When the disease not been treated poor.
Can be progressive when not treat with the true
treatment .

John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
COMPLICATIONS
Physiologic (infection, swelling, stiffness)
hardware-related (implant extrusion, breakage,
prominence)
growth-related (undercorrection, overcorrection)
John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
DIFFERENTIAL DIAGNOSIS
Physiologic genu varum,
Nonphysiologic causes of genu varum
skeletal dysplasias (achondroplasia)
metabolic diseases (renal osteodystrophy, vitamin D
resistant rickets)
post-traumatic deformity
post-infectious sequelae

John Anthony Herring, MD. Chapter 22: Disorder of the Leg. In: Tachdjian's Pediatric Orthopaedics 4
th
edition; Elsevier Saunders; 2008
Intoeing gait
THANK YOU