Knock Knees

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    DEFINITION Defined by position of knees such that,

    when standing with knees together, the

    medial malleoli are not touching.

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    CAUSESUnilateral

    Asymmetric growth:

    1-Trauma.

    2-Infection.

    3-Tumor to tibia.

    Bilateral

    Physiological: common

    Metabolic: renal

    osteodystrophy, rickets,

    hypophosphatemia.

    Neuromuscular: cerebral

    palsy.

    Haemotological:myelodysplsia

    Skeletal dysplasia:

    congenital dislocation of

    patella

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    Presentation Knees touch each other while

    standing.

    Legs are curved inwardly.

    Too much distance between feet.

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    EXAMINATION

    In the consultation room:

    1- Always compare thetwo knees.

    2- Watch the patient

    walk.

    3- Looks at the knees

    whilst standing.

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    Measurement of intermalleolar

    distance

    intermalleolar

    distance is a Distance

    between two malleoli

    when the knees aregently touching with

    legs in adduction.

    Up to 3 and a half

    inches (9 centimeters)

    with child lying down

    is acceptable.

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    Possible Complications

    Difficulty walking (very rare).

    Self-esteem changes related to cosmetic

    appearance of knock knees.

    If left untreated (for patients with

    intermalleolar distance which is more than

    9 cm and for age group > 7 years), knockknees can lead to early arthritis of the

    knee.

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    Management

    RAPRIOP

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    Reassurance1- Most parents are happy to be reassured that their child's

    deformity is within normal limits and will disappear.

    2- Some may need their confidence boosted by returningfor fresh measurements to be made six-monthly until

    they are convinced it is disappearing.

    3- For those who are still sceptical, radiographicexamination may be sufficient to alleviate their anxiety

    with or without the addition of an orthopaedic opinion.

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    Advice To measure natural

    improvement, Advice

    Parents to takephotographs of the child

    in standing with their

    kneecaps pointing

    forward every 6 months.

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    Prescription (Treatment)

    Non-Operative

    Special shoes,

    exercise programs,

    splints and braces are

    not recommended, as

    these conditions

    usually correct and

    improve over time

    with normal growth.

    Operative

    Epiphysiodesis

    (physeal stapling) of

    medial side, or

    corrective osteotomy

    in children > 10 years

    old with intermalleolar

    distance > 10 cm.

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    When to Refer ? Age > 7 years with knock knees.

    Unilateral problem i.e Asymmetry of legs.

    Intermalleolar distance > 3.5 inches (9

    cms).

    Associated symptoms e.g Pain, Limp.

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    InvestigationsX-rays

    No X-ray required until >

    18 months of age, then

    AP and lateral standingfull leg length views.

    Laboratory tests

    CBC, phosphorus,

    creatinine and alkaline

    phosphotase may beordered if a systemic or

    metabolic abnormality is

    suspected.

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    Observe (Follow Up)

    Observe the patient every 6

    months.

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    Prevention

    There is no known prevention

    for normal knock knees.

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    Thank you References:

    1- Oxford handbook of Paediatrics.

    2- Oxford handbook of General Practice.

    3- Knock knees and bow legs for Dr. W J W SHARRAR,

    BRITISH MEDICAL JOURNALhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1639432/pdf/b

    rmedj00510-0046.pdf

    4-Bowlegs and Knock-knee, The Royal Children's Hospital

    Melbourne

    http://www.rch.org.au/emplibrary/ortho/03BOWLEGS.pdf

    5- Knock knee, Medline Plus

    http://www.nlm.nih.gov/medlineplus/ency/article/001263.htm

    6- Angular deformities of the lower extremity, bow legs and

    knock knees, Pediatrics: a primary care approach.