5. Bone Impairments
Deformations of whole bones:
• Persistent femoral anteversion
• Increased tibial torsion
• Bowing of long bones
Most often treated by osteotomies.
5
6. Joint Impairments
Deformations of joints from local
deformation of bones and/or cartilage and or
pathology in ligamentous constraints.
• Knee flexion contracture
Tend to be treated by osteotomies or guided
growth (eight plates or stapling)
6
9. “Lever-arm disease”
All bones act mechanically as levers.
“Lever-arm disease” or “dysfunction” really just means
bony abnormality and is not sufficiently specific to be
useful.
Often used to refer to torsional malalignment but the way
that this affects lever mechanisms is particularly poorly
understood.
“Lever-arm disease” is a phrase which is best avoided!
9
16. Normal femur development
16
Von Lanz T (1953). Z Anat 117:317-45.
Shands A, Steele M (1958). Journal of Bone and Joint Surgery 40-A:803.
Crane L (1959).Journal of Bone and Joint Surgery 41-A:421.
Fabry G, MacEwen GD, Shands AR (1973). Journal of Bone and Joint Surgery 55-A:1726-1738.
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18
Anteversion(degrees)
Age( years)
Lanz
Shands
Crane
Fabry
17. Femoral anteversion
The reduction in femoral anteversion is
almost certainly a consequence of bone
remodelling of the whole femur and not just
the femoral neck.
17
27. 27
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycleHip abductor strength 3(2) 3(2)
Hip adductor tone (Ashworth) 1 1
Hip internal rotation range 57°int 61°int
External rotation range 8°ext 5°ext
Femoral anteversion 21°int 24°int
28. 28
a
Features: Comments:
a. too much int. hip rotation through cycle bilaterally
Supplementary data: left right Comments:
Hip internal rotation range 57° 61°
Hip external rotation range 8° 5°
Femoral anteversion 21° 24°
Hip abductor strength 3 3
Impairment: Bilateral persistent femoral anteversion Evidence: clear Effect on walking: major
Impairment: Bilateral hip abductor weakness Evidence: clear Effect on walking: major
29. Hemiplegia
29
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
Hip abductor strength 3(1) 5(2)
Hip adductor tone (Ashworth) 1 0
Hip internal rotation range 56°int 44°int
External rotation range 1°ext 33°ext
Femoral anteversion 31°int 15°int
Features: Comments:
Supplementary data: left right Comments:
Impairment: Evidence: Effect on walking:
Impairment: Evidence: Effect on walking:
a. Increased left hip. rot. throughout
a
c. Increased left ext. pel. rot. throughout Compensation for internal hip rot
c
d
d. Inc. bilat. int. foot prog. throughout On left consequence of int. hip rot
On right consequence of int. pel. rot.
b b. Right hip within normal limits
Internal hip rot. range 56 44
External hip rot. range 1 33
Femoral anteversion 31 15
Hip abductor strength 3 5
Left femoral anteversion
Left hip abductor weakness
clear
clear
marked
marked
34. Normal tibia development
34
Can be increased or decreased in CP suggesting different mechanism to anteversion
Staheli, L.T., et al., J Bone Joint Surg Am, 1985. 67(1):39-47.
35. Knee forward foot out
Is it in the tibia or in the foot?
35
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
Ankle rotation
normal so
deformity must
be in tibia
Ankle rotation
sufficiently
external to
explain foot
progression
51. “True” joint contractures
• Consequence of focal impairment of
bone, cartilage andor ligaments
• Distinguish from limited joint range as a
consequence of short muscles
51
52. 52
Knee flexion is probably the impairment limiting knee flexion
Measured
knee flexion
contracture
