A 3-year-old girl is brought to the office by her mother for evaluation of her legs. The mother says, "I have noticed that her knees turn in more than before, and I am concerned that my daughter will be teased for 'walking funny.' Her grandmother insists that she needs special shoes to fix her knock-knees." The patient's father wore "corrective shoes" as a child and "now walks normally." The patient is otherwise healthy and has had no fever, joint pain, or swelling. She is a picky eater and her diet consists mostly of bread, pasta, cheese, and 1 cup of cow's milk a day. The patient is active and "sometimes a bit clumsy" but has never had a fracture or serious injury. She started walking at age 14 months and now can climb up and down stairs while alternating feet. She takes no daily medications or vitamin supplements. Vital signs are normal. Weight and height are at the 60th and 75th percentile, respectively. Physical examination reveals a well-appearing girl with a steady gait, legs swinging outward as she walks. No medial thrust is observed with ambulation. Legs are equal in length. With the legs extended and knees touching, a small gap is present between the ankles. There is mild valgus angulation at the knee. Which of the following is the most appropriate advice regarding this patient's condition?

Question

A 3-year-old girl is brought to the office by her mother for evaluation of her legs.  The mother says, "I have noticed that her knees turn in more than before, and I am concerned that my daughter will be teased for 'walking funny.'  Her grandmother insists that she needs special shoes to fix her knock-knees."  The patient's father wore "corrective shoes" as a child and "now walks normally."  The patient is otherwise healthy and has had no fever, joint pain, or swelling.  She is a picky eater and her diet consists mostly of bread, pasta, cheese, and 1 cup of cow's milk a day.  The patient is active and "sometimes a bit clumsy" but has never had a fracture or serious injury.  She started walking at age 14 months and now can climb up and down stairs while alternating feet.  She takes no daily medications or vitamin supplements.  Vital signs are normal.  Weight and height are at the 60th and 75th percentile, respectively.  Physical examination reveals a well-appearing girl with a steady gait, legs swinging outward as she walks.  No medial thrust is observed with ambulation.  Legs are equal in length.  With the legs extended and knees touching, a small gap is present between the ankles.  There is mild valgus angulation at the knee.  Which of the following is the most appropriate advice regarding this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ad_f937_8f63_d17c3b3d0633_MD0005_00 This patient has physiologic genu valgum, a condition in which the knees angulate toward midline, giving the appearance of "knock-knees." Genu valgum, part of the normal progression of lower extremity alignment, occurs in children age 2-5. Patients with physiologic genu valgum do not have significant pain or difficulty ambulating. They are of normal height. On examination, bilateral leg curvature is symmetric with no leg-length discrepancy and no medial thrust (ie, knee protrudes medially while walking); with walking, legs can appear to swing outward. With knees extended and pointed forward and distal femurs touching, <8 cm between the medial malleoli is considered physiologic genu valgum. Pes planus (ie, flatfoot) also commonly accompanies genu valgum.Diagnosis is clinical; however, radiographs are indicated if there is a history of metabolic disease, lower-extremity fracture, infection, tumor, or joint swelling/warmth. Imaging is also indicated if genu valgum is severe (ie, medial malleoli distance >8 cm), progressive (ie, worsens after age 4-5), persistent (ie, present after age 7), unilateral, causing medial thrust, or associated with short stature (Choice E). These findings are concerning for pathologic causes of genu valgum, which can be secondary to trauma, metabolic conditions, skeletal dysplasia, or neoplasms. Treatment of physiologic genu valgum is reassurance and observation, as spontaneous correction is expected by age 7. (Choice A) Orthotic braces are ineffective and not recommended, as the condition typically resolves without intervention. (Choice B) Physical therapy is not required, as it will not alter the progression of physiologic genu valgum. Although patients with developmental delay benefit from physical therapy, this patient is meeting developmental milestones (eg, ambulating by 14 months, climbing stairs while alternating feet). (Choice D) Vitamin D supplementation is the treatment for rickets (vitamin D deficiency), which can result in pathologic genu varum or genu valgum. Rickets is unlikely in patients with adequate vitamin D intake, normal height and development, and no medial thrust. Educational objective: Genu valgum ("knock-knees") is a symmetric angulation of the knees toward the midline that occurs in children age 2-5. Patients are asymptomatic and have normal stature. Treatment is reassurance, and spontaneous correction is expected. References: Genu valgum and flat feet in children with healthy and excessive body weight. (http://www.ncbi.nlm.nih.gov/pubmed/26914720)

A 3-Year-Old Girl Is Brought to the Office by Her