A 13-month-old girl is brought to the office by her maternal grandmother for a well-child visit. The grandmother is the girl's primary caregiver while the parents work full-time. The girl is happy and active, but the grandmother is concerned that she is not yet walking. When she takes the child to the playground, the girl crawls and cruises along the playground equipment. The child wears sunscreen and a wide-brim hat outdoors. Every day, the child is fed expressed breast milk in a cup and eats a variety of foods, including meat, fruit, and dark-green vegetables. She also eats yogurt but refuses to drink cow's milk. The child takes an oral vitamin D supplement daily and no daily medications. Medical history is significant for a cesarean delivery at 39 weeks gestation for breech presentation. Weight and length are at the 65th and 30th percentiles, respectively. Physical examination shows equal leg lengths. Bilateral hip, knee, and ankle joints have full range of motion. When the patient stands with her feet together, a symmetric, mild tibiofemoral outward bend results in a gap between the knees. The child is able to stand for only a few seconds before she falls to the ground and resumes crawling. Which of the following is the best next step in management of this patient?

Question

A 13-month-old girl is brought to the office by her maternal grandmother for a well-child visit.  The grandmother is the girl's primary caregiver while the parents work full-time.  The girl is happy and active, but the grandmother is concerned that she is not yet walking.  When she takes the child to the playground, the girl crawls and cruises along the playground equipment.  The child wears sunscreen and a wide-brim hat outdoors.  Every day, the child is fed expressed breast milk in a cup and eats a variety of foods, including meat, fruit, and dark-green vegetables.  She also eats yogurt but refuses to drink cow's milk.  The child takes an oral vitamin D supplement daily and no daily medications.  Medical history is significant for a cesarean delivery at 39 weeks gestation for breech presentation.  Weight and length are at the 65th and 30th percentiles, respectively.  Physical examination shows equal leg lengths.  Bilateral hip, knee, and ankle joints have full range of motion.  When the patient stands with her feet together, a symmetric, mild tibiofemoral outward bend results in a gap between the knees.  The child is able to stand for only a few seconds before she falls to the ground and resumes crawling.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ae_9578_8f63_c9593cf1d3c1_MD0005_00 This child's symmetric bow-legs with normal growth pattern are most likely due to physiologic genu varum, a deformity in which the knees curve away from midline. Due to the normal progression of lower extremity alignment, genu varum is considered physiologic from birth to age 2 years. It is not associated with delayed walking (average age to walk: 12-15 months), and cruising and standing alone briefly at this age are normal. Patients with physiologic genu varum have the following: Bilateral symmetric bowing of the femurs and tibias Normal stature No leg length discrepancy No lateral thrust (eg, knee joint protrudes laterally when walking) Femoral condyle distance <6 cm on examination Physiologic genu varum is a clinical diagnosis; imaging and laboratory studies are unnecessary unless pathologic bowing (eg, Blount disease, rickets, skeletal dysplasia) is suspected. Bilateral leg x-rays are indicated if bowing is progressive, unilateral, persistent after age 3 years, or associated with short stature (eg, possible metabolic disease) (Choice B). Management of physiologic genu varum is reassurance and observation, as spontaneous correction is expected. (Choice A) Exclusive breastfeeding and low sun exposure are risk factors for vitamin D deficiency (eg, rickets). Although rickets causes symmetric bowing, it is unlikely in a patient who is taking vitamin D supplementation and has a normal height. (Choice D) Orthotics are ineffective and not recommended, as the condition typically resolves without intervention. (Choice E) Referral for possible surgical intervention is indicated if there is pathologic genu varum (eg, severe bowing, leg length discrepancy) despite medical therapy. Educational objective: Physiologic genu varum presents in infants age 0-2 years with bilateral, symmetric bow-legs, normal stature, and no lateral thrust. Diagnosis is clinical, and management is reassurance and observation. References: Lower extremity rotational and angular issues in children. (http://www.ncbi.nlm.nih.gov/pubmed/25439018) Management of bow legs in children: a primary care protocol. (http://www.ncbi.nlm.nih.gov/pubmed/28459895)

A 13-Month-Old Girl Is Brought to the Office by Her