varus

Generality

Varismo is the orthopedic term that includes all those deformities of the limbs, in which, due to an anomalous relationship between two adjacent skeletal segments, the most distal of these two presents a medial deviation, ie it tends to approach in an atypical way to the sagittal plane.

There are various types of varus; among the most common types, we note: the launching knee, the hallux varo, the coxa vara and the cubito varo.

Review of the medial-lateral and proximal-distal terms

In anatomy, medial and lateral are two terms of opposite meaning, which serve to indicate the distance of an anatomical element from the sagittal plane, ie the anteroposterior division of the human body, from which two equal and symmetrical halves are derived.

Mediale means " near " or " closer " to the sagittal plane, while lateral means " far " or " farther " from the sagittal plane.

PROXIMAL-DISTAL

As medial and lateral, also proximal and distal are two anatomical terms of opposite meaning.

Proximal means " closer to the center of the body " or " closer to the point of origin ". Referring to the femur, for example, it indicates the portion of this bone closest to the trunk.

Distal, on the other hand, means " farther from the center of the body " or " farther from the point of origin ". Always referring to the femur, as an example, it indicates the portion of this bone furthest from the trunk (and closer to the knee joint).

What is varus?

Varismo is the orthopedic term that indicates the deformities of the limbs, in which, due to the anomalous relationship between two adjacent skeletal segments, the most distal of these two presents a medial orientation, ie it tends to approach in an atypical way to the sagittal plane.

The presence of varus can have different repercussions on the articulation in which the deviated bone segment participates, repercussions that may be of an anatomical nature and, in the most serious cases, also of a functional nature.

Furthermore, painful symptoms and various complications can also arise from varus.

It is the opposite of valgism

Varus is the opposite condition to valgism . With the term valgismo, in fact, the doctors refer to the deformities of the limbs, in which, due to an anomalous relationship between two adjacent skeletal segments, the most distal of these two presents a lateral orientation, ie it tends to move away atypically from the sagittal plane.

Like varus, valgus can alter the anatomy and function of the joint in which the deformed bone segment participates and cause symptoms and complications.

Types

Varus can affect various bones (and joints) of the human body.

Among the most common anatomical sites of varus, include:

The knee . Varus of the knee is better known as a varus knee ;
The big toe . The hallux varus takes the most appropriate name of varus hallux ;
The hip . In the orthopedic field, hip varus is known as coxa vara ;
The elbow . The varus of the elbow is a condition called, more properly, cubitus varus .

Of the most unusual anatomical sites of varus, on the other hand, only the ankle is noted. Ankle varus is best known as an equine-varus or clubfoot .

Knee launch

The varus knee is the deformity of the lower limbs which mirrors a misalignment of the femur and tibia, such that the two knees point outwards, bones facing away from each other.

In other words, those who suffer from a varus knee have an angulation of the femurs, which involves the abnormal distancing of the two knees from the sagittal plane (lateral direction).

In common parlance, the launching knee is known in at least 3 other ways, which are: " knee knees ", " bow knees " and " knees in parentheses ". To justify the use of these different words is the appearance of the lower limbs, in people with a launching knee: they actually bear a resemblance to the vowel O, with an arc or a couple of round brackets.

The main causes and risk factors of the knee launch include:

The very young age (NB: in this case, the deformity is often temporary);
The rickets;
Malformed femoral fractures;
Some neurological disorders;
Repeated and poorly treated knee ligament injuries;
Intoxication from fluorine or lead;
Gonarthrosis;
Bone infections that have compromised normal skeletal development;
Blount's disease;
Some developmental disorders;
Some forms of skeletal dysplasia.

As a rule, the milder forms of a knee are asymptomatic and have no consequences on everyday life (for some they are an aesthetic problem, but nothing more). The most serious forms, on the other hand, are painful and potentially capable of involving complications, affecting the ligaments of the knee and / or the medial meniscus of the knee .

The varus knee is the anatomical deformity of the lower limbs opposite to the so-called valgus knee, in which the two knees point inwards, ie in the same direction.

The diagnosis of a knee is immediate and is based on simple observation of the lower limbs and, in particular, of the knees.

The knee launch requires the planning of an ad hoc treatment, only when it is symptomatic and the clinical manifestations dependent on him strongly compromise the quality of life of the wearer.

Therefore, in all cases where it is free of symptoms, it is not subjected to any therapy, not even the least invasive.

In general, in attempting to treat the varus knee and the associated symptomatology, doctors give precedence to a conservative treatment, reserving the right to resort to surgery only if the aforementioned conservative treatment should fail or not be sufficiently effective.

Conservative treatments include: the use of orthopedic and / or plantar shoes, physiotherapy, postural gymnastics, chondroprotective and anti-inflammatory injections and hyaluronic acid injections.

With regard to surgical treatment, the latter consists of a delicate remodeling operation of the distal end of the femur, known as the femoral osteotomy .

In the varus knee, the leading bone segment of the varus phenomenon is the tibia, to be precise the distal end of the tibia.

Figure: comparison between normal knees and "bow knees". As can be seen from the image, in the varus knee, the tibia has an atypical medial deviation.

Hallux varus

The big toe is the anatomical deformity of the first toe, so that the phalanges of this finger have an anomalous medial orientation, compared to the metatarsal.

The hallux varus can be a congenital condition (ie present since birth) or an acquired condition. The causes of acquired hallux hallux include:

Violent injuries to the big toe;
Rheumatoid arthritis;
Ankylosing spondylitis;
Polio;
Charcot-Marie-Tooth disease;
Hallux valgus surgery is not successful. In such situations, the hallux is a surgical complication and is also called iatrogenic hallux .

In general, mild forms of hallux are asymptomatic, while severe forms are responsible for a rich symptomatology, which includes:

Toe pain
Changes in the overall shape of the foot. These changes derive from the thrust that the first phalanx of the big toe, due to its deviation, imprints on the other toes;
Reduced mobility of the big toe;
Lameness due to pain;
Difficulty wearing shoes.

The big toe is the anatomical deformity of the first toe opposite to the hallux valgus, in which the first metatarsus has an anomalous medial orientation, while the two phalanges point in an atypical way towards the other toes (ie in the lateral direction ).

To formulate a precise diagnosis of hallux varus, which also provides an estimate of the extent of deformation, the following are fundamental: observation of the foot, baropodometric examination and foot radiography.

The big toe recalls the doctor's attentions and is subjected to therapy, only when it is symptomatic and the clinical manifestations, dependent on him, strongly affect the quality of life of the wearer (eg: inability to wear any type of shoe).

Therefore, in asymptomatic cases, no therapy is provided, not even the least invasive.

Today, individuals with hallux varus can rely on both conservative care and surgical care ; however, it is necessary to point out that, usually, during the planning of the most adequate therapy, doctors tend to give precedence to conservative treatments, reserving the right to resort to surgery only in the case of a failure of the latter.

Among the possible conservative treatments of hallux varus, we note: rest from all those activities that cause pain in the foot, the use of custom-made shoes, the application of ice on the painful area, the use of custom-made orthoses, physiotherapy and NSAID intake.

As for the surgical treatment, the latter usually consists of a wedge-shaped osteotomy of the head of the metatarsal or of the base of the first phalanx of the big toe. The final aim of the wedge-like osteotomy for the hallux is to realign the two phalanges of the first finger with respect to the metatarsal I.

In the varus hallux, the protagonist bone segment of the varus phenomenon is the complex of the two phalanges that constitute the first toe.

Figure: hallux valgus. As can be seen from the image, the first phalanx of the big toe is oriented towards the inside of the foot. Image from en.wikipedia.org

Coxa vara

In medicine, the deformity of the hip is called coxa vara, so the angle formed by the femoral head-neck combination (proximal epiphysis) and the femur body (diaphysis) measures no more than 120 degrees, or at least 5-15 degrees less than normal.

As a result of this anomalous angulation, individuals with coxa vara have a femur, whose proximal epiphysis assumes an almost horizontal orientation, with respect to the diaphysis.

Mono- or bi-lateral deformity, coxa vara can be a congenital or acquired defect.

The causes of coxa vara acquired include:

The rickets;
Some bone diseases, such as Paget's disease, imperfect osteogenesis or osteoporosis;
Perthes' disease;
Osteomyelitis;
Hip trauma at a young age, such as to interfere with the correct growth process of the femur;
Fibrous dysplasia (is a type of bone cancer).
Some inflammatory conditions of infectious origin, such as tuberculosis;

If mild, coxa vara is asymptomatic ; on the other hand, if severe, it is responsible for various symptoms and complications, including: hip pain, joint stiffness (always dependent on the hip), lameness, shortening of one or both lower limbs and, finally, unusual muscle development hip abductors .

The coxa vara is the skeletal deformity opposite to the coxa valga, in which the angle formed by the proximal epiphysis of the femur and the diaphysis of the femur measures at least 140 degrees, ie between 5 and 15 degrees more than normal.

If the femur of a person with coxa valga is observed, it is possible to notice how the combination of head and neck of the femur tends to line up, in an atypical way, with the body of the femur.

For an accurate diagnosis of coxa vara, the following are essential: physical examination, medical history and hip radiography. Sometimes, on hip radiography, doctors could add some other diagnostic imaging tests, including: nuclear magnetic resonance and / or CT scans.

Expected only in the presence of symptoms incompatible with a normal life, the treatment of coxa vara is exclusively of a surgical nature and consists of an osteotomy, aimed at remodeling the proximal femoral portion.

As a rule, coxa vara surgical operations provide good results.

In the coxa vara, the protagonist bone segment of the varus phenomenon is the body of the femur, which, with respect to the proximal epiphysis of the femur, has a more marked medial orientation than normal.

Figure: comparison between normal hip, coxa valga and coxa vara. Image from en.wikipedia.org

Cubito launch

Doctors call the skeletal deformity cubitus varus which, in the upper limbs extended along the sides and with the palms of the hands facing forward, determines a lower tendency than the normal forearm to distance itself from the body.

In other words, the cubitus varus is the deformity of the elbow, so that, with the upper limb extended, the axis of the humerus (arm bone) forms with the axis of the ulna-radio complex (bones of the forearm) an angle in medial position (ie between the side and upper limb) of a width not exceeding 5 degrees. It is important to remember that, in people without cubit launching, the above angle measures between 11 and 14 degrees (so it is decidedly wider than in the cubit valgus).

The cubitus varus may have a congenital or acquired origin.

Among the main causes of acquired cubitus, the supracondyloid fractures of the humerus certainly deserve a mention (see fracture of the humerus).

The cubitus varus can be mono- or bi-lateral; except for special exceptions, it is unilateral when it has an acquired origin, while it is bilateral when it has a congenital nature.

The mild forms of cubitus varus are generally symptom- free and free from repercussions in everyday life; on the contrary, severe forms alter certain motor functions of the upper limb (eg, limited flexion of the arm) and are potentially capable of causing damage to the ulnar nerve, to the point of inducing neuropathy .

The ulnar nerve neuropathy is responsible for tingling and decreased sensitivity, at the level of the last two fingers of the hand, and a loss of control of some forearm and hand muscles.

The cubitus varus is the skeletal deformity opposite the cubit valgus, in which, with the upper limb extended, the axis of the humerus forms with the axis of the ulna-radio complex an angle in a medial position of 15 degrees or higher.

To formulate an accurate diagnosis of cubitus varus, the following are indispensable: physical examination, anamnesis and an x-ray of the elbow (magnetic resonance imaging and CT scans are rarely performed).

As a rule, doctors only treat symptomatic and incompatible forms of varus cubitus with a normal life. In these situations, the therapy is exclusively surgical and consists of a closed wedge osteotomy, followed by a period of physiotherapy .

According to the doctors, timely treatment of a symptomatic elbow varus is very often associated with a favorable prognosis.

In the varus cubitus, the protagonist bone segment of the varus phenomenon is the ulna-radio complex, which assumes a more marked medial orientation than normal.