valgus

Generality

Valgism is the orthopedic term that includes all those deformities of the limbs, in which, due to the anomalous relationship between two adjacent skeletal segments, the most distal of these two presents a lateral deviation, ie it tends to move away atypically from the sagittal plane.

There are various types of valgus; among the most common types, we note: the valgus knee, the hallux valgus, the coxa valga and the cubit valgus.

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 valgus?

Valgism is the orthopedic term that indicates the deformities of the limbs, in which, due to an abnormal 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.

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

Furthermore, painful symptoms and various complications can also result from valgus.

It is the opposite of varism

Valgism is the opposite condition to varism . With the term varus, in fact, doctors refer to skeletal deformities, in which, due to an anomalous relationship between two adjacent skeletal segments, the most distal of these two presents a medial orientation, that is, it tends to approach in an atypical way the plane sagittal.

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

Types

Valgism can affect several bones (and joints) of the human body.

The most common anatomical sites of valgus include:

The knee . The valgus of the knee is known as the valgus knee ;
The big toe . The hallux valgus is known as hallux valgus ;
The hip . Hip valgus is better known as coxa valga ;
The elbow . The valgus of the elbow is called cubito valgo .

Among the most unusual anatomical sites of valgus, however, we note:

The foot . The valgismo of the foot is more properly called valgus foot ;
The hand . The valgismo of the hand does not have particular denominations;
The wrist . The valgus of the wrist is a condition also known as Madelung's deformity .

Knee valgus

Also known as "X-knees", the valgus knee is the deformity of the lower limbs that reflects a misalignment of the femur and tibia, such that the two knees point towards each other .

In other words, those suffering from valgus knee have an angulation of femurs and tibias, which involves the anomalous orientation towards the sagittal plane (hence in the medial direction) of the two knees.

Among the main causes and risk factors of the valgus knee are: the very young age (NB: in this case, the deformity is often temporary), rickets, some neurological disorders, badly established femoral fractures, gonarthrosis, infections bones that have compromised normal skeletal development, severe knee injuries, some developmental disorders and, finally, some forms of skeletal dysplasia.

As a rule, the milder forms of valgus knees are asymptomatic and have no repercussions on everyday life (for some they are an aesthetic problem, but nothing more). The most serious forms instead, tend to be painful and potentially responsible for complications, affecting the ligaments of the knee and / or the lateral meniscus of the knee .

The valgus knee is the anatomical deformity of the lower limbs opposite to the so-called varus knee, in which the two knees point outwards, that is in the opposite direction to each other.

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

The valgus knee requires the planning of a treatment only when it is symptomatic and the clinical manifestations that it induces strongly affect the quality of life of the wearer.

Therefore, in all cases in which it is asymptomatic, it is not subjected to any therapy, not even the least invasive.

In general, in attempting to resolve the valgus 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 valgus knee, the leading bone segment of the valgus phenomenon is the tibia, to be precise the distal end of the tibia.

Figure: comparison between normal knees and "knees to X". As can be seen from the image, in the valgus knee, the tibia has an atypical lateral deviation.

Hallux valgus

Hallux valgus is the anatomical deformity of the first toe, so the metatarsus has an anomalous medial orientation, while the two phalanges point in an atypical way towards the other toes (ie in a lateral direction).

From this it follows that the head of the metatarsal (NB: the head of a metatarsal is the distal end of the latter and the bone portion bordering the first phalanx) and the base of the first phalanx (NB: the base of a phalanx is the proximal end of the latter) form a protrusion on the medial side of the foot, commonly known as " onion ".

Hallux valgus can be a mono- or bi-lateral deformity.

Currently, there is little clarity on the precise causes of hallux valgus; according to the most recent medical studies, causal and risk factors would be possible:

Rheumatoid arthritis;
Gout;
Psoriatic arthritis;
The presence of congenital anatomical defects, of a hereditary nature, such as flat feet ;
The rickets;
Some neuromuscular and connective tissue diseases (eg: Marfan syndrome);
Hallux trauma of a certain size;
The use of inappropriate shoes (eg: narrow-toed shoes, heeled shoes, shoes that are too small, etc.).

Normally, when it is in its infancy or in its mildest form, the hallux valgus is asymptomatic, that is, it does not produce symptoms. When instead it is at an advanced stage or is immediately serious, it is responsible for a rich symptomatological picture, which includes:

Pain, even at rest, in the area presenting the so-called onion. The painful sensation is due to an inflammatory process;
Redness, numbness and swelling . The area of interest is, of course, the big toe;
Thickening of the skin, which becomes hard and calloused. It mainly concerns the "onion";
Changes in the overall shape of the foot . These changes derive from the thrust that the phalanges of the big toe, due to their deviation, exert themselves to the damage of the other toes;
Difficulty walking, resulting from the presence of pain.

The most serious or inadequately treated forms of hallux valgus are conditions from which various complications can arise, both local (eg: joint degeneration, bursitis, metatarsalgia, dislocations of the other toes, etc.) and postural (eg: valgus knee, stiffness of the hips, lumbar lordosis associated with low back pain etc.).

Hallux valgus is the anatomical deformity of the first toe opposite to the varus hallux, in which the phalanges of the first toe exhibit an anomalous medial orientation with respect to the first metatarsal.

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

The hallux valgus 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 bearer.

Thus, in all asymptomatic cases (mild forms and early forms), no therapy is provided, not even the least invasive.

Today, those suffering from hallux valgus can have both conservative care and surgical care ; however, it is important to point out that, generally, in the choice of the most appropriate therapeutic plan, doctors tend to give precedence to conservative treatments, reserving the use of surgery only in the case of a failure of the latter.

Among the possible conservative treatments of hallux valgus, we note: rest from all those activities that cause pain in the foot, the use of orthotics, the application of ice on the painful area, the choice of appropriate footwear, the use of custom orthoses, physiotherapy, NSAIDs and corticosteroid injections for anti-inflammatory purposes.

As regards instead the treatment of a surgical nature, the latter consists almost always in the metatarsal osteotomy . The intent of the metatarsal osteotomy for the hallux valgus is to realign the metatarsal I with respect to the two subsequent phalanges.

In the hallux valgus, the protagonist of the valgus phenomenon is the complex of the two phalanges that make up 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 valga

In medicine, the deformity of the hip is called coxa valgus, so the angle formed by the binomial head-neck of the femur (proximal epiphysis of the femur) and the body of the femur (diaphysis of the femur) measures at least 140 degrees, ie between 5 and 15 degrees more than normal.

In other words, individuals with coxa valga have a femur, in which the proximal epiphysis tends to align with the diaphysis .

The possible causes of coxa valga include:

Some neuromuscular diseases, such as cerebral palsy, polio or dysraphism ;
Some forms of skeletal dysplasia, such as mucopolysaccharidosis or Turner syndrome ;
Hip trauma at a young age, such as to interfere with the correct growth process of the femur.

Mono- or bi-lateral deformity, coxa valga can be asymptomatic (mild cases) or responsible for symptoms (more severe cases), such as: hip pain, loss of joint mobility (clearly from the hip) and lameness .

There are three typical complications of a coxa valga that is not adequately treated: the abnormal shortening of one or both limbs, osteonecrosis of the proximal femoral epiphysis (in particular of the femoral head) and development of abnormalities of the hip muscles .

Coxa valga is the skeletal deformity opposite to the coxa vara, in which the angle formed by the proximal epiphysis of the femur and the diaphysis of the femur measure less than the normal 125-135 degrees.

If the femur of a person with coxa vara is observed, it is possible to notice that the combination of head and neck of the femur is placed strongly in a horizontal position with respect to the body of the femur.

For an accurate diagnosis of coxa valga, the following are essential: physical examination, medical history and hip radiography.

As regards the treatment of coxa valga, the indications are the same as those for the valgus knee and the hallux valgus, namely:

If the condition is asymptomatic, no therapy is expected;
If the condition is responsible for symptoms, doctors give precedence to conservative therapy and, only if the latter does not work, they resort to surgery.

Conservative therapy mainly involves physiotherapy exercises and the use of walking aids (eg: crutches or sticks).

Surgical therapy, instead, consists of a delicate operation of derotative osteotomy of the proximal femur .

In the coxa valga, the protagonist bone of the valgus phenomenon is the body of the femur, which, with respect to the proximal epiphysis of the femur, has a lateral orientation greater than normal.

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

Cubito valgus

Doctors call the skeletal deformity cubito worth that, in the upper limbs extended along the sides and with the palms of the hands facing forward, determines a tendency above the normal forearm to move away from the body.

In other words, the cubit valgus is the deformity of the elbow, so that, with the upper limb extended, the axis of the humerus (arm bone) forms an angle with the axis of the ulna-radio complex (bones of the forearm) medial position (ie between the hip and upper limb) of 15 degrees or higher. It is important to remember that in people without a cubit valgus, the above angle measures between 11 and 14 degrees (so it is less wide than in the cubit valgus).

The cubit valgus may have a congenital or acquired origin. Among the causes of congenital cubit valgus, two genetic diseases are reported: Turner syndrome and Noonan syndrome ; among the causes of cubito valgus acquired, on the other hand, fractures and strong traumas, which occurred at a young age, against the lateral epicondyle of the humerus (see fracture of the humerus) are certainly worth mentioning.

The cubit valgus can be a mono- or bi-lateral deformity; 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 cubit valgus are generally asymptomatic and without repercussions in everyday life; on the contrary, the severe forms alter certain functions of the upper limb (eg: the movement of supination of the arm) and are potentially capable of damaging the ulnar nerve, to the point of inducing paralysis.

Ulnar nerve paralysis 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 cubit valgus is the skeletal deformity opposite the cubit varus, 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 amplitude not exceeding 5 degrees.

To formulate an accurate diagnosis of cubit valgus, the following are indispensable: physical examination, anamnesis and an x-ray of the elbow (the CT scan is rarely practiced as well).

As a rule, doctors only treat the symptomatic forms of cubit valgus. In such situations, the therapy consists in the surgery of derotative humerus osteotomy, followed by a period of physiotherapy treatment .

The prognosis after a valgus surgery of the elbow depends, above all, on the severity of the deformation.

In the cubit valgus, the leading bone segment of the valgus phenomenon is the ulna-radio complex, which assumes a lateral orientation greater than normal.