OCOC 4034

ORTHOPEDIC CONDITION
OF LOWER LIMB

GENU VARUM
KUMPULAN 7 ADOC 1/2023
MOHD HAFIZ BIN ABDULLAH RIJAL
NUR ALWANNI BINTI YUSOFF
NAFIZAH BINTI ISMAIL
 DEFINITION

• Genu varum is a medical condition also

known as bowlegs
- Genu : knee
- Varum: angles in
• a condition which the knees stay wide apart
when a person stands with the feet and
ankles together
• the knees curve outward, leaving a wide
space.
 CAUSES
• Congenital
- Folded position in uterus
• Illness :
1) Blount’s disease
- idiopathic tibia vara that affects the proximal tibia
- Affects the inner edge of the upper shin bone at the knee growth plate
2) Bone dysplasias
- Abnormal development of bone
3) Arthritis
- Affects the inside of the knee more than the outside
4) Lead or fluoride poisoning
- Skeletal fluorosis can make bone to deform and abnormal growth
5) Rickets
- Vitamin D deficiency cause abnormal bone growth
6) Paget’s disease
- Chronic disorder that can result in enlarged and misshapen
bones
 PATHOPHYSIOLOGY

• Childhood obesity can place excessive weight or pressure on the

joints, contributing to Blount’s disease and arthritis, among other
conditions.
• Walking at an early age (before 11 months) can increase the risk
for Blount’s disease and thus bow legs.
• Having a family member who had bow legs may indicate a genetic
tendency for bow legs, including degenerative conditions such as
osteoarthritis.
 INVESTIGATION
• Physical examination
- Check the lateral and medial collateral
ligament (ligaments on either side of the
knee joint that help in back and forth
movement of knee)
- The intercondylar distance examination :
if the leg distance is more than hand
breadth is an indicator for genu varum

• Imaging
- Hip and bilateral lower limb xray
standing (ap lateral view)
 CLINICAL FEATURES

• Knees not touch when

standing with feet together
(ankles touching)
• Bowing of legs is same on
both side of the body
(symmetrical)
• Bowing of knees outward
 MANAGEMENTS

2) Radiology
Non surgery management
- Xray bilateral lower limb (standing)
1) Physical asessment ap and lateral view
- Check the lateral and medial 3) Vital sign
collateral ligament (ligaments on - Vital sign BP, PR, RR, TEMP, SPO2,
either side of the knee joint that pain score for baseline data
help in back and forth 4) Pain management
movement of knee)
- Analgesic IV tramadol 50 mg tds
- The intercondylar distance given to reduce pain
examination : if the leg distance
is more than hand breadth is an
indicator for genu varum
5) Physiotherapy
- Exercises for Improving Balance during ambulating
6) RICE
- Rest
- ice compression for 20 minutes 4-8 times a day
- compress to help reduce swelling
- Elevate on pillow to reduce swelling
7) Splint / brace
- Refer occupational therapist to get special
splint/brace and reduce pain
8) Nutrition
- Diet high calcium and vitamin D (RICKETS)
 MANAGEMENT

Surgery management : osteotomy (cutting bone and sometimes adding bone

tissue to reshape or realign your bones)

PRE OPERATION:
- Full explaination regarding operation is to help in realignment the bone thus can
help in better ambulation – patient less worry and understood
- Vital sign taken such as blood pressure, pulse rate, respiration rate, temperature,
spo2 level, pain score as baseline data
- Consent taken is correct signed by patient/parents and doctor for medico legal
- Investigation - blood test (FBC, COAG PROFILE, BUSE, ) taken for pre
operation baseline data
- GXM 2-4 pints to staandby for transfusion intraoperative
- radiology – xray hip and bilateral lower limb AP/lateral
- Referral
- Anesthesia doctor to review patient and condition to look if patient fit for operation
and decide either operation will be done under general anesthesia or spinal anesthesia
- Medical if age >35 years and having any comorbid for cardiac assessment
- Dental to detect for any dental carries that can cause infection
- NBM at least 6 hours prior operation to prevent aspiration pneumonia
intraoperative and start IV drip infusion such as IVD normal saline 4pint over 24
hours once NBM to maintain hydration
- Medication
- Antibiotic such as IV cefuroxime 1.5g to bring to ot as antibiotic prophylaxis
- Sedative such as Tab midazolam 3.75mg ON and ot call for relaxation
- Skin preparation using chlorhexidine 4% over operation site and cover with
sterile towel to prevent infection
• POST operation management
- Assess CONDITION either alert or drowsy and to see side effect of
anesthesia like vomiting
- supine position post operation until fully concious and maintain in
supine position for 6 hours if operation done under spinal anesthesia to
prevent spinal headache
- Vital sign monitoring for 15 minutes once for first 1 hour, ½ hour once
for next hour , hourly until stable followed by 4 hourly if stable to
monitor any abnormality. Inform stat to doctor if any abnormality
(hypotension, tachycardia) – symptoms of hypovolemic shock
- Monitor dressing site regularly to see if any bleeding and inform stat to
doctor and reinforce bandage if soaked
- Medication
- Analgesic given such as IV Tramadol 50mg tds to reduce the pain
- Antibiotic given such as IV cefuroxime 750mg tds to prevent infection
- Continue iv drip normal saline 4pint/24hours until patient fully concious to maintain hydration
- Encourage patient to take high protein and vitamin diet like chicken and fruits for wound
healing.
- Blood investigation such as FBC taken to look for HB level post
operation to detect blood loss or internal bleeding (low level <10g/dl)
- Neurovascular assessment 6P’s
- level of pain using pain score ruler
- compare skin colour with non operative side either pink or pallor and
CRT<2second
- check DPA and PTA to check if weak or normal pulse present
- examine using pin point device over extrimities to check if having numbness feeling
- ask patient to move extrimities and compare with unaffected side
 REHABILITATION

1) Physiotherapy
- Advice to start passive ROM and deep breathing
exercise after 1-2 days post operation to prevent
DVT and pneumonia
- Start ambulation with crutches/walking frame with
physiotherapist after allowed by doctor either CRYO CUFF
full/partial weight bearing THERAPY
- Put ice pack or cryo cuff therapy at operation site to
reduce swollen
- Start on CPM exercise (continuous passive motion)
to keep the leg in flexion and extension position
continuously to help reduce swelling and prevent
DVT CPM EXERCISE
 REHABILITATION

2) RICE 3) SPLINT/BRACE

- Rest - Wear brace all the time to maintain

alignment
- ice compression for 20 minutes 4-
8 times a day 4) NUTRITIONS

- compress to help reduce swelling - Diet high calcium and vitamin D

(RICKETS)
- Elevate on pillow to reduce
swelling
 HEALTH EDUCATION

1) Physiotherapy and exercises

- maintain a healthy lifestyle and do gentle
exercises to correct foot structure gradually.
- Single leg standing: Standing on one foot
- Tandem standing: Standing with one foot
directly in front of the other TANDEM STANDING BOSU BALL TRAINING
- BOSU ball training: Exercising while using a
BOSU balance trainer, a platform on top of
a round dome
- Balance board or BAPS board: Standing on
boards that wobble to help improve
balance

BALANCE BOARD
2) Orthotic shoes
- For athlete that involve in high impact
activity such as running, they can use
orthotic shoes. This is a shoe insert specially
crafted to correct the way you walk.
3) Medication
- Advice patient to take analgesic given Tab
- Tramadol 50mg tds to help reduce pain during
exercise
- Finish antibiotic such as Tab Cefuroxime 500mg tds
for completion of treatment
4) Nutritions
- Advice to take diet high protein and vitamin (chicken and
vegetables) for promote wound healing
- High calcium diet (milk) for speed up bone healing
5) Wound care
- dressing followed physician’s order (OD/EOD dressing) and to
come to hospital stat if develop sign and symptoms of infection
6) TCA
- Follow TCA date as given and TCA stat if worsening in
condition such as swollen, bleeding and infection
 COMPLICATION

1) NON SURGERY
• arthritis in the knees or hips
• Athletes with bow legs have an increased risk of Achilles
tendonitis (injury in the tendon near the heel)
• Difficulty walking and running
• Deformities, such as a difference in leg lengths if only one leg
is bowed
• Higher risk of arthritis later
• Knee instability
2) SURGERY
- Infection over operation site
- Deep vein thrombosis due to not ambulate post operation
• Compartment syndrome (increased pressure in a muscle
compartment)
• Recurrence of deformity
• Growth disturbance
 NURSING PROBLEM

1) Pain related to disease process (genu varum)

- Access pain score using pain score ruler to get the score and manage accordingly
- Rest in bed and elevate lower limb higher than level og heart to reduce the pain and
swollen
- Give analgesic such as IV tramal 50mg tds as prescribed by doctor to reduce pain
- Help in activity daily living (ADL) – sponging, change diapers to minimal pain
- To do deep breathing exercise when hurts for muscle relaxation and control pain
- Diversional therapy – reading, listening to music to divert from thinking about pain
- Moral support from family members for patient to be more relax and reduce pain
2) Anxiety related need to undergo surgery
- Assess patient’s expression to look level of anxiety and ask if any
complaints for next action to be taken
- Give proper explaination regarding operation is to help in
ambulation and avoid using medical term so that patient less worried
- Explain to patient that operation will be done under general/spinal
anesthesia, and analgesic will be given regularly post operation so
that patient don’t think too much about the pain
- Diversional therapy- encourage patient to reading magazine or
listening music to divert worries
- Emotional support by family members and staff so that patient more
confident
3) Potential infection over operation site (post operation osteotomy)
- Change dressing over operation site with aseptic technique if soaked
- Keep dressing dry and clean to prevent cross infection
- Monitor vital sign 4 hourly especially temperature (>37.5◦c) that shows sign of
infection
- Explain to patient sign and symptoms of infection such as redness and swollen
thus they can inform if develop any sign
- Advice patient do not touch dressing with dirty hand
- Give antibiotic iv cefuroxime 750mg tds for prophylaxis
- Advice patient to take care of personal hygiene properly that can cause infection
over operation site
- Apply 5 moment hand hygiene to prevent nosocomial infection
 REFERENCES

• Kolbe, N.; Haydon, F.; Kolbe, J.; Dreher, T. Single-Stage Tibial Osteotomy for Correction
of Genu Varum Deformity in Children. Children 2023, 10, 377.
https://doi.org/10.3390/children10020377
• WebMD. (n.d.). 4 best exercises for Varus knee: Best bets, getting started, and more.
WebMD. Retrieved March 30, 2023, from https://www.webmd.com/a-to-z-guides/best-
exercises-varus-knee
• Bowed legs (Blount's disease) - orthoinfo - aaos. OrthoInfo. (n.d.). Retrieved March 30,
2023, from https://orthoinfo.aaos.org/en/diseases--conditions/bowed-legs-blounts-disease/
THANK YOU