eMedicine Specialties > Orthopedic Surgery > Pediatrics

Congenital Coxa Vara: Workup

Author: Robert Mervyn Letts, MD, FRCS(C), FACS, Former Chief, Department of Surgery, Division of Pediatric Orthopedics, Children's Hospital of Eastern Ontario, University of Ottawa; Consultant Pediatric Orthopedic Surgeon, Sheikh Khalifa Medical City, UAE
Coauthor(s): Ken K Kontio, MD, FRCSC, Assistant Professor, Department of Surgery, University of Ottawa; Consulting Surgeon, Department of Surgery, Division of Orthopedics, Children's Hospital of Eastern Ontario, Ottawa Children's Treatment Centre
Contributor Information and Disclosures

Updated: Jan 27, 2009

Workup

Imaging Studies

  • Radiography
    • CCV is differentiated radiographically from other forms of proximal femoral varus by the characteristic finding of an inverted Y-shaped lucency (see Image 2). This lucency is made up of the proximal physeal plate and a fragment of bone inferolateral to the physis, which represents a contained area of abnormal calcification.
    • Other more generic radiographic features are shared with the other causes of coxa vara. These include a decreased neck shaft angle, often approaching or less than 90°; a smaller and flatter femoral head; a more vertical orientation of the physeal plate; decreased femoral anteversion or even retroversion of the head on the femoral neck; coxa brevis; and, often, a shallow acetabulum with a more oval shape.
    • Scrutinize films for evidence of acquired or metabolic causes of coxa vara, such as avascular necrosis, slipped capital femoral epiphysis (SCFE), septic destruction of capital femoral epiphysis or metaphysis, fibrous dysplasia, and rickets.
    • In Weinstein et al's study in which they proposed quantifying CCV with the HEA, they also suggested that rather than using the Hilgenreiner line, which can change with pelvic obliquity induced by the commonly associated limb-length discrepancy, a horizontal line parallel to the ground can be drawn instead. Values for hips affected with CCV average 40-70° but may be as high as 70-90°, as found in the Weinstein study. This physeal angle remains the most commonly used means for quantification of vertical tilt of the proximal femoral physis at presentation and during follow-up, as well as for evaluating the amount of correction achieved with surgical intervention.
  • CT scan, with possible 3-dimensional reconstructions
    • CT scan can be used to help delineate the proximal femoral defect. It commonly reveals displacement of the proximal femoral epiphysis and associated metaphyseal spike of bone, from its normal superior-anterior position on the femoral neck to an inferior-posterior position. This results in relative femoral retroversion with respect to the head-shaft relationship.
    • CT scan may provide useful information regarding femoral anteversion or retroversion and the amount of bone stock in the area, which is important information for preoperative surgical planning.
  • MRI
    • MRI findings include widening of the growth plate with expansion of cartilage medio-distally between the capital femoral epiphysis and femoral metaphysis.
    • The usefulness of MRI as a preoperative imaging modality, in both diagnosis and surgical planning, is relatively limited.

Related eMedicine topics:

 Avascular Necrosis

Fibrous Dysplasia

Histologic Findings

See Pathophysiology.

More on Congenital Coxa Vara

Overview: Congenital Coxa Vara
Workup: Congenital Coxa Vara
Treatment: Congenital Coxa Vara
Follow-up: Congenital Coxa Vara
Multimedia: Congenital Coxa Vara
References
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References

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Further Reading

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Keywords

coxa vara, congenital coxa vara, CCV, developmental coxa vara, infantile coxa vara, cervical coxa vara, childhood coxa vara, proximal femoral varus, proximal femoral focal deficiency, PFFD, congenital short femur, congenital bowed femur

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Contributor Information and Disclosures

Author

Robert Mervyn Letts, MD, FRCS(C), FACS, Former Chief, Department of Surgery, Division of Pediatric Orthopedics, Children's Hospital of Eastern Ontario, University of Ottawa; Consultant Pediatric Orthopedic Surgeon, Sheikh Khalifa Medical City, UAE
Disclosure: Nothing to disclose.

Coauthor(s)

Ken K Kontio, MD, FRCSC, Assistant Professor, Department of Surgery, University of Ottawa; Consulting Surgeon, Department of Surgery, Division of Orthopedics, Children's Hospital of Eastern Ontario, Ottawa Children's Treatment Centre
Ken K Kontio, MD, FRCSC is a member of the following medical societies: Canadian Medical Association, Canadian Orthopaedic Association, Christian Medical & Dental Society, Ontario Medical Association, and Pediatric Orthopaedic Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Mininder S Kocher, MD, MPH, Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston
Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the History of Medicine, American Medical Association, American Orthopaedic Society for Sports Medicine, and Massachusetts Medical Society
Disclosure: Smith & Nephew Endoscopy Consulting fee Consulting; ConMed Linvatec Consulting fee Consulting; Covidian Consulting fee Consulting; EBI Biomet Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

George H Thompson, MD, Director, Pediatric Orthopedics, Rainbow Babies and Children's Hospital
George H Thompson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dennis P Grogan, MD, Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa
Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

 
 
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