History and Physical Examination

Tibial bowing is often obvious and is present at birth. The foot is usually dorsiflexed to such a degree that it makes contact with the anterior aspect of the distal tibia. The posterior bow of the tibia is less obvious but can be easily palpated. A dimple may be present in the skin posterior to the apex of the bow.^[19]

The Galeazzi test (see the image below), typically used to assess hip dislocation, can also be used to assess any congenital disorder that results in a significant limb-length inequality. The examination is performed with the patient supine and the hips and knees flexed. The result is considered positive if knee height is asymmetric. It is also helpful to assess whether the limb-length inequality is primarily from the femur or from the tibia and to assess limb length in someone with knee or hip flexion contractures.

Posteromedial tibial bowing. The Galeazzi test. Note the difference in the height of the flexed knees.

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Differential diagnoses include the other types of tibial bowing, such as anterolateral and anteromedial bowing. Intrauterine fracture or osteogenesis imperfecta may also result in tibial bowing.^{[20, 21]}These are often easily differentiated on the basis of physical examination findings in which the direction of the tibial bowing and the associated foot deformity are noted.

Anteromedial bowing is often associated with congenital loss of the lateral rays of the foot and fibular deficiency. Anterolateral bowing is associated with a pseudarthrosis of the tibia that may be obvious radiographically at birth or may develop with growth. Approximately 50% of children with anterolateral bowing are eventually diagnosed with neurofibromatosis.

Workup

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Media Gallery

Anteroposterior radiograph of a 1-year-old child with posteromedial tibial bowing.
Lateral radiograph of a 1-year-old child with posteromedial tibial bowing.
Anteroposterior and lateral radiograph of a 9-year-old child with posteromedial tibial bowing. Note that the bowing has significantly improved.
Posteromedial tibial bowing. The Galeazzi test. Note the difference in the height of the flexed knees.
Scanogram of a patient with posteromedial tibial bowing and a limb-length inequality.
A hydroxyapatite-coated Schanz pin used to secure external fixator devices to the bone.

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Author

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD, FAAOS, FAOA Professor of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine; Professor of Orthopaedic Surgery and Faculty of Sports Medicine Fellowship, Baylor College of Medicine; Sports Medicine Orthopaedic Surgeon, Department of Orthopaedics, UT Health San Antonio; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Clinical Orthopaedic Society, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; Conmed; JRF<br/>Received research grant from: Arthrex, Inc.; MTF.

Additional Contributors

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

Disclosure: Nothing to disclose.

Tibial Bowing Clinical Presentation

History and Physical Examination

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