Blount Disease Imaging

Author: Jugesh Cheema, MD; Chief Editor: Felix S Chew, MD, MBA, Med 4 NOV
2016

Overview

Blount disease (also known as infantile tibia vara) is characterized by bowing (unilateral or
bilateral) and length discrepancy in the lower limbs (see image below). Approximately 80%
of infantile cases and 50% of late-onset cases are bilateral. A nontender bony protuberance
can be palpated along the medial aspect of the proximal tibia, representing the deformed
medial tibial metaphysis.

Infantile Blount disease. Radiograph in a 21-

month-old boy shows bilateral bowing with definitive medial tibial beaking on the left. On the right,
the appearance is consistent with physiologic bowing or early Blount disease. Follow-up radiographs
were required.

Erlacher reported the first case of tibia vara in 1922.[1] In 1937, Blount reported 13 more cases
and reviewed all of the 15 cases that were reported in the literature up to that time. Blount
suggested the term tibia vara; however, the eponym drawn from his name remains in common
use.[2]
Normal age-related angulation changes in the knee joint

A pronounced varus angulation is seen in newborns and in children younger than 1 year.
Varus angulation is believed to be secondary to in utero molding of the lower extremities, and
this gradually resolves after children start walking.

Varus angulation usually corrects by the time children reach approximately 18-24 months of
age or after they have been walking for approximately 6 months.

During the ages of 2 and 3 years, pronounced valgus angulation changes occur. The valgus
position then partially corrects over the following few years, reaching the adult pattern of
mild valgus by 6-7 years of age. Any varus angulation at the knee joint seen in individuals
older than 2 years is therefore considered abnormal, and such a finding is the basis for the
diagnosis of tibia vara, or Blount disease.

Preferred examination

Radiographic changes found in Blount disease are usually diagnostic. Radiographs provide
the most information in this disease because they can be obtained with the patient in an erect
position and they provide broad coverage of the area of interest. Magnetic resonance imaging
(MRI) can have limited usefulness in the differential diagnosis of difficult cases. Such cases
include those in patients with early growth-plate and marrow changes that are not specific
enough to be diagnosed as Blount disease by radiographic findings.[3, 4, 5, 6]

In patients with early changes, it is difficult to differentiate physiologic bowing from other
conditions by radiography. Changes in the growth plate are not easy to detect on radiographs.

MRI cannot be performed with the patient in the erect position, and it does not provide
coverage broad enough to diagnose Blount disease. In addition, MRI is more expensive than
radiography, particularly because many patients must undergo repeat imaging to evaluate the
changes due to Blount disease.

Radiography

Radiography is the primary modality used to diagnose tibia vara.

Radiographic findings primarily involve the posteromedial parts of the proximal tibial
epiphysis, growth plate, and metaphysis. A standing anteroposterior radiograph of both legs is
used to demonstrate bowing and abnormality at the medial aspect of the proximal tibia. In
more advanced cases, bowing is seen at both ends of the tibia. On lateral knee radiographs, a
posteriorly directed projection at the proximal tibial metaphyseal level is seen.

Different radiologic measurements have been used in an attempt to confirm the presence of
Blount disease. The femoral-tibial angle helps confirm the varus position of the leg, but it can
be misleading secondary to the rotation of the leg, which may be positional or due to a
coexisting rotational abnormality.

The metaphyseal-diaphyseal angle has been suggested to provide more precise indications of
Blount disease than the femoral-tibial angle, as shown below. The metaphyseal-diaphyseal
angle is obtained by measuring the angle formed between a line drawn parallel to the top of
the proximal tibial metaphysis and another line drawn perpendicular to the long axis of the
shaft of the tibia. Overlap may be found in measurements between patients with and without
tibia vara.

Infantile Blount disease. Radiograph in a 21-

month-old boy shows bilateral bowing with definitive medial tibial beaking on the left. On the right,
the appearance is consistent with physiologic bowing or early Blount disease. Follow-up radiographs
were required.

Angle measurements are 9 3.9 in cases of physiologic bowing and 19 5.7 in patients
with Blount disease. Reportedly, angles greater than 20 confirm true tibia vara in children,
whereas angles of 15-20 may or may not indicate tibia vara.

Another angle used is the tibial metaphyseal-metaphyseal angle. This angle is larger than the
metaphyseal-diaphyseal angle in children with the most marked bowing and indicates distal
tibial bowing in severe cases.

In 1952, Langenskiold first proposed a 6-stage classification of radiographic changes. This

remains the most commonly used system.[7, 8, 9] This classification was not intended for use in
determining the prognosis or the most desirable type of treatment, and the author cautioned
against such use. However, the fact remains that surgical treatment commonly is needed for
any child with stage 3-6 changes.[10, 11] See the images below.
 Depiction of the 6 stages of the
Langenskiold classification of tibia vara, as they would be seen on radiographs.

Adolescent Blount disease in a 12-year-old girl. Image

shows mild changes in the medial tibia. The growth plate is widened and slightly depressed.

Recent studies

Sabarwhal and Zhao attempted to establish reference values for the hip-knee-ankle angle and
assess the relationship between it and the anatomic femoral-tibial angle in children by
studying standing full-length radiographs of lower extremities without abnormalities. They
measured the angle between a line connecting the center of the ossified femoral head and the
center of the distal femoral epiphysis and another line connecting the center of the distal
femoral epiphysis and the center of the talar dome.

The authors found that there was a linear relationship between the hip-knee-ankle and
anatomic femoral-tibial angles in the children. Despite varying hip-knee-ankle angles at
different ages, the mean absolute difference between that angle and the anatomic femoral-
tibial angle remained relatively constant.[12]
Lavelle et al compared the 2 techniques to measure the tibial metaphyseal-diaphyseal angle
(MDA), involving the use of both the lateral border of the tibial cortex and the center of the
tibial shaft as the longitudinal axis for radiographic measurements. The use of digital images,
according to the authors, poses another variable in the reliability of the MDA. They found
that using either the lateral diaphyseal line or center diaphyseal line produces reasonable
reliability with no significant variability at angles of 11 or less or greater than 11.[13]

Degree of confidence

In the most severe cases, the diagnosis can be made with a high degree of confidence in the
presence of a tibial metaphyseal-diaphyseal angle measurement of 20 or more. However, in
less-severe cases, measurements may not be confirmatory, and differentiating tibia vara from
physiologic bowing is difficult. In such patients, 6 months of follow-up observation is
recommended (see image below).

Infantile Blount disease. Radiograph in a 21-

month-old boy shows bilateral bowing with definitive medial tibial beaking on the left. On the right,
the appearance is consistent with physiologic bowing or early Blount disease. Follow-up radiographs
were required.

False positives/negatives

Extreme physiologic bowing may cause false-positive results. Early or less-severe Blount
disease may be misdiagnosed as physiologic bowing of the legs when measurements and
medial tibial changes are not confirmatory.

Some authors have suggested that children with a metaphyseal-diaphyseal angle greater than
11 eventually develop tibia vara, whereas those with measurements less than 11 have
physiologic bowing. Other authors have found standard deviations of 2.6 and 4.6. Still
others have recommended 6 months of follow-up observation to better differentiate the 2
conditions.

The differential diagnoses of Blount disease include physiologic bowing, congenital bowing,
rickets, Ollier disease, trauma, osteomyelitis, and metaphyseal chondrodysplasia.

Difficulty may be encountered in differentiating infantile tibia vara from physiologic bowing
of the legs. However, the proximal tibial angulation is acute in Blount disease, occurring
immediately below the medial metaphyseal beak. This feature results in a metaphyseal-
diaphyseal angle greater than 11. In physiologic bowing, angular deformity results from a
gradual curve involving both the tibia and the femur.

Congenital bowing must be considered. The angulation may occur in the middle portion of
the tibia, with a normal-appearing distal femur and proximal tibia.

Mild or healing rickets with residual bowing may be difficult to differentiate from stage 2
infantile tibia vara. However, rickets affects the skeleton in a generalized and symmetric
fashion, with loss of the zone of provisional calcification in the physis. In addition, the typical
biochemical abnormalities of rickets help differentiate the conditions.

Ollier disease may result in tibial bowing but can be differentiated easily on radiographs by
the presence of enchondromas.[14]

Regarding trauma, growth-plate injuries of the proximal tibia may result in a deformity
resembling tibia vara.

Osteomyelitis may be another mimic. Growth plate disturbance secondary to infection may
result in an appearance similar to Blount disease.

In patients with metaphyseal chondrodysplasia, multiple metaphyseal deformities are seen, as

is a short stature. Radiologically, the changes in this condition mimic those of rickets, but no
abnormal serum biochemical results are noted.

Magnetic Resonance Imaging

Although radiographic findings in Blount disease are usually diagnostic, MRI has the
advantage of direct depiction of the epiphysis and the growth plate. How MRI can aid in
evaluation and treatment of patients with Blount disease is debatable.

MRI has a distinct advantage in a subset of patients with advanced or recurrent tibia vara. In
these patients, MRI can demonstrate the extent of the physeal bar to quantify the percentage
of physeal involvement. On a T2-weighted image, an open physis is bright and the physeal
bar appears black. Early physeal fusion of the medial proximal tibial and, less frequently,
medial distal femoral physis can occur from the injury of chronic weight bearing. This injury
can lead to progressive genu varus from medial tethering of the growth plates. Removal of
the physis medially may help restore normal growth.[15, 16, 17]

An article about MRI changes in bowleg deformities of early infancy suggested a possible
role for MRI in differentiating physiologic bowing from Blount disease.[18] Children who
eventually had Blount disease were found to have a depression of the medial physis and
abnormal signal intensity in the metaphysis in addition to the lesion in the epiphysis. In
comparison, children with physiologic bowing were found to have high signal intensity only
in the epiphyseal cartilage. However, most patients with combined changes did not develop
Blount disease. See the image below.[5, 6]

Adolescent Blount disease. Coronal

T1-weighted MRIs of the left knee in an 11-year-old boy show Blount disease affecting the entire
tibial growth plate and the lateral part of the distal femoral plate. Signal intensity changes in the
marrow of the metaphysis and epiphyseal flattening are evident in the medial portion of the tibia;
this is the classic depiction.

Degree of confidence

MRI does not yet have a well-established role in the evaluation of Blount disease. MRI can
be useful to the orthopedist who wishes to know which portion of the medial knee (epiphysis,
physis, metaphysis) is injured and what corrective steps must be undertaken. MRI is also
useful in the assessment of possible development of a physeal bar.

Nuclear Imaging

Multiphase bone scintigraphy is sensitive in assessing normal and abnormal growth plate
functions in the growing skeleton.[19] Mechanical loading and stress factors influence
scintigraphic uptake at the growth plate. When immobilization is prolonged and when closure
begins, growth-plate activity decreases.

In patients with angular deformities of the legs, the half of the growth plate with greater
mechanical loading becomes more active than the other half. In patients with Blount disease,
increased uptake occurs medially in the tibial plate, and scintigraphic changes may also be
seen in the distal femur. Scintigraphy is not used for diagnosis, but it can be useful in making
treatment decisions. See the image below.
 Blount disease scintigraphy. Bone
scanning is used to assess growth-plate activity in a 10-year-old boy. Affected areas show increased
physeal uptake until closure begins. At that time, activity decreases. The proximal tibial growth plate
on the right has increased uptake throughout. On the left, the medial tibial physis has begun to close.