Physical Therapy Interventions: A Case Report of Building Strength, Confidence, and Mobility in a Seven-Year-Old With Congenital Femoral Deficiency With Coxa Vara

Congenital femoral deficiency (CFD) and congenital coxa vara (CCV) are rare conditions characterized by abnormal development of the femur and hip joint, respectively. This case report documents the rehabilitation journey of a seven-year-old child diagnosed with CFD and CCV, highlighting the efficacy of physical therapy interventions in enhancing strength, balance, normal gait patterns, confidence, and mobility. Through a comprehensive physiotherapy regimen tailored to the specific needs of the patient, significant improvements in muscle strength, joint stability, and functional mobility were observed over the course of treatment. Moreover, the implementation of targeted exercises and adaptive strategies not only facilitated physical gains but also contributed to bolstering the child’s confidence and overall quality of life. This case underscores the pivotal role of physiotherapy in addressing the complex challenges associated with congenital orthopedic anomalies, ultimately fostering independence and well-being in pediatric patients.


Introduction
Femoral dysplasia is a condition characterized by a range of developmental abnormalities, including femoral deficits varying from slight shortening to complete absence, as well as structural changes such as coxa vara, pseudarthrosis, and hip dislocation [1].Congenital femoral deficiency (CFD), also known as proximal femoral focal deficiency, is an uncommon birth defect affecting the hip, femur, and knee.The degree of deformity can vary, ranging from modest shortening to proximal or distal deficiency, or in extreme cases, total loss of the femur [2,3].CFD has an incidence of 1.1-2.0 per 100,000 live births [1].Longitudinal reduction syndromes are characterized by distinct deformity patterns, with the most evident anomaly taking the front stage.Gillespie's classification system takes into account longitudinal deficiency, proximal femur morphology, and hip stability [4][5][6].Choosing the best therapy for a patient depends on criteria such as surgical competence, prosthetic availability, and patient and family preferences.The treatment options include surgical lengthening or prosthetic management.The surgical method can be done by using an Ilizarov ring fixator, or even in a few cases, after a failed attempt at prosthetic management, Syme's amputation is done [4,7,8].
Congenital coxa vara (CCV) is a developmental anomaly that causes a reduced femoral neck-shaft angle, a shortened femoral neck, and a short lower limb (LL).CCV is thought to be caused by a deficiency in enchondral ossification of the femoral neck's medial half.The specific etiology is unclear [9,10].CCV is a very uncommon malformation, occurring in around one in every 25,000 live births.Patients with CCV frequently exhibit gait problems or limb length asymmetry [9].Coxa vara can be effectively treated surgically by adjusting the Hilgenreiner epiphyseal angle to around 35 degrees or the neck shaft angle to more than 120 degrees to prevent the recurrence of the deformity [11,12].Various techniques have been utilized to fix the femoral osteotomy, including tension band wire, angle blade plates, dynamic sliding hip screws, and external fixators [11,13].
Nonoperative management of CFD mainly includes physiotherapy, bracing, and the use of prosthetics.Physical therapy includes the use of thermal therapy, massage, range of motion (ROM) exercises, strengthening exercises, and gait training [14,15].Physiotherapy for coxa vara deformity is prescribed as a nonoperative as well as a postoperative surgical procedure [16].Physical therapy includes bracing, positioning, and ROM exercises.Weight-bearing and gait training are the key components of the intervention [9,17].

Clinical findings
Informed consent was obtained by the child's mother before the examination.Cranial nerve examination, reflexes, motor tone assessment, and sensory examination were intact.Romberg's test, single-leg stance test, functional reach test, and tandem stance test were positive.Upper limb ROM was normal.There was a significant decrease in the LL ROM bilaterally.Manual muscle testing (MMT) assessment showed reduced strength in bilateral LL.Table 1 shows true limb length and segmental limb length measurements.Table 2 shows the pre-and post-rehabilitation findings of the ROM assessment.Table 3 shows the MMT assessment of pre-and post-rehabilitation.

Limb length Right Left
True 52 cm 47 cm Segmental: From the greater trochanter of the femur to the patella 27 cm 22 cm From the patella to the lateral malleolus 25 cm 25 cm

Diagnostic assessment
The patient had CFD and coxa vara.The investigation X-ray was done to diagnose the conditions.Figure 1 shows a CCV deformity.Figure 2 shows the reduced length of the left femur bone.The yellow circle shows the upper placement of the knee joint in the left leg.
The red arrow shows the right femur, which is longer than the left femur.

Physiotherapy intervention
The patient reported complaints of impaired balance, an abnormal gait pattern, pelvic instability, and reduced strength.Consequently, a physiotherapy protocol was planned.

Outcome measures
A functional gait assessment was done to assess the gait of the patient.The Berg Balance Scale and functional reach test were used for the assessment of balance.SF-36 was used to assess the quality of life.
Outcomes were assessed on day one before starting the rehabilitation and after four weeks postrehabilitation.Table 5 shows the outcomes used for the patient to assess progression.Figure 3 shows pelvic tilts given to the patient on a Swiss ball.Figure 4 shows play therapy (ball kicking).Figure 5 shows gait training (walking over obstacles).Figure 6 shows stretching given for hip adductors.

Discussion
CFD encompasses various forms of longitudinal deficiency, such as proximal focal femoral deficiency, lateral distal femoral hypoplasia, knee cruciate ligament deficiency, and involvement of the contralateral limb [18,19].Treatment aims to optimize function through limb equalization and correction of deformities, utilizing strategies ranging from nonsurgical approaches to lengthening, shortening, and complex limb reconstruction [19].Coxa vara is a very rare condition caused by a faulty femoral epiphyseal plate.The femoral head and acetabulum appear to be normal at birth and throughout the first few months of life.However, when bone development and weight bearing occur, the mechanics of the hip joint change significantly, resulting in secondary alterations and joint incongruity [20].In 2013, Monsell concluded in his study that physical therapy plays a vital role in CFD patients, both in cases where surgical procedures are not required and in cases that require surgical procedures.It helps in improving strength, balance, gait patterns, and overall well-being [4].In this case, the patient had reduced strength, balance impairments, gait abnormalities, and pelvic instability.The physiotherapy protocol was focused on strength training and improving balance and gait patterns.Psychosocial support and counseling for both child and parents helped significantly improve the prognosis and results.Patients' mental and physical health improved significantly.

Conclusions
The case report highlights the significant role of physical therapy interventions in enhancing strength, confidence, and mobility in a seven-year-old with CFD and CCV.Through tailored exercises and interventions, the patient demonstrated notable improvements in muscle strength, functional abilities, balance and gait impairment, and overall well-being.This underscores the importance of early and targeted interventions for pediatric patients with complex orthopedic conditions, emphasizing the potential for physical therapy to empower individuals and optimize their quality of life.

FIGURE 2 :
FIGURE 2: Reduced length of the left femur (CFD)

TABLE 3 : MMT assessment of bilateral LL
Oxford Scale: Grade 0: no contraction; Grade 1: flicker of movement; Grade 2: full ROM with gravity; Grade 3: full ROM against gravity; Grade 4: full ROM against gravity with minimum resistance; Grade 5: full ROM against gravity with maximum resistance LL, lower limb; MMT, manual muscle testing; ROM, range of motion

Table 4
shows the planned physical therapy protocol for the patient.

TABLE 4 : Planned physical therapy protocol for the patient
LL, lower limb; ROM, range of motion