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Key Clinical Message In dealing with bowed limbs along with increased alkaline phosphatase (ALP), even if the typical changes to the face are not very noticeable at first glance, Paget's disease of the bone (PDB) should be suspected, and the necessary investigations should be carried out to confirm the diagnosis. Abstract Paget's disease of the bone (PDB) is the second most prevalent metabolic bone disorder worldwide with disorganized bone remodeling. Here, a patient is presented with pain and bending of the right leg, whose skull and forehead changes are not noticeable at first glance, but with clinical suspicion and additional diagnostic evaluations, PDB diagnosis is confirmed for the patient.

Key Clinical Message: In dealing with bowed limbs along with increased alkaline phosphatase (ALP), even if the typical changes to the face are not very noticeable at first glance, Paget's disease of the bone (PDB) should be suspected, and the necessary investigations should be carried out to confirm the diagnosis. Paget's disease of the bone (PDB) is the second most prevalent metabolic bone disorder worldwide with disorganized bone remodeling. Here, a patient is presented with pain and bending of the right leg, whose skull and forehead changes are not noticeable at first glance, but with clinical suspicion and additional diagnostic evaluations, PDB diagnosis is confirmed for the patient. [ABSTRACT FROM AUTHOR]

• Persistent mechanical compression leads to cartilage channel compression and ischaemic chondronecrosis. • Ischaemic chondronecrosis is the proposed aetiopathology of Blount's disease. • Blount's disease shares similarities with Perthes disease in terms of its aetiology, radiological features, and histological characteristics. • MRI quantitative mapping of T2, T1ρ, adiabatic T1ρ, and RAFF can be employed in early detection of ischaemic chondronecrosis. Infantile Blount's disease primarily affects toddlers, leading to tibia vara with or without growth arrest. While the disease's association with abnormal compressive forces on the proximal tibial physis is widely accepted, its precise aetiopathology remains elusive. This hypothesis suggests that ischaemic chondronecrosis serves as a previously unaddressed cause of Blount's disease. Notably, it is also the foremost theory to offer a comprehensive explanation for the specificity of involvement of the posteromedial tibial epiphysis, addressing a crucial aspect that was overlooked in prior research. The theory of pressure-induced ischaemic chondronecrosis is supported by a compelling body of radiological and histological evidence. Experimental studies on femoral heads in animals highlight the susceptibility to ischaemic injury in the absence of an ossific nucleus. The proposed mechanism could explain the delayed ossification observed in the proximal medial tibial epiphysis in Blount's disease. Comparisons with Perthes' disease reveal striking parallels in radiographic and histological features, pointing toward a shared aetiology of vascular insult. Despite both conditions progressing through similar stages, the distinction lies in Perthes' being characterised by osteochondral necrosis, while Blount's results from chondronecrosis. The potential applications of this hypothesis extend to early detection and prevention, emphasising the avoidance of compression on the medial tibial epiphysis. The study suggests a reevaluation of brace therapy and exploration of the role of serial valgus casting, especially in the early stages of insult and limited to walking time, as a preventive measure against ischaemic chondronecrosis and its complications. In conclusion, this hypothesis sheds light on a novel mechanism of Blount's disease. Further research is warranted to validate and refine this proposition, offering promising avenues for addressing a century-long enigma in its aetiology. [ABSTRACT FROM AUTHOR]