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Pediatric Orthopaedics

Bow-Legs

Overview

Bow-leggedness (genu varum), as the name suggests, is a deformity that causes the lower limbs to have an archer’s bow appearance. It can be caused by diseases, injury or tumours. Some lifestyle activities can also cause bow-legs due to posture, for example jockeys.

Bow-legs can often be spotted amongst toddlers. The causes of bow-legs in children can be divided into three types; physiologic genu varum, Blount’s disease and rickets. Physiologic genu varum is not due to an underlying condition and the legs would appear normal after the child is about 4 years-old. It is due to variations of appearance and posture, like sitting on the ground with the soles of the feet faced together.

Blout’s disease, which also results in a similar physical appearance, is a deformity affecting the shin bone (tibia) and can cause it to have an inward angulation. This is thought to have been caused by the failure of the growth plate on the inner part of the knee to develop normally. Children affected by Blout’s disease remain bow-legged even after 4-years old.

Rickets, on the other hand, is a disease where the bones are deformed due to lack of calcium, phosphorus and/or vitamin D. One of the appearances, due to the deformity of the bones, could be bow-legs.

Treatment

For physiologic genu varum, it almost always corrects itself as the child grows. This spontaneous correction occurs by time the child is between 3 to 4-years old. In very rare instances, physiologic genu varum does not completely correct itself until the child hits adolescence. In such cases, surgerical correction may be required.

For Blout’s disease, if the disease is identified early when the child is still a toddler, the surgeon might prescribe the use of braces, as the child grows until the bow-leg is corrected. If the condition is not corrected after the child turns 4-years old, the surgeon might recommend surgical correction to prevent permanent damage to the bones and joints. When Blout’s disease was not identified early and the child hits adolescence, bracing would not be effective anymore and surgery would be required.

For rickets, a metabolic specialist may be involved alongside regular orthopaedic follow-up. The condition can often be controlled by medication alone. For those with deformities that does not improve despite medication, surgery may be recommended.

Surgery

Bow-legs can be corrected by procedures such as “Guided Growth” or “Tibial Osteotomy”.

  • Guided growth
    • The surgery stops the healthy side of the growth plate from growing to help the abnormal side to “catch-up”. Over the course of the child’s natural development, the leg will be straightened.
  • Femoral Osteotomy
    • This surgery re-shapes knee joint, usually by cutting the distal femur to correct the alignment. The part where the bone is cut is held in place either by internal or external fixation.

Knock-Knees

Overview

Knock knees (genu valgum), is a deformity that causes the lower leg to angle inwards, causing the ankles to be apart when the knees are touching one another. It can be caused by diseases, injury or tumours. It is common to spot knock knees amongst toddlers under 3-years old. This is due to the physiological changes that occur from the moment the child learns to walk (physiologic genu valgum). The legs will straighten over time as the child grows and usually are fully straightened by about 7 to 8-years old. As not all children develop at the same pace, some may only resolve knock knees at about 10-years old.

Rickets is a metabolic disease that can also cause genu valgum. In rickets, the bones are deformed due to lack of calcium, phosphorus and/or vitamin D.

Treatment

For physiologic genu valgum, it almost always corrects itself as the child grows. This spontaneous correction occurs by time the child is about 7 to 8-years old. If the condition does not correct itself after this age, the surgeon may recommend the use of braces or orthopaedic shoes. In very rare instances, physiologic genu valgum does not completely correct itself until the child hits adolescence. For such cases, the surgeon might recommend surgical correction.

For rickets, a metabolic specialist may be involved alongside regular orthopaedic follow-up. The condition can often be controlled by medication alone. For those with deformities that does not improve despite medication, surgery may be recommended.

Surgery

Knock knees can be corrected by procedures such as “Guided Growth” or “Tibial Osteotomy”.

  • Guided growth
    • The surgery stops the healthy side of the growth plate from growing to help the abnormal side to “catch-up”. Over the course of the child’s natural development, the leg will be straightened.
  • Femoral Osteotomy
    • This surgery re-shapes knee joint, usually by cutting the distal femur to correct the alignment. The part where the bone is cut is held in place either by internal or external fixation.

Clubfoot

Overview

Clubfoot (congenital talipes equinovarus) is a common birth defect (1 in 1000 babies) involving either one or both feet. The affected foot will appear as though it has been internally rotated at the ankle joint.

If left untreated, the foot will stay twisted and the child will walk on the outside part of the affected foot.

Causes

There is no known cause (idiopathic) for clubfoot. Although it may occur with other congenital problems, it is associated with family history of clubfoot, gender and loosely connected to pregnancies that are complicated by infection, use of drugs and smoking.

Clubfoot is not caused by the positioning of the foetus in the womb or something the mother did or did not do during pregnancy.

Treatment

The most common treatment for clubfoot is the Ponseti method and it should be within the first two weeks of birth. The affected foot is gently stretched towards a more correct foot position and a long-leg cast is applied from the toes all the way to the groin. The cast is left on for about one week before it is removed, for the foot to be stretched again. A new cast is applied to hold the new stretched position. The process is repeated up to 8 times until the foot can be manipulated to the correct position.

In most cases, the heel tendon (archilles tendon) is cut before the final cast. This cast will only be removed after the achilles tendon has healed and regenerated to the correct length.

If the Ponseti method is unsuccessful (although rarely), corrective surgery may be required.

Perthes’ Disease

Overview

Perthes’ disease (osteochondritis of the hip) is a form of osteonecrosis of the hip joint that is found only in children. This occurs when blood supply is temporarily interrupted to the ball part (femoral-head) of the hip joint. The condition has no known cause and affects children between 4 to 10-years old, with the upper and lower age limits at 12 and 2 respectively.

It consist of 4 stages:

  1. Femoral-head necrosis.
  2. Fragmentation and re-absorption of bone.
  3. Re-ossification of bone.
  4. Healing of bone.

The concern is mainly the healing and remodelling of the new femoral-head, which ideally should be rounded to fit into the socket of the hip. If the condition is not identified and monitored early, the femoral head may have a flattened head and this may lead to an early onset of osteoarthritis in adulthood.

Symptoms

  • Change in the way the child walks or runs
  • Pain in hip or groin, especially on internal rotation of the hip joint
  • Pain in knee (referred pain)

Treatment

The goal of treatment is to prevent or minimize femoral head deformity and to restore hip movement. Generally, the younger the child, the better the treatment outcome. There are many treatment options available and the surgeon will consider all the factors carefully when conceptualising the treatment plan. Some include plain monitoring, other include the use of braces. For severe cases, especially when the condition is diagnosed when the child is approaching adolescence, surgery may be required.

Flat Foot

Overview

Flatfoot (pes planus) is a condition where the arch on the inside part (medial) of your foot collapse, making your entire sole of the foot to be in contact with the ground. This condition can affect either foot or both. The arch provides a springy connection between the forefoot and the heel. This helps absorb the force when weight-bearing and dissipates the impact to the ankles and knees. Due to the functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg, flatfeet can cause problems in the ankles and knees.

Most infants and toddlers appear to have little or no arch. This is because the arches develop as the child learns to stand and walk. The majority of children would have developed the arches by the time they are 6-years old, some only nearing adolescence and others never develop an arch.

Most people have no signs or symptoms associated with flatfeet. Some people however, experience foot pain, particularly in the arch area. The pain may worsen when walking or standing for long duration. If the condition does not cause any pain, no treatment is usually necessary.

Types

  • Paediatric flatfoot
    • Flexible flatfoot
      • Flatfoot appearance only occur when weight-bearing
      • Arch appears when foot is lifted off the ground
    • Rigid flatfoot
      • Flatfoot appearance intact with or without weight-bearing
  • Adult acquired flatfoot
    • Can be due to
      • Posterior tibial tendon dysfunction (PTTD)
      • Trauma
      • Diabetes
      • Rheumatoid arthritis
      • Ageing
      • Pregnancy

Treatment

The goal of treatment is to reduce pain and to correct the arch (if necessary). The surgeon will assess the type, cause and severity of your condition and give his recommendations.

Non-surgical treatment (children)

If a child has no symptoms, treatment is often not required. The surgeon may observe the child periodically and re-assess the condition over time. If the child has symptons, the surgeon may prescribe some non-surgical treatments.

  • Painkillers
    • to reduce inflammation and to help cope with the pain
  • Shoe modification and orthotic devices
    • to support the foot may also be helpful to improve the way the foot moves
  • Physical therapy sessions
    • stretching exercises and activity modifications can help with the symptoms

Non-surgical treatment (adults)

Depending on the cause of the acquired flatfoot, the surgeon will recommend the treatment options available to help with the symptoms. Seek treatment early as the progression of the condition can be stopped, so that the symptoms may resolve without the need for surgery.

  • Painkillers
    • to reduce inflammation and to help cope with the pain
  • Shoe modification and orthotic devices
    • to support the foot may also be helpful to improve the way the foot moves
  • Immobilisation
    • a boot or cast to damaged tendons to heal

Surgery (adults and children)

In severe cases, the surgeon may recommend surgical correction to relieve the symptoms and improve foot function. Surgery usually do not only involve correcting the arch. This is because, for severe cases, associated problems are usually involved, like a tendon tear or rupture.

In-Toe Walking

Overview

In-toe walking, or walking “pigeon-toed”, is when a child walks with the feet turned inwards, instead of pointing straight. It can either affect one foot or both feet. It starts to become apparent when the child starts to walk and will usually correct itself by the time the child is about 8-years old. It is normal for parents to be worried if their child has an unusual walking style.

The condition does not cause pain and in the vast majority of children affected by in-toeing, the foot or feet will correct itself as they grow. However, for a small number of children, this abnormal gait could be associated with other underlying problem. It would be best to see an orthopaedic specialist if:

  • walking style worsen instead of improves
  • one foot straightens out more than the other
  • pain or walk with a limp
  • known developmental delays (talking included)

To help the child, the doctor must first make a diagnosis to find out the structural cause of in-toeing, as there are three possibilities:

  • Tibial torsion
    • Lower leg (tibia) twisted inwards
      • Knee pointed straight
      • Ankle pointed inwards
      • Foot pointed in the same direction as the ankle
  • Femoral anteversion
    • Thigh bone (femur) twisted inwards
      • Knee pointed inwards
      • Ankle pointed in the same direction as the knee
      • Foot pointed in the same direction as the knee and the ankle
  • Metatarsus adductus
    • Bones in the mid-foot (metatarsals) pointed inwards
      • Knee pointed straight
      • Ankle pointed straight
      • Midfoot and toes pointed inwards

Treatment

As mentioned earlier, the majority of in-toeing children will grow to walk normally over time. The use of leg braces and special shoes were practiced previously, however studies have shown that this is unnecessary. Surgical intervention are also rarely necessary.

The procedures described below are surgical correction of severe cases of in-toeing.

  • For tibial torsion
    • Rotational tibial osteotomy. This procedure involves cutting the shin bone and rotating it outwards
  • For femoral anteversion
    • Rotational femoral osteotomy. This procedure involves cutting the thigh bone and rotating it outwards
  • For metatarsus adductus
    • Release of forefoot joints
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