Locomotor

Learning Resource
Paediatric Orthopaedics

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Problems Present at birth

a. Clubfeet
The term club foot is used to describe a condition in which both the
hind foot and the fore foot are in equinus, varus and adduction. The
feet tend to clap together rather than face the floor. The problem
tends to run in families and is more common in Polynesians (7/1000
c.f 1/1000 in Europeans). The aetiology is unknown but in the Maori
population there is a strong genetic tendency. In the newborn child it
is normally possible to dorsiflex the ankle so that the dorsum of the
foot touches the shin. In a club foot this is not possible. Sometimes a
child is born with a mobile deformity due to uterine moulding which
resembles the clubfoot appearance, but the above manoeuvre can be
performed and such feet require no treatment. The spine must be
checked to ensure that the foot deformity is not secondary to a spina bifida. Treatment should
commence within the first week of birth. Initially this consists of manipulation and strapping applied
by a competent orthopaedic surgeon. In some children this is successful and at about one month of
age holding plasters are used and maintained till the child is 4 – 6 months of age. In the remainder
some form of soft tissue correction by open operation is required at 3 months. In older children in
whom the deformity has been incompletely corrected, further soft tissue operations are available and
at the age of 4 years bony procedures such as osteotomies and fusions become feasible. The
objective is to obtain a plantigrade mobile painless foot.

Your obligation as a general practitioner is to ensure that a competent surgeon commences

treatment on the child’s feet early in the neonatal period.

b. Sternomastoid "Tumour" and Torticollis

From time to time you will see children who were normal at birth and subsequently develop a
torticollis in the next few weeks with a swelling in one sternomastoid muscle, the so‐called
sternomastoid tumour of uncertain aetiology. In order to prevent permanent contracture and facial
asymmetry, treatment consisting of gentle purposeful stretching of the contracted muscles and fascia
is required. This method of treatment is almost always successful if supervised by a physiotherapist.
Children with persistent asymmetry should be referred for soft tissue release. Remember that
torticollis that occurs after the neonatal period can have a number of causes including infection or
inflammation in the cervical region (atlanto‐axial rotatory subluxation), tumour, ophthalmological
causes or congenital cervical spine anomalies. In general these patients should be referred for an
assessment by an orthopaedic surgeon.

c. Limb Deficiencies
You may see children born with amputations, partially or completely absent limbs or duplications.
These seldom require immediate treatment but early orthopaedic opinion should be sought as
physiotherapy may help considerable in the control of contractures and deformities.

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 d. Brachial Plexus Palsies (Erbs Palsy)
You should be aware of the obstetric manoeuvres which cause brachial plexus injuries at birth, which
are diagnosed by the absence of movement in one arm. The initial management is one of observation.
The outlook for Erb’s palsy is generally good, but some children with persistent weakness may benefit
from tendon transfer in later childhood. It is important therefore to maintain passive motion by a
programme of physiotherapy if weakness is still present by 2 months of age.

e. Developmental Dislocation of the Hip (DDH)

In the first three months, the diagnosis is by clinical examination and not by x‐rays. You should be
familiar with the Barlow and Ortolani tests. The risk factors for DDH include first born female, breech
presentation and family history of DDH. Beware of the female child where there is a family history of
hip dislocation as an infant. The early management is by splintage in
flexion and abduction and must be carried out by an orthopaedic
surgeon.
By 4 6 months of age, the presenting symptom may be
shortening or asymmetry of the skin folds in the pelvis or
limitation of abduction of the affected hip. X‐ray at this age
is mandatory. Treatment is by reduction, either closed
(Pavlik Harness or hip spica) or open (medial approach) and
splintage.

At the onset of walking, the child will present with a

Trendelenburg limp, skinfold asymmetry shortening and
limitation of abduction of the hip. The disorder may be far less obvious when both hips are dislocated.
However, the child will still have a waddling gait and limited hip abduction.

Problems present in future years

a. Intoeing
An intoeing gait is very common, especially around the age of 3 to 7 years. In fact, one in ten
children aged between two and five years will intoe as they walk. The intoeing can arise from
the hip (femoral anteversion), the tibia (internal tibial torsion) or, much less commonly, from
the foot (metatarsus adductus). The information below relates principally to the management
of intoeing due to increased femoral anteversion and internal tibial torsion, which account for
more than 95% of the presentations with intoeing gait. Additional information on metatarsus
adductus can be found further down the information page.
Usually, intoeing does not cause the child to have any functional disability. However,
sometimes, it seems as though the intoeing gait is causing increased tripping or falling. Tripping
and falling when walking or running is very common in the first five years of life and not caused
exclusively by intoeing. Any tripping or falling should improve as the child gets older and is not
of concern specifically unless there are other abnormalities in the developmental history or on
neurologic examination.
Intoeing gait will improve as the child grows and will continue to improve over the first 10 to 12
years of life. You can reassure the parents that mild intoeing is not linked to any functional
disability or predisposition to arthritis as an adult. In fact, fast runners e.g. tennis players or
sprinters, often benefit from the ability to intoe [as the alignment of the foot for push‐off is
improved by increased internal tibial torsion].

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Your assessment of a child who has intoeing gait should include a brief developmental and birth
history (checking developmental milestones); a brief neurologic examination (looking for
spasticity in the lower limbs); examination of hip range of motion, particularly hip internal and
external rotation in extension and hip abduction; clinical examination of the spine (looking for
curvature or hairy patch); a measure of tibial torsion; and an assessment of gait, both running
and walking.
If you detect a limp or are concerned about lack of hip range of motion, then you should arrange
for an AP pelvis to check hip development. If you have concerns about the developmental
history or your findings on neurologic examination, then you should consider referral for a
paediatric medical opinion. However, if your assessment confirms that the child is healthy,
developing normally and has no other abnormal findings on examination other than intoeing,
then you can safely observe the child until the age of 10 to 12 years.
You should be aware that there are no braces, special shoes or orthotics that will make the
slightest bit of difference to the improvement of the intoeing. The best treatment is therefore
OBSERVATION. Serial digital videos of the child's gait made by the parents over a number of
years may assist with this process.
If, by the age of 12 years, the intoeing has not improved and is of major cosmetic concern to the
patient and family, then the patient can be referred to the Starship Orthopaedic Department for
a consultant opinion. However, it is very unlikely that any treatment will be required.

History

 Is the child otherwise healthy, especially no concerns regarding DDH or cerebral palsy?
 Is there any limp?

Examination

 Any limp?
 What is the hip internal and external rotation?
 Do the hips abduct symmetrically?
 What does the foot thigh angle measure? (picture)
 If the intoeing is in the foot (metatarsus adductus) is it passively correctable?
 Is the spine straight?
 Any lower limb weakness or spasticity?

Red Flags:

 Rigid deformity in the foot

 Reduced hip abduction or pain in the hip (requires AP pelvis)
 Limp
 Scoliosis or neurological abnormality (spasticity, weakness).

In summary, intoeing is very common and does not cause any functional disability as an adult.
Intoeing improves as the child grows and is not influenced by special shoes, orthotics or braces.

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It is very common for children to present between the ages of 18 months and 4 years with in‐toeing
when they walk. This gives rises to problems with falling when the children run however has not been
shown to have any longterm sequelae. The “problem” may be at the level of the hip, tibia or foot

Many children present with instability of gait and falling, particularly when running. Such children
should be examined neurologically to ensure there is no evidence of cerebral palsy, nervous
system tumour or malformation. The vast majority are "clumsy children" and the problems
resolve with growth and maturity of the neural and musculoskeletal system. The problem is to
ensure that the gait abnormalities, particularly those of recent onset after a period of normal
walking are not due to an ongoing pathological process

B. Knock Knees (Genu Valgum)

The majority of children are slightly knock kneed especially around the age of three to seven years. It is
normal for children of this age to have one to two inches between the medial malleoli when standing
upright with the knees together (called the inter‐malleolar distance). By seven to ten years the legs
usually become straighter although most adults still have mild genu valgum (5 to7 degrees).
Genu valgum does not usually cause problems in later life and only in very unusual circumstances does it
require any intervention as a child. There is NO early treatment that makes a difference to the leg
position in adulthood. In particular, there are no braces, special shoes or orthotics that will make the
slightest bit of difference to the appearance of the legs.
The assessment of a child with knock knees includes taking a brief developmental and growth history; a
brief neurologic assessment of tone and power in the lower limbs; and a review for systemic illness (e.g.
rickets, known renal dysfunction, steroid intake). The genu valgum is best measured by the inter‐
malleolar distance and can be documented by a photograph.
If you have any concerns about the child's development, growth or neurologic status in addition to the
genu valgum, then you should consider referral to a paediatric medical clinic. If the child has a known
chronic medical condition, in addition to genu valgum, then we suggest seeking a review with their
paediatrician prior to referring to the Orthopaedic Department.
If the child is otherwise healthy, growing normally and on track with their developmental milestones, then
the best management is OBSERVATION. Serial photographs of the child over time can help document the
improvement expected with normal skeletal growth.
If, by the age of 10 years, the genu valgum has not improved and is of major cosmetic concern to the
family, then the patient can be reviewed by the orthopaedic department.

History

 Age
 Any history of major trauma or infection in lower limb(s)?
 Any history of renal impairment or rickets?
 Any history of chronic disease involving long‐term use of medications such as steroids, chemotherapy
agents?

Examination

 Is it symmetric?
 What is the intermalleolar distance in cm?

Things to be concerned about (Red Flags):

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 Genu valgum occurring after fracture or bone / joint infection
 History of chronic illness (e.g. poor renal function, rickets, prolonged steroid use)
 Unilateral genu valgum
 Stature below the third percentile (suggests metabolic disease or bone dysplasia).

In summary, knock‐knees are normal in children aged 3 to 7 years and are part of normal skeletal growth.
Knock‐knees improve with growth and do not require treatment unless there are other underlying
medical conditions (see red flags above).

C. Bow Legs (Genu Varum)

"Life is a bell‐shaped curve . . ."
The lower limbs often appear bowed in the first couple of years of life. This is called physiologic
bowing and is part of normal skeletal growth. The bowing improves spontaneously as the child
approaches 2.5 to 3 years of age and does not require specific treatment. Special shoes,
orthotics or cables will not make any difference to the natural history.
In rare cases bow legs can be due to disorders of calcium and vitamin D metabolism, renal
disease or a skeletal dysplasia (with multiple bone abnormalities). If you have a child with bow
legs and there are any risk factors for vitamin D deficiency (such as ‐ recent immigrant, diet
lacking in calcium, inadequate exposure to sunshine due to traditional clothing) then please
order serum calcium, phosphate, and vitamin D levels at presentation.
If these blood tests are normal and the child is above the third percentile for height and weight,
then you can safely observe the child until the age of 2.5 years. If there is an abnormality in the
vitamin D, calcium or phosphate levels or you have a concern about the child's growth and
development in addition to the bow legs, then you should consider referring for a paediatric
medical review.
If the bowing persists past the age 2.5 to 3 years, and other tests are normal, then the child can
be referred to the orthopaedic department.
Parents may want to take a picture of their child standing to compare as she/he grows to
demonstrate improvement.
Minimum Data Required (for your referral to be considered)

History
Any family history of bow legs?
Any family history of metabolic bone disease, dwarfing conditions?
Any history of trauma or infection in the lower limbs?
Is the child otherwise healthy with adequate nutrition?
Is there long‐term use of anti‐convulsants (can be associated with alterations in vitamin D
metabolism)?

Examination:
Age of child
Weight and height and percentile for age (very important)
Is the bowing symmetrical on both sides?
Include a copy of the serum calcium, phosphate and vitamin D levels with your referral

Things to be concerned about:

 Unilateral bowing
 Recent immigrant (rickets) or unusual diet or lack of sunshine

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  Possible metabolic bone disease or other bone condition (short stature)
 Not resolving after 3 years

In summary, measure the child’s height and weight and consider checking calcium,
phosphate and vitamin D levels if there are any risk factors as above. If the height and weight
are above the 3rd percentile and the serum measurements are normal, then the most likely
diagnosis is physiologic bow legs. We recommend observation till the age of 2½ to 3 years of
age with a re‐referral at that point if there are clear indications.

Children’s Feet

a. Flat Feet
Many parents seek help with children who have loss of the longitudinal arch and the classic appearance
of a flat‐foot. If it is a mobile deformity, it corrects when the child stands on tiptoe. Such mobile flat
feet are seldom symptomatic even as adults and the problem hinges around excessive breakdown of
shoes. Although various forms of wedge insoles and braces have been devised, mobile flat feet do not
respond to orthotic treatment and management should be by parental reassurance.

Beware of the problem of the rigid flat foot. This occurs in slightly older children. Repeated
manipulation of the foot will give rise to spasm in the peroneal muscles producing the so‐called
peroneal spastic flat foot. Many of these are idiopathic, but some arise as a result of infections in the
hind foot or various forms of tarsal coalition. The management of these is complex and you should
refer any rigid flat foot to an orthopaedic surgeon for further investigations. If you, the observer, can
manipulate the child’s foot to a normal posture and the arch reconstitutes on standing on tiptoe, then
the child does not have a significant rigid flat foot.

b. Cavus Feet and Claw Toes

Form time to time you will see a child with a very high arch or so‐called cavus deformity of the foot
which is commonly accompanied by a claw deformity of the toes. Beware of this deformity as it
commonly indicates some form of neurological abnormality. This may be either spina bifida or a rather
more rare disorder such as Charcot‐Marie‐Tooth disease. Always examine the spine of such children to
exclude the presence of a spina bifida and in general these children should be referred to a neurologist
or an orthopaedic surgeon for assessment.

c. Adolescent Bunions
It is not uncommon for teenage girls to present with a moderate degree of bunion or hallux valgus.
There is commonly a family history of the disorder. The foot is broad with a so called metatarsus
primus varus or adduction deformity of the first metatarsal bone with subsequent lateral deviation of
the great toe. By far the most common reason for seeking medical advice is the cosmetic appearance
of the foot and the difficulty the patient is having in fitting fashionable shoes. The patients commonly
disguise this with various forms of complaint about pain in the foot and some will, of course, have
genuine problems with shoe fitting. Some 300 operations have been devised for this deformity, which
indicates that no one procedure is very successful. Surgery is best deferred until the patient is skeletally
mature.

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Back Problems

a. Scoliosis
A scoliosis is a lateral curvature of the spine. If the curve persists when the child bends
forward, at which time rib rotation is also seen, the curve is structural. Postural curves
do not give rise to a rib hump and disappear when the child bends forward. All
structural scoliosis must be referred to an Orthopaedic surgeon as many curves are
progressive. In general, idiopathic scoliosis presents as a right sided thoracic curve in
an adolescent. Left sided curves have a higher incidence of an underlying neurological
cause. You should be aware that scoliosis is not a painful condition. Back pain plus
scoliosis may indicate non‐idiopathic causes such as tumour or spinal cord abnormality.

You should read a short text book account of spondylolisthesis.

Children’s Hip Problems

a. Legg‐ Calve‐Perthes Disease (Perthes disease)

This is a disorder which commonly affects 4‐8 year olds although the age can vary from 3 to 12 years.
It is defined as avascular necrosis of the femoral head, histology confirming repeated waves of
avascularity. There is some evidence though that Perthes disease is a more generalised disease with
associated delayed bone age and a typical body habitus (thin and small). Over 2‐3 years the femoral
head heals and reconstitutes but the child may be left with a deformed femoral head, which
predisposes to early arthritis in the 40s and 50s. The aim of orthopaedic treatment is to improve the
chances that the femoral head will reconstitute to a spherical shape but the evidence that surgical
treatment makes a difference is still controversial. The cause is unknown but abnormalities in the
fibrinolytic system have been suggested. All children with Perthes disease diagnosed on X‐ray should
be referred to an orthopaedic surgeon as the outcome can be poor in older children.

b. Slipped Capital Femoral Epiphysis

(SCFE)
This occurs in adolescents and can be either
“stable” (the patient limps in) or “unstable” (the
patient is carried in). The history is one of pain in
the hip OR knee with a limp characterised by
external rotation of the leg. Examination shows
fixed external rotation of the hip when the hip is
flexed with no internal rotation. In 25% of cases
the slip will be bilateral. X‐rays show posterior
displacement of the femoral head on the femoral
neck occurring at the level of the growth plate
(see B,C,D of Figure). A frog lateral X‐ray is the
most useful X‐ray to rule out a slip and should
always be requested in addition to the AP view.
The treatment is surgical stabilisation of the SCFE
with pinning in situ and all patients should be
referred acutely to hospital once the diagnosis is

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made by x‐ray. Sudden severe displacement of a mild SCFE can occur following minor trauma and this
will lead to a worse outcome for the hip. Most SCFEs are idiopathic however there can be an endocrine
cause (eg. hypothyroidism, hypopituitaryism). and this should be considered if a SCFE occurs outside
the normal age range (which is 10‐14 for girls and 10‐16 for boys)

c. Irritable Hip
This occurs in the same age range as Perthes disease and is characterized by a painful hip with limited
motion but normal x‐ray and blood tests. The pain settles quickly with rest with no long‐term
sequelae. The major problem is to differentiate it from other serious conditions such as septic arthritis
and Perthes disease. Very occasionally, JCA or rheumatic fever can present as isolated hip pain but
usually the abnormal blood tests will indicate that the diagnosis is not irritable hip.

d. Septic Arthritis
Covered in paediatric infections

N.B. All children's hip disorders can present with pain in the knee.
Thus, if the knee looks normal, examine the hip.

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 DDH PERTHES SCFE SEPTIC HIP IRRITABLE HIP
Age at At birth  4 ‐ 8 years 10 ‐ 14 years  Neonate  Adult 3‐8 years
Can be from 2 to 12 but less 10 ‐ 16 years  Less common outside this
presentation common age range
Sex ratio F>M M>F M:F = 2:1 M>F M:F=2:1

Incidence 1:1000 1:1000 1:1000 ? up to 3% of population

Racial More common in European More common in European More common in More common in Maori and More common in Europeans
Incidence Unusual in Maori/Polynesian Pacific Islanders Lower incidence in African
Maori/Polynesian ? 4x as common Americans
Symptom Nil initially Pain, limp Pain, limp ‐ foot externally Neonate: swollen thigh, Pain, limp
rotated refusal to move leg
Child ‐ pain with movement,
Signs 0 ‐ 6 months hip Limited ROM Limp Lies with leg abduct, ER and Limited
dislocatable Loss of hip internal rotation Obligatory external rotation flexed Loss of hip internal rotation
4 ‐ 6 months hip abduction Fixed flexion contracture of leg as hip is flexed Fixed Flexion contracture
in flexion Lack last 10° ‐ 15° of flexion
Blood Tests Normal Normal Normal CRP elevated in 95% Normal
ESR > 20 in 80%
WWC > normal
X‐ray Unreliable before 3 ‐ 4 Avascular necrosis and Frog‐lateral view essential, Normal Normal
months collapse of femoral head shows femoral head post.
Diagnostic at 3 months Evolving findings over 2 displaced on femoral neck
onward years as femoral head
reconstitutes
Other Tests U/S 0‐3 months can show Bone scan can show CT will show relationship of Aspiration of hip is the Hip U/S ‐ will show effusion
location of hip. avascular head head and neck but not GOLD standard but false negatives possible.
3‐DCT for joint anatomy in MRI ‐ research more than routinely necessary Does not identify cause of
older children pre‐op clinical practice effusion
Treatment Pavlik Harness < 6 mths < 6 yrs mostly conservative Percutaneous in‐situ pinning Open wash‐out of hip and IV Bed‐rest
Open reduction plus cast > 6 >6 yrs operative to prevent progression antibiotics six weeks Traction 2‐3 days
mths Resolves without sequelae
Other procedures later

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