conditions are relatively common. In most cases the observed abnormalities
are simply variations of normal development and with growth these
deformities undergo spontaneous correction (physiological deformity).
No treatment is therefore required for these cases. On the other
hand, in a minority of cases the deformities are due to sinister
conditions and treatment may be necessary (pathological deformity).
When faced with a child with a limb deformity, the question that
needs to be answered is whether the deformity is physiological
or pathological. As mentioned earlier physiological deformities
require no treatment other than reassurance. On the other hand,
pathological deformities may require intervention.
Rule of 5 Ss is a useful tool to distinguish between
physiological and pathological deformities in paediatric practice
and consists of the following:
• Systemic Disorders
A child with a physiological
deformity would generally be asymptomatic, have symmetrical deformities,
exhibit no stiffness in the affected joints and has no underlying
systemic disorders or syndromes. In contrast, a child with a pathological
deformity is often symptomatic (pain) and the deformity maybe
asymmetrical with stiffness in the affected joints. There may
also be associated systemic disorders or syndromes.
In most cases this
information could easily be obtained by taking a history and clinical
examination. Occasionally additional investigations such as plain
radiographs, blood tests or scans are needed to complete the assessment.
The clinical features
and the management of following common paediatric orthopaedic
conditions are discussed below:
Dysplasia of the Hip (DDH)
• Intoe Gait
• Knock Knees & Bow Legs
• Flat Foot
• Calcaneovalgus Foot
• Club Foot
|• Irritable Hip
• Perthes' Disease
• Slipped Upper Femoral Epiphysis
• Growing Pains
HIP DYSPLASIA (DDH)
This paediatric hip
condition was previously known as congenital dislocation of the
hip (CDH). Recently the name was changed to DDH as it was recognised
that in this condition the hip may exhibit a spectrum abnormalities,
which only in a minority of cases it presents as a dislocated
hip at birth (<25%). In most cases the hip shows various degrees
of dysplasia or subluxation (partial dislocation). In a small
number of cases the hip may actually be normal at birth, but become
abnormal later in life.
The incidence of this condition is about 2-4 cases per 1000 live
births. Females are more frequently affected than males by 4:1.
It may be bilateral in 25% of cases.
The Natural History. If
this condition is left untreated, it would lead to serious complications
such as a severe limp, limb shortening, scoliosis or early onset
of osteoarthritis in the hip as an adult. Following subgroup of
children are particularly at risk of DDH:
• Breech presentation.
• Positive family history.
• Babies with lower limb abnormalities at birth.
• Babies with spinal deformities at birth.
• Syndromic children.
If this condition is detected early within the first few months
of life, it could easily be treated with a short period of bracing
with successful outcome in over 95% of cases.
Late presentation for example in a walking child is associated
with a much worse prognosis. Treatment in the walking age group
is generally more complex and prolonged, often requiring open
surgical procedures. Early detection and treatment is therefore
paramount to ensure a successful outcome and to avoid the need
for major surgery.
Screening for this
condition In United Kingdom is mandatory and is carried out at
birth, 6 weeks and 8 months of age. Most cases are therefore detected
at an early age and treated appropriately.
of DDH are:
• Limitation of abduction in flexion (all age groups).
• Hip or thigh asymmetry (all age groups).
• Extra deep crease around the back of the thigh.
• Positive Barlow or Ortolani Tests (<2 months of age).
• Short leg or limping (walking age group).
It is important to note that these physical signs are more obvious
in unilateral cases due to limb asymmetry. In bilateral cases
these signs could easily be overlooked. Limited abduction (<60°)
in both hips should raise the suspicion that both hips may be
In difficult cases or high risk groups further investigations
is recommended. For a child younger than 5 months ultrasound examination
is indicated and for over 5 months plain radiographs.
Treatment. The basic
principals for treatment are:
• Reduce the dislocation or subluxation.
• Hold the reduction until hip stabilises.
• Careful follow-up until skeletal maturity.
In a child less than 6 months of age the reduction can easily
be achieved by flexing and abducting the hips (frog position).
The reduction is usually maintained using a brace such as a Pavlik
harness for a period of 2-3 months.
In a child in the age group of 6-18 months this condition is associated
with major soft tissue contractures. To achieve reduction a period
of traction for 1 week is usually necessary. This is then followed
by an attempt of closed reduction under general anaesthesia. The
reduction would require confirmation using an arthrogram (injection
of dye into the hip joint under X-ray control). In the cases that
there is resistance to reduction, additional surgical procedures
such as tenotomy (tendon release) or limited open reduction of
the hip may be necessary. Following this procedure the reduction
is maintained using a frog plaster for a period of at least 4
In a walking age child (>18 months) major surgery is often
required to reduce and stabilise the hip. this could be in the
form of an open reduction of the hip +/- pelvic or femoral osteotomy.
Postoperatively a period of casting in a hip spica is necessary
for 10 weeks.
for this condition is directly related to the age of the child
at the time of presentation and the severity of the hip dysplasia.
In children less
than 6 months of age 98% success rate is generally expected. This
is reduced to 95% if the child is within the age group of 6-24
months and 85-90% if the child is over the age of 2 years at the
time of treatment.
Careful follow-up until
skeletal maturity (age 16 years) is needed to confirm satisfactory
progress and to identify complications such as recurrent dysplasia
or avascular necrosis (loss of blood supply to femoral head) at
an early stage.
Abduction & Extra Thigh Crease
& Ortolani Tests
Harness - Frog Plaster
Traction & Arthrogram
Reduction with Femoral or Pelvic Osteotomy
Intoe gait (pigeon
toed) is a common childhood problem. It is estimated to occur
in 10% of children between ages of 2-5 years. In most cases this
is an entirely benign condition and is a feature of normal variation
of growth pattern.
Lack of any symptoms such as pain, symmetrical deformities, absence
of any stiffness in the affected joints and no associated systemic
disorders or syndromes indicates a benign condition with excellent
Most children with this deformity spontaneously stop intoeing
before the age of 9 years. No treatment is therefore required
in the majority of cases.
There are 3 main causes of intoe gait:
• Persistent femoral anteversion
• Internal tibial torsion
• Forefoot adductus
Persistent Femoral Anteversion (PFA).
PFA is excessive anterior rotation within the upper femur. Normally
in adults the upper femur is anteriorly rotated in relation to
the lower femur (femoral condyles) by 15°. In young children
this angle is about 30°, but this steadily reduces to adult
angles by the onset of adolescent growth spurt.
On examination of the hips in children with PFA, the most striking
feature is excessive range of internal rotation, but limited external
As previously mentioned in most cases this is an entirely benign
condition and requires no treatment.
is normally rotated externally in relation to the femur by 20°.
This is best measured by comparing the intermalleolar axis to
the intercondylar axis. Another simple way of assessing this relationship
is to measure the thigh-foot angle with the child in prone position
and knees flexed to 90°.
In ITT the tibia is found to be internally by more than 10°-20°.
This phenomenon is extremely common at birth and rapidly remodels
to normal levels within the first few years of life. However,
in a minority of cases ITT may persist until onset of adolescent
growth spurt. This condition is unlikely to persist
into adult life and rarely creates problems severe enough to require
treatment or correction.
is another important cause of intoe gait. In this condition the
foot has a curved lateral border rather than straight. The forefoot
therefore appears to be turned in (bean shaped). This condition
could easily be distinguished from club foot as there are no fixed
deformities within the hind foot.
This condition has a tendency for spontaneous correction with
age. Long-term prognosis is usually very good and treatment is
not required in most cases.
For severe cases, especially when it is unilateral, application
of serial corrective casts could be very effective. Surgical correction
is rarely needed .
- - - - - - - Intoe Gait
of Intoe Gait
KNEES & BOW LEGS
deformities of the lower limbs are common during childhood. In most
cases this is an entirely benign condition and represent a variation
in the normal growth pattern.
Presence of symmetrical deformities and absence of symptoms, joint
stiffness, systemic disorders or syndromes indicates a benign condition
with excellent long-term outcome. In contrast deformities which
are asymmetrical and associated with pain, joint stiffness, systemic
disorders or syndromes may indicate a serious underlying cause and
The most common deformities that would be discussed here are Bow
Legs (Genu Varum) and Knock Knees (Genu Valgum).
The Natural History.
It is important to note that a newborn initially presents with bow
legs. With normal growth, knees gradually become straight by the
age 18 months. With further normal development knees gradually drift
into valgus (knock knee). This knock knee deformity is maximal at
around age 3-4 years. By the age 7 years knee angle (tibiofemoral
angle) return to normal adult values of 5°-7°.
This is well illustrated by the opposite graph (Salenius 1975).
The shaded area in light green indicates the 2 standard deviations
(SD) from the average. Tibiofemoral angles within this range are
considered to be within normal limits.
Treatment is not required
for physiological deformities. i.e. deformities within 2 standard
deviation or deformities that are not associated sinister features
such as pain, asymmetry, stiffness, systemic disorders or syndromes.
Treatment for pathological deformities depends on the underlying
disorder and the severity of the deformity.
Metabolic deformities such as rickets could simply be corrected
with medical treatment i.e. calcium and vitamin D supplements.
Prior to skeletal maturity (<14 years in females and 16 years
in males) deformities could be corrected slowly using partial growth
plate arrest (hemiepiphysiodesis). For severe deformities or after
skeletal maturity corrective osteotomy or may be needed.
Hemiepiphysiodesis -- Osteotomy
Flat foot is a common
finding in childhood. This is broadly divided into 2 groups i.e.
flexible or rigid flat foot.
Flexible Flat Foot
is the more common variety (95%). It is generally observed in
the younger child and is frequently associated with generalised
joint laxity. This condition is rarely symptomatic or limits the
level of activity.
A classical finding in flexible flat foot is that the foot arch
develops normally when the child stands on tip toes. whilst standing
normally the flat foot deformity recurs.
In vast majority of cases flexible flat foot is a benign condition
and requires no treatment. Recent long-term studies have shown
that old methods of treatment such as insoles or surgical shoes
have no beneficial effect on the ultimate outcome.
Rigid Flat Foot
on the other hand is a sinister finding and often associated with
serious conditions such as tarsal coalition or congenital vertical
Unlike flexible flat foot, rigid flat foot is frequently a painful
disorder. In this condition when the child stands on tip toes,
the medial foot arch does not develop normally. On examination
the foot is found to be stiff, lacking normal range of movement
in the subtalar joint.
Congenital vertical talus (CVT) is a rare but serious foot deformity.
It generally presents at birth and rarely responds to conservative
treatment. 50% of cases are associated with underlying neuromuscular
conditions or syndromes. Surgical intervention is frequently required
as this is a painful condition as an adult. surgical correction
is generally carried out at age 1 year.
Tarsal coalition is
a relatively common condition (1-2% of population). Most cases
are relatively asymptomatic and do not come to the attention of
the medical profession.
Tarsal coalition is usually asymptomatic in the younger child
and only becomes painful during the adolescent growth spurt. There
2 main varieties of tarsal coalition are: Talo-calcaneal coalition
and Calcaneo-navicular coalition. Both varieties present with
pain and stiffness in the foot.
Treatment for tarsal coalition is controversial. My preference
for early cases is to excise the coalition and insert a fat graft
into the gap to stop the coalition from reforming. Other methods
of treatment are: short period of casting in a walking plaster
or subtalar fusion.
& Shoe Inserts
This is the most common
paediatric foot deformity. As the name implies, in this condition
the hindfoot is in excessive calcaneus (dorsiflexed) and valgus
position. In a walking child, on weight-bearing the foot has an
excessively everted and pronated appearance.
This is an entirely benign condition in majority of cases. It
is usually secondary to joint laxity and immature muscle pattern
as seen in the newborn or a young child.
This condition is rarely associated with hip dysplasia (DDH) and
screening for this condition is required.
Other than gentle stretching
exercises no other treatment is generally required and long-term
prognosis is excellent.
FOOT (Congenital Talipes Equinovarus)
foot is the second most frequent paediatric foot condition. It affects
2 per 1000 live births and could be bilateral in 25% of cases. Males
are more frequently affected than females by 2:1.
The deformities in club foot are complex and involves the whole
foot, ankle and leg. In the hind foot the ankle joint is flexed
(equinus deformity) and the heel is turned in (varus deformity).
In the forefoot there is a high medial arch (cavus deformity) and
the foot has a bean shaped and curled outer border (forefoot adductus
deformity). The whole leg, foot including calf muscles are smaller
on the affected side.
In 30% of cases this deformity is flexible and rapidly resolves
after birth. In the remaining 70% the deformity is stiff and if
left untreated it would lead to severe painful deformities in the
long-term and the affected child could end up walking on the outer
aspect of the foot.
Most cases of club foot are idiopathic (unknown cause) in nature
and the child is otherwise entirely normal. In minority of cases
(<5%) this deformity is secondary to other conditions such as
neuromuscular disease or syndromes. There is also an increased risk
of developmental dysplasia of the hip (DDH) in children with club
foot and screening for this condition is therefore mandatory.
Treatment for flexible
club foot is stretching exercises under the supervision of a physiotherapist.
Rapid resolution of the deformity is generally expected within weeks
and it is unlikely other methods of treatment would be necessary.
For rigid or inflexible deformities my preference is to use Ponseti's
method of treatment. This is currently gathering increasing popularity
and recent comparative studies have shown results equivalent or
even superior to traditional methods of treatment such as surgical
soft tissue releases.
Ponseti Treatment in
my experience this is best suited for infants and young babies (<
6 months age).
Treatment starts initially by stretching the deformity to its maximal
position of correction and applying an above knee cast using plaster
of Paris or Softcast. This is repeated on a weekly basis for 6 weeks
and a new cast is applied on each occasion.
In 20% of the cases complete correction of the deformities is observed
within this 6 week period of stretching and casting. However, in
80% of cases the hind foot equinus deformity may persist. In these
cases the complete correction of the deformity is achieved at week
7 by performing a small operation to release the tendo-Achilles
(percutaneous tendo-Achilles release).
When complete correction of the deformities has been achieved an
above knee cast is applied for another 6 weeks. At 12 weeks following
start of treatment, all casting is discontinued.
To avoid recurrence of deformity use of a Denis Browne splint at
night time is recommended until age 2 years. Note splinting is not
required during day time.
The success rate of Ponseti treatment is about 85-90%. For failed
cases or children with severe recurrent deformity, surgery may be
required at a later date. In general the procedures necessary to
treat failed Ponseti cases are lesser in magnitude as compared with
traditional operative procedures for correction of club foot deformity.
Most cases with recurrent deformity after Ponseti treatment need
a simple tendon transfer at the age 3-4 years (tibialis anterior
Prognosis With appropriate
treatment we expect most children (>95%) with clubfoot deformity
to lead a normal life into adult hood and even take part in strenuous
N.B. in a small number of cases club foot deformity may not respond
to stretching or Ponseti's treatment. These cases would require
surgical soft tissue release at around age 1 year.
in Club Foot
Calf Muscles & Smaller Foot
Stretching & Application of Serial Corrective
is the commonest cause of hip pain or limping in a young child.
The peak age group is 3-8 years. Although this is a hip condition,
in about 30% of cases the pain may initially be felt in the knee
or the thigh.
The underlying pathology in this condition is formation of fluid
under tension (effusion) within the hip joint. The exact cause of
this effusion is unknown, but viral infections, minor trauma or
allergy have been implicated.
Diagnosis is usually
made on clinical grounds. The affected hip is generally irritable
on movement but relatively comfortable when the hip is kept in the
position of flexion and abduction. Signs of sepsis such as high
temperature, rapid pulse, flushing, limb swelling or erythaema are
Best method of investigation is ultrasound of the hip to confirmed
the presence of the effusion and blood tests to rule out rise in
inflammatory markers. Plain radiographs of the hips is also taken
to exclude rare associations such as Perthes' disease. Radiographs
may occasionally confirm presence of an effusion by showing a subtle
medial joint space widening.
hip is a benign and self-limiting condition. In most cases it spontaneously
resolves within 48-72 hours. During the painful episode rest is
advisable and this could be done at home. Other than anti-inflammatory
drugs no other treatment is usually required.
If symptoms fail to resolve within the 48-72 hours or there is deterioration
of general condition, urgent specialist review is necessary.
In Affected Hip
Perthes' disease is
avascular necrosis of the femoral head of unknown aetiology. The
interruption of the blood supply to the femoral head results in
collapse, fragmentation and progressive deformity of the hip joint.
It affects the age groups 4-10 years. Males are more frequently
affected than females by 4:1 and it is bilateral in 25% of cases.
A child suffering from this condition usually presents with hip
pain or a limp. However, in 30% of cases the pain may initially
be referred to the thigh or the knee. This could on occasions
result in missed or delayed diagnosis, especially if the hips
are not radiographed routinely in a child with knee or thigh pain.
Perthes' disease is recognised to undergo a number of well defined
radiological stages i.e. necrosis, fragmentation, healing and
The Natural History
of untreated Perthes' disease is eventual healing and revascularisation
of the necrotic femoral head within 2-3 years. In 75% of the cases
the healing process results in a round congruent hip joint with
good to excellent outcome in the long-term. In these cases no
treatment other than careful follow-up is necessary.
In contrast in
25% of untreated cases this condition results in severe deformity
of the hip joint. In these cases operative intervention may be
required to improve the outcome.
It is important to note that from onset of Perthes’ disease
i.e. necrosis stage until the lesion heals (healing stage) it
may take up to 2-3 years. Regardless of the prognosis, the affected
child is expected to experience intermittent pain and limping
during this period until healing stage is reached.
Treatment is not
required for children with good prognosis. Good prognosis is indicated
by the following clinical features:
• Age less than 6 years at the onset of symptoms.
• Less than 50% of head involvement.
• No stiffness or shortening on examination.
On the other hand bad prognosis is indicated by the following
• Age more than 7 years at the onset of symptoms.
• More than 50% of head involvement.
• Significant stiffness or shortening on examination.
In poor prognosis group operative intervention could improve the
outcome. In general there are 2 class of operations available
to treat Perthes's disease: i) Containment, ii) Corrective Osteotomy.
Containment is most suitable for cases within the necrosis or
fragmentation stages. During these early stages the femoral head
remains malleable and the aim is to contain the femoral head deep
within the acetabulum until healing occurs. The acetabulum which
is hemispherical in shape helps to remodel the femoral head into
a spherical shape. Varus femoral or pelvic osteotomy are the operations
generally done for containment.
Corrective osteotomy is more suitable for cases that have entered
the healing or remodelling stages. in these stages the femoral
head deformity is unlikely to remodel by containment . Corrective
osteotomy aims to address residual problems such limb shortening
or limited abduction in the hip. the most popular type of osteotomy
in this situation is a valgus lengthening osteotomy.
of Perthes' Disease
- Fragmentation - Healing - Remodelling
History of Untreated Perthes' Disease
than 50% Head Involvement
than 50% Head Involvement
UPPER FEMORAL EPIPHYSIS
This is the commonest
cause of hip pain in the adolescent age group (10-15 years). Males
are more frequently affected than females by 2:1. It may be bilateral
in 30% of cases. Positive family history, obesity and hormonal
abnormalities such as hypogonadism, hypothyroidism and hypopituitarism
are well known associations.
The pathology is a stress fracture through the upper femoral growth
plate resulting in a progressive slip of the femoral head over
the femoral neck. The affected limb shortens and externally rotates
as the deformity increases with time.
The Natural History. If
this condition is left untreated it may result in severe
limb shortening, fixed external rotation and stiffness of the
hip. This may then be followed by early onset of osteoarthritis
in adulthood. In a small number of cases sudden catastrophic failure
of the growth plate may occur, resulting in severe deformity and
loss of blood supply to the femoral head (avascular necrosis)
with serious long-term sequelae.
In most cases the condition presents with a limp and pain in the
hip or groin. However, in 30% of cases the pain may initially
be referred to the knee or the thigh creating diagnostic difficulties.
To avoid a missed or late diagnosis, it is vital to take radiographs
of the hips as well as the knees in any adolescent presenting
with thigh or knee pain.
N.B. In this condition the hip radiographs should routinely include
2 views at right angles as in the early stages the classical AP
view may appear to be normal . The lateral view usually reveals
the slipped epiphysis (see the top radiographs).
Treatment of choice
for this condition is insertion of a single cannulated screw percutaneously
under X-ray control. With modern techniques this could be achieved
using a small stab incision. Postoperative recovery is generally
rapid, but a period of protected weigh-bearing with crutches for
6 weeks is recommended.
For severe slips additional procedures in form of open reduction
or corrective osteotomies may be necessary. Fortunately this a
rare occurrence, especially if this condition has been picked
up early before severe deformities have developed.
of the unaffected hip is a common point of debate. It is recognised
that in 30% of cases, slips may occur in both hips.
Onset of symptoms in the unaffected side indicates the need for
prophylactic screw fixation. My current practice is also to fix
the unaffected hip in cases associated with hormonal abnormalities.
Prognosis of this condition is dependent on the
severity and the stability of the slip.
A stable slip is defined as a slip were the individual is able
to weight-bear on the affected limb. In unstable slips weight-bearing
is not possible due to the severity of symptoms. In general stable
slips with slip angles of less than 30° carry excellent long-term
prognosis when treated appropriately.
Unstable slips or slips more than 50° carry a more guarded
prognosis. Occasionally these cases are complicated by conditions
such as avascular necrosis (loss of blood supply to the femoral
head) or chondrolysis (loss of cartilage of the head of femur).
These complications cause severe deformity or stiffness in the
affected hip and result in early osteoarthritis.
Upper Femoral Epiphysis
Stabilisation Under X-Ray Control
In a child or skeletally immature adolescent, tendons insert into
bone through a specialised cartilaginous tissue called apophysis.
This tissue ossifies and turns into bone when skeletal maturity
is reached in the adolescence.
During growth spurt apophyses are vulnerable to traction injury
(micro-avulsion). Clinically this may manifest
itself as painful or prominent apophyses. Positive family history,
obesity and strenuous activity are some of the predisposing factors.
The most frequent site for apophysitis is the tibial tubercle, which
is also referred as Osgood-Schlatter's disease. Other common sites
are the heel (Sever's disease) and medial aspect of the foot (navicular
apophysitis). Rarely the hip may also be affected.
Treatment for this
condition is generally conservative and nonsurgical. During the
active phase, reduction in the level of activity and mild painkillers
are recommended. During remission normal activities could be commenced
with caution. Rarely for severe symptoms shoe inserts or casting
could be tried.
Prognosis for most
cases of apophysitis is excellent in the long-term. This condition
spontaneously heals when skeletal growth ceases in the late adolescence.
Unfortunately during the active phase of the disease which may last
a number of years, intermittent symptoms are expected. In an active
sporting child this could become a great nuisance and necessitate
reduction in level of activity until resolution of symptoms occurs
in late teens.
is a common condition, especially in the age group of 3-10 years.
Classically symptoms are worse at nights. Usually the child wakes
up in the middle of the night complaining of pain in both legs or
knees. After a short period of massage and rubbing the painful area,
symptoms resolve and the child goes back to sleep. In the day time
symptoms are uncommon.
The exact cause of growing pains is unknown. It has been postulated
that skeletal growth which mainly takes part at night, increases
the limb length and this increases the stress on the soft tissues
which tend to lag behind in growth.
Growing pains is a diagnosis of exclusion. Mode of presentation,
age of the child and bilateral nature of the symptoms are strongly
suggestive. However, thorough clinical examination and plain radiographs
are needed to exclude rare but serious conditions such as tumours
or infection which could mimic growing pains.
Treatment for this condition is symptomatic. Regular stretching
exercises and a short course of mild painkillers at night could
be helpful. In the long-term this condition spontaneously resolves.