Orthopaedic Problems in Childhood

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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Orthopaedic problems in children are common. They can be congenital, developmental or acquired, including those of infectious, neuromuscular, nutritional, neoplastic and psychogenic origin. Some of the more common disorders include those of the areas below.

  • Metatarsus adductus - this is a congenital problem with forefoot adducted and sometimes supinated. It is usually treated by manipulation, casting and occasionally surgery[1].
  • Calcaneovalgus foot - this occurs in neonates with hyperdorsiflexion of foot, abduction of forefoot and heel valgus increased. It is usually caused by positioning in utero and resolves itself when the baby starts to stand. Severe cases (often associated with cerebral palsy) may need tibiotalocalcaneal fusion[2].
  • Planovalgus deformity - this is another common condition associated with cerebral palsy[3]. In ambulatory children calcaneal lengthening is an effective procedure for the correction of mild-to-moderate deformity. In non-ambulatory children with severe deformity there is a high relapse rate and surgery is unlikely to be helpful.
  • Talipes equinovarus - various abnormalities of the tibia, fibula and bones of the foot form a composite abnormality, also known as club foot. Treatment options include manipulation, casting, splinting and surgery[2].
  • Hypermobile pes planus - flexible flat feet are common in neonates and young children[4]. The condition usually resolves by age 6 years but after that requires ankle stretch exercises and foot orthoses if symptomatic. There is no evidence that flexible flat foot has any effect on sporting prowess.
  • Tarsal coalition - this is peroneal spastic flat foot with painful rigid flat foot and spasm of the lateral calf muscle, appearing after age 9 years. It may be managed non-operatively (eg, with casts, shoe inserts) or surgically. In calcaneonavicular coalition, the interposition of fat between the two resected bones helps to improve symptoms and restore function[5].
  • Pes cavus - this causes a high arch which does not flatten with weight-bearing. Treatment options include physical therapy, orthotics and surgery, depending on severity[6].
  • Curly toes - usually involving the fourth and fifth toe. This is usually inherited, bilateral and without symptoms. 25-50% resolve by age 3-4 years; otherwise surgery is required[7].
  • Overlapping fifth toe - this overrides the fourth toe and causes pain in half of cases, requiring surgery.
  • Polydactyly - this is the most common deformity of the foot and can vary from minor degrees of soft tissue duplication to major skeletal abnormalities. The most common abnormality is an extra fifth toe. Surgical removal is the usual treatment. A check should be made for other deformities.
  • Syndactyly (web toes) - needs no treatment but check for other deformities.
  • Hammer toe - there are extended metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints with a hyperflexed proximal interphalangeal (PIP) joint. It usually affects the second toe and may need surgery if painful.
  • Mallet toe - this is a flexion deformity of the DIP. It may need surgery if causing symptoms.
  • Claw toe - this is dorsiflexion of the proximal phalanx on the lesser MTP joint and concurrent flexion of the PIP and DIP joints. Podiatric advice and sometimes surgery are indicated.
  • Ingrowing toenail - the edge of the nail grows into the surrounding soft tissue and may cause a paronychia. Treatment options range from conservative management with warm soaks and antibiotics, to various surgical procedures.
  • Internal femoral torsion - the most common cause of in-toeing in children aged >2 years; it is usually treated by correction of an abnormal sitting position.
  • Internal tibial torsion - the most common cause of in-toeing in children aged <2 years; it normally resolves spontaneously when the child starts to walk.
  • External tibial torsion - this is often associated with calcaneovalgus foot and also resolves upon walking.
  • Genu varum (being bow-legged) - this is caused by a tight posterior hip capsule; it usually resolves by the age of 2 years. Exclude rickets; consider night splint or osteotomy if the condition is severe.
  • Genu valgum (being knock-kneed) - this is usually benign and normally resolves by the age of 5-8 years; surgery may be appropriate if the condition is persistent by age 10 years.
  • Leg length discrepancy - usually due to growth asymmetry; treatment options include surgical correction of the longer or shorter leg, or inhibition of growth of the longer leg.
  • Popliteal cyst (Baker's cyst) - treatment for this synovial cyst is usually conservative unless underlying internal derangement of the knee requires arthroscopy.
  • Osteochondritis dissecans - intra-articular osteochondrosis of unknown aetiology; treatment options include immobilisation, non-steroidal anti-inflammatory drugs (NSAIDs), surgery and, more recently, chondrocyte transplantation.
  • Tibial apophysitis (Osgood-Schlatter disease) - usually requires conservative treatment with activity modification, physical treatment, bracing, orthotics and, rarely, excision of the tibial tubercle in the event of non-union[8].
  • Patellar subluxation and dislocation - this is a congenital disorder usually treated by immobilisation; surgery is considered if chronic.
  • Discoid lateral meniscus - a congenital malformation of the lateral meniscus; it has a preponderance to tear, requiring arthroscopic repair if troublesome[9].

Hip pain in children can be due to a number of causes[10]. Diagnosis requires careful history taking and examination. Arthroscopy of the hip is being increasingly used in paediatric patients to investigate and treat pain in the joint.

  • Developmental dysplasia - this is a spectrum of disorders that affects the proximal femur, acetabulum and hips. Early recognition prevents long-term morbidity. Treatment under 6 months is a Pavlik harness; above 6 months, closed reduction and a Pica cast are required.
  • Septic arthritis and osteomyelitis - this is commonly due to Staphylococcus aureus. Treatment is usually emergency aspiration, arthroscopy, drainage and debridement with antibiotic cover.
  • Transient monoarticular synovitis - this is a common cause of limping and often occurs after a respiratory infection. Treatment options include rest, physiotherapy and NSAIDs.
  • Perthes' disease - this is idiopathic avascular necrosis of the femoral head. Primary interventions include bed rest, analgesia and bracing. An operation to redirect the ball of the femoral head - known as a femoral varus osteotomy - is sometimes required.
  • Slipped capital femoral epiphysis - in this condition, the femoral head 'slips' posteriorly and into varus. It is most common in obese or rapidly growing males aged 12-15 years. Management is usually surgical pinning of the hip.
  • Surgical dislocation of the hip has been used in the management of several congenital hip conditions.
  • Scoliosis and kyphosis.
  • Spondylolysis and spondylolisthesis - spondylosis is a defect in the pars interarticularis. It is the most common cause of spondylolisthesis in which one vertebra slips forward on to the vertebra below it. Treatment includes physical therapy, NSAIDs and in patients with severe spondylolisthesis, posterior spinal fusion.
  • Discitis - this is an uncommon condition in children. Clinical features include refusal to walk, back pain, inability to flex the lower back and a loss of lumbar lordosis. In some patients the disc is merely swollen; in others, calcification can be seen. MRI scans suggest the aetiology is injury to the vascular supply to the disc[11]. The treatment is intravenous antibiotics followed by oral antibiotics.
  • Torticollis - the most common form is muscular; in infancy, it is usually due to injury during delivery. Management options include observation, physical therapy, bracing and in persistent cases, Botox® injections. If the condition is due to the presence of a tight fibrous band, resection can give good functional and cosmetic results.
  • Atlanto-axial instability - this is uncommon but potentially serious and often associated with Down's syndrome. Treatment is not required unless spinal cord compression occurs, in which case surgical stabilisation is required.
  • Sprengel's deformity - this is failure of the scapula to descend to the normal location[12]. It can be unilateral or bilateral. No treatment is required unless the condition is severe, in which case corrective surgery is performed.
  • Nursemaid's elbow - the annular ligament becomes trapped in the radiohumeral joint. It is also known as subluxation of the radial head. Simple manipulation can reduce the subluxation but recurrence may require ligament reconstruction[13].
  • Panner's disease - this is osteochondrosis involving the capitellum. It is a rare disease, sometimes associated with young athletes. Symptoms often resolve with reduction in physical activity.
  • Ganglion - this is most commonly found on the dorsum of the wrist.
  • Radial club hand - this is a rare deformity caused by absence of the radius. It can be congenital or acquired - eg, by destruction of the radius secondary to osteomyelitis or trauma. Surgical correction using bone grafting and other techniques can produce a functionally acceptable result.
  • Polydactyly and syndactyly.
  • Congenital trigger thumb and finger - this is caused by thickening of the tendons or muscles just below the first pulley of the digit. Surgical release is curative.

Further reading and references

  1. Hutchinson B; Pediatric metatarsus adductus and skewfoot deformity. Clin Podiatr Med Surg. 2010 Jan27(1):93-104. doi: 10.1016/j.cpm.2009.09.005.

  2. Muir D, Angliss RD, Nattrass GR, et al; Tibiotalocalcaneal arthrodesis for severe calcaneovalgus deformity in cerebral palsy. J Pediatr Orthop. 2005 Sep-Oct25(5):651-6.

  3. Karamitopoulos MS, Nirenstein L; Neuromuscular Foot: Spastic Cerebral Palsy. Foot Ankle Clin. 2015 Dec20(4):657-68. doi: 10.1016/j.fcl.2015.07.008. Epub 2015 Oct 21.

  4. Banwell HA, Paris ME, Mackintosh S, et al; Paediatric flexible flat foot: how are we measuring it and are we getting it right? A systematic review. J Foot Ankle Res. 2018 May 3011:21. doi: 10.1186/s13047-018-0264-3. eCollection 2018.

  5. Masquijo J, Allende V, Torres-Gomez A, et al; Fat Graft and Bone Wax Interposition Provides Better Functional Outcomes and Lower Reossification Rates Than Extensor Digitorum Brevis After Calcaneonavicular Coalition Resection. J Pediatr Orthop. 2017 Oct/Nov37(7):e427-e431. doi: 10.1097/BPO.0000000000001061.

  6. Vlachou M, Beris A, Dimitriadis D; Modified Chuinard-Baskin procedure for managing mild-to-moderate cavus and claw foot deformity in children and adolescents. J Foot Ankle Surg. 2008 Jul-Aug47(4):313-20.

  7. Tokioka K, Nakatsuka T, Tsuji S, et al; Surgical correction for curly toe using open tenotomy of flexor digitorum brevis tendon. J Plast Reconstr Aesthet Surg. 2007 Mar 9.

  8. Sanchis-Alfonso V, Dye SF; How to Deal With Anterior Knee Pain in the Active Young Patient. Sports Health. 2017 Jul/Aug9(4):346-351. doi: 10.1177/1941738116681269. Epub 2016 Nov 1.

  9. Kocher MS, Logan CA, Kramer DE; Discoid Lateral Meniscus in Children: Diagnosis, Management, and Outcomes. J Am Acad Orthop Surg. 2017 Nov25(11):736-743. doi: 10.5435/JAAOS-D-15-00491.

  10. Tay G, Ashik M, Tow B, et al; Hip pain in the paediatric age group - transient synovitis versus septic arthritis. Malays Orthop J. 2013 Jul7(2):27-8. doi: 10.5704/MOJ.1307.011.

  11. Swischuk LE, Jubang M, Jadhav SP; Calcific discitis in children: vertebral body involvement (possible insight into etiology). Emerg Radiol. 2008 Nov15(6):427-30. Epub 2008 Jul 8.

  12. Khan Durrani MY, Sohail AH, Khan I, et al; Sprengel's Deformity. J Ayub Med Coll Abbottabad. 2018 Jan-Mar30(1):135-137.

  13. Krul M, van der Wouden JC, Kruithof EJ, et al; Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2017 Jul 287:CD007759. doi: 10.1002/14651858.CD007759.pub4.