Orthopaedic Problems in Childhood

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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:

  • 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. 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.[3]
  • 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. The condition usually resolves by age 6 years but after that requires ankle stretch exercises and foot orthoses if symptomatic.[4] 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 - this is 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; exclude rickets; night splint or osteotomy if severe.
  • Genu valgum (being knock-kneed) - this is usually benign and normally resolves by the age of 5-8 years; surgery if persistent by age 10.
  • 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.[9]
  • 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.[10]
  • Patellar subluxation and dislocation - this is a congenital disorder usually treated by immobilisation; surgery is considered if chronic.[10]
  • Discoid lateral meniscus - a congenital malformation of the lateral meniscus; it has a preponderance to tear, requiring arthroscopic repair if troublesome.[11]

Hip pain in children can be due to a number of causes. Diagnosis requires careful history and examination.[12]Arthroscopy of the hip is being increasingly used in paediatric patients to investigate and treat pain in the joint.[13]

  • 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 epiphyses - in this condition, the femoral head 'slips' posteriorly and into varus. It is most common in obese or rapidly growing males aged 12-15. Management is usually surgical pinning of the hip.
  • Surgical dislocation of the hip has been used recently in the management of several congenital hip conditions.[14]
  • 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.[15] The treatment is intravenous followed by oral antibiotics.
  • Torticollis - the most common form is muscular; in infancy, 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.[16] Consider other trauma, congenital defects, and tumours.[17]
  • 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. It can be unilateral or bilateral. No treatment is required unless the condition is severe, in which case corrective surgery is performed.[18]
  • 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.[19]
  • 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.[20]
  • 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.[21]
  • 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. One series showed that a percutaneous procedure is as effective as open surgery.[22]

Further reading and references

  1. Wan SC; Metatarsus adductus and skewfoot deformity. Clin Podiatr Med Surg. 2006 Jan23(1):23-40, vii-viii.

  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. Ettl V, Wollmerstedt N, Kirschner S, et al; Calcaneal lengthening for planovalgus deformity in children with cerebral palsy. Foot Ankle Int. 2009 May30(5):398-404.

  4. El O, Akcali O, Kosay C, et al; Flexible flatfoot and related factors in primary school children: a report of a screening study. Rheumatol Int. 2006 Sep26(11):1050-3. Epub 2006 May 3.

  5. Mubarak SJ, Patel PN, Upasani VV, et al; Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. 2009 Jul-Aug29(5):418-26.

  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. Calmbach WL, Hutchens M; Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician. 2003 Sep 168(5):917-22.

  9. Peterson L, Minas T, Brittberg M, et al; Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am. 200385-A Suppl 2:17-24.

  10. Houghton KM; Review for the generalist: evaluation of anterior knee pain. Pediatr Rheumatol Online J. 2007 May 45(1):8.

  11. Hart ES, Kalra KP, Grottkau BE, et al; Discoid lateral meniscus in children. Orthop Nurs. 2008 May-Jun27(3):174-9

  12. Houghton KM; Review for the generalist: evaluation of pediatric hip pain. Pediatr Rheumatol Online J. 2009 May 187:10.

  13. Roy DR; Arthroscopy of the hip in children and adolescents. J Child Orthop. 2009 Apr3(2):89-100. Epub 2008 Nov 18.

  14. Rebello G, Spencer S, Millis MB, et al; Surgical dislocation in the management of pediatric and adolescent hip deformity. Clin Orthop Relat Res. 2009 Mar467(3):724-31. Epub 2008 Nov 12.

  15. 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.

  16. Lee IJ, Lim SY, Song HS, et al; Complete tight fibrous band release and resection in congenital muscular torticollis. J Plast Reconstr Aesthet Surg. 2009 Jun 16.

  17. Do TT; Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. 2006 Feb18(1):26-9.

  18. Kadavkolan AS, Bhatia DN, Dasgupta B, et al; Sprengel's deformity of the shoulder: Current perspectives in management. Int J Shoulder Surg. 2011 Jan5(1):1-8. doi: 10.4103/0973-6042.80459.

  19. Krul M, van der Wouden JC, van Suijlekom-Smit LW, et al; Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012 Jan 181:CD007759. doi: 10.1002/14651858.CD007759.pub3.

  20. Kobayashi K, Burton KJ, Rodner C, et al; Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg. 2004 Jul-Aug12(4):246-54.

  21. Ring D, Prommersberger K, Jupiter JB; Posttraumatic radial club hand. J Surg Orthop Adv. 2004 Fall13(3):161-5.

  22. Wang HC, Lin GT; Retrospective study of open versus percutaneous surgery for trigger thumb in children. Plast Reconstr Surg. 2005 Jun115(7):1963-70

  23. Tsirikos AI, Riddle EC, Kruse R; Bilateral Kohler's disease in identical twins. Clin Orthop Relat Res. 2003 Apr(409):195-8.

  24. Mucopolysaccharidoses; National Institute of Neurological Disorders and Stroke

hiI was wondering if anyone had ever undergone surgery for Hammer toes and how the surgery had gone Also was the surgery carried out under a Local anaesthetic or a general one.Many thanks.

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