Orthopaedic problems in childhood

Orthopaedic problems in children are common. They can be congenital, developmental or acquired. Causes include those of infectious, neuromuscular, nutritional, neoplastic and psychogenic origin. An overview of some of the more common paediatric orthopaedic conditions is given below.

Foot

• Metatarsus adductus - this is a congenital problem, affecting 0.2% of births, whereby the forefoot is adducted and sometimes supinated. Treatment is usually nonoperative (using manipulation, casting, splinting) or surgical if correction is not complete by the age of 4.¹

• Calcaneovalgus foot - this occurs in neonates with hyperdorsiflexion of foot, abduction of forefoot and heel valgus increased (in its most severe form, the foot rests upwards and outwards, with the toes almost against the shin). It is usually caused by positioning in utero and resolves itself after a few months, or when the baby starts to stand at the latest. Severe cases (often associated with cerebral palsy) may need tibiotalocalcaneal fusion.²

• Planovalgus deformity - this is another common condition, and can occur in cerebral palsy.³ The longitudinal arch of the foot is abnormally flat. In ambulatory children with cerebral palsy, 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. ⁴

• Hypermobile pes planus - flexible flat feet are common in neonates and young children.⁵ The condition usually resolves by age 6 years but after that, ankle stretch exercises and foot orthoses are required if the child remains symptomatic. There is no evidence that flexible flat foot has any effect on future sporting ability.

• Tarsal coalition - this refers to a peroneal spastic flat foot with painful rigid flat foot and spasm of the lateral calf muscle. It is typically first noted after the age of 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.⁶

• Pes cavus - this causes a high arch which does not flatten with weight-bearing. Treatment options include physical therapy, orthotics or surgery, depending on the severity. ⁷

Toes

• Underlapping toes ('curly toes') - usually involve the fourth and fifth toes. These are usually inherited, bilateral and asymptomatic. 25-50% resolve spontaneously by age 3-4 years; otherwise surgery is required.⁸

• 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 head-to-toe review should be performed to exclude additional deformities.

• Syndactyly (web toes) - needs no treatment but, again, a thorough review to exclude additional deformities is required.

• Hammer toe - these are extended metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints with a hyperflexed proximal interphalangeal (PIP) joint. The second toe is most commonly affected. Surgery may be required if pain is reported.

• Mallet toe - this is a flexion deformity of the DIP. Surgery may be required if the toe(s) causes symptoms.

• Claw toe - this is dorsiflexion of the proximal phalanx on the lesser MTP joint and concurrent flexion of the PIP and DIP joints. Podiatry input and surgery may be 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.

Legs

• Internal femoral torsion - this is the most common cause of in-toeing in children aged >2 years; it is used to be treated by correction of an abnormal sitting position but this has been shown to not change prognosis. Femoral anteversion usually resolves by age 19, otherwise physiotherapy is used or surgical options are considered if mobility is significantly affected.

• Internal tibial torsion - this is 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 (see above) and also resolves upon walking.

• Genu varum (bow-legged) - this is caused by a tight posterior hip capsule; it usually resolves by the age of 2 years. Exclude rickets. Consider using a night splint or an osteotomy if the condition is severe.

• Genu valgum (being knock-kneed) - this is very common and is usually benign. It typically resolves by age 5-8 years; surgery may be appropriate if the condition is persistent beyond age 10.

• Leg length discrepancy - usually due to growth asymmetry; treatment options include use of physiotherapy and/or orthotics to correct muscular imbalance. Surgical correction of the longer or shorter leg may be considered.

Knee

• Popliteal cyst (Baker's cyst) - treatment for this synovial cyst is usually conservative unless an underlying internal derangement of the knee requires arthroscopy.

• Osteochondritis dissecans - this is an intra-articular osteochondrosis of unknown aetiology. Treatment options include immobilisation, non-steroidal anti-inflammatory drugs (NSAIDs), surgery or chondrocyte transplantation.

• Tibial apophysitis (Osgood-Schlatter disease) - usually requires conservative treatment with activity modification (temporary reduction), physical treatment, bracing, orthotics and, rarely, excision of the tibial tubercle in the event of non-union.⁹

• Patellar subluxation and dislocation - this is a congenital disorder usually treated by immobilisation. Surgery is considered if dislocations are recurrent.

• Discoid lateral meniscus - a congenital malformation of the lateral meniscus; it has a preponderance to tear, requiring arthroscopic repair if troublesome.¹⁰

Hip

Hip pain in children can be due to a number of causes.¹¹ 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 Spica cast are required.

• Septic arthritis and osteomyelitis - this most commonly originates from localised Staphylococcus aureus infection. 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 overweight or rapidly growing males aged 12-15 years. Management usually involves surgical pinning of the hip.

• Surgical dislocation of the hip is sometimes recommended for several congenital hip conditions.

Spine

• 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 inability to walk, back pain, 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 of the disc.¹² Treatment with intravenous antibiotics is typically followed by a prolonged course of oral antibiotics.

Neck

• 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, surgical resection can give good functional and cosmetic results.

• Atlanto-axial instability - this is uncommon but potentially serious. It is often associated with Down's syndrome. Treatment is not required unless spinal cord compression occurs, in which case surgical stabilisation is necessary.

Shoulder

• Sprengel's deformity - this is failure of the scapula to descend to its usual location.¹³ It can be unilateral or bilateral. No treatment is required unless the condition is severe, in which case corrective surgery is performed.

Elbow

• Nursemaid's elbow (also known as 'pulled elbow' or subluxation of the radial head) - the annular ligament becomes trapped in the radiohumeral joint. Simple manipulation, particularly hyper-pronation, can reduce the subluxation but recurrence may require ligament reconstruction.¹⁴

• 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.

Wrist

• 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, for example caused by destruction of the radius secondary to osteomyelitis or trauma. Surgical correction using bone grafting and other techniques can produce a functionally acceptable result.

Hand and fingers

• 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.

Generalised disorders

• Arthrogryposis multiplex congenita. This refers to the development of multiple joint contractures affecting two or more areas of the body prior to birth.

• The osteochondroses include Perthes' disease, Osgood-Schlatter disease, Scheuermann's disease (juvenile kyphosis) and Köhler's disease (idiopathic osteochondrosis of the tarsal navicular bone).

• Inherited connective tissue disorders, including Ehlers-Danlos syndrome and Marfan's syndrome and the mucopolysaccharidoses.

• The osteochondrodysplasias - eg, achondroplasia.

• The osteopetroses, including the osteoscleroses, craniotubular dysplasias and hyperostoses.