Orthopaedic Problems in Childhood

Orthopaedic problems in children are common. They can be congenital, developmental or acquired, including those of infectious, neuromuscular, nutritional, neoplastic and psychogenic origin.¹ 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.²
• 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 baby starts to stand. Severe cases (often associated with cerebral palsy) may need tibiotalocalcaneal fusion.³
• Plano-valgus deformity 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.⁴
• Clubfoot - various abnormalities of the tibia, fibula and bones of the foot form a composite abnormality, also known as talipes equinovarus. Treatment options include manipulation, casting, splinting and surgery.^3,5
• Hypermobile pes planus - flexible flat feet is common in neonates and young children. It usually resolves by age 6 years but after that requires ankle stretch exercises and foot orthoses if symptomatic.⁶ There is no evidence that flexible flat foot has any effect on sporting prowess.
• Tarsal coalition - this is peroneal spastic flatfoot with painful rigid flatfoot and spasm of lateral calf muscle appearing after age 9 years. It may be managed non-operatively (e.g. with casts, shoe inserts) or surgically.⁷ In calcaneonavicular coalition, the interposition of fat between the two resected bones helps to improve symptoms and restore function.⁸
• 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.^9,10

• Curly toes - usually involving 4th and 5th toe, this is usually inherited bilateral and without symptoms. 25-50% resolve by age 3-4 years; otherwise surgery is required.¹¹
• Overlapping fifth toe - this overrides 4th toe and causes pain in half of cases, requiring surgery.¹²
• Polydactyly - this is the commonest 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 5th toe. Surgical removal is the usual treatment. A check should be made for other deformities¹³
• Syndactyly (web toes) needs no treatment but check for other deformities.¹⁴
• Hammer toe - this is extended metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints with a hyperflexed proximal interphalangeal joint. It usually affects the 2nd toe and may need surgery if painful.¹⁴
• Mallet toe - this is a flexion deformity of DIP. It may need surgery if causing symptoms.¹⁴
• Claw toe - this is dorsiflexion of the proximal phalanx on the lesser MTP joint and concurrent flexion of the proximal interphalangeal (PIP) and DIP joints. Podiatric advice and sometimes surgery is indicated.¹⁴
• Ingrown 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.¹⁵

• Internal femoral torsion - most common cause of in-toeing in children >2 years; usually treated by correction of abnormal sitting position.
• Internal tibial torsion - most common cause of in-toeing in children <2 years and normally resolves spontaneously when child starts to walk.
• External tibial torsion - often associated with calcaneovalgus foot and also resolves upon walking.
• Bowlegs - genu varum - is caused by tight posterior hip capsule; usually resolves by age 2; exclude rickets; night splint or osteotomy if severe.
• Knock-knees - genu valgum - usually benign and normally resolves by age 5-8 years; surgery if persistent by age 10.
• Leg length discrepancy - usually due to growth asymmetry; treatment options include surgical correction of longer or shorter leg, or inhibition of growth of longer leg.¹⁷

• Popliteal cyst - a synovial cyst (also known as Baker's cyst); treatment usually conservative unless underlying internal derangement of the knee requires arthroscopy.¹⁹
• Osteochondritis dissecans - intra-articular osteochondrosis of unknown aetiology; treatment options include immobilisation, non-steroidal anti-inflammatory drugs (NSAIDs), surgery and, more recently, chondrocyte transplantation.²⁰
• Osgood-Schlatter disease - tibial apophysitis; usually conservative treatment with activity modification, physical treatment, bracing, orthotics and, rarely, excision of tibial tubercle in the event of non-union.²¹
• Patellar subluxation and dislocation - congenital disorder usually treated by immobilisation; surgery if chronic.²¹
• Discoid lateral meniscus - a congenital malformation of the lateral meniscus; it has a preponderance to tear, requiring arthroscopic repair if troublesome.²²

• Hip pain in children can be due to a number of causes. Diagnosis requires careful history and examination.²⁴
• Arthroscopy of the hip is being increasingly used in paediatric patients to investigate and treat pain in the joint.²⁵
• Developmental dysplasia - this is a spectrum of disorders that affects the proximal femur, acetabulum and hips. Early recognition prevents long-term morbidity. Treatment under six months is a Pavlik harness, above six months closed reduction and a Pica cast is 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.
• Calvé-Legg-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 upper femoral epiphyses - in this condition, the femoral head 'slips' posteriorly and into varus. It is commonest in obese or rapidly growing males aged 12-15. Management is usually surgical pinning of the hip.²⁶
• Surgical dislocation of the hip has been used recently in the management of several congenital hip conditions.²⁷

• Scoliosis.
• Kyphosis.
• Spondylolysis and spondylolisthesis - spondylosis is a defect in the pars interarticularis. It is the commonest cause of spondylolysthesis in which one vertebra slips forward onto the vertebra below it. Treatment includes physical therapy, NSAIDs and in patients with severe spondylolisthesis, posterior spinal fusion.²⁸
• 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.²⁹ The treatment is intravenous followed by oral antibiotics.³⁰

• Torticollis - the commonest 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.³¹ Consider other trauma, congenital defects,and tumours.³²
• 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.³³

• Sprengel's deformity - this is failure of the scapula to descend to normal location. It can be unilateral or bilateral. No treatment is required unless the condition is severe, in which case corrective surgery is performed.³⁴

• 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.³⁵
• Panner's disease - this is osteochondrosis involving capitellum. It is a rare disease, sometimes associated with young athletes. Symptoms often resolve with reduction in physical activity.³⁶

• Ganglion - this is most commonly found on the dorsum of the wrist.
• Radial clubhand - this is a rare deformity caused by absence of the radius. It can be congenital or acquired, e.g. by destruction of the radius secondary to osteomyelitis or trauma. Surgical correction using bone grafting and other techniques can produce a functionally acceptable result.³⁷

• Polydactyly and syndactyly.
• Congenital trigger thumb and finger - this is caused by thickening of the tendons or muscles just below first pulley of the digit. Surgical release is curative. One series showed that a percutaneous procedure is as effective as open surgery.³⁸

• Arthrogryposis multiplex congenita
• The osteochondroses including, Calvé-Legg-Perthes disease, Osgood-Schlatter disease, Scheuermann's disease (juvenile kyphosis) and Köhler's disease (idiopathic osteochondrosis of the tarsal navicular bone)^39,40
• Inherited connective tissue disorders, including Ehlers-Danlos syndrome and Marfan's syndrome and the mucopolysaccharidoses⁴¹
• The osteochondrodysplasias, e.g. achondroplasia
• The osteopetroses, including the osteoscleroses, craniotubular dysplasias and hyperostoses⁴²

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