Pediatric

Orthopedics: Lower
Extremity Disorders
St. Francis University
PA Program
September 25, 2001

Todd Lang, MD
Family Practice
 What is Peds Ortho?
 Fundamentals of kids’ bones
 Many unusual congenital deformities

 Developmental (Congenital) Hip

dysplasia

 MY Opinion: best done at a tertiary

care center unless very routine or
specially trained surgeon
 Goals
 Remember the foot anatomy!
 Learn a few new words

 See some interesting pictures

 Generally describe disorders and

treatments
 Create limited differentials

 Use AAP guidelines for hip dysplasia

Dorsal View
Lateral View
Medial View
 Varus
 Bent or twisted inward toward the
midline of the body
 Bowlegged is varus def. of the knee

 Can be confusing because will

occasionally refer limb instead of body
 I try to avoid this word, since there are
other ways to speak
 Orthopods love to use it
 Valgus
 Bent or twisted away from midline of
body or limb
 Orthopods refer to knock-kneed as

genu valgum as is deformity of the

knee joint away form the body midline
 Still a rotten set of words
 Equinus
 Like a horse’s foot
 Refers to having plantarflexion due to

shortened heel cord

 Leads to toe-toe gait not heel-toe
 Adduction Abduction
 Adduction moves it towards the
midline of the body or limb.
– Think of ADDing it to the body
– Fingers adduct
– Pronounce A D duct
 Abduction moves it away
– Pronounce A B duct
– Doing the splits abducts hips.
 Arthrodesis
 Surgical stiffening (fusion) of a joint

 Triple Arthrodesis: fusion of the

talonavicular, talocalcaneal,
calcaneocuboid joints to stabilize the
foot
 Osteotomy
 Simply means cutting a bone

 Used throughout surgery

In-Toeing=Pigeon Toed

 Ddx:
– Metatarsus adductus
– Internal tibial torsion
– Internal hip rotation
 Can be from contracture
 Can be from excessive femoral anteversion
 All are worsened by childhood positions
– Reverse tailor
– Prone with internal rotation
 Diagnosing In-Toeing
 Compare position of patella to foot
 Check malleoli related to tibial tubercle with leg
over table edge
 Lie them prone and flex knee 90 degrees and
measure hip internal and external rotation (>30
deg difference is abnl)
 Examine the foot for hindfoot line meeting toes
 Examine foot for convex lateral
border/concave medial border
 Tx Tibial torsion
 No evidence that in-toeing causes
adult trouble
 Treat with reassurance

 Avoid problem postures

– Sit in chair
– Sleep on side
 Resolves with growth and dev.
 Shoes, stretching not helpful
 Hip Contracture Tx
 Roller skating!
 Avoid positions as above

 Usually resolves by age 6

 Occasionally surgery needed if not

better by age 8
 Metatarsus Adductus
 Cause of “toeing in”
 Mild, moderate,
severe
 Imagine heel
bisector line
– Normally bisects
toes 2&3
– Helps grade
severity
 Metatarsus Adductus
 Bilateral in 50%
 More common in
1st born
 10% of pts have
acetabular
dysplasia so
check the hips
 Treatment of Met Add
 Treatment is shoes or serial casting and
stretching to restore normal flexibility
 Start early in life
 Most mild cases resolve spontaneously
 Use conservative tx before surgery
 Surgery for:
– Pain
– Deformity
– (Appearance)
Metatarsus Adductus
 Surgery for Met Add
 After fail conservative tx

 2-4 yr-Tarsometatarsal capsulotomies

 Cuts ligamentous joint capsule

 4 yr-Multiple metatarsal osteotomies

 Cuts bones
 Surgery for Met Add

 Closing wedge
osteotomies at the
base (not head) of
the metatarsals
 Internal fixation
holds until healed
 Calcaneouvalgus feet
 From in utero foot on uterus wall
 Dorsiflexed, forefoot abduction, heel

valgus
 Ass. w/ext tibial torsion

 Normal plantar flexion

 Calcaneouvalgus feet
 Distinguish from:
– Congenital vertical talus
– Posteromedial tibial bowing
– Paralyzed gastrocnemius
 PE+AP/lat simulated wt bearing Xrays
 Usually requires no tx
 Dorsiflexion resolves in 6 mo
 Tibial bowing resolves with 6-12 mo of
walking
 Flatfoot=Pes Planus
 Usually flexible: if not weight bearing,
looks like normal arch present
 Variety of opinions on “correct”
approach to flexible flatfeet
 Normal arch develops in later
childhood
 Many adults have some degree of
flatfeet—most without sx
 Flexible Pes Planus
 This is among the most aggravating
condition for parents and grandparents
 “My brother couldn’t go in toe the War
because he had flat feet”
 Reassurance and reexamination

 Evaluate for other orthopedic problems

 Are they telling you he can’t walk right or

that they thing his foot looks funny?
Tx: Flexible Pes Planus
 0-3 years old: no treatment unless very
strong family hx of persistent flatfeet
 3-9 years, no sx: explain to parents that

we don’t know what is best

– No long term follow up studies for natural
history
– No evidence that shoe modification alters foot
structure
Tx: Flexible Pes Planus
 3-9 y/o with sx related to FPP:
– Arch support, special shoes
– Custom orthosis, sturdy shoes
 10-14 y/o no sx: no treatment
 10-14 y/o with sx:

– Molded orthosis, sturdy shoes

– Verify that it corrects anatomy with Xray
Tx: Flexible Pes Planus
 Little role for muscles in maintaining
the arch—strengthening not helpful
 Surgery should only be done if:

– Pain necessitates it—not cosmetics

– Parents/pt will trade inversion/eversion for
relief of pain and disability
 A version of arthrodesis usually done
 Selection of the surgery is why there is

a peds ortho fellowship!

 Flexible Flatfeet
 Standing Xrays in both AP and lateral
planes, & nonstanding lateral oblique
views necessary to evaluate severity of
deformity
 Shows the talocalcaneal divergence on
the dorsoplantar view and plantar flexion
of the talus on the lateral view.
 Whoopi!
 Clubfoot
 AKA Talipes Equinovarus
 1/1000 incidence

 50% with bilateral deformity

 Do abnormal bones deform soft tissue?

 Do abnormal soft tissues deform bone?

Clubfoot
 Anterior view:
adduction and
supination of
forefoot and
equinus of
hindfoot.
Clubfoot
Posterior

view:
inversion,
plantar flexion,
and internal
rotation of
calcaneus, as
well as cavus
deformity with
transverse
plantar crease.
 Evaluation of Clubfoot
 Roentgenograms
– Nonambulatory child: anteroposterior and
stress dorsiflexion lateral of both feet.
– Ambulatory child: Add Anteroposterior
and lateral standing
 Analyze various angles formed by
bones to determine problems and
solutions
 Normal Foot Analysis
 Dorsiflexion
lateral view of
normal left
foot.
 Talocalcaneal
and
tibiocalcaneal
angles
 Clubfoot Analysis
 Dorsiflexion lateral
view of right
clubfoot
 Talocalcaneal angle
of zero
 Negative
tibiocalcaneal angle
 Clubfoot Treatment
 Initially nonoperative
– Manipulation
– Casting
– Repeat Q1-2 weeks
– Works for some (15-80%!)
 Surgery
– Necessary for rigid deformities
– Releases ligaments to move bones
 Surgery
 Necessary for rigid deformities
 Releases ligaments to move bones

 Later, uses osteotomies to move bone

 Later, uses arthrodesis to fuse bones

 Out-Toeing
 DDx:
– Contracture
– External femoral torsion (retroversion)
– External tibial torsion
– Calcaneovalgus
– Flat feet
 Dx Out-Toeing
 Often ass with genu valgum deformity
 May be worsened with prone sleeping

or wide diapers pad and walkers

 Examine patella and malleoli to

localize lesion
 Tx Out-Toeing
 Stretch if hip deformity
 Avoid Aggravating positions

 Observe and reassure, resolution

 Surgery rarely needed

 Bowlegs=Genu varum
 Normal in most pts
 Spont resolution in 95% with walking

 Converts to knock-knee, then resolves

age 4-7
 stand with touching malleoli, measure

inter-femoral condylar distance

 Differential
 Ddx: rickets, Blount’s Dz (tibia vara)
 Radiographs help if severe bowing
 Blount’s Dz=tibia vara
 Differential growth of upper medial
tibial epiphysis-maybe from abnl
pressure
 C/b unilateral (physiologic
bow=bilateral)
 More in obese

 Gets worse, not better

 Early recognition matters

Forces in utero
 See why this
bends your
tibia?
 Physiologic
genu varum
 bowlegs
 Resolves on
6-12 mo. of
walking
 Normal Tibiofemoral Angle
 Time bends your bones
 Genu Valgum
Knock-Knees
 Ddx: physiologic, asymmetric growth,
metabolic disorders, skeletal dysplasia,
congenital abnormalities, neuromuscular
disorders
 Causes other than physiologic or post-
traumatic are unusual.
 Physiologic occurs from ages 3-5 and
resolves from 5-8 years old.
 History and physical should suggest causes
besides physiologic.
 Torsional Profile
 There are a series of angles that can be
calculated from the position of various bones
& joints in relation to each other
 These are relatively simple to calculate but
not simple to explain without a child
 The angle or distorted differently for different
orthopedic disorders and changed somewhat
throughout growth and development.
 These are pretty esoteric charts.
Internal Femoral Torsion

 This is the most common cause of in-

toeing in children > 2 y/o age.
 2:1 female to male ratio

 Related to generalized ligamentous

laxity
 Treatment is usually observation.

 Correction usually occurs

spontaneously around school age.
 Limb Length
Discrepancy
 Makes an odd gait
 Causes scoliosis

 May cause back pain

 Compensation may injure other joints

 Limb Length
Discrepancy
 37% of the leg length comes from
distal femoral physis.
 28% comes from proximal tibial

physis.
 Thus, problems around the knee can

cause largest length discrepancies

 Bone Age
 Bone age is and important concept in
growth and development
 It is based on a 1950 Atlas and is
calculated from a radiograph of the left
hand and wrist
 This, coupled with growth charts
predicts remaining growth and helps
predict need for correction.
 LLD Diagnosis
 Not always simple because of
compensatory deformity
– Scoliosis
– Contracture
 Use both physical and radiographic
study
Scanogram
 Radioopaque
measuring rule
 Three
exposures
 Helps objectify
bone measures
 LLD DDx
 Damage to the physis
– Trauma
– Infection
 Asymmetrical paralytic conditions
– poliomyelitis
– or cerebral palsy
 Conditions that affect bone growth by
stimulating asymmetrical growth
– Tumors
– juvenile rheumatoid arthritis
– postfracture hypervascularity.
 Idiopathic unilateral hypoplasia/hyperplasia
 LLD Treatment
 Tailored to condition and patient chars.
 Lengthen one or shorten the other

– Shoes/orthotics/prosthetics
– Surgery
 Not simple because of continued growth
and interpersonal variability
 Final LLD of 1.5cm excellent outcome
 Surgery for LLD
 Epiphysiodesis-artificial closure of the
growth plate
 Shortening or lengthening of diaphysis

– Tightens or slackens the muscles

– Allows continued epiphyseal growth
 Each has own set of complications
 Dev. Hip Dysplasia
 developmental hip dysplasia detected
in 1/5000 infants at 18 months.
 High litigation area of medicine

 This makes people order more things

in hopes that they will protect self

 Does it work? No evidence that it

does.
 Guidelines help defend you.
 Dev. Hip Dysplasia
Risk Factors
 Girl (newborn risk of 19/1000).
 + Fam Hx developmental hip dysplasia newborn
risk boys of 9.4/1000 and 44/1000 girls
 Breech presentation
newborn risk boys of 26/1000 and 120/1000 girls
– Breech may be ass. with later hip problems
– Acetabular dysplasia-Xray at 6 months?
 Consider screening test in the highest prevalence
groups
Congenital Hip Dysplasia
Follow Up Exams
 Hips must be examined at every well-baby
visit according to the schedule for well-baby
exams.
 If there is suspicion of Dev. Hip Dysplasia:
– Re-exam by other PCP
– consultation with an orthopod,
– US if infant < 5 months
– Radiography if infant > 4 months
– Between 4-6 months of age, US and radiography
equally effective diagnostic imaging studies.
AAP Practice Guideline
Hip Dysplasia
 All newborns are to be screened by
physical examination.
 screening done by a properly

trained health care provider:

physician, pediatric NP, PA, or PT.
 US all newborns not recommended
AAP Practice Guideline
Hip Dysplasia
 If a + Ortolani or Barlow sign found at
newborn examination, refer to ortho
 If results of birth physical are "equivocally"
positive (i.e., soft click, mild asymmetry, but
neither an Ortolani nor a Barlow sign), then
follow-up exam by peds in 2 weeks
 Peds should reexamine the hips at 2 weeks
before refer to ortho or US
AAP Practice Guideline
Hip Dysplasia
 If the results of newborn exam are + (i.e.,
presence of an Ortolani or a Barlow sign),
an US examination not recommended.
Treatment not influenced by US, but based
on exam.
 If the results of the newborn exam +,
pelvis/hips radiograph not recommended
 use of triple diapers not recommended.
 Take Homes
 If a kid has one skeletal problem, don’t miss
the rest of their skeletal problems.
 Many orthopedic diseases of childhood
resolve on their own.
 It is your duty to be able to determine which
ones will not to resolve on their own.
 Use your specialists for these diseases.
 Use AAP guidelines for hip dysplasia.
 Take Homes
 Recall basic anatomy of foot and ankle
 Understand and use words defined in this
lecture
 Be able to describe the basic deformity of
the above conditions
 Create a limited differential diagnosis for
genu valgum and varum, in-toeing and
out-toeing.
 Bibliography
 Clinical practice guideline: early detection of
developmental dysplasia of the hip. Pediatrics 2000
Apr;105(4 Pt 1):896-905.
 Canale: Campbell's Operative Orthopaedics, 9th ed.,
Copyright © 1998 Mosby, Inc.
 Behrman: Nelson Textbook of Pediatrics, 16th ed.,
Copyright © 2000 W. B. Saunders Company
 http://www.medmedia.com/med.htm
Wheeless’ Textbook of Orthopaedics
 http://www.foottalk.com/index.htm
 Mercier, L. Practical Orthopedics, 5th Ed. Mosby 2000.