Orthopaedic Problems in Foot Children

Posted by: Indonesian Children | August 15, 2009

Orthopaedic Problems in Foot Children

Orthopaedic problems in foot 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:

Foot

Metatarsus adductus – this is a congenital problem with forefoot adducted and sometimes supinated. it is usually treated by manipulation, casting and occasionally surgery.
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.
Clubfoot – various abnormalities of the tibia, fibula and bones of the foot form a composite abnormality, also known as talipes equinovarus. Treatment options including manipulation, casting, splinting and surgery.
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.
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.
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.

Toes

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.
Overlapping fifth toe – this overrides 4th toe and causes pain in half of cases, requiring surgery.
Polydactyly – this is the commonest deformity of the foot and can vary from minor degrees of soft tissue duplication to major skeletal abnormalities. The commonest abnormality is an extra 5th 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 and distal interphalangeal (DIP) joints with a hyperflexed proximal interphalangeal joint. It usually affects the 2nd toe, and may need surgery if painful.
Mallet toe – this is a flexion deformity of DIP. It may need surgery if causing symptoms.
Claw toe – this is dorsiflexion of the proximal phalanx on the lesser metatarsophalangeal (MTP) joint and concurrent flexion of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. Podiatric advice and sometimes surgery is indicated.
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.

Knee

Popliteal cyst – a synovial cyst (also known as Baker’s cyst), treatment 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
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
Patellar subluxation and dislocation – congenital disorder usually treated by immobilisation, surgery if chronic

Hip

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 Staph 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.
Legg-Calve-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.

Generalised disorders

Arthrogryposis multiplex congenita
The osteochondroses including, Legg-Calve-Perthes, Osgood-Schlatter, Scheuermann’s disease (juvenile kyphosis) and Kohler’s disease (idiopathic osteochondrosis of the tarsal navicular bone).²⁹^,³⁰
Inherited connective tissue disorders including Ehlers-Danlos and Marfan‘s syndromes and the mucopolysaccharidoses³¹
The osteochondrodysplasias -e.g. achondroplasia
The osteopetroses including the osteoscleroses, craniotubular dysplasias and hyperostoses