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:
- 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.
- 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.
- 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
- 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.
- 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
- Fixsen JA, Valman HB; ABC of 1 to 7. Minor orthopaedic problems in children. Br Med J (Clin Res Ed). 1981 Sep 12;283(6293):715-7. Blakemore LC, Cooperman DR, Thompson GH; The rigid flatfoot. Tarsal coalitions. Clin Podiatr Med Surg. 2000 Jul;17(3):531-55. [abstract] Thordarson DB; Congenital crossover fifth toe correction with soft tissue release and cutaneous Z-plasty. Foot Ankle Int. 2001 Jun;22(6):511-2. [abstract] Morley SE, Smith PJ; Polydactyly of the feet in children: suggestions for surgical management. Br J Plast Surg. 2001 Jan;54(1):34-8. [abstract] Toe Deformities in Children; Orthoseek.com 2007 Zuber TJ; Ingrown toenail removal. Am Fam Physician. 2002 Jun 15;65(12):2547-52, 2554. [abstract] Hip, Leg, and Foot Abnormalities; Merck Manuals 2005 Leg Length Discrepancy; Orthoseek.com 2007 Calmbach WL, Hutchens M; Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician. 2003 Sep 1;68(5):917-22. [abstract] ; Metatarsus adductus and skewfoot deformity. Clin Podiatr Med Surg. 2006 Jan;23(1):23-40, vii-viii. [abstract]
- Wan SC
- Muir D, Angliss RD, Nattrass GR, et al; Tibiotalocalcaneal arthrodesis for severe calcaneovalgus deformity in cerebral palsy. J Pediatr Orthop. 2005 Sep-Oct;25(5):651-6. [abstract]
- 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 Sep;26(11):1050-3. Epub 2006 May 3. [abstract]
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