Common Orthopedic Problems Page 1 Grace Chong, PGY-1_May 2008

Common Orthopedic Problems

COMPETENCY
The resident should be able to know the differential diagnosis and evaluation of common orthopedic problems of
the lower extremities in children.


CASE
The patient is a 4 year-old girl who is brought in to the clinic by her mother who is concerned that her daughters
feet face inward. She had an unremarkable pregnancy with an uncomplicated delivery, born via normal
spontaneous vaginal delivery. Her child began walking by 18 months of age and has had normal neuromuscular
development since birth. Her foot positioning has not affected her level of activity or function, and the patient is
otherwise healthy. The patient is growing well and gaining weight well with height and weight percentiles in the
50
th
percentile. Her mother has noticed some clumsiness in her childs gait, and the patient is often found sitting in
a W position. Her mother recalls that her brother had this same problem when he was little, but resolved on its
own by elementary school. The patient denies pain, fever, swelling, or limp.


QUESTIONS
1. How do you evaluate intoeing in patients?
2. What is the most likely etiology?
3. What questions do you ask in a history of a child with orthopedic complaints?
4. What is the best evaluation?
5. What is the best treatment?


REFERENCES
1. Scherl, S. Common Lower Extremity Problems in Children. Pediatrics in Review; 2004; 25; 52-60.
2. Larson, C.B. Common Orthopedic Problems in Children: Summary of Round Table Discussion. Pediatrics
1956; 17; 786-791.
3. Sass, P., Hassan, G. Lower Extremity Abnormalities in Children. American Family Physician; 2003; V. 68,
N.3; 461-468.
4. Green Wb. Genu varum and genu valgum in children: differential diagnosis and guidelines for evaluation.
Compr Ther 1996; 22. 22-9.
















Reviewed by: Rita Rossi-Foulkes, MD
Common Orthopedic Problems Page 2 Grace Chong, PGY-1_May 2008

Common Lower Extremity Problems in Children

History and Physical Exam
Important to know parental concerns.
Include maternal pregnancy history for perinatal events and motor development.
Clarify when the problems began (before or after walking).
Family history for abnormalities. Identify the concern gait vs cosmesis.
Signs and symptoms, aggravating factors (i.e. torsional deformities more obvious with fatigue)
Sitting habits (i.e. internal tibial torsion often associated with sitting on feet; femoral anteversion associated
with W sitting position)
Physical should include height and weight. Spine exam for scoliosis, sinus openings, tufts of hair.
Neurological exam to r/o neuromuscular disorders. Check leg lengths for discrepancies to r/o DDH. ROM
of joints and joint laxity (which can mimic torsional/angular deformities). Check for flat feet, curved
lateral borders of feet (metatarsus adductus).

Definitions
Anteversion: anterior twist of femoral head away from frontal plane
Retroversion: posterior twist of femoral head away from frontal plane
Valgum: bone angulation distal to a joint or angulation in a part of the bone away from midline
Varum: angulation of a bone or within a bone toward midline

Children may be susceptible to developmental lower extremity disorders of varying degrees of seriousness. The
timely diagnosis and management can minimize potential deformities and loss of function. These common
problems can be grouped into 4 categories:
(1) Rotational deformities
(2) Angular deformities
(3) Foot deformities
(4) Hip disorders
(5) Other


(1) What are rotational deformities?

Include intoeing and outtoeing. Intoeing is caused by one of three deformities: metatarsus adductus, internal tibial
torsion, or increased anteversion of the femur. Outtoeing is less common with the opposite causes of intoeing:
femoral retroversion and external tibial torsion. The normal range of rotation is measurements that fall within two
standard deviations of the mean. In general, bars, braces, shoes to correct rotational deformities no longer widely
used. Most will resolve spontaneously with few problems into adulthood.

Rotational profile tests
Foot progression angle (gait angle): the direction the childs feet point when he/she walks. Intoeing =
negative; outtoeing =positive. Most adults have an angle of +10 degrees.
Forefoot alignment: if sole of foot deviates medially and the lateral border is C shaped, metatarsus
adductus exists.
Heel bisector: extrapolate bisector line to determine deviation.
Thigh-foot angle: angle between heel bisector line and line down center of thigh while prone and knees
flexed to 90 degrees. Normally between 0 and +10 degrees. Negative angles imply intoeing; positive
angles imply outtoeing. The angle describes the degree of tibial torsion.
Internal and external rotation degrees: Measure hip rotation with child supine and knees flexed to 90
degrees. Internal rotation measured by fully abducting legs. External rotation by fully adducting legs.
Normally equal rotation (45 degrees 20) in both directions. Increased internal rotation with femoral neck
axis rotated anteriorially in relation to the frontal plane indicates femoral anteversion.
Intercondylar/intermalleolar distance: to measure the degree of genu varum or valgum respectively.


Metatarsus adductus and heel bisectors Thigh-foot angle
pedsinreview.org Vol 25 No 2 Feb 2004 pedsinreview.org Vol 25 No 2 Feb 2004

Intoeing (Pigeon-toed gait)
Three possible origins: foot, between the knee and ankle, and between the hip and knee. Normally, the femoral
neck is anteverted about 40 degrees at birth. In intoeing due to the hip, this angle may be up to 70 degrees.

Metatarsus adductus (forefoot adduction): most common congenital foot deformity. Tarsal and
phalangeal bones (the forefoot) are angled toward the midline of the body, often believed to be related to
fetal positioning in utero. The amount of adduction can be quantified by the angle of deviation from the
heel bisector line. A normal heel bisector should land between the 2
nd
and 3
rd
rays of the foot; hitting the
3
rd
ray is considered mild, 4
th
ray is moderate, and 5
th
ray is severe. One can also classify flexibility to
determine treatment: hold the heel in neutral position and attempt to abduct the forefoot to a neutral
position. If this cannot be done, the deformity is rigid. Correctible measures are related to the rigidity of
the defect: an infant straightens the foot in response to being tickled along the lateral border of the foot in
active metatarsus adductus, only with gentle pressure in passive forms, and no correction in rigid forms.
Flexible metarsus adductus can be managed by stretching exercises during the first 8 months of life.
Treatment: active: spontaneous resolution, passive, stretching performed 5x/foot, lasting 10 seconds each,
with each diaper change, rigid: casting/bracing.

Internal tibial torsion: origin of intoeing is between the knee and the ankle (so child walks with patella
facing forward and feet pointing inward), often left side affected more than the right. Results in internal
foot progression angle and internal foot-thigh angle. Tibia twists, also a packaging defect. Most common
cause of intoeing in children <3 years old. Treatment rarely necessary and often improves with ambulation.
90% of cases resolve by 8 years of age. Avoiding prone sleeping and sitting on feet to enhance resolution.

Medical femoral torsion (increased femoral anteversion): intoeing origin between the knee and the hip
(so child walks with patella and feet pointing inward). Femur twists; increased internal hip rotation and
decreased external rotation on exam. Most common cause of intoeing in children >3 years old, often
familial and often bilateral. Often found sitting in W position and gait may appear clumsy. Often
resolves without intervention, correctly slowly by 8-10 years of age. Measure hip range of motion every 6-
12 months to document decrease in femoral anteversion.

Common Orthopedic Problems Page 3 Grace Chong, PGY-1_May 2008


FIGURE 7. Intoeing. The origin of
intoeing may lie in the leg or the foot.
Internal tibial torsion is commonly
associated with sitting on the feet (A).
Increased femoral anteversion is
commonly associated with sitting in a
"W" position (B).

aafp.org. Vol 68. No 3. Aug 2003
Common Orthopedic Problems Page 4 Grace Chong, PGY-1_May 2008


Outtoeing: much less common than intoeing, packaging defect. Fetal positions with hips and knees flexed ,ankles
dorsiflexed, and legs and feet externally rotated may lead to external tibial torsion and calcaneovalgus feet
(opposites of internal tibial torsion and metatarsus adductus). Improves with ambulation.

Flat feet: common in children because arch development occurs before 4 years of age. Check for
flexibility: if arch appears on toe standing, considered flexible flat foot often due to ligamentous laxity.
Spontaneous corrected expected.
External tibial torsion: often unilateral more right-sided. Often seen in children between 4-7 years of age.
Tibia rotates laterally with growth, making the torsion worse. If thigh-foot angle >40 degrees, may warrant
surgery, but no surgery until child is >10 years (high complication rate otherwise).
Femoral retroversion: external rotation of the hip often due to intrauterine packing. Common in early
infancy and seen in obese children. Obvious when prewalking child stands and his/her feet turned out
nearly 90 degrees (Charlie Chaplin appearance). If unilateral, seen more on right side. If resolution is
not spontaneous, will need orthopedic referral persistent retroversion can be associated with
osteoarthrosis, increased risk of stress fracture, and SCFE.



(2) What are angular deformities?

Often physiologic or a normal variant. Often physiologic or normal variant. Serial measurement of intercondylar/
intermalleolar distance to document gradual spontaneous resolution. If no resolution, consider pathologic angular
deformities. Pathologic if unilateral, asymmetric, or painful. See table below.


TABLE 3
DDx for Genu Varum and Genu Valgum
Genu varum Genu valgum
Physiologic bowlegs Hypophosphatemic rickets
Infantile tibia vara Previous metaphyseal fracture of the proximal tibia
Hypophosphatemic rickets Multiple epiphyseal dysplasia
Metaphyseal chondrodysplasia Pseudoachondroplasia
Focal fibrocartilaginous dysplasia
Other DDx: Blount disease, tumor, infection, renal disease, dwarfisms.
Greene WB. Genu varumand genu valgumin children: differential diagnosis and guidelines for evaluation. Compr Ther 1996;22:22-9


Radiographs if genu varum or valgum:
1. beyond 2 standard deviations for age
2. height <25
th
%
3. genu varum increasing in severity
4. asymmetry of limb alignment




Genu valgum
(knock-kneed):
peaks at 2-4 years of age.


Genu varum
(bowlegs):
birth until 2 years of age.
If persists beyond 3 years
of age, can cause damage
to the medial knee.

aafp.org. Vol 68. No 3. Aug 2003 aafp.org. Vol 68. No 3. Aug 2003


(3) What are foot deformities?

Foot shape and size vary in all degrees, as does gait pattern.

Long arch strain: Long arch strain is often due to abnormal stress on the longitudinal ligament. There may be an
area of tenderness or pain in the area of inflammatory repair.

Talipes Equinovarus (clubfoot): 1:1000 live births, 50% bilateral. M:F 2.51:1. Congenital deformitiy with
multifactorial inheritance. May be a component of dysmorphic syndromes or neuromuscular disorders. 3
components: metatarsus adductus, equines, and hind-foot varus. Not a packaging defect. Etiology not known, but
may be due to a primary germ defect or early intrauterine vascular event. Tarsal bones misaligned, misshapen,
smaller in size of foot and ipsilateral calf. May be seen with prenatal ultrasound, but operator-dependent and false
positives common. Association between clubfoot and DDH. Treatment: serial casts, surgery, or both.

Cavus foot (high-arched foot): normal variant with no intervention, but if new-onset, unilateral, painful, or
progressive, consider neurologic problems such as Friedrichs ataxia, Charcot-Marie-Tooth, tethered spinal cord, or
spinal lesion. Treat underlying problem, can use bracing and surgery if refractory.

Calcaneovalgus foot: often the result of intra-uterine position. The heel is angled away from midline and ankle in
dorsiflexion. Packaging defect, better with stretching exercises and time, often resolves spontaneously within 6
months.. Associated with external tibial torsion.

Pes planus (flat foot): may be a normal variant or autosomal dominant inheritance pattern. Shoe inserts may help
if patients complain of pain; otherwise reassurance of parents if flexible pes planus. If rigid pes planus (arch does
not reform when patient is on hi/her toes), may cause fused tarsal bones (aka tarsal coalition) in adolescence
causing more stress on neighboring joints and pain. Symptomatic treatment or surgery to remove bony blockage
and restore movement in affected joint.



(4) What are hip deformities?

Developmental dysplasia of the hip (DDH): spectrum of abnormally developed hips.. May not be only purely
congenital and change develop and change over time. 1:1000 live births. Risk factors: female, first-born, family
history, breech. Screen by looking for asymmetries in the number of skin folds in the thigh, range of abduction,
and height of affected knee (Galeazzi sign). Barlow and Ortolani tests to elicit clunks as the femoral head moves in
and out of the acetabulum. Barlow dislocates the hip place fingers on greater trochanters with thumbs on knees,
Common Orthopedic Problems Page 5 Grace Chong, PGY-1_May 2008

adduct legs and push down on the knees. while the Ortolani test relocates a dislocated hip. Placing fingers on the
greater trochanters and thumbs on the knees, abduct legs and lift up on trochanters. Both tests become difficult to
interpret as infants reach 3-4 months of age. Galeazzi sign and decreased abduction may be the only physical signs
at that time.

Ultrasonography of the hips is the imaging study of choice until 4-6 months of age because bones may not be
completely ossified yet. Difficult to diagnose, up to 5% of cases may be missed by examiners. Examine patients
repeatedly for first year. Children with isolated DDH reach their developmental milestones on time and did not
have difficult ambulating. If untreated, DDH may lead to severe early degenerative hip arthritis. Treatment
designed to relocate and stabilize the femoral head in the acetabulum. Brace with Pavlik harness until 6 months of
age. Body cast for children between 6 and 12 months of age. Surgery if >1 year old.

Slipped Capital Femoral Epiphysis (SCFE)
Femoral head displacement from femoral neck through the growth plate during a period of rapid growth in
adolescence. Often present with groin/knee/thich pain/limp. May also have external foot rotation on affected side,
external rotation and abduction with hip flexion, and internal rotation of hip that is limited or painful. Average age
11-13 years for girls, 13-15 years for boys, often more common in African-Americans and obese children. Can also
be related to hormonal disorders if <10
th
% for height or <10 years old, start endocrine evaluation. AP and frog
lateral radiographs of pelvis for diagnosis. Important to get views of both sides because SCFE can be bilateral in
20% of cases, often with one asymptomatic side. Treatment is surgery with placement of screws.


Legg-Calv-Perthes disease (LCP)
Idiopathic avascular necrosis of femoral head. 4-8 year old boys. May present with knee/thigh/hip pain and/or
limp. Limited abduction and internal hip rotation on exam. AP and frog lateral pelvic radiographs to diagnose (no
weight-bearing XRs); often shows sclerosis, flattening, and fragmentation of femoral head. Treatment somewhat
controversial: PT vs bracing vs surgery vs protection against weight-bearing. Rarely bilateral.



XR of SCFE. pedsinreview.org XR of LCP. pedsinreview.org
Vol 25 No 2 Feb 2004 Vol 25 No 2 Feb 2004



(5) Other

Toewalking
Normal phase in gait development. 3 year-old children develop heel-toe gait; toewalking >4 years is abnormal.
May be due to an underlying neurologic disorder (CP, tethered spinal cord, muscular dystrophy, spinal lesion or
tumor, myopathy). Treatment includes PT (to stretch out Achilles tendon). If stretching alone does not lengthen
the tendon, serial stretch casting (new casts every 2 wks for 4-8 weeks) can be successful. Botulinum toxin has
been used to help decrease muscle tone for 4-6 months and can help with stretch casting. If all other treatments fail,
surgical lengthening of the tendon is used.


Common Orthopedic Problems Page 6 Grace Chong, PGY-1_May 2008