Flat foot is common, most children under the age of three are flat footed as the arch does not develop until this age. Treatment is rarely necessary under this age. In the older child treatment, usually by insoles, may be appropriate if there is aching pain with walking or activity or the flat foot is severe and it is likely that problems will develop in the future. Patients with flat feet are often quite loose jointed and there may be a family history. Mild forms of flat foot are best managed by supportive footwear of the boot type preferably with a supportive heel cup and shock absorbing sole. Surgery is rarely required for this sort of flat foot.
There is a rare form of flat foot when the foot is stiff, this often causes pain and surgery is often required.
Intoeing can arise from anywhere in the leg from the foot to the hip. Shoe inserts are often recommended for intoeing but these may be unhelpful if the problem is in the hip.
In a normal child virtually all causes of intoeing will improve with growth. In toeing from the hip occurs because of persistent femoral anteversion – this is a twist at the top of the thigh bone (femur) just below the hip.
It is commoner in children who are loose jointed and those who habitually sit in the W position which should be discouraged. In the leg intoeing may occur because of a twist on the femur or tibia, in the foot intoeing may be due to the foot pointing inwards (metatarsus varus). With growth and improving coordination most causes of intoeing will improve.
Knock knee and bow leg.
Bow leg and knock knee often give rise to anxiety. Most infants are bow legged, with growth the legs straighten usually by the age of 3 or 4. Some children may then become knock kneed, it is not until the age of 7 that legs start to assume the normal adult shape. Whilst most cases of bow leg and knock knee will improve some will not and treatment may be necessary. The important features of physiological bowing are :-
Club foot is one of the commoner orthopaedic problems. It can be picked up on an antenatal ultrasound but it is sometimes difficult to assess the severity. The treatment of club foot can be conservative i.e. without operation or by surgery. The Ponsetti technique has rightly become very popular in the management of club foot and can be started soon after birth. In this technique the foot is gently manipulated in a particular manner and plaster casts applied regularly to stretch the foot round. The Achilles tendon is tight in club foot and is usually cut (tenotomy) about 6 – 8 weeks into treatment. One or two plasters may then be applied but the patient then wears special boots on a bar for up to three years although when older this is at night only. Very good results have been reported for club feet treated by the Ponsetti technique and surgery is less common than it used to be. The Ponsetti technique is available and at the Portland Hospital is carried out by the Physiotherapy team.
If surgery is needed then the first operation is usually carried out at about 7 – 8 months of age. Surgery tends to be reserved for the more severe cases that do not respond to the Ponsetti plaster technique or those who for whatever reason present late for treatment. Unfortunately in these cases relapse can occur with growth and further surgery may be necessary. Severe cases of club foot sometimes occur as part of a more general problem. The full range of options in club foot surgery are available from soft tissue release, tendon transfer, bony surgery and Ilizarov treatment.
Dislocated Hip (DDH).
DDH (developmental dysplasia of the hip) is uncommon, about 1 in 2000 babies is born with a dislocated hip. The condition is of variable severity with mild forms just consisting of a shallow hip socket whilst in severe forms the hip is completely dislocated. All babies should have their hips checked after birth and at an 8 week check. In babies it may be noted that there is a click or a clunk on examination of the hip or sideways movement is limited, sometimes one leg is noticeably shorter or there is an extra skin crease. In older children the problem may come to light because of a limp. The dislocated hip is not painful. The condition is commoner in breech babies, in girls and if there is a family history. Whilst DDH can be diagnosed clinically it is best to check the hip by ultrasound examination.
DDH is much easier to treat when diagnosed early and we use the Pavlik harness which holds the hip in a stable position. The success rate is over 90% with a low risk of complications but we advise review every 10 days to check the harness is correctly fitted and an ultrasound every three weeks to monitor progress. In most cases the baby is in the harness for about 8 – 10 weeks. In older children it is not possible to use the harness and surgery becomes increasingly likely. Surgery can be complex.
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American Academy of Orthopaedic Surgeons
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If you have an orthopaedic condition and wish to be advised on the most appropriate treatment, please call + 44 (0)207 390 8351 to schedule an appointment.
The Hungarian Orthopaedic Association has awarded Mr Robert Hill Honorary Membership of the Hungarian Orthopaedic Association in recognition of his contributions to Hungarian Orthopaedics.
Latest publications & Research
Posteromedial bowing of the tibia: a benign condition or a case for limb reconstruction ?
Johnathan Wright, Robert Hill, Deborah Eastwood, Peter Calder, Sally Tennant.
Presented at European Orthopaedic Society Meeting Oslo 2018.
Limb Lengthening and Reconstruction Surgery Case Atlas. Pediatric Deformity. Edited by Robert Rozbruch and Reggie Hamdy.
6 Case Studies.
Springer Reference. 2015