Doctor in the House: Common orthopaedic problems among infants and young children

    Most young kids may go through a phase in their growing years where they may have any of the conditions described below, but will grow out of them without any intervention. This includes flat feet, knock knees, bow legs, pigeon toes or toe walking. There are other more serious orthopaedic problems like Developmental Dysplasia of the hip or talipes equinovarus earlier known as “club foot” which need to be treated promptly to get good results.

    Let’s look at a few of these conditions:

    Flat feet or pes planus

    Flat feet or pes planus is exactly as the name suggests — the feet are flatter on the bottom and allow the whole sole to touch the floor when the baby is standing. They are normal in babies and toddlers because the arches in the foot are not developed.

    The arches develop through childhood but many individuals don’t develop arches in their feet. It’s quite commonly seen and tends to run in families. They don’t cause any problems and don’t need any specific treatment. However, if there is pain, then they need to be seen by an orthopaedic doctor. They may be recommended some arch supports or stretching exercises or even special shoes. Again, these are only needed if there is pain and discomfort.

    Bow legs or genu varus

    This is when the leg curves outward at the knee when both the ankles and foot touch. Infants and toddlers often have bow legs. This self-corrects by three to four years. They usually don’t bother the child, are not associated with pain or discomfort and don’t affect the child’s ability to walk or run.

    Sometimes, these children may walk with their toes pointed inward called in-toeing or pigeon toes. This usually resolves on its own. When babies are born with slightly curved or bow legs it is usually because some of the bones had to rotate slightly when they were growing in the womb to fit in the tight space. When children initially start walking, it may appear to get worse before it starts to improve. Children who start to walk at a younger age tend to have more noticeable bowing. They tend to correct by the time the child is four years of age.

    Rarely, it may be due to more serious problems like rickets, where there is a deficiency of vitamin D or a growth disorder of the bone called BLOUNT disease. An equally rare cause may be infections involving that area or tumours.

    In certain situations where it is not straightening or if bowing is asymmetrical or if the child is in pain or limping, then a specialist opinion may be sought.

    These may need treatment with brace or surgery in Blount disease or vitamin D supplementation in rickets. Physiological bowing does not need treatment.

    Knock knees or genu valgum

    Knock knees refers to a condition wherein when the child is standing, the knees touch but the ankles and feet remain apart. Knock knees often happen as normal part of growth and development in children. It’s rarely serious and straightens by seven to eight years.

    In rare cases, children with severe or rigid club foot may need more extensive surgery (Source: Getty Images/Representational)

    Parents usually notice this and are worried that the child will trip and fall. This is part of normal growth but, in rare cases, it may be because of vitamin D deficiency or a fracture involving the growth plate of one of the bones of the knee joint.

    Sometimes, being overweight can lead to knock knees or tumours involving the knee joint.

    Most children don’t need treatment as it is self-correcting. If it is caused due to vitamin D deficiency, this is usually corrected with vitamin D and calcium supplementation.

    If there is pain or discomfort and difficulty in running, they may be advised surgery.

    DDH or developmental dysplasia of the hip

    In this condition, there is a problem with the development of the baby’s hip. It can affect one or both sides and the problem usually arises before the birth of the child. Any baby can develop DDH but some have a higher chance, it’s more prevalent in first-born children, girl child and breech presentation at birth. Occasionally, it is seen in families. Most children treated early have no hip problems as an adult and are happy active children.

    The hip joint is a ball-and socket-joint where the top end of the thigh bone is the ball and the socket is part of the pelvis. The ball moves around the joint but does not come out of the joint. This lets us move our hips front back and side to side and supports our body when we are walking and running. In DDH, the hip is not formed properly and the ball part of the joint maybe completely or partially out of the socket. This is because the socket is shallow. If this is not fixed the hip joint will not grow properly and there will be pain while walking and development of arthritis of hip at an early age.

    In DDH, usually there is no pain in babies. The hips are usually examined at birth to screen for this condition. Occasionally, children develop DDH after birth. To prevent this, it is important not to swaddle too tightly and to make sure there is enough room for the baby to move her legs.

    Parents may notice a clicking sound when hips are moved, they may notice one leg shorter is than the other and skin folds don’t line up under the buttocks or thigh. When children start to walk, they may notice a limp. Presence of any one of the above findings necessitates examination of the baby’s hip and a detailed ultrasound. An X-ray works well when they are older; it is not advisable at birth.

    The goal of treatment is to keep the head of femur, which is the ball of the hip joint, in the socket so that the joint develops normally.

    There are three modalities of treatment:

    – bracing
    – closed reduction and casting
    – open reduction which is surgery and casting

    Children under six months are usually treated with a harness called Pavlik harness. The baby is kept in this position for 6 to 12 weeks and regular checks are needed along with serial ultrasound to check everything is as it should be. Most children will only need this done if picked up early.

    If this does not yield the correction required, they will move on to closed reduction or open reduction and casting. A hip spica is given to hold the hip in place and the baby wears the cast for two to four months.

    Open reduction or surgical reduction is usually done if diagnosed late or if open reduction fails.

    These children will need regular follow-up with an orthopaedic doctor till they are 16 to 18 years of age to see that the hip is growing well.

    Club foot or Talipes equinovarus

    Talipes Equinovarus is a common foot abnormality, in which the foot points downwards and inwards. Usually seen at birth, it is more common in boys. It may involve one or both feet. If either of the parents have club foot, there is a 20-30 per cent chance of their baby having club foot.

    Most of the time, the cause is not found and its called idiopathic club foot. Sometimes, it may be associated with DDH or spina bifida, arthrogryposis or myotonic dystrophy.

    Sometimes, there are predisposing factors. The extrinsic variety is usually milder and may be due to the shape of the uterus, large baby or less fluid in the amniotic sac.

    The intrinsic variety is more severe, the foot is smaller and the calf muscle on that side is smaller. There might be an abnormality of one of the ankle bones called talus.

    Occasionally, the diagnosis is made from an antenatal ultrasound. The ultrasound cannot assess the severity and can only be done after birth.

    Treatment currently involves casting, bracing and surgery.

    Most doctors use the PONSETI method. This usually involves serial casting beginning within the first week of birth. The success of the treatment depends on the overall flexibility of the foot and parents compliance with appointments for casting and bracing till at least four years of age.

    Some children will need a small surgery called percutaneous transverse Achilles lengthening. In rare cases, children with severe or rigid club foot may need more extensive surgery.

    (Dr Saroja Balan is consultant neonatologist and paediatrician at the Indraprastha Apollo Hospital, New Delhi. Her column appears every fortnight)

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