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New Treatments for In-Toeing, Bow Legs, Limp, Back Pain and Scoliosis

Metatarsus adductus. This is a deviation of the forefoot medially. Youíll see this at birth. But you can see that as this foot is coming up, itís all of a sudden taking a right turn here in-toeing, bow legs, limp, back pain, scoliosis. Itís coming up but then moving in medially at the metatarsus. And it is probably in most cases a positioning defect, a packaging defect. It was a little tight in utero and everything got a little squished. And you will see is therefore in situations where the child is in an abnormal position.

Treatment; it depends again on whether itís flexible. If itís flexible you donít have to do anything. We often tell the parents to go in and stretch it many times a day. That gives the parents, basically, something to do until it gets better on its own. Itís not going to hurt, but probably not helpful. Very rarely if you ever have a flexible foot that persists beyond a year, some people will try to cast it at that point.

Calcaneovalgus foot. This should be familiar to you. This is something that most pediatricians donít know about. Itís real, real common and we just kind of look at it and say, "Ah, it looks like it will get better. Donít worry about it" and fortunately we are right. But if you want a formal term to go with it, itís called a calcaneovalgus foot. This is a kid who comes out and his foot is kind of plastered up against the anterior tibial surface.

Club foot. This is a club foot and club foots can be isolated deformities or they can be associated with other abnormalities. The formal name for it is talipes equinovarus and again it varies from a flexible deformity that you can correct in the newborn period just by pushing on, to the more common form where it is actually dysplastic. In the dysplastic form, which is more common, these ankle bones are malformed and no matter what you do surgically to realign it.

External rotation contracture of the hip, this is pretty simple. Basically, when you see a child beginning to walk, what way do their feet normally point? They usually point out, right? In fact if you have a child who walks straight, something is actually wrong. Most kids, when they walk, their feet point out and the reason is that their hips are basically have an external rotation contracture thatís further augmented, that weíve had them in diapers for the first 6-12 months of life. So if you see a child who is starting to walk and one foot is straight and one foot is out.

Congenital torticollis; these are the kids who come in with their head turned to one side and on the side away from it thereís this little mass in the sternocleidomastoid. The exact etiology of this is still not clear. The latest theory is that it might be equivalent to an intrauterine compartment syndrome in the sternocleidomastoid muscle. This is not just simply a bleed at the time of birth. This has been going on for some time prior to delivery and actually there is fibrosis and stuff like that going on, if you were to biopsy it.

Treatment is to try and stretch him back and if after a year, year and a half, you canít get it to stretch back most people will start to do some releasing procedures in an effort to prevent any permanent facial asymmetry.

Brachial plexus injury; three forms that are in your handout. Erb-Duchenneís which we generally see at 4-5. This is the kid, the child whose arm is adducted, internally rotated. The other way to think about an Erbís is they canít throw a baseball. They canít adduct and bring their arm externally rotated like this. The Klumpke, which is intrinsic to the hand and the wrist. So these kids can move their elbow, they can move their shoulder, but they canít move their wrist and tend to have a floppy hand and canít grasp really well.

Treatment. Your differential is primarily a couple of things. Clavicular fractures can obviously make kids not want to move their arms, although theyíll usually hold their arms more just at the side, like this. They are usually not extended and internally rotated like you see with a brachial plexus injury. So itís a little different. Be aware though that with clavicular injuries you may not feel crepitus all the time. Rarely you can actually get a fracture through the proximal humerus.

Letís talk about medial tibial torsion real quickly. This is far and away the most common cause of in-toeing in a young child. It can be associated with other things. Tibia vera is Blountís disease, which weíll talk about. Metatarsus adductus. You get a kid who really looks like he in-toes, if heís got tibial torsion and his forefoot goes in, drives the parents crazy. Genu verum, or bow legs which actually also exacerbates the appearance of it, and some of the myelodysplasias. The key thing that we do in the clinic is just look at the second one, position of the medial lateral malleoli, because Ö just feel down real quickly, just feel down to your own leg with your foot pointing forward. Your medial malleoli should be slightly anterior of your lateral Ö I hope. In most of you. If you have your tibia in-turned then what happens is that instead of that medial malleoli being anterior, it starts to become equal or reversed.

Okay, medial femoral torsion, or internal rotation or medial rotation of the femur. This is present at birth and gradually externally rotates over time, but the reason you donít see it at birth is because you have that external rotation contracture at the hip. So as that external rotation contracture goes away, the residual internal rotation that was there becomes evident. Key thing for the Boards; you are not going to see this until you are 4-6 years of age.

The other way that we look at it is this way, and this is the best way to look for a rotation around the hip. This is an important maneuver to know how to do for all of hip disease, because almost all hip disease causes problems with internal rotation. Put the child on his stomach. Have his legs come out 90 degrees at the knee, and then see how far you can rotate him from straight up. From zero degrees. You have to think about it for a second, though. This is internal rotation of the femur. The femur is rotating inwards, even though you are bringing the leg laterally.

The other way to do it, is if you can sit like that, youíve got femoral anteversion. The rest of us canít get our rear end on the ground because our femurs arenít internally rotated. So if they can sit in a reverse tailor position they have femoral anteversion.

Bow legs. Again, fortunately, developmentally normal in most cases. These kids are both absolutely normal. There is nothing wrong with them, this is the normal variant. It can be pretty extensive. You are actually born bow legged but nobody notices it because you are lying down wearing a diaper. And you actually become straight by the time you are about 2-3 years of age, and then you become knock-kneed by about 4-5 years and gradually by about 9 years of age you become as close to straight again as you are going to get.

Knock knees. Kind of the same idea as with bow legs. Again this is normal to be a little knock-kneed by the time you are about 3 years of age. We call it genu valgum. Genu recurvatum; that means when you stand straight you hyperextend at the knee, so your legs actually kind of fold backwards and that will make you look even more knock-kneed.

Transient synovitis of the hip. If they give you a kid who is between 3-5 years of age who is refusing to walk, you need to think about either this or septic arthritis. Most common cause is transient synovitis. It used to be called toxic synovitis and basically we donít know what causes it. We keep thinking itís a viral cause but we canít quite isolate that virus. But these are kids who come in either refusing to walk or limping. Very typically the pain is worse in the morning but So if these kids donít get better you have think about Legg-Perthes.

Toddlers fracture. Pretty common. This is the fracture right there, little spiral fracture on the tibia. Typically kids under 2-5 years of age as they are learning to walk, it doesnít take a whole lot of force to do this. You can have a kid who is holding onto the table and turns to go the other direction and then falls to the ground in pain. Very, very minimal amounts of force to cause this to happen.

Legg-Perthes disease. This is avascular necrosis of the femoral head. By definition, Legg-Perthes is the idiopathic form of this disease. There are other pathologic conditions that can cause you to have an avascular necrosis but Legg-Perthes is the idiopathic form of it. This is also a great Board question because itís got a fairly tight age range.

Slipped capital femoral epiphysis. Another one, the key thing is age. If they give you an early adolescent child with hip pain think slipped capital femoral epiphysis until proven otherwise. This is a disorder where the femoral head slips off of the metaphysis of the femur, and itís seen in females usually at about 11-13 years of age and in males a little bit later, because their growth spurt is a little bit later, maybe about 12-15.

Osgood-Schlatterís. This is one you guys are pretty familiar with. This is the kid who comes in with pain right over his tibial tuberosity. This is seen again in kids in the first half of their adolescent years, usually around 11-15, and itís only bilateral in about 25%. So itís not unusual for these kids to present with unilateral disease.

Letís talk about some foot problems. Flat feet. We get this all the time from parents. "Does my kid have a flat foot?" Because everybody is still convinced that if you have flat feet you are going to have lots of foot problems in the future, which in reality really doesnít occur. Be aware that in most normal kids there is a big pad of fat sitting under your arch until you are about 3-4 years of age. So you cannot tell if somebody has a flat foot until after 3-4 years of age.

Metatarsus primus verus. These are the kids whose big toes go in this direction. The metatarsal is going toward the midline. Thatís the metatarsal verus. So instead of going straight, this first metatarsal is coming medially. As a result, the big toe gets forced back this way and then you end up with a big pressure point here that becomes a bunion. This is seen Ö usually weíll see this in kids over time, usually late elementary school, teenage years.

Severís disease you can think of as the Osgood-Schlatter of the Achilles tendon. So where that Achilles tendon inserts into the bone, at that apophysitis, you get essentially a tendonitis. That actually heals over time also as the childís bone/tendon area starts to mature. Thatís usually treated with heel lifts, sometimes with steroid injections.

Kohlerís disease. This is an avascular necrosis of the navicular, which is right here. None of us can read foot films, obviously, as pediatricians but this bone is usually about this size and itís this little wedge. Basically this whole bone has just gone through an avascular necrosis and compressed. So what they come in with is pain on the dorsum of the foot, right in the middle of the dorsum of the foot. These are usually pre-pubertal kids, 4-8 years of age, and it heals over time.

Lastly a tarsal coalition. In some kids there are cartilaginous and fibrous connections between different of the ankle bones and as you go through puberty they start to ossify and that leads to a foot that is becoming rigid, and that is painful. So the key here is lack of motion in the ankle. These you can pick up on x-ray although sometimes they are hard to see and you sometimes have to do CT scans. Treatment in most cases ends up being surgical to try to release those bony bridges.

Scoliosis. Lateral curvature of the spine with some rotation. More common in females, and a lot more common to have to require treatment. Very strong familial pattern. Realize that there are non-idiopathic causes, so certainly if you see scoliosis out of the normal teenage adolescent range or if there is something else going on that makes you suspicious, there are a whole host of other things that can cause it. A lot of times when you have something going on in the spine or in the spinal cord or at the disc level, you will end up splinting and getting scoliosis.