London Paediatric Orthopaedic

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London Paediatric Orthopaedic Revision Course
Normal variants (and self-limiting problems) in
children's orthopaedics
Mark Paterson Paediatric Orthopaedic
Surgeon Royal London Hospital
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In childrens orthopaedics..

• most perceived problems are
• not pathological but merely
• normal variants
• 90 of all childhood
• orthopaedic problems
• will resolve spontaneously

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Important to..

• identify any true pathology
• that needs to be treated
• give reassuring explanation to
• patient and parents

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FRCS Orth.

• unlikely to turn up in clinicals
• possibly in MCQs
• more likely in children's viva

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normal variant
"physiological"
pathological but self-correcting
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normal variant
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normal variant
"physiological"
Bow leg knock knee sequence
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normal variant
"physiological"
pathological but self-correcting
e.g. moulding effects, curly toes
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• basic motor development
• bow-legs and knock-knees
• intoeing
• flat feet
• generalised joint laxity
• idiopathic toe walking

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Sitting 6 mos
(Crawling 9 mos)
Standing 12 mos
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6 weeks old
11 months old
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physiological genu varum
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Bow legs - differential diagnosis

• physiological
• Blounts disease
• rickets
• skeletal dysplasia

When does physiological genu varum
become Blounts?
Example of Blount's disease on internet
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Blount's
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Rickets
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Pathological knees
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Knock-knee
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Intoeing
18 all children walk with in-toed gait (Scrutton
1968)

• persistent femoral anteversion PFA
• internal tibial torsion ITT
• metatarsus adductus

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Staheli's Rotational Profile

• foot progression angle
• hip rotation
• thigh foot angle

young children in-toe mean adult value
10 (range -3 to 20)
mean 10
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Normal ranges of internal / external hip rotation
Usually IR gt ER
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Femoral anteversion
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Femoral anteversion

• relationship of IR/ER to femoral anteversion
• clinical estimation is accurate (Gage et al)
• normal reduction in anteversion with age (Fabry)

1yr 39 2 yrs 31 10 yrs 24 16 yrs
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Femoral anteversion vs age (after Fabry)
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Persistent femoral anteversion......... intern
al rotation from hips downward - look at knee
caps usually symmetrical grows out by 9-10 yrs
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Internal tibial torsion
TFA correlates well with transmalleolar axis
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persistent femoral anteversion
internal tibial torsion
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Tibial torsion possible indications for surgery

• torsion exceeding 40
• gt 8yrs old with TFA gt2SDs from mean

No evidence for long term damage / stress to
knee, ankle or foot
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Metatarsus adductus flexible hook foot
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Metatarsus adductus

• passive correction

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Metatarsus adductus

• passive correction
• medial stretches

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Metatarsus adductus

• passive correction
• medial stretches
• serial casting, boots

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Metatarsus adductus

• passive correction
• medial stretches
• serial casting, boots
• surgery abductor hallucis release
• TMT capsulotomies
  

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Flat foot

• Flexible Flat Foot (90)
• Rigid structural flat foot (10)

• joint laxity
• (heavy child)

• congenital vertical talus
• neuromuscular disorder
• tarsal coalition

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flexible flat foot.......toe-standing test
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Flexible flat foot
Prospective controlled study of effect of
corrective shoes, heel cups, custom-moulded inser
ts or no treatment. Follow up 3 years later. NO
SIGNIFICANT DIFFERENCE ! Wenger et al JBJS
1989
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Nonspecific musculoskeletal pain

• growing pains
• common -
• 13 boys / 18 girls
• Oster and
  Neilson 1972
• 4-25 all children
• Peterson
  1977
• peak incidence 4 - 8 yrs

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Nonspecific musculoskeletal pain

• Classic symptom complex -
• nocturnal episodes
• pain in thigh, calf or behind knee
• responds to parental massage
• back to sleep after 10-30 mins
• entirely normal in morning
• no physical findings
• no limp
• 
  (diurnal variant exists)

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Nonspecific musculoskeletal pain

• Cause
• initially said to be rheumatic
• ?related to growth BUT
• - growth velocity relatively slow
• - same growth curves as others
• strong association with headaches and
• abdo pain - pain-prone families Naish
  and Apley 1951
• generalised joint laxity

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Nonspecific musculoskeletal pain
Possible muscle fatigue problem - Two groups
studied
EXPLANATION AND REASSURANCE
QUADS AND HAMSTRINGS STRETCHES
Fewer episodes over 18mo. period in stretch
group

Baxter Dulberg 1988
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Nonspecific musculoskeletal pain

• Management
• exclude treatable pathology -
• rheumatological
• hip disease
• osteoid osteoma
• leukaemia etc
• explanation and reassurance
• spontaneous resolution to be
• anticipated

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Constitutional joint laxity

• awkward gait
• frequent falls and trips
• poor walking endurance
• flat feet and knock knees
• night pains

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Toe walking

• neurological immaturity, thus
• normal variant in young children
• autism and behavioural
• abnormalities
• congenital short TA
• cerebral palsy
• BEWARE UNILATERAL
• TOEWALKER