Injury and disease have a unique effect on the developing skeletons of children. The pediatric orthopedics program at DOC has evolved to reflect these unique challenges. Our pediatric orthopedists specialize in the early detection and proper management of childhood injuries and disorders.
In toeing also called “pigeon-toed”, is an abnormal condition characterized by inward facing of the toe or feet instead of being straight. Parents may observe their children having in toeing at an early age when they start walking. But usually in toeing corrects itself without any specific treatment as the child grows up to around 8 years of age.
In toeing is normally painless and should not be considered an indication of arthritis. Children of different age groups may have in toeing due to various reasons. Severe deformity (in toeing) may cause misstep in young children while walking or running. Children having in toeing associated with any pain and swelling should be evaluated by an orthopedic surgeon.
The causes of in toeing depend upon the area involved in the misalignment. The most common conditions responsible for in toeing are:
- Metatarsus Adductus (Curved foot)
- Tibia Torsion (Twisted shin)
- Femoral Anteversion (Twisted Thighbone)
These conditions are inherent in nature that may occur individually or in association with other orthopedic conditions. Due to the genetic involvement, such conditions cannot be prevented, only treated.
This is a condition where the foot of the child may bend inward from the middle to the toes. This condition is similar to clubfoot deformity. Usually the condition naturally improves in the first 4-6 months. Babies of 6-9 months having severe deformity should be treated with casts or specially designed shoes. In majority cases, these simple treatment methods are helpful and surgery is rarely needed.
In tibial torsion, the lower leg (tibia) of the child is deformed inward. This abnormal rotation of the legs can occur before birth, for the baby to fit in the limited space of the womb. The alignment of the lower legs may show gradual improvement after the birth, with the growing age of the child. Usually tibial torsion improves without any specific treatment in the child up to school age. Treatment procedures such as splints, special shoes and exercise programs are not effective for tibial torsion. Surgery is the only option for treating tibial torsion and is considered only in children 8-10 years old, having substantial problems even with walking.
Femoral anteversion, also known as excessive femoral torsion, is characterized by abnormal inward bending of the thighbone (femur). The condition is most evident in children 5-6 years of age. The abnormal twisting of the femur results in inward bending of the knees and feet while walking. Children suffering from this condition usually sit in a "W" position. The condition may improve with the increasing age of the child. Treatment procedures such as splints, special shoes and exercise programs are ineffective. Surgery is the only option for treating femoral anteversion and is performed only in children 8-10 years of age, having substantial problems even in walking. During the surgical procedure, the femur is cut to be aligned properly.
Knee Angular deformities (Knock legs and Bow legs)
Angular deformities of the knee are common during childhood and usually are variations in the normal growth pattern. Angular deformity of the knee is a part of normal growth and development during early childhood. Physiologic angular deformities vary with age as:
- During first year: Lateral bowing of tibia
- During second year: Bow legs (knees and tibia)
- Between 3-4 years: Knock Knees
The condition usually becomes more evident when the child is 2 to 3 years old and normally corrects itself by the time a child is 7 or 8 years old. However, if the condition is not corrected it could be a sign of an underlying disease that requires treatment.
A perfectly aligned knee has its load-bearing axis on a line that runs through the hip, knee and ankle. Based on the inward/ outward inclination of the head of tibia/fibula; knee angular deformities are classified as:
- Genu valgum (knock-kneed): Head of tibia/fibula (not the joint itself), is inclined away from the midline of the body
- Genu varum (bow-legged): Head of tibia/ fibula is inclined toward the midline of the body
Genu Varum (bowed legs): Bowed legs are very common in toddlers. If a child has bowlegs, one or both legs curve outwards. When your child stands, there is a distinct space between the lower legs and knees. Bowed legs are rarely seen in adolescents. In most of the cases, children with bowed legs are significantly overweight.
The common causes of bowed legs include:
- Physiologic Genu Varum: Most children below the age of 2, show bowing of the legs as a part of normal physiological process. Normally the bowing will correct by 3 to 4 years of age and the legs may have a normal appearance.
- Blount’s disease: It is a condition in which there is an abnormality of the growth plate at the upper portion of the tibia (shinbone).
- Rickets: It is bone disease that occurs in children due to deficiency of calcium, phosphorus, or vitamin D that are essential for healthy bone growth.
The most obvious symptom is bowing of the legs that appear when a child stands and walks. Other common symptoms are awkward walking pattern and turning in of the feet (in toeing). Bowed legs usually does not cause any pain, however discomfort in the hips, knees, and/ or ankles may occur during adolescence.
Genu valgum (knock-kneed)
Knock knees is a condition in which the legs curve inward at the knees. When a child stands, the knees appear to bend toward each other and the ankles are spread apart.
Knock knees most often develop as a part of normal growth. In some cases, especially if the child is 6 years of age or older, knock-knees may occur as a result of other medical problems such as injury of the shin bone, osteomyelitis (bone infection), overweight, and rickets.
The diagnosis of bow legs or knock knees is made through a physical examination. In addition, X-rays may be taken if a child is older than 2 ½ years and has symmetrical legs.
Treatment for Bow legs
As the child grows the condition usually corrects itself. For children with severe, unresolved bow legs, doctors may recommend non-surgical treatment options such as bracing, physical therapy, and medications. If non-surgical treatment options do not correct your child’s bow legs, then surgery is considered.
Treatment for Knock-knees
Most children with knock knees do not require any treatment, but if the condition persists after age 7, then a night brace attached to an orthopedic shoe may be recommended. If the separation between the ankles is severe, surgery may be an option.
- Elbow Fractures in Children
- Forearm Fractures in Children
- Pediatric Thighbone Fracture
Adolescent Idiopathic Scoliosis
Scoliosis is a medical condition characterized by an abnormal lateral curvature of the spine, either to the left or to the right. Adolescent idiopathic scoliosis (AIS) is a type of scoliosis that occurs in children between 10 and16 years of age. The term “idiopathic” means that the cause of scoliosis is unknown, the exact cause of idiopathic scoliosis is unknown in most of the cases, but there seems to be a genetic predisposition. The incidence is higher among girls compared to boys.
The common signs and symptoms of adolescent idiopathic scoliosis include limb length inequality, uneven shoulder levels or protrusion of one shoulder blade, walking abnormality, abnormal curvature of the spine, inequalities in the levels of the hip, uneven trouser lengths, ill-fitting clothing and back pain.
Adolescent idiopathic scoliosis is usually noticed by a parent or detected by a teacher during a routine physical examination.
Your physician will diagnose scoliosis based on the following criteria:
- History: To diagnose the problem, your doctor will ask about your child's past and present medical history, as well as any family history of scoliosis.
- Physical Examination: Your doctor will perform a physical examination using the forward bending or Adams test, to define the curve.
- Adams Forward Bend Test- During this test, the child is asked to bend forward with the arms extended forward. Your doctor looks for the symmetry of the hips and shoulders, and the curvature of the spine from the sides, front and the back. Any abnormalities along the back could be a sign of scoliosis.
- X-ray: X-ray of the spine is taken from the front and the side to confirm the diagnosis and also to measure the degree of the curvature.
- Neurological Examination: Here the patient’s reflexes are tested and any neurologic changes are noted.
The treatment of adolescent idiopathic scoliosis is important because if left untreated, the curvature may result in significant deformity and can cause psychological distress and physical disability for your child. In addition, the deformity can have serious physical consequences. As the vertebrae rotate, the rib cage is affected, and this can lead to serious heart and lung problems. In order to compensate for the major curve and maintain the balance, the spine may develop a secondary curve above or below the AIS curve.
Treatment options include non -surgical and surgical treatment. The non –surgical treatment options include:
- Observation: If scoliosis is mild with a curve of less than 15 to 20 degrees, the child is observed for a specified period of time, to monitor the curve.
- Bracing: Bracing is recommended to prevent the progression of the scoliotic curve. It is effective in growing children with a spinal curvature between 20° and 40°.
Surgical correction of adolescent idiopathic scoliosis may be necessary if non-surgical treatment fails and if the curvature is severe. The aim of the surgery is to correct the curve, prevent curve progression and to stabilize the spine. Scoliosis surgery usually involves spinal instrumentation (i.e. rods, screws) and fusion (bone graft) that secure the spine to stop curve progression.
Your spine surgeon can discuss all aspects of the procedure, including risks and benefits, so that you and your child are well informed. If your child develops signs and symptoms suggestive of AIS consult your doctor immediately. They are the most reliable resource to answer all your questions and help you understand the condition better.
Cerebral palsy is a neurological disorder that occurs in infants or in early childhood and affects body movements, balance, posture, and muscle coordination. It is the result of damage to one or more parts of the brain that controls movements. Most often, the disorder is present at birth but the signs may not be detected until 3 years.
Types of Cerebral Palsy
The three types of cerebral palsy are:
Spastic cerebral palsy —involves muscle stiffness causing difficult jerky movements. It is the most common type (70-80% of cases) and is classified further based on the parts of the body affected as:
- Diplegia (both the legs are affected)
- Hemiplegia (half side of the body is affected)
- Quadriplegia (entire body is affected)
Athetoid cerebral palsy —causes slow, involuntary and uncontrolled movements. It accounts for about 10-20% of the cases and affects any part of the body, including the face, mouth and tongue.
Ataxic cerebral palsy — causes an unsteady gait and affects balance and coordination. It is seen in about 5-10% of cases.
The early signs and symptoms of cerebral palsy include:
- Delayed developmental milestones such as head control, roll-over, sitting, crawling and walking in infants.
- Infantile reflexes such as sucking reflex and startle reflex, which usually disappears within 3-6 months, may persist for a long time.
- Muscles may become very stiff or unusually relaxed. Body movements may be jerky or abrupt, or slow and uncontrolled.
- Joints may become very stiff because of differing levels of pressure exerted on them by muscle of different tones.
- Seizures may occur in early years with some cases of cerebral palsy.
- Speech may not be clear in some individuals as they are unable to control the muscles of the tongue, mouth and throat which help in speech.
- Drooling of saliva and difficulty in swallowing may be seen.
- Child may not react to sound or may have a delayed speech.
- Dental cavities may occur more commonly because of defective tooth enamel and difficulty in maintaining good oral hygiene.
- Bowel and/or bladder control may be difficult because of lack of muscle control.
Cerebral palsy may be caused due to one or more factors listed below:
- Brain damage in the early years of life
- Infections such as bacterial meningitis or viral encephalitis
- Head injury following an accident, a fall, or child abuse
- Fetal brain damage because of infections during pregnancy
- Birth injuries during delivery
A risk factor is something that increases your chance of developing a disease. Risk factors for developing cerebral palsy include the following:
- Maternal health problems such as infections, seizures, or thyroid disorder may increase the risk of fetal brain damage.
- Rh factor incompatibility (condition in which pregnant woman has Rh-negative blood and the baby in her womb has Rh-positive blood) may cause fetal brain damage.
- Complications during childbirth
- Pre-term delivery
- Infants weighing less than 2 pounds at birth (low birth weight)
- Severe physiologic jaundice which may develop after birth
- Lack of adequate supply of oxygen to the brain either at the time of delivery or after birth
If any of the signs or symptoms discussed is present in your child, then a thorough medical evaluation by your physician is necessary. The diagnosis of cerebral palsy is made based on information gathered from the family medical history and any problems that occurred during pregnancy and labor. Some of the tests your doctor may order include:
- Laboratory studies: Blood and urine tests may be ordered to check for any hormonal and metabolic conditions. DNA testing and chromosomal analysis may be done to rule out genetic disorders.
- Imaging techniques: These tests help to detect the cause and extent of cerebral palsy.
- Ultrasound of the brain – done to detect any abnormality such as bleeding or brain damage
- Computed tomography (CT) scan of the brain clearly reveals any abnormalities.
- Magnetic resonance imaging (MRI) of the brain helps to define the internal structure of the brain more clearly than other methods.
- Your doctor may order MRI of the spinal cord in children with spastic leg muscles and lack of bladder and bowel control.
- Other tests:
- Electroencephalography (EEG): This test is done to detect the types of seizures.
- Electromyography (EMG) and Nerve Conduction Studies (NC’S): These tests help to rule out other nerve and muscle disorders.
Rehabilitation: A rehabilitation program includes physical therapy, use of special equipment, and treatment for spasticity.
- Physical therapy (PT): It involves stretching exercises, and other activities that can develop flexibility and strengthen the muscles. PT helps to develop skills such as holding the head up, sitting unsupported, or walking. Use of braces, splints, and casts may be recommended.
- Special equipment’s such as walkers, positioning devices, and wheelchairs help to improve function in children with cerebral palsy.
- Treatment for spasticity includes direct injections into the muscles or oral medications.
Occupational therapy: OT helps teach physical skills needed to function independently in life such as eating, dressing, and teeth brushing.
Speech/language therapy: This type of therapy helps the child to improve speech and overcome problems of communication.
Drug therapy: Drug therapy helps to reduce the effects of cerebral palsy and prevent complications.
Surgical treatment for cerebral palsy includes dorsal rhizotomy, implantation of a baclofen pump, and tenotomy.
Some of the causes of cerebral palsy which include pre-term birth, low birth weight, infections and head injuries can be prevented with the following measures:
- Prenatal care with regular checkups helps to maintain a healthy pregnancy and avoid preterm labor.
- Avoid smoking, alcohol consumption, and medications during pregnancy as these can increase the risk of premature delivery.
- Immunization against rubella (measles) during pregnancy protects you from the disease and the risk of cerebral palsy in your child.
- Routine vaccinations are given to your children to prevent infections such as meningitis that can cause cerebral palsy.
Spina bifida is the most common birth defect which is known as neural tube defect that affects the central nervous system (brain and spinal cord). Most commonly it occurs in the first month of pregnancy because of incomplete development of the spinal cord or its coverings.
The 3 variants of spin bifida have been identified and they are:
- Spina bifida occulta: It is the mildest and harmless form of spina bifida. The spinal cord and the nerves are normal but there may be a small defect or gap between the vertebra and does not cause any health problems.
- Meningocele: It occurs when the membranes of the spinal cord enlarge and protrude creating a cyst from the spinal opening. The defect is invisible through the skin and causes no problems.
- Myelomeningocele: This is the most severe form of spina bifida. It occurs when the spinal cord is exposed through the opening in the spine resulting in neurological problems. Children with this condition may have partial or complete paralysis of the parts of the body that are below the spinal opening. Most infants born with this condition also have hydrocephalus (accumulation of fluid in and around the brain), problems with bowel and bladder control, and other learning disabilities.
Children with spina bifida occulta exhibit no physical signs of the condition. In some cases, defects are recognized as a small dimple, birthmark, or a hairy patch at the site of the defect. In meningocele and myelomeningocele, fluid filled sac is visible on the spine. In most severe cases of myelomeningocele the nerves and the tissues from the spinal cord may get exposed.
Spina bifida affecting spinal cord may cause problems such as inability to control bowel movements, urinary incontinence, lack of sensation in the legs and feet, partial or complete paralysis of the legs, and less often, in the arms.
The exact cause for spina bifida remains unknown however certain factors may contribute to spina bifida and include genetic factors, environmental factors such as nutrition and radiation, and folic acid deficiency during early pregnancy.
Most cases of spina bifida can be diagnosed before birth with the help of prenatal tests such as alpha-fetoprotein (AFP) test, ultrasound, and amniocentesis. Postnatal tests include X- rays, CT scan of skull, and MRI and ultrasonography of the spinal area.
Treatment for spina bifida depends on clinical symptoms and most often includes physical therapy, antibiotics to prevent infection, and teaching the child bowel and bladder habits. Surgery is usually recommended after birth at an early age and they include spina bifida repair and ventriculoperitoneal shunting.
Congenital Hip Disorders
Developmental dysplasia of the hip (DDH) or Hip dysplasia is a condition which is seen in infants and young children as a result of developmental problems in the hip joint. The femur (thigh bone) partially or completely slips out of the hip socket causing dislocation at the hip joint. It is most common in first born baby with family history of the disorder. The exact cause for hip dysplasia is not known. Genetic factors play an important role in causing this birth defect. DDH can be mild or severe and can affect one or both hips. It is more common in girls and usually affects the left hip. DDH does not cause any pain and so the condition may not be noticed until the child starts to walk.
The common symptoms of hip dysplasia include:
- Position of the legs may differ (dislocated hip may cause leg on that side to turn outwards)
- Restricted movement on the side of hip dislocation
- The leg may appear shorter on the side where hip is dislocated
- Skin folds of fat on the thigh or buttocks may appear uneven.
In normal hip, the head of the femur (thigh bone) fits well into the socket (acetabulum) whereas in hip dysplasia, the socket and femoral head are not congruent because of their abnormal development. During hip examination, the doctor may also look for the difference in range of motion of the hip, presence of uneven skin folds around the thigh and difference in leg length from side to side. In infants less than 6 months, an ultrasound may be advised to confirm the diagnosis.
The treatment for DDH depends on both the age of the child and severity of the condition. The aim of treatment is to keep the femoral head in good contact with the acetabulum so that the hip can develop normally. A pavlik harness may be used to keep the hip in flexion and abduction may be advised. Only when conventional treatment is not effective, surgery to put the hip back into place may be advised.