Chapter 19: Pediatrics

Evaluation of the Pediatric Patient Pediatric

Biomechanics:
Normal Values (Newborn to Adult)
Congenital Deformities
Pediatric Radiology
Pediatric Gait Patterns
Intoe Gait
Pediatric Fractures
The Limp in Childhood
Juvenile Hallux Valgus
Biomechanical Examination of the Child
Corrective Casting Techniques in Infants
The Toe-Walking Child
 PEDIATRICS
Evaluation of the Pediatric Patient
1. Examination of the Neonate:
a. Apgar score (Dr. Virginia Apgar: 1953): It is based upon observations made
at 1 and 5 minutes after birth of the heart rate, respiration, muscle tone,
reflex irritability, and skin color (scores of 0-1-2 are given for each). The
lower the score the more depressed the infant. Low scores indicate severe
acidosis.

b. Proportional measurements
i. Head circumference (averages 13 inches/slightly larger than the chest)
ii. Chest circumference
iii. Sitting height (crown rump height roughly equal to the head
circumference)

c. General postural considerations: depends on the in-utero position

i. Cephalic delivery
ii. Brow delivery
iii. Breech delivery

d. Examination of the head and neck

i. Check for equal eye movements
ii. Head should be held in the midline
iii. ROM of the neck tested

e. Examination of the upper extremities

i. Palpation of the humerus: see if the anterior bulge of the humeral head
absent (produces a dislocated shoulder), and check for fracture of humerus.
ii. Cleidocranial dysostosis: clavicles absent (this condition is detected
later in life due to gait changes from femoral neck deformity).
iii. Check ROM shoulders: if limited then possible dislocation
iv. Check ROM elbows: if limited possible arthrogryphosis
v. Check fingers and nails the absence of which are caused by
congenital abnormalities

f. Examination of the spine: The infant is placed on his abdomen, and the
hand is run over the spine and palpation for scoliosis/kyphosis is performed.
i. Congenital scoliosis: is concerned with scoliosis arising in association with
congenital vertebral anomalies. Some children with congenital scoliosis show
curvature at birth, but many do not. The anomalies and variations in
development of the vertebrae may be single or multiple and may be
associated with other anomalies, particularly in the ribs, which are frequently
combined with spina bifida.
ii. Congenital kyphosis: kyphosis at birth is almost always due to congenital
anomaly of the vertebral column.
iii. Klippel-Feil syndrome: absence of one or more cervical vertebrae, or
two or more fused together, with brain stem abnormalities
iv. Vertebral agenesis: absence of only the coccygeal segment to
absence of all the lumbar and sacral vertebrae.
v. Spina bifida: see section Congenital Deformities

g. Examination of the lower extremities

i. Gross abnormalities
ii. Examination of the hip (dislocation/ femoral rotation/neonatal
osteomyelitis)
iii. Examination of the knee and leg (dislocation/bowing of tibia/tibial torsion).
Bowing of the tibia in the infant is present in achondroplasia.
iv. Examination of the foot (metatarsus adductus/calcaneovalgus/ convex pes
planus/ talipes equinovarus)

h. Examination of CNS (muscle tone/reflexes): Usually, at birth, the infant is

limp, but after the first or second cry he develops good muscle tone.
i. Shortly after birth, the newborn flexes himself into a position of comfort,
the position he occupied in-utero. Motor activity should be observed for
symmetry, myoclonic jerks, and convulsive movements. Poor muscle tone in
an infant after a few minutes of age is a grave sign. Infants who remain limp
longer than a few minutes should be suspected of having anoxia, necrosis,
CNS lesions, vascular. collapse, hypoglycemia or mongolism.
ii. Some important-reflexes present at birth include:
 Blink reflex: which occurs when a bright light is directed to each eye
 Rooting reflex: elicited by stroking the angles of the lips with the finger
 Normal suck reflex: elicited by placing a sterile nipple in the mouth
 Grasp reflex: elicited in the palms and soles by placing a finger at the
bases of the fingers or toes
 Moro reflex: is very important and is elicited by startling the baby while
he is on his back. Normally the infant reacts by first extending his arms,
then flexing his arms, clenching his hands, and flexing his knees and hips.
The Moro reflex should demonstrate for symmetry and overall vigor.

NOTE* Absence of this response in the newborn indicates severe CNS injury
or deficiency. Absence of the Moro reflex in one arm indicates a fractured
humerus, brachial nerve palsy, or fractured clavicle. Absence of the Moro
reflex of one leg indicates lower spinal injury, myelomeningocele, avulsion
of the cord, or dislocated hip. A hyperactive Moro reflex indicates tetany,
tetanus (not clostridium), or CNS infection. This reflex should disappear by
the 5th month.

2. Neurological Examination of the Infant:

a. Plantar response
i. Either normal or
ii. Babinski (should disappear by age 1 year)
b. Palmar grasp
i. Either normal or
ii. Abnormal (should be normal by age 4 months)
c. Plantar grasp
i. Either normal or
ii. Abnormal (should disappear by age 1 year)
d. Deep tendon reflexes (hypo or hyperreflexia/absent/symmetrical)
i. Patellar
ii. Achilles
iii. Biceps/triceps/flexor carpi radialis
e. Ankle clonus (absent or present)
f. Examination of the anterior fontanelle (should close by age 2 years)
i. Bulging indicates excessive cranial pressure
ii. Depression indicates dehydration
g. Head and neck control (infant should have control by age 2 months)
h. Muscle power
i. Motor skills of the lower extremities: developmental average landmarks
i. Crawls: 3-5 months
ii. Creeps: 7-9 months iii. Stands: 9-14 months
iv. Cruises: 9-12 months
v. Walks: 7-18 months (average is 13 months)

2. Orthopedic examination of the Infant:

a. Examination for dislocated hip (discussed under the heading: Congenital
Deformities)
b. Determination of femoral position (normal=2 x external rotation)
c. Frontal plane knee motion
d. Transverse plane knee motion
e. Determination of malleolar position
f. Ankle dorsiflexion/plantarflexion (should be equal)
g. Examination of the digits and nails
h. Check for spina bifida (check the lower back for any abnormalities)

3. History Taking:
a. Pregnancy:
i. Maternal trauma ?
ii. Any medications?
iii. Complications? Hemorrhaging?
iv. Delivery: Full-term, premature (<38 weeks- 1500 grams), natural,
prolonged, C-section, fetal distress?
Pediatric Biomechanics-Normal Values: Newborn
to Adult
1. Chart of normal findings:
Part Birth Position Adult Position
Thigh/Femur/Hip Angle of head and neck of femur=150° At age 6 years=125°
(angle of Inclination)
Externally rotated 60° At age 6 years=0
Femoral torsion (angle declination)=30° At age 6 years=10°
Total range of motion=150° Past puberty=100°
Knee (Birth) (1&1/2-3yr) (3-6yr) (7-puberty) (puberty-18) (over 18) (over 60)
Genu Varum Straight Genu valgum Straight Genu valgum Straight G. valgum
Genu Recurvatum=5-10° At age 6 years =0°
Externally rotated=30° At age 6 years=0°
Frontal plane rotation=5-10° At age 6 years=0-5°
Transverse plane rotation=5-15° At age 6 years=0-5°
Leg/Tibia Varum(approx. 15°) At age 18 years=0-2° varum
Tibial torsion at birth=0° 1 yr=6°, 2-3 yr=10-15°, 5-6 yr=18-23°
Malleolar torsion at birth=0° 5-6 yr=13-18°
Rearfoot At birth= 10° varus approx. At 6 years=2-5° varus
Talocalcaneal angle=30-50° At 6 yrs=25-30°
Calcaneal inclination angle=approx. 14° At 6 yrs=20° approx.
Talar declination angle=approx. 30° At 6 yrs=21° approx.
Calcaneal stance @ 1 yr=5-10° 5 yr=3-8° 8 yr=<2° external rot.
Dorsiflexion=45° approx. After age 18=10V min
Forefoot Varus 10-15° At age 6=0-2° varus
Metatarsus adductus=15-35° Adult=15-22°

Congenital Deformities
1. Dislocated Hip:
At birth there may be no clinical sign of dysplasia of the hip, so periodic
examinations during the first year are therefore necessary. No clinical sign
is diagnostic by itself. This can present with an older child that limps.
a. Girls are more susceptible than boys
b. Unilateral cases are more common than bilateral, with infants born by
breech more at risk.
c. Diagnostic tests:
i. Ortolani's sign: with adduction of the thighs, a click when the femoral
head is either made to enter the acetabulum or emerge from it, or
telescoping of the flexed and adducted thigh on the pelvis.
ii. Barlow's sign: like Ortolani's sign, except using abduction.
iii. Anchor sign: The infant should be examined while on his abdomen and a
difference in gluteal folds of the two thighs is checked. A difference in the
number of folds can indicate a dislocated hip (not accurate).
iv. Galezzi's sign: while the hips are flexed and the knees flexed while the
baby is on his back, a dislocated hip results in a lower knee position on the
affected side.
v. Abduction test: while the infant is on his back, flex the knees and then
bring them down to the table in the flexed position. A dislocated hip will
have limitation of abduction on the affected side.
d. Radiological examination: The value of radiography of the hip of young
babies is limited by 3 important factors: that only AP views of the pelvis
can be taken; that much of the hip joint is cartilaginous; and that excessive
radiation should be avoided.

NOTE* Two AP views should be taken: one with the lower limbs lying together
and a second with the hips medially rotated and abducted by 45 degrees.

i. Acetabular index: the angle formed by a line touching the inferior margin of
the ilium and Hilgenreiner's line. Greater than a 30 degree angle is indicative
of a dislocated hip (only useful in a unilateral dislocations).
ii. Hilgenreiner's horizontal reference line: across the upper edges of the
ischiopubic joint. In the normal child, the metaphysis should lie well below
this line, and the epiphysis should only just reach to this line
iii. Perkin's vertical reference line: a perpendicular line dropped through the
anterior inferior iliac spine at right angles to Hilgenreiner's line. Normally, the
femoral epiphysis and the beak-like medial side of the epiphysis on its inner
side.
iv. Shenton's line: lies along the upper margin of the obdurator foramen and
continues outward and downward along the under surface of the femoral
neck and the medial aspect of the shaft of the femur. This forms an even
curve in the normal baby, but is interrupted in the dislocated hip.
v. Simon's line: from the lateral margin of the ilium to the upper and outer
edge of the acetabulum, and then continues downwards and outwards along
the upper margin of the femoral neck. This forms an even curve in the
normal baby, but is interrupted in the dislocated hip.

NOTE* Shenton's line and Simon's line can be identified even before the
femoral epiphysis is present. When the epiphysis has appeared, then
other information can be obtained by drawing Hilgenreiner's line and
Perkin's line.
vi. Von Rosen's Sign: an AP radiograph is taken with the hips extended and
the thighs abducted 45 degrees and medially rotated. A line drawn along the
axis of the shaft of the femur running close to the anterior superior iliac spine
and crossing the center of the spinal column above the lumbosacral junction
constitutes a positive sign for dislocated hip.
e. Trendelenberg Gait: seen with bilateral dislocated hips
f. There are three forms of congenital hip:
i. Acetabulum dysplasia
ii. Neuromuscular problems
iii. Capsular laxity
Measurements from the above diagram for detection of congenital hip:
Keats TE, Lusted LB: Atlas of Roentgenographic Measurements, Yearbook Medical Publishers, Chicago, 1985, with
permission
1= Hilgenreiner's line, Y line, or symphyseal line, drawn horizontally through the cotyloid
notches of the acetabula
2 & 3= Distances from the apex of the femoral head to Hilgenreiner's line (1), normally these
distances are equal
4= Shenton's line. Follows the upper arched contour of the obdurator foramen, thus marking
the lower margin of the pubic bone, and is continued as a regularly curved line Into the lower
boarder of the femoral neck
5= Break in the continuity of Shenton's line, indicating a dislocation or fracture
6= Fusion of the ischiopubic syndrosis, may be delayed with a dislocation
7= The angle of the acetabulum. If this angle is more than 300 in the newborn and 25° in the
one year old it Is said that there is a "steep acetabular roof" and indicative of a dislocation
(should decrease to 20° by age 2)
8= The diaphyseal interval, the distance between the diaphysis of the femur and
Hilgenreiner's line. This distance should be less than 6 cm
9= If in the newborn the distance of the pivotal point (point of intersection of line 8 and
Hilgenreiner's line) from the tip of the acetabular angle Is more than 16 mm, subluxation
must be suspected
10= This is the horizontal distance between the vertical line of Ombredanne (Perkin's line)
and line 8. This distance is normally less than one-half the epiphyseal width (not illustrated)
11= The vertical line of Ombredanne (Perkin's line) which intersects the upper jutting edge
of the acetabular roof and is perpendicular to Hilgenreiner's line. The center of ossification of
the normal femoral head lies below the horizontal line and medial to the vertical line. In
cases of dislocation this center will be above and lateral respectively
12= The parallelogram of Kopitz. In cases of dislocation a rhomboid will be observed, and the
head of the femur will have an eccentric position
13= The guide line of the Y symphysis down from the center of the acetabulum to the center
of the head
14= The axis of the neck of the femur
15= The angle between 13 and 14 is normally 120°-125°
2. Spina Bifida:
a. Spina bifida occurs in about 1 out of every 1000 live births, the common
problem with this deformity is neuropathy (sensory deficit)
b. Minor degrees of spina bifida affecting the 5th lumbar vertebrae are
insignificant and pose no problems.
c. Spina bifida can be grouped into three clinical entities:
i. Simple meningocele: which may be present anywhere in the spine,
however, most common in the lumbosacral/sacral region, and is caused by a
failure of fusion of the vertebral arches with cystic degeneration of the
meninges. It presents itself with a swelling in the back covered by skin or a
thin membrane. It is flaccid and capable of being transilluminated. The
swelling consists of herniation of the dura and arachnoid filled with cerebral
spinal fluid. The lower limbs show no deformity or any abnormal reflexes.
ii. Open myelomeningocele: most commonly seen in the lumbar/lumbosacral
spine. Patients seen at one day old present with an oval area of red glistening
tissue at the center of the lesion constituting the dysplastic portion of the
spinal cord. The skin is often thin or shows pigmentation in the region
adjoining its junction with the membranous area. In 50% of the children born
with this there may be one or more abnormalities depending upon the cord
level: adduction/lateral rotation of the hip, fixed or limited flexion of
the knee or fixed recurvatum, equinus, equinovarus, calcaneus,
calcaneovalgus, equinovalgus, vertical talus, and clawtoes. The
deformity is always bilateral and symmetrical
iii. Closed myelomeningocele and spina bifida occulta: presents with a
lipomatous or cystic swelling, abnormal pigmentation, hair, and formation of
a dermal sinus. The vertebral arches are unfused, but there is no gross
distention of the meninges. This generally occurs at L5 or S1.
3. Congenital Calcaneovalgus:
This is the most frequently encountered congenital podiatric deformity. It is
the prime cause of the flexible flatfoot deformity.
a. It can be unilateral or bilateral, but is usually bilateral, one side being more
severe than the other.
b. Etiology:
i. Abnormal intrauterine position
ii. Excessive internal limb rotation in fetal life
c. Physical findings:
i. The dorsal surface of the foot is in contact with the anterior surface of the
lower leg.
ii. Redundant skin folds in the lateral malleolar area and tight skin at the
anterior ankle.
d. Clinical findings:
i. The foot lies in acute extention and slight valgus.
ii. Forefoot varus
iii. Rearfoot valgus
iv. Tendo achilles is tight
v. Plantarflexion restricted/ dorsiflexion greater than 15 degrees
vi. Prominent talar head (plantarmedial prominence)
e. Pathology:
i. Talocalcaneal ligaments are relaxed or lacking
ii. The navicular is laterally displaced to the talus
iii. The distal aspect of the calcaneus is laterally displaced
iv. External tibial torsion co-exists in majority of cases

NOTE* According to Ganley, in infants, cartilage is stronger than bone and

therefore osseous structures do not cause the deformity but rather adapt
to the deforming forces.

f. Radiological changes:
(Lateral View)
i. Increased talar declination angle
ii. Plantarflexed talus
iii. The talar head overlaps the distal superior calcaneal surface
iv. The bisection of the talus falls below the cuboid ossification center
(D-P View)
i. Grossly excessive-talocalcaneal angle
g. Treatment:
i. Manipulation: the foot is brought down perpendicular to the ankle
with the heel in neutral position (5 times per correction, 3 times per day
for mild cases)
ii. Casting: applying a BK or AK cast, the foot is held in equinus with
plantarflexion of the first metatarsal and adduction of the forefoot to align
the T-N joint. The rearfoot held in neutral position. Casting weekly for 3-6
months. Following casting, Ganley splints used for 6 months @ 12
hours/day.

NOTE* The key to the treatment is gentle, gradual, and persistent

correction. iii.
Surgery: reserved when the T-C angle exceeds 30-35 degrees

4. Convex Pes Valgus (Vertical talus/congenital rigid flatfoot):

Is a rare condition which presents clinical findings at birth similar to
congenital calcaneovalgus, but is very different and more severe. Abnormal
radiographic findings consistent with rigid flatfoot will appear with patients at
rest and during weightbearing. The range of motion of the subtalar joint is
the key clinical finding in the evaluation of this condition.
a. Etiology: Talonavicular dislocation where the navicular subluxes over the
talus.
b. Usually found with other congenital deformities and/or endocrine
disturbances.
i. Arthrogryposis multiplex congenita
ii. Myelomeningocele
iii. Cerebral palsy
iv. Coarctation of the aorta and high palate
v. Congenital dislocation of the hip vi. Clubfoot
vii. Nail-patella syndrome
viii. Multiple pterygium syndrome
ix. Marfan's syndrome
x. Down's syndrome (trisomy 21)
xi. Trisomy 13-15, and 18
xii. Neurofibromatosis
xiii. Mental retardation
c. Clinical Findings:
i. A rigid deformity with the heel in neutral/vertical
ii. A depression if found anterior to the lateral malleolus
iii. A convex plantar aspect (rocker bottom foot)
iv. Forefoot is abducted and there is dorsiflexion of the forefoot on the
rearfoot.
v. Tendoachilles is tight and the anterior muscle group is tight
vi. Talar movement is impossible (no supination)
vii. Calcaneal equinus
d. Pathology: Soft tissue and osseous

NOTE* The structures attached to the navicular plantarly will be stretched,

while those structures attaching dorsally will be contracted. The
tibionavicular, talonavicular, and calcaneofibular ligaments hold the
deformity so that the calcaneus cannot be manually inverted.

Soft Tissue Pathology: structures contracted, due to dorsiflexion at the

midtarsal joint
i. Tibionavicular ligament (Deltoid)
ii. Talonavicular ligament
iii. Anterior ms. group
iv. Peroneus brevis/longus
v. Triceps surae
vi. Calcaneofibular ligament
vii. Posterior ankle and subtalar capsule
Soft Tissue Pathology: structures stretched
i. Spring ligament
ii. Tibialis posterior, FDL, and FDB
Osseous Pathology:
i. Subluxation of the navicular on the talar neck
ii. Talus locked in the vertical position
iii. Calcaneus in a 20-25° equinus position
iv. Talar head subluxed below the navicular
v. Talar head has an abnormally flat surface
vi. Talar neck is hypoplastic, develops an abnormal facet
vii. Talus has an hourglass shape
viii. Anterior surface of the calcaneus is deviated laterally
ix. Subtalar facets are abnormal due to the abnormal T-C articulation (the
anterior facet is absent/middle facet is hypoplastic/posterior facet is
malformed
x. Calcaneocuboid subluxation (dependent on the type of deformity)
e. Radiographic findings:
I. T-C angle increased (usually >45°)
ii. Talus perpendicular to the tibial longitudinal axis iii. Equinus calcaneal
position
iv. Dorsal dislocation of the navicular on the talus v. Lateral forefoot
subluxation
v. Talocalcaneal overlap
vi. Navicular is dorsiflexed and laterally displaced to the talar head (it is
usually cartilaginous until age 3 years so its position must be evaluated via
position of the talar head and the medial cuneiform f. Treatment:
conservative vs. surgical
i. Conservative: Serial long-leg casting up to 6 months of age, with the foot in
a position of ankle plantarflexion, an inverted heel, forefoot in adduction to
reduce the T-N dislocation, and the knee flexed 90°. The key to successful
results is lining up the T-N joint. If a proper result occurs, the patient will have
an equinovarus foot type which would then have to be corrected.
ii. Surgery: Herdon-Hyman and Craig

NOTE* Aggressive surgical approach is indicated when the T-N joint is non-
reducible

5. Metatarsus Adductus (Metatarsus varus):

The latter is the more severe form of this condition. Met. adductus is
where the anterior part of the foot deviates medialward and there is a varus
angulation at the T-M joints. The heel may be neutral or in valgus and if it is
in valgus it is a more severe form., This condition is not usually noticed at
birth but about 8 weeks later. The incidence of metatarsus varus has
increased 4x in the past 25 years.
a. Classification:
i. Flexible
ii. Rigid
iii. Functional dynamic
iv. Skew foot
b. Etiology:
i. Arrested ontogenetic development
ii. Uterine pressure
iii. Abnormal muscle/tendon insertions of the adductor hallucis/FDB
c. Clinical Assessment:
i. Degree of inversion/adduction
ii. Medical concavity/lateral convexity
iii. Associated met primus adductus
iv. No rearfoot involvement except with a skew foot v. Use "V" finger test
d. Radiographic findings: Angle of met adductus on DP view is normally 15-
35° at birth and should decrease to 25°.
 NOTE* The metatarsus adductus angle is the angle formed by the
intersection of two lines, the bisection of the second metatarsal and the
perpendicular of the lesser tarsus. The lesser tarsus is is bisected in the
infant using the following
technique:
1. A line is drawn from the distal medial talus to the medial base of the 1st
metatarsal, and its midpoint marked.
2. A line is drawn from the calcaneus to the base of the 4th metatarsal, and
its midpoint marked.
3. A line is drawn connecting the two midpoints from 1 and 2, and this line is
bisected.
4. A perpendicular line is drawn at the midpoint of line 3, which is the final
reference line that is the bisection of the lesser tarsus.

e. Treatment:
i. Manipulation
ii. Shoe therapy
iii. Wheaton Brace (works well in a flexible deformity in child under 1
year old)
iv. Serial cast immobilization (cast with the calcaneus in neutral/with an
abductory forefoot force) Use 2 sets of casts .
v. Orthoses
vi. Surgery: Should postpone surgery until after age 2-3 years (HHS: soft
tissue; Johnson: cartilaginous; Lepird and Berman 8 Gartland: osseous)

6. Talipes Equinovarus:
Clubfoot may be acquired or congenital. At birth, other disturbances such as
hip dysplasia/neuromuscular disorders/poliomyelitis/tibial epiphysis
abnormality must be ruled out in with patients with clubfoot.
a. Incidence:
i. 1:1000 births (according to Kite)
ii. Increases to 1:35 if a sibling has clubfoot
iii. Males to female ratio is 2:1
b. Etiology:
i. Arrest of fetal development (Max Bohm: JBJS, 1929)
ii. Combination of inheritance and environmental factors (Ruth WyneeDavis:
JBJS, 1929)
iii. Primary germplasm defect (George Settle: JBJS, 1963) iv. Genetic factors
(Palmer)
c. Physical findings:
i. Medial border concave/lateral border convex ii. Talar head prominent
laterally with inversion iii. Palpation of a medially displaced navicular
iv. Deep furrowed creases along the medial longitudinal arch area and the
posterior ankle.
d. Clinical findings:
i. Inversion and adduction of the forefoot
ii. Inversion of the rearfoot
iii. Talocalcaneal equinus/tibiotalar equinus
iv. No dorsiflexion
v. Associated with tibial torsion and cavus deformity (with cavus deformity
there is also plantarflexion of the forefoot on the rearfoot).
e. Types:
i. Rigid: usually genetic and very resistant to treatment (seen with small,
inverted, plantarflexed calcaneus, and posterior leg atrophy)
ii. Flexible: usually due to intrauterine position and usually responds to
casting.
f. Pathology:
i. The major defect is in the talus, with the head and neck medially and
plantarly deviated, the superior surface is anterior displaced out of the ankle
mortise, and the sinus tarsi is opened as the anterior facet is tilted medially.
ii. The T-N and C-C joints face medially and plantarly, with the C-C lying below
the T-N joint.
iii. Tibia is usually OK, occasionally, tibial torsion involved iv. Soft tissue
contractures:
 Posterior- ankle capsule, STJ capsule, calcaneofibular ligament,
tendoachilles.
 Medial- spring ligament, deltoid ligament, ms. TP, FDL, FHL.
 Plantar- plantar fascia, abd. hallucis, FHD.
g. Radiographic findings:
i. DP view reveals S angle of Kite (T-C angle): 0-15° with clubfoot
ii. DP view reveals superimposition of talar head and the anterior surface of
the calcaneus.
iii. DP view reveals ossification center of the navicular is medially displaced
iv. Lateral view with dorsiflexion and forced equinus, reveals calcaneal
inclination angle of approx. 17° (normal is 45°).
v. Lateral view reveals a bisection of talus is above the metatarsals h.
Treatment: Conservative vs. surgical
i. Serial casting (Kite: JBJS 1963): must be done early and as follows
• First, correct the forefoot adduction- Position the forefoot in
abduction and push in and up under the calcaneocuboid joint and forcing the
forefoot laterally. Abduction is positive and will cause a flatfoot condition
• Second, correct the inverted heel- Before the equinus can be
corrected these 2 deviations must be treated and corrected first (if not a
rockerbottom foot will develop). The cuboid must be brought up to the
calcaneus and the navicular must be brought up to the talus.

NOTE* Do not attempt to fix the equinus until the foot is mildly flat
Third, correct the equinus- By dorsiflexing at the ankle.

NOTE* Maintain the casts until a correction is achieved and then follow with a
Ganley splint for the same amount of time that casting was utilized
i. Radiographic findings consistent with a failed treatment:
i. Forefoot is dorsiflexed on the rearfoot at the midtarsal joint
ii. Rocker-bottom deformity
iii. Flat-topped talus (can be due to talar head ischemic necrosis from
compression)

7. Congenital Deformities of the Forefoot:

a. Overlapping lesser toes
b. Juvenile hallux valgus:
i. Treat with splinting
ii. Treat with surgery- (soft tissue/chondrotomy)
c. Syndactyly (webbed toes)- usually 2nd and 3rd toe:
i. Due to embryonic developmental arrest
ii. Associated with Apert's syndrome (acrocephalosyndactyly)
iii. Treat with corrective plastic surgery (elective plastic surgery)
d. Polydectyly (supernumerary toes):
i. Associated with Ellis-van Creveld syndrome (chondroectodermal dysplasia)
ii. Treat with surgery: resection of non-functional digit (no muscle/tendon
attachments)

NOTE* Functional digit articulates with metatarsal head properly and has
better blood supply
e. Congenital short metatarsals:
i. Short 4th metatarsal can be associated with pseudohyperparathyroidism or
pseudopseudohyperparathyroidism
ii. Treat with metatarsal lengthening procedure
f. Ectrodactyly (lobster claw foot): absence of 2 or more metatarsals and their
associated phalanges.
g. Long toes: Associated with Marfan's syndrome (also seen are visual
problems, ligamentous laxity, long fingers, and mitral valve prolapse)
h. Edematous feet: Associated with Milroy's disease
i. Enlarged or giant toes (macrodactyly): Associated with von
Recklinghausen's disease (CT scan of CNS to check for neurofibromas)

Pediatric Radiology
1. Roentgenographic Development of the Foot:
a. Important ossification points to remember:
i. 1st bone to ossify before birth: calcaneus
ii. Last bone to ossify before birth: cuboid
iii. 1st bone to ossify after birth: lateral cuneiform
iv. Last tarsal bone to ossify after birth: navicular at 3.5 years
v. Calcaneal apophysis appears at age 7 years
vi. Sesamoids appear at age 12 years
b. Ossification at birth:
i. Talus
ii. Calcaneus
iii. Cuboid (can be absent in the premature baby)
iv. Metatarsals
v. Proximal phalanges
vi. Middle and distal phalanges 2-4
vii. Distal phalanx 1
c. Age 3 months: lateral cuneiform
d. Age 4 months: tibial epiphysis
e. Age 6 months: cuboid and lateral cuneiform articulate
f. Age 7 months: talar neck appears, base of metatarsals widen
g. Age 11 months: fibular epiphysis appears
h. Age 18 months: phalangeal epiphyses appear
i. Age 24 months: medial cuneiform and ossification of epiphysis of
metatarsal 1
j. Age 30 months: intermediate cuneiform ossifies
k. Age 36 months: ossification of epiphysis of metatarsals 2, 3, and 4
l. Age 3.7 years.: ossification of navicular
m. Age 4.2 years: ossification of epiphysis metatarsal 5
n. Age 4.9 years: alignment of tarsal and metatarsal bones

NOTE* Boys lag behind girls with regard to skeletal age

o. Age 6.7: ossification of calcaneal epiphysis

p. Age 12 years: sesamoids appear
q. Age 13 years: os trigonum and os vesalianum appear
r. Age 14 years: fusion of epiphyses of distal phalanges of toes 2, 3, and 4
s. Age 15 years: epiphyseal fusion of tibia/fibula, metatarsals 2/3/4, and
phalanges 1, 3, 4, and hallux.
t. Age 17.5 years: epiphyseal fusion complete

2. The Osteochondroses: (also see chapter: The Arthropathies)

These are a group of related disorders which effect the primary or secondary
centers of ossification. Its etiology probably relates to some type of vascular
disturbance to the ossification center, during the time of their greatest
developmental activity.
a. Osgood-Schlatter's disease (osteochondrosis of the tibial tubercle):
i. Clinical appearance: Complaint of pain at the anterior aspect of the knee.
Occurs between the ages of 11-15 most commonly in boys who participate in
sports. On examination there is enlargement of the tibial tubercle, with a
maximum area of tenderness at the insertion of the patellar tendon.
ii. Etiology: Tendonitis of the distal portion of the patellar tendon with
secondary hypertrophic new bone formation
iii. X-ray findings: Soft tissue swelling anterior to the tibial tuberosity (acute
stage), irregularity in the ossification center of the proximal tibial tubercle is
a normal variation, late stages a prominent/irregular tibial tuberosity with or
without a small particle of bone anterior and superior to the tibial tuberosity.
iv. Differential diagnosis: Must R/O osteogenic sarcoma
v. Treatment: Restriction of excessive physical activities, severe cases
immobilization of the knee.
b. Kohler's Disease (osteochondritis of the tarsal navicular):
i. Clinical appearance: Affects boys (80%) 3-6 years old. Can be a
spontaneous onset (pain and swelling over the navicular) or brought on by
injury. A limp (antalgic gait) may be present with the child walking on the
lateral side of the foot.
ii. Etiology: Abnormalities in ossification of the navicular from compression of
the bony nucleus at a critical stage of growth of the navicular.
iii. X-ray findings: A disc-like navicular is visualized, with irregular ossification,
intermingled plaques and hazy fibrocystic degeneration. There is soft tissue
swelling around the bone.
iv. Treatment: In mild cases stop strenuous exercises and use rigid
orthoses. In severe cases a BK cast in supination for 6-8 weeks.
c. Freiberg's Disease (osteochondritis of the second metatarsal):
i. Clinical appearance: Usually seen in young active adolescents (after
age 13). It is more common in females, and is usually unilateral affecting
the 2nd metatarsal head primarily (can affect others). Pain is localized under
the affected metatarsal head, with swelling and limitation of motion at the
m.p.j.
ii. Etiology: Due to a vascular insufficiency from trauma to the epiphyseal
area.
iii. X-ray findings: Widening of the joint space with effusion and soft tissue
swelling in the early stages. Later there is a flattening of the head of the
affected metatarsal, a narrowing of the joint space, and subarticular
sclerosis. There is never any ankylosis.
iv. Treatment: Orthoses to remove pressure from the metatarsal head in
mild cases. For severe cases use a BK cast for 4-6 weeks, or if symptoms
persist into adult life a metatarsal head resection or total joint replacement.
d. Sever's Disease (calcaneal apophysitis):
i. Clinical appearance: Seen in children ages 8-14 years. Most common
in boys 10-11 with a cavus foot type. Complaints are pain in the heel
especially after rigorous activity. Pain is exacerbated by squeezing the
medial/lateral epiphyseal margins of the calcaneus.
ii. Etiology: Excessive traction on the calcaneal apophysis
iii. X-ray findings: Multiple centers of ossification, a moth eaten appearance
of bone, and apophyseal sclerosis (all of which also can be seen in a normal
apophysis)
iv. Treatment: Cessation of rigorous physical activity, stretching of posterior
muscles, shock absorbing heel pad, and/or orthoses. If severe then a BK cast.

Pediatric Gait Patterns

1. Parameters of Normal Gait:
a. Early independent ambulator (1 year) characteristics:
i. Wide base of gait
ii. Prolonged hip and knee flexion
iii. Arms abducted with elbows extended to increase stability
iv. High cadence
v. Low velocity
vi. Short step length
b. Toddler (1-2 years) characteristics:
i. Narrowing base of gait
ii. Reciprocal arm swing
iii. Increased step length
iv. Increasing velocity
v. Mild foot drop
c. 2 year old characteristics:
i. Reduced external rotation during arm swing
ii. Decreased pelvic tilt
iii. Knee flexion in early stance
iv. Knee extention in late stance
v. Emerging heel strike
vi. Disappearance of mild foot drop
d. 3 year old (early mature gait) characteristics:
i. High cadence
ii. Low velocity
iii. Increasing stride length with growth of limb
iv. Increasing single support phase
e. 7 year old characteristics:
i. Decreasing cadence
ii. Increasing stride length
f. Full mature gait characteristics:
i. Increased single support phase
ii. Increased velocity
iii. Increased stride length
iv. Increased ratio of pelvic span to ankle spread
v. Decreasing cadence

2. Abnormal Gait Patterns:

a. Spastic gait: Manifested by internal rotation and adduction of the entire
limb, with hip/knee/ankle in marked flexion. Seen with cerebral palsy, familial
spastic diplegia, paraplegia, and hemiplegia.
b. Dyskinetic gait: A constant movement abnormality with a high degree of
variability from patient to patient and gait cycle to gait cycle. It is
characterized by motion involving considerable effort, often with deliberate,
almost concentrated step. Seen with cerebral palsy, Huntingtons chorea, and
dystonia musculorum deformans.
c. Ataxic gait: Characterized by a marked instability during single limb
stance with an alternating wide/narrow base during double support. During
swing phase the limb will swing widely and cross the midline. Seen with
multiple sclerosis, tabes dorsalis, diabetic polyneuropathy, Fredrich's ataxia.
d. Waddling gait: A labored walking, exhibiting difficulty with balance,
proximal pelvic instability, leading to a lumbar lordosis. May see an
associated equinovarus foot type. Seen with Duchenne muscular dystrophy,
limb-girdle muscular dystrophy, Beckers muscular dystrophy, spinal muscular
atrophy, and congenital dislocated hips.
e. Steppage gait: Gait exhibits a swing phase drop foot. Seen with Charcot
Marie-Tooth, polio, Guillain-Barre syndrome, CVA, paralytic drop foot, and
fascioscapulohumeral dystrophy.
f. Vaulting gait: Gait changes include a high cadence, increased lateral
trunk movement, scissoring and instability from step to step, suggesting a
loss of balance. Seen with myotonic dystrophy.
g. Equinus gait: Gait exhibits a swing phase ankle plantarflexion with no
heel contact. Seen with cerebral palsy, Charcot-Marie-Tooth, muscular
dystrophy, spinal muscular atrophy, schizophrenia, osseous block of the
ankle, and habitual toe walking.
h. Festinating gait: Gait changes include loss of reciprocal arm swing,
decreased velocity, shuffling, decreased stride length, and increased
cadence. Seen with Parkinson's disease.
i. Trendelenberg gait: Stance phase of each step leads to a contralateral
tilt
of the pelvis with a deviation of the spine to the affected side. Seen with
dislocated hip or weakness of gluteus medius.

Intoe Gait
1. Evaluation:
a. History:
i. Onset of the problem: What age? Sudden onset? How long?
ii. Severity of the problem: Difficulty walking? Falling? Does not want to
play? More pronounced in rigid shoes?
iii. Developmental history: as previously discussed
iv. Hospitalizations/ injuries v. Family history
b. Observation of gait:
i. Angle of gait: in-toe or out-toe or rectus
ii. Position of the knee at midstance: externally/ internally deviated,
straight
iii. Presence of a limp?
iv. Presence of equinus?
v. Early heel lift off?
vi. Bouncing gait?
vii. Rapid out-toe after midstance?
viii. Excessive pronation? No arch present?
c. Examination of hips: (performed in younger children: < 2 years)
i. Should be able to abduct hips at least 70° (flexing hips and knees)
d. Determination of femoral position:
i. Mark the center of both knees and position them straight up
ii. With the child lying down" and the hip and knee extended, rotate the
femur inward (estimate the number of degrees)

NOTE* This is done by rotating the knee and visualizing this by noting the
numbers on a clock, whereby each hour equals 30°. So if the knee moves
from the straight up position to 2 o'clock (external) that equals 60° of
external rotation.

iii. Rotate the femur outward (estimate the number of degrees of motion)
iv. Perform the same examination with the hip flexed an then with the knee
flexed (to eliminate soft tissue elements)

NOTE* If the measurements vary with positional changes then the abnormal
endings are due to soft tissue tightness. If the measurements are the same
then the problem is torsional within the femur.

e. Average rotation of the hip joint:

i. Up to 1 year old: twice external to internal rotation
ii. At 5 years old: internal = external rotation
f. Internal femoral position/can produce an in-toe gait:
i. Anti-torsion and retroversion
External femoral position/can produce an out-toe gait:
ii. Retrotorsion and retroversion g. Examination of the knee joint:
i. Normal frontal plane motion: birth/5-10°,decreases to 0-5° at 6 years
old
ii. Normal transverse plane motion: birth/5-15°, 0-5° at years old
iii. Pseudomalleolar torsion (pseudolock): excessive transverse plane
motion at the knee can result in in-toe gait (usually 15-35°)
h. Examination of malleolar position (tibial torsion: add 5° to malleolar
torsion):
i. measure the malleoli with a goniometer
ii. Values: birth/0-5°, 6 years old/13-18° (less than this = in-toe gait)
i. Other deformities causing in-toe gait:
i. Talar neck adductus
ii. Clubfoot
iii. Talipes varus
iv. Metatarsus adductus
v. Spastic posterior tibial ms.
vi. Genu varum
vii. Tibia varum
j. Treatment:
i. Not all cases warrant treatment
ii. The cases that should be treated are those in which 8° of improvement
would not bring their feet into a straight-forward position,
those children having difficulty walking, or a destructive foot type
iii. Manipulation of the soft tissues by the parent
iv. Functional orthoses to control pronation
v. Gait plates (child must have a propulsive gait)
vi. D-B bar (inhibits abnormal sleeping positions- use 1 " wider than hips)
vii. Ganley splint (like D-B bar but neutralizes pronation at the STJ)
viii. Plaster cast for pseudolock
viii. Surgery
Pediatric Fractures
1. Anatomical Considerations:
a. Epiphysis
i. Pressure epiphysis: At the articular surface, involved with growth
ii. Traction epiphysis: Not at the articular surface and not involved with
growth (femoral trochanter, tibial tuberosity, calcaneus, base 5th metatarsal)
b. Diaphysis
c. Metaphysis
d. Epiphyseal plate: Zone between the epiphysis and the metaphyseal plate
Microscopic appearance (multiple cell types)
i. Resting cells
ii. Proliferating cells
iii. Endochondral cells
e. Points to remember:
i. Matrix makes the plate the strongest at areas close to the epiphysis and
metaphysis.
ii. The zone of provisional calcification, where cells are dividing and
calcification begins, is the weakest part of the region, poor in matrix;
epiphyseal injuries usually occur at this part.
iii. Due to the separation at the middle of the physis, it leaves the
proliferating cell zone uninterrupted; thus there is usually no interference in
bone growth, as long as circulation to the physis remains intact.
iv. Diaphyseal blood supply will nourish the layer of endochondral ossification
without crossing the epiphyseal plate.
v. Epiphyseal blood supply will enter through the joint capsule and through
the perichondrium to the epiphysis zone area of the epiphyseal plate (2
types: intracapsular & extracapsular).
vi. When making a diagnosis a minimum of 3 views should be taken and
bilateral x-rays should be taken.

Note* The physis contains 3 parts:

a. Zone of Growth: containing the dividing and resting cells
b. Zone of Maturation: for calcification
c. Zone of Transformation: for ossification
The Zone of Ranvier is a groove surrounding the periphery of the physis and
is
composed of..
a. Fibroblasts
b. Mesenchymal tissue (undifferentiated cells-multipotential)
c. Osseous ring of Lacroix (an extention of the metaphyseal cortex)
The Zone of Ranvier functions so that longitudinal and latitudinal growth of
the
physis proceeds in harmony
Note* Remember that the periosteum in the child is more vascular, thicker,
loosely attached and stronger than in the adult

2. Results of a Swedish study of epiphyseal fractures:

a. The risk of fractures increases at ages 11-12 in females and 13-14 in males
b. Chance of epiphyseal fracture is 42% till age 16 in males and 27% in
females.
c. Fractures at the epiphysis peak at 2 years of age and again between 11-14
years of age.
d. 13.4% of the fractures occur in the foot and ankle e. 21 % of the injuries
are sports related
f. Pathological fractures should be taken into account occurring due to minor
trauma in diseases such as: renal disease, cystic fibrosis, growth hormone
deficiency, diabetes mellitus, Turner's syndrome.

3. Important points to remember:

a. Haversian canal system in children is more extensive as compared to that
of adults, especially in the metaphysis.
b. Children's fractures can be of compression or tension type; in adults
compact bone fails in tension only.
c. Incomplete failure in tension results in a greenstick fracture
d. In. children, the strongest skeletal segment is the periosteum, the weakest
being the growth plate.
e. Due to the strong periosteum one rarely sees open fractures in children
Intermediate strength is the epiphysis which is protected by joint congruency
and cartilage.
f. Capsule and ligaments are a continuation of the periosteum, which mostly
bypasses the epiphysis, distributing forces to the growth plate and
metaphysis.

4. Classifications of epiphyseal fractures:

a. Salter-Harris: Is an anatomic classification applicable to most physeal
injuries. There are problems associated with this classification: the size of the
epiphyseal/metaphyseal fragment is not quantified. There are 5 types:

Type 1: complete separation of the epiphysis with no fracture of bone Type 2:

fracture along the epiphysis then through the metaphysis producing a
triangular fragment
Type 3: extends from the joint surface to the epiphyseal plate, along the
plate to the periphery
Type 4: extends from the joint surface to the epiphysis and plate and through
a portion of the metaphysis
Type 5: severe crush injury and compression of the plate

NOTE* Type 6 was added by Rang, a bruising of the peripheral growth plate
secondary to blunt trauma, resulting in a peripheral osseous bridge causing
angular deformity (treat with resection of the osseous bridge with
correction of the angular deformity)

i. S-H Type 1: Fibular fracture

 occurs due to inversion stress
 may appear as an isolated injury or in combination with a medial corner
injury to the ankle (Salter 3 Tibial)
 diagnosis is difficult (there should be at least one cm of lateral soft tissue
swelling around the plate area)
 these fractures may or may not be displaced
 good prognosis
 apply short-leg walking cast for at least 3 weeks
 occurs in ages < 12

ii. S-H Type 1: Tibial fracture

 occurs from shear stress due to external rotation injuries
 can occur with fibula shaft fracture which is usually transverse
 may be displaced or nondisplaced

 good prognosis
 treat with closed reduction (prn) and immobilze in NWB A-K cast for 3
weeks plus 2 weeks in a B-K cast

iii. S-H Type 2: Fibular fracture

 caused by eversion and external rotation of the foot
 treat with 3-4 weeks in a B-K cast
 occurs in the older age group where the epiphyseal plate is more bonded
(age 13)

iv. S-H Type 2: Tibial fracture

 caused by eversion (small medial fragment), external rotation (large
medial fragment), or plantarflexion (posterior fragment)
 associated with a fibular fracture
 may be displaced or non-displaced
 average age is 13
 triangular fragment called Thurston-Holland sign medially
 opposite disruption called Lamellar sign laterally, is the overhang of the
proximal end of the tibia over its distal end as the fracture shifts laterally
 prognosis is good
 application of B-K cast for 3-4 weeks and mild manipulation by reversing
the mechanism of injury (avoid excessive manipulation because the
germinal cells are already damaged)

iv. S-H Type 3: Tibial fracture

 caused by inversion
 may or may not be displaced (take MO x-ray of the ankle to determine
amount of displacement)
 treat if non-displaced with A-K cast for 3 weeks and a B-K cast for 3 weeks
 treat if displaced (by more than 2 mm) with ORIF (the fixation must not
cross the plate)
 good prognosis if alignment is restored

v. S-H Type 4: Tibial fracture

 caused by a continuing inversion force greater than that in a Salter 3
injury
 treat same as Salter 3 tibial for non-displaced and displaced, except that
additional fixation is needed for the metaphyseal fragment (proper
anatomical reduction/alignment is necessary)
 these are rare
 possible growth disturbances
vi. S-H Type 5: Tibial fractures
 caused by severe axial loading across the plate resulting in multiple
fracture lines
 these fractures may lead to premature fusion across the whole plate
causing a limb length discrepancy
 may lead to fusion on one side or from front to back causing asymetrical
 angulation of the limb
 treat if displaced by ORIF to restore articular congruity
 prognosis is poor

vii. S-H Type 6:

 due to bums or avulsions
 loss of growth plate substance
 epiphyseodesis can result with premature epiphyseal plate closure with
progressive shortening and angular deformity

viii. Summary of S-H fractures:

 the younger the patient the greater the chance of deformity
 type 1 and 2 have a better prognosis than types 3 to 6
 a non-displaced epiphyseal fracture has a better prognosis
 a compression fracture has the poorest prognosis
 blood supply interruption leads to growth arrest
 infection in addition to a fracture can be disastrous
 reduction (open or closed) should be done gently within 10 days after
trauma
 healing of epiphyseal injuries takes 3 weeks as compared to 4-6 weeks for
bone
 the resulting deformity has to be treated surgically
 follow-up for growth retardation should be done for at least 3 years
 radiological studies with markers indicate 5 types of post-traumatic
growth patterns: symmetrical growth, initial/temporary growth
stimulation, initial/temporary growth retardation, initial/ progressive
growth retardation, and initial/permanent growth arrest.
b. Dias and Tachdjian: Added a classification of physeal injuries based in
Lauge-Hansen and Salter-Harris. The first term describes the position of the
foot at the time of impact, and the second term refers to the direction of
the talus taken by the injuring force. It involves 4 types:
i. Supination-plantarflexion
 Result in Salter 2 fracture of the distal tibia with the metaphyseal
fragment
posteriorly
ii. Supination-external rotation
 Stage 1:Characterized by Salter 2 of the distal tibia
 Stage 2: Characterized by a short oblique fibula fracture above the distal
fibula physis
iii. Supination-adduction
 Stage 1:Characterized by Salter 1 or 2 of the distal fibula
 Stage 2: Characterized by Salter 3 or 4 of the distal tibia
iv. Pronation-external rotation
 Stage 1: Characterized by a Salter 1 or 2 of the tibia
 Stage 2: Characterized by a fibula fracture above the level of the tibiotalar
joint with the metaphyseal fragment lateral

c. Juvenile Tillaux fracture:

i. An avulsion fracture of the distal lateral tibial tubercle by the anterior
tibiofibular ligament due to an external rotation force
ii. This fracture is seen on an A-P view as a S-H type 3 fracture of the lateral
distal tibial epiphysis, involving from 20-50% of the width of the epiphysis
iii. Usually occurs in ages 12-14, because of closure of the medial half of the
epiphysis and not the lateral half

iv. Treat if non-displaced with a A-K cast for 6-8 weeks with some internal
rotation of the lower end of the cast

NOTE* Treatment is ORIF if displaced with lag screw technique from distal
lateral to proximal medial (can cross the physis since growth is already
completed)

Note* To best view this fracture, take an oblique x-ray in which the fibula is
rotated internally to eliminate the overlap of the tibia to better see the
entire distal tibial epiphysis

vii. Triplane fractures:

  combination of a central vertical Salter 2 and Salter 3 tibial fracture
 can be missed on routine x-rays
 treat as per Tillaux type
The Limp in Childhood
Limp is an exaggeration or deficiency of normal gait which may be painful or
painless. It may be associated with paralysis, spasticity, contractures, loss of
supporting structures, limb length discrepancy, and ataxia. It should be
considered to reflect serious disease until proven otherwise. Except in the
most obvious causes, a complete review of history and general physical
exam is necessary and if indicated appropriate lab studies, x-rays, and
consultations. Looking at limp by age groups is helpful.
1. The Beginning Walker:
a. Congenital hip dislocation
b. Trauma (always consider abuse)
c. Septic joint (diagnosis urgent especially in the hip)
d. Osteomyelitis
e. Synovitis
f. Neuromuscular disorders

2. The Walking Child:

a. Congenital dislocated hip
b. Cerebral palsy (may only manifest itself as intoeing)
c. Discitis (pain on straight-leg raising)
d. "Toxic" synovitis (must r/o septic hip, labs are WNL, a small percentage
develop Legg-Perthes disease)
e. "Growing pains"
f. Legg-Calve-Perthes disease

3. Preteens-Teens:
a. Congenital dislocated hip
b. Slipped proximal femoral capital epiphysis (the patient is usually larger
and male; holds leg in internal rotation; in gait patient lurches over the
involved hip

SUMMARY OF TYPES OF LIMP

Age (Yr) Antalgic Paralytic Short Leg Contracture Loss of Support
Birth-4 Trauma, infection Cerebral palsy, Congenital, coxa Spina bifida, CHD, trauma,
spinal vara, cerebral van, spine I:
muscular CHD, infection palsy, CHID, Infec-
atrophy, tion
5-10 Trauma, Cerebral palsy, Spina bifida, Trauma, CHD, Trauma, polio, infec-
infection, spina trauma, Legg- tion, muscular dys-
rheumatoid bifida, muscular CHD, Infection, Calve-Perthes dis- trophy
arthritis, dys- rheumatoid ease, infection,
11-14 Legg-Calve-
Trauma, trophy,
Muscularpolio arthritis
infection, trauma, rheu-
Infection, trauma, Trauma, slipped capi-
synovitis, dystrophy, slipped capital Legg-Calve- tal femoral epi-
slipped capital polio, peripheral femo- Perthes physis, inadequate
femo- nerve trauma, ral epiphysis, neo- disease, slipped treatment, CHD
ral epiphysis, CNS plasm capi-
infec-
CHD, Congenital heart disease. neoplasm, tal femoral
Juvenile Hallux Valgus
1. Classification:
a. Congenital:
i. Aplasia: small toes, cleft foot, or amputated toes (a secondary HAV/
interphalangeus, no met primus varus)
ii. Congenital vertical talus: overgrowth of the medial column
iii. Residual met adductus
b. Hyperlaxity (hypermobile pes planus):
i. Physiologic
ii. Pathologic: Down's and Marfan's syndrome
c. Adolescent:
i. Advanced met primus varus secondary to
 trapezoidal medial cuneiform
 oblique 1st met-epiphyseal line
 oblique 1st met-medial cuneiform joint
ii. Associated hypermobile pes planus
d. Neurologic:
i. Equinovalgus: contracted achilles with overpull of the peroneals
ii. Spasticity of the adductor hallucis
e. Superimposed factors:
i. Extrinsic: shoes, ballet
ii. latrogenic

2. Treatment: Treatment depends upon the underlying etiology, age, and

clinical findings.
a. Akin procedure: for hallux interphalangeus
b. Tendon sling with Modified McBride
c. Lapidus procedure
d. Cotton procedure (sagittal plane opening wedge of medial cuneiform for
1st metatarsal elevatus)
e. Hemiepiphysiodesis at the proximal phalanx and base of the first
metatarsal
f. Proximal 1st metatarsal osteotomies (Austin, Mitchell) good up to 140 IMA
g. Distal 1st metatarsal osteotomies

3. Complications:
a. The most common complication seen with correction of juvenile bunion is
shortening of the first metatarsal. This is a result of interruption of growth of
the physis from
i. Base wedge osteotomies
ii. Epiphysiodesis
 NOTE* The extent of shortening is dependent on the amount of dissection
about the physis and the age of the child
b. Avascular necrosis from metatarsal head osteotomies
c. Over or undercorrection

Biomechanical Evaluation of the Child

1. The initial visit:
a. Perinatal history:
i. Was the child full term or premature (premature children are at more risk
for neurological problems)
ii. Standard delivery, breech delivery (dislocated hip), or cesarean section
b. Developmental landmarks:
i. When did the child start to ambulate? (the normal range is 9-16 months) If
a child is delayed in this then you must explore mechanical pathology,
musculoskeletal pathology, and neurologic deficit

2. Gait evaluation:
a. Head tilt: Observe the position of the head in gait. An obvious tilt away
from the midline would indicate a possible limb length deficit
b. Shoulder and pelvis level: If the child walks with an obvious shoulder drop,
one should observe the level of the pelvis.

NOTE* Generally, an apparent shoulder drop in a young child may be c.

consistent with a shortened limb on that side. In a child under the
age of 12 or 13, the shoulder drop is to the shortened side as there
is generally no scoliosis present until that age. This is in contrast to
the adult where the shoulder drop is typically on the contralateral
side from the shortened limb
Patellar position: An important landmark when exaluating the child with
transverse plane deformities of the legs.

NOTE* If a child has an adducted gait and the patellar position is internally
rotated ("squinting patella") then at least a portion of the deformity is at
the femoral level. If the patellar position is normal, this indicates a
problem within the knee, tibia, or the foot

d. Angle of gait: Typically a child's angle of gait should be more in an external

position. If a child's gait is adducted on the transverse plane because of a
torsional abnormality, that angle of gait is generally consistent. However,
some children demonstrate an angle of gait deformity that varies
considerably from step to step. In these cases, special attention should be
directed to the amount and direction of transverse plane knee rotation
present on the off-weight-bearing examination. In other instances, some
children will exhibit an "adducting" (rather than an adducted) gait at heel
contact which is due to tight medial musculature.
e. Calcaneal position: Most children have a pes planus on weight-bearing. A
child's calcaneus is normally everted at the onset of ambulation which can
persist till the age of 6-7 years old.

NOTE* Calcaneal eversion should reduce approximately 1° per year.

Therefore a child with a calcaneal eversion of 6-7° should reduce to 3.
perpendicular by the age of 7 (a rough estimate) Off-
weight-bearing examination:
a. Hip range of motion: External vs. internal rotation measured with the child
supine has about a 2:1 ratio for the first few years. The total ROM measures
more than 1000. Both the amount of external rotation and the total ROM
diminishes over the first few years and essentially becomes symmetrical at
the age of 5-6 through adulthood. This is measured with a Martin's
goniometer placed on the epicondyles of the femur. If a marked amount of
internal hip rotation is noted compared with external rotation, the
examination should include evaluation of motion with the hip extended and
hip flexed positions (determines whether structural vs. positional)
b. Knee range of motion: At birth through 4 years there may be a total of 20-
30° of transverse plane rotation available at the knee. This decreases
drastically at age 3-4. In a normal child under the age of 3 there should be a
symmetrical amount of internal and external rotation of the tibia relative to
the femoral segment. However, if there is 300 of external rotation available
from a resting position with minimal internal rotation this indicates that the
tibia is being maintained in an internally rotated position (congenitally short
hamstring or medial head of the gastrocnemius)
c. Tibial torsion: This is assessed by measuring malleolar position, by
determining the amount of anterior rotation of the tibial malleolus relative to
the fibular malleolus (measured by a goniometer placed on the malleolei or
tractograph placed on the plantar aspect of the foot). At birth there is no
tibial torsion present, however, this gradually increases in an external
direction through the first 7-8 years to a normal adult value of 13-18°. Tibial
torsion is generally 5° greater than malleolar position.
d. Ankle joint dorsiflexion: At birth there is unrestricted ankle joint
dorsiflexion (can approach 75°) , reduces to 20-25° by age 3, reduces to 15°
by age 10, and reduces to 10° by age 15. When obtaining this measurement
the subtalar joint is held in neutral position or the midtarsal joint will unlock
thereby introducing additional forefoot dorsiflexion. If dorsiflexion is limited
with the knee extended, retake the measurement with the knee flexed. If
there is limited ankle dorsiflexion with the knee extended but greater than
150 with the knee flexed, the child has a gastrocnemius equinus. If the
limitation is present with the knee extended and flexed then a gastroc-soleus
equinus is most likely responsible (an osseous equinus is uncommon in this
age group)
e. Subtalar joint range of motion: Since a child under the age of 3 has an
apropulsive gait, measurement of the STJ ROM is not essential. Only after the
age of 3 when a heel-toe propulsive gait is initiated, does a functional
orthoses become useful, and therefore so does the STJ measurement. Rangle
of motion is accomplished by bisecting the calcaneus and measuring full
eversion and inversion. This is generally more than the adult values. The foot
must be measured in a slight dorsiflexed position for accuracy.
f. Midtarsal joint range of motion: The STJ is placed in neutral position and the
MTJ is locked (in this fashion the 2 axes of the MTJ cross each other and limit
extraneous midtarsal joint mobility upon examination). A forefoot varus or
valgus deformity upon examination will not be outgrown, and any degree of
forefoot deformity should be supported to prevent abnormal compensation

4. Weight-bearing examination
a. Relaxed and neutral calcaneal stance position: The calcaneal bisector on
weight bearing should be noted. Abnormal calcaneal eversion in the child can
be due to compensated forefoot varus (frontal plane),
compensated gastrocnemius equinus (sagittal plane), and internal
tibial/femoral torsion (transverse plane).
b. Tibia varum: The angle that the distal one-third of the tibia makes relative
to the ground with the STJ in neutral position is tibial varum (generally 0-5° in
the child)
c. Genu varum/genu valgum, genu recurvatum: The child demonstrates
changes in frontal plane position at the genicular region at different ages . If
excessive genu varum is detected and does not reduce with time, the
possibility of Blount's disease or juvenile rickets should be investigated. If
genu valgum is noted and does not decrease with time, then functional
orthoses should be used to reverse the severe pronatory force to the feet. A
posterior deflection of the femur into the tibia may be present measuring 5-
10° until the age of 5. If any amount greater than this is present before the
age of 5, or any amount present at all after 5 should be checked for
pathology
d. Limb length inequality: This is done by palpating the anterior superior iliac
spine, and measuring to the tip of the medial malleolus. Repeat
measurement 2-3 times consecutively for consistency. If there is asymmetry
in their levels, further investigation is necessary

Corrective Casting in Infants

1. Application of the cast:
a. Only gentle force is exerted
b. Webril® is utilized and should be no more than 2 layers thick with 3-4
layers at the posterior-of the heel and at the upper limit of the cast. It should
be wrapped under a slight stretch making a snug fit. It should extend one-
half inch beyond the plaster
c. Use extra-fast setting plaster
d. Babies usually require only 1 roll of 3 inch plaster and 2 inch rolls for
newborns

2. Calcaneovalgus deformity:
a. The assistant grasps the thigh and toes and then holds the hip, knee, and
foot in the anteroposterior plane with the foot in equinus
b. With the foot held in equinus, the metatarsal adducted, apply pressure in
three areas:
i. The posterior aspect of the heel
ii. Over the talus medially
iii. Laterally over the 5th metatarsal area

3. Metatarsus adductus:
a. Failure to appreciate the rearfoot malalignment (talocalcaneal breach on
AP x-ray) will result in failure of treatment and produce a severe flatfoot
deformity
b. Pressure should be applied in three areas:
i. Pressure laterally over the cuboid area
ii. Counter pressure medially on the talar head (attempts to close down the T-
C angle)
iii. Pressure along the 1st metatarsal medially
iv. If the hallux is in adduction due to contraction of the abductor hallucis, a
strip of plaster is used to hold the hallux in a rectus or slightly abducted
position

4. Talipes equinovarus:
a. Apply 2-3 casts consecutively,, with the foot in "unlocked" equinus position
b. Apply three point pressure:
i. Evert the heel by pressure medially
ii. Lateral counter-pressure over the talar head in an attempt to open up the
T-C angle (to try to move the calcaneus laterally from beneath the talar
head)
iii. Pressure along the 1st metatarsal medially

NOTE* Response to this should be a dramatic improvement in the transverse

and frontal plane alignment. Later casts are applied with the forefoot to
rearfoot in a neutral position and the knee flexed to stretch the posterior
structures (equinus is overcome by pulling down on the posterior of the heel
and applying dorsiflexion pressure, making sure some of the pressure is on
the calcaneocuboid area). Being overzealous will result in a rocker-bottom
foot with the calcaneus in an equinus attitude.

5. Tibial torsion:
a. The cast is applied from the toes to midthigh with the foot in mild equinus,
the knee flexed to at least 300
b. The corrective force is exerted by holding the thigh stable and rotating the
foot to the end range of motion (avoid inversion or eversion while doing this)

The Toe-Walking Child

Toe-walking may be a result of idiosyncratic or idiopathic factors with no
pathological background, or can follow serious neuromuscular,
psychological, and skeletal pathologies. Therefore, the etiology of habitual
toe-walking is determined by exclusion:
1. Examination:
a. Medical history: As above
b. Gait Evaluation:
c. Physical examination:
i. Musculoskeletal
ii. Biomechanical
iii. Neurologic

2. Differential diagnosis:
a. Cerebral palsy: A fixed nonprogressive neurologic deficit acquired before,
during or in the months after birth. The spastic form is most likely to produce
a toe-walking gait
b. Pseudoscissor gait: Must be recognized and differentiated from the scissor
gait of CP. This condition occurs when there is a combination of habitual toe-
walking and adducted limb position due to internal tibial
and/or femoral position. The child with a pseudoscissor gait will have more
stability than a child with a scissors gait
c. Mental retardation: There are behavioral clues to a diagnosis such as
dependency on routine, distractibility, fear, lack of spontaneity, poor
judgment, and repetitive physical activities that are disturbing to others
(rocking, head banging, temper tantrums, etc.)
d. Clumsy child syndrome: A behavioral problem characterized by poor
control of motor function, impulsiveness, short attention span, and
hyperkinesis
e. Autism: Autistic children are principally disturbed in their lack of emotional
rapport and in their behavioral characteristics. They show seclusiveness,
irritability when seclusiveness is disturbed, day dreaming, bizarre behavior,
decrease of interest, regression of interpersonal interests, and sensitivity to
criticism. There is a gradual withdrawal from affective contact with people
f. Dystonia musculorum deformans: A disease of the basal ganglia
characterized by slow, powerful twisting and writhing movements
g. Delayed maturation of the corticospinal tracts: Results in spastic toe-
walking due to the lack of inhibition of the stretch reflexes. This condition
disappears by the age of 6-8
h. Diastematomyelia: Consists of a partial or complete division of the spinal
cord by tissue located in the midline of the spinal canal. There is a mixed
upper and lower motor neuron deficit involving the bladder and bowel
function and progressive disturbances in gait develop by the age of 2-3
i. Muscular dystrophy (Duchenne and limb-girdle: Toe-walking is the result of
a disturbance of antagonistic balances of the variously affected muscle
groups. With limb-girdle MD the first symptoms appear in the 2nd decade.
With Duchenne's MD the child may walk later than expected with frequent
falls when learning to walk
j. Peroneal muscular atrophy: This disorder begins in the feet and legs
producing difficulty in walking, paresthesias of the legs, and muscle cramps.
There is early weakness of the intrinsic muscles of the feet, ankle
dorsiflexors, and peroneals. The patellar DTR is lost, vibratory and position
sense are diminished
k. Gastrocnemius soleus muscle equinus: The most common entity is the
habitual toe-walking child. The Silferskjold test first used to differentiate
spastic gastrocnemius equinus from spastic gastrosoleus equinus can be
usefully applied to evaluate nonspastic short calf muscles. Clinically, a child
with a gastrocnemius soleus muscle equinus will stand with an abducted
stance angle and will often exhibit a genu recurvatum and significant
midtarsal pronation
1. Clubfoot: A deformity in which the leg and foot are said to resemble a club,
and is associated with congenital hip dislocation, arthrogryphosis multiplex
congenita, spinal abnormalities, and neuromuscular disease. The form of
clubfoot that leads to toe-walking is talipes equinovarus.
a. Shoe therapy: Rigid sole high top shoe
b. Orthoses therapy: Heel lifts, gait plates, and knee-ankle-foot orthoses c.
Short leg casting
c. Auditory feedback: A method of cognitive muscle management
d. Surgical intervention: With a significant structural gastrosoleus muscle
equinus