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