Hersheychapter 19

8/9/2019 Hersheychapter 19

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Chapter 19: PediatricsEvaluation of the Pediatric Patient PediatricBiomechanics:

Normal Values (Newborn to Adult)

Congenital DeformitiesPediatric RadiologyPediatric Gait PatternsIntoe GaitPediatric FracturesThe Limp in Childhood

Juvenile Hallux ValgusBiomechanical Examination of the Child

Corrective Casting Techniques in InfantsThe Toe-Walking Child


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PEDIATRICSEvaluation of the Pediatric Patient1. Examination of the Neonate:a. Apgar score (Dr. Virginia Apgar: 1953): It is based upon observations madeat 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 severeacidosis.

b. Proportional measurementsi. Head circumference (averages 13 inches/slightly larger than the chest)ii. Chest circumferenceiii. Sitting height (crown rump height roughly equal to the headcircumference)

c. General postural considerations: depends on the in-utero positioni. Cephalic delivery

ii. Brow deliveryiii. Breech delivery

d. Examination of the head and necki. Check for equal eye movementsii. Head should be held in the midlineiii. ROM of the neck tested

e. Examination of the upper extremitiesi. Palpation of the humerus: see if the anterior bulge of the humeral headabsent (produces a dislocated shoulder), and check for fracture of humerus.

ii. Cleidocranial dysostosis: clavicles absent (this condition is detectedlater in life due to gait changes from femoral neck deformity).iii. Check ROM shoulders: if limited then possible dislocationiv. Check ROM elbows: if limited possible arthrogryphosisv. Check fingers and nails the absence of which are caused bycongenital abnormalities

f. Examination of the spine: The infant is placed on his abdomen, and thehand is run over the spine and palpation for scoliosis/kyphosis is performed.i. Congenital scoliosis: is concerned with scoliosis arising in association withcongenital vertebral anomalies. Some children with congenital scoliosis show

curvature at birth, but many do not. The anomalies and variations indevelopment of the vertebrae may be single or multiple and may beassociated with other anomalies, particularly in the ribs, which are frequentlycombined with spina bifida.ii. Congenital kyphosis: kyphosis at birth is almost always due to congenitalanomaly of the vertebral column.iii. Klippel-Feil syndrome: absence of one or more cervical vertebrae, ortwo or more fused together, with brain stem abnormalitiesiv. Vertebral agenesis: absence of only the coccygeal segment to


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absence of all the lumbar and sacral vertebrae.v. Spina bifida: see section Congenital Deformities

g. Examination of the lower extremitiesi. Gross abnormalitiesii. Examination of the hip (dislocation/ femoral rotation/neonatalosteomyelitis)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 pesplanus/ talipes equinovarus)

h. Examination of CNS (muscle tone/reflexes): Usually, at birth, the infant islimp, 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 forsymmetry, myoclonic jerks, and convulsive movements. Poor muscle tone inan infant after a few minutes of age is a grave sign. Infants who remain limplonger 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.

2. Neurological Examination of the Infant:a. Plantar responsei. Either normal orii. Babinski (should disappear by age 1 year)b. Palmar graspi. Either normal orii. Abnormal (should be normal by age 4 months)c. Plantar graspi. Either normal or

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


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ii. Abnormal (should disappear by age 1 year)d. Deep tendon reflexes (hypo or hyperreflexia/absent/symmetrical)i. Patellarii. Achillesiii. Biceps/triceps/flexor carpi radialise. Ankle clonus (absent or present)f. Examination of the anterior fontanelle (should close by age 2 years)i. Bulging indicates excessive cranial pressureii. Depression indicates dehydrationg. Head and neck control (infant should have control by age 2 months)h. Muscle poweri. Motor skills of the lower extremities: developmental average landmarksi. Crawls: 3-5 monthsii. Creeps: 7-9 months iii. Stands: 9-14 monthsiv. Cruises: 9-12 monthsv. Walks: 7-18 months (average is 13 months)

2. Orthopedic examination of the Infant:a. Examination for dislocated hip (discussed under the heading: CongenitalDeformities)b. Determination of femoral position (normal=2 x external rotation)c. Frontal plane knee motiond. Transverse plane knee motione. Determination of malleolar positionf. Ankle dorsiflexion/plantarflexion (should be equal)g. Examination of the digits and nailsh. 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 (


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Pediatric Biomechanics-Normal Values: Newbornto Adult1. Chart of normal findings:

Part Birth Position Adult Position

Thigh/Femur/Hip Angle of head and neck of femur=150(angle of Inclination)

Externally rotated 60Femoral torsion (angle declination)=30Total range of motion=150

At age 6 years=125

At age 6 years=0At age 6 years=10Past 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=5-10Externally rotated=30Frontal plane rotation=5-10Transverse plane rotation=5-15

At age 6 years =0At age 6 years=0At age 6 years=0-5At age 6 years=0-5

Leg/Tibia Varum(approx. 15) At age 18 years=0-2 varumTibial torsion at birth=0 1 yr=6, 2-3 yr=10-15, 5-6 yr=18-23Malleolar torsion at birth=0 5-6 yr=13-18

Rearfoot At birth= 10 varus approx.Talocalcaneal angle=30-50

Calcaneal inclination angle=approx. 14Talar declination angle=approx. 30Calcaneal stance @ 1 yr=5-10 5 yr=3-8Dorsiflexion=45 approx.

At 6 years=2-5 varusAt 6 yrs=25-30

At 6 yrs=20 approx.At 6 yrs=21 approx.8 yr=


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can be taken; that much of the hip joint is cartilaginous; and that excessiveradiation should be avoided.

i. Acetabular index: the angle formed by a line touching the inferior margin ofthe ilium and Hilgenreiner's line. Greater than a 30 degree angle is indicativeof a dislocated hip (only useful in a unilateral dislocations).ii. Hilgenreiner's horizontal reference line: across the upper edges of theischiopubic joint. In the normal child, the metaphysis should lie well belowthis line, and the epiphysis should only just reach to this lineiii. Perkin's vertical reference line: a perpendicular line dropped through theanterior 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 innerside.iv. Shenton's line: lies along the upper margin of the obdurator foramen andcontinues outward and downward along the under surface of the femoralneck and the medial aspect of the shaft of the femur. This forms an evencurve 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 outeredge of the acetabulum, and then continues downwards and outwards alongthe upper margin of the femoral neck. This forms an even curve in thenormal baby, but is interrupted in the dislocated hip.

vi. Von Rosen's Sign: an AP radiograph is taken with the hips extended andthe thighs abducted 45 degrees and medially rotated. A line drawn along theaxis of the shaft of the femur running close to the anterior superior iliac spineand crossing the center of the spinal column above the lumbosacral junctionconstitutes a positive sign for dislocated hip.e. Trendelenberg Gait: seen with bilateral dislocated hips

f. There are three forms of congenital hip:i. Acetabulum dysplasiaii. Neuromuscular problemsiii. Capsular laxity

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

NOTE* Shenton's line and Simon's line can be identified even before thefemoral epiphysis is present. When the epiphysis has appeared, thenother information can be obtained by drawing Hilgenreiner's line andPerkin's line.


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Measurements from the above diagram for detection of congenital hip:Keats TE, Lusted LB: Atlas of Roentgenographic Measurements, Yearbook Medical Publishers, Chicago, 1985, withpermission

1= Hilgenreiner's line, Y line, or symphyseal line, drawn horizontally through the cotyloidnotches of the acetabula2 & 3= Distances from the apex of the femoral head to Hilgenreiner's line (1), normally thesedistances are equal4= 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 lowerboarder of the femoral neck5= Break in the continuity of Shenton's line, indicating a dislocation or fracture6= Fusion of the ischiopubic syndrosis, may be delayed with a dislocation7= The angle of the acetabulum. If this angle is more than 300 in the newborn and 25 in theone 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 andHilgenreiner's line. This distance should be less than 6 cm9= If in the newborn the distance of the pivotal point (point of intersection of line 8 andHilgenreiner's line) from the tip of the acetabular angle Is more than 16 mm, subluxationmust be suspected10= 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 edgeof the acetabular roof and is perpendicular to Hilgenreiner's line. The center of ossification ofthe normal femoral head lies below the horizontal line and medial to the vertical line. Incases of dislocation this center will be above and lateral respectively12= The parallelogram of Kopitz. In cases of dislocation a rhomboid will be observed, and thehead of the femur will have an eccentric position13= The guide line of the Y symphysis down from the center of the acetabulum to the centerof the head14= The axis of the neck of the femur15= The angle between 13 and 14 is normally 120-125


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2. Spina Bifida:a. Spina bifida occurs in about 1 out of every 1000 live births, the commonproblem with this deformity is neuropathy (sensory deficit)b. Minor degrees of spina bifida affecting the 5th lumbar vertebrae areinsignificant 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 afailure of fusion of the vertebral arches with cystic degeneration of themeninges. It presents itself with a swelling in the back covered by skin or athin membrane. It is flaccid and capable of being transilluminated. Theswelling consists of herniation of the dura and arachnoid filled with cerebralspinal fluid. The lower limbs show no deformity or any abnormal reflexes.ii. Open myelomeningocele: most commonly seen in the lumbar/lumbosacralspine. Patients seen at one day old present with an oval area of red glisteningtissue at the center of the lesion constituting the dysplastic portion of thespinal cord. The skin is often thin or shows pigmentation in the regionadjoining its junction with the membranous area. In 50% of the children bornwith this there may be one or more abnormalities depending upon the cordlevel: adduction/lateral rotation of the hip, fixed or limited flexion ofthe knee or fixed recurvatum, equinus, equinovarus, calcaneus,calcaneovalgus, equinovalgus, vertical talus, and clawtoes. Thedeformity is always bilateral and symmetricaliii. Closed myelomeningocele and spina bifida occulta: presents with alipomatous or cystic swelling, abnormal pigmentation, hair, and formation ofa dermal sinus. The vertebral arches are unfused, but there is no grossdistention of the meninges. This generally occurs at L5 or S1.3. Congenital Calcaneovalgus:This is the most frequently encountered congenital podiatric deformity. It isthe prime cause of the flexible flatfoot deformity.a. It can be unilateral or bilateral, but is usually bilateral, one side being moresevere than the other.b. Etiology:i. Abnormal intrauterine positionii. Excessive internal limb rotation in fetal lifec. Physical findings:i. The dorsal surface of the foot is in contact with the anterior surface of thelower 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 varusiii. Rearfoot valgusiv. Tendo achilles is tightv. Plantarflexion restricted/ dorsiflexion greater than 15 degreesvi. Prominent talar head (plantarmedial prominence)e. Pathology:


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i. Talocalcaneal ligaments are relaxed or lackingii. The navicular is laterally displaced to the talusiii. The distal aspect of the calcaneus is laterally displacediv. External tibial torsion co-exists in majority of cases

f. Radiological changes:(Lateral View)i. Increased talar declination angleii. Plantarflexed talusiii. The talar head overlaps the distal superior calcaneal surfaceiv. The bisection of the talus falls below the cuboid ossification center(D-P View)

i. Grossly excessive-talocalcaneal angleg. Treatment:i. Manipulation: the foot is brought down perpendicular to the anklewith the heel in neutral position (5 times per correction, 3 times per dayfor mild cases)ii. Casting: applying a BK or AK cast, the foot is held in equinus withplantarflexion of the first metatarsal and adduction of the forefoot to alignthe T-N joint. The rearfoot held in neutral position. Casting weekly for 3-6months. Following casting, Ganley splints used for 6 months @ 12hours/day.

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 tocongenital calcaneovalgus, but is very different and more severe. Abnormalradiographic findings consistent with rigid flatfoot will appear with patients atrest and during weightbearing. The range of motion of the subtalar joint isthe key clinical finding in the evaluation of this condition.

a. Etiology: Talonavicular dislocation where the navicular subluxes over thetalus.b. Usually found with other congenital deformities and/or endocrinedisturbances.i. Arthrogryposis multiplex congenitaii. Myelomeningoceleiii. Cerebral palsyiv. Coarctation of the aorta and high palatev. Congenital dislocation of the hip vi. Clubfoot

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

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

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


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vii. Nail-patella syndromeviii. Multiple pterygium syndromeix. Marfan's syndromex. Down's syndrome (trisomy 21)xi. Trisomy 13-15, and 18xii. Neurofibromatosisxiii. Mental retardationc. Clinical Findings:i. A rigid deformity with the heel in neutral/verticalii. A depression if found anterior to the lateral malleolusiii. A convex plantar aspect (rocker bottom foot)iv. Forefoot is abducted and there is dorsiflexion of the forefoot on therearfoot.v. Tendoachilles is tight and the anterior muscle group is tightvi. Talar movement is impossible (no supination)vii. Calcaneal equinusd. Pathology: Soft tissue and osseous

Soft Tissue Pathology: structures contracted, due to dorsiflexion at themidtarsal jointi. Tibionavicular ligament (Deltoid)ii. Talonavicular ligament

iii. Anterior ms. groupiv. Peroneus brevis/longusv. Triceps suraevi. Calcaneofibular ligamentvii. Posterior ankle and subtalar capsuleSoft Tissue Pathology: structures stretchedi. Spring ligamentii. Tibialis posterior, FDL, and FDBOsseous Pathology:i. Subluxation of the navicular on the talar neckii. Talus locked in the vertical position

iii. Calcaneus in a 20-25 equinus positioniv. Talar head subluxed below the navicularv. Talar head has an abnormally flat surfacevi. Talar neck is hypoplastic, develops an abnormal facetvii. Talus has an hourglass shapeviii. Anterior surface of the calcaneus is deviated laterallyix. Subtalar facets are abnormal due to the abnormal T-C articulation (theanterior facet is absent/middle facet is hypoplastic/posterior facet ismalformed

NOTE* The structures attached to the navicular plantarly will be stretched,while those structures attaching dorsally will be contracted. Thetibionavicular, talonavicular, and calcaneofibular ligaments hold thedeformity so that the calcaneus cannot be manually inverted.


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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 calcanealpositioniv. Dorsal dislocation of the navicular on the talus v. Lateral forefootsubluxationv. Talocalcaneal overlapvi. Navicular is dorsiflexed and laterally displaced to the talar head (it isusually cartilaginous until age 3 years so its position must be evaluated viaposition of the talar head and the medial cuneiform f. Treatment:conservative vs. surgicali. Conservative: Serial long-leg casting up to 6 months of age, with the foot ina position of ankle plantarflexion, an inverted heel, forefoot in adduction toreduce the T-N dislocation, and the knee flexed 90. The key to successfulresults is lining up the T-N joint. If a proper result occurs, the patient will havean equinovarus foot type which would then have to be corrected.ii. Surgery: Herdon-Hyman and Craig

5. Metatarsus Adductus (Metatarsus varus):The latter is the more severe form of this condition. Met. adductus iswhere the anterior part of the foot deviates medialward and there is a varusangulation at the T-M joints. The heel may be neutral or in valgus and if it isin valgus it is a more severe form., This condition is not usually noticed atbirth but about 8 weeks later. The incidence of metatarsus varus has

increased 4x in the past 25 years.a. Classification:i. Flexibleii. Rigidiii. Functional dynamiciv. Skew footb. Etiology:i. Arrested ontogenetic developmentii. Uterine pressureiii. Abnormal muscle/tendon insertions of the adductor hallucis/FDBc. Clinical Assessment:

i. Degree of inversion/adductionii. Medical concavity/lateral convexityiii. Associated met primus adductusiv. No rearfoot involvement except with a skew foot v. Use "V" finger testd. Radiographic findings: Angle of met adductus on DP view is normally 15-35 at birth and should decrease to 25.

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


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e. Treatment:

i. Manipulationii. Shoe therapyiii. Wheaton Brace (works well in a flexible deformity in child under 1year old)iv. Serial cast immobilization (cast with the calcaneus in neutral/with anabductory forefoot force) Use 2 sets of casts .v. Orthosesvi. Surgery: Should postpone surgery until after age 2-3 years (HHS: softtissue; Johnson: cartilaginous; Lepird and Berman 8 Gartland: osseous)

6. Talipes Equinovarus:

Clubfoot may be acquired or congenital. At birth, other disturbances such aship dysplasia/neuromuscular disorders/poliomyelitis/tibial epiphysisabnormality 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 clubfootiii. Males to female ratio is 2:1b. 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 prominentlaterally with inversion iii. Palpation of a medially displaced naviculariv. Deep furrowed creases along the medial longitudinal arch area and theposterior ankle.d. Clinical findings:i. Inversion and adduction of the forefoot

NOTE* The metatarsus adductus angle is the angle formed by theintersection of two lines, the bisection of the second metatarsal and theperpendicular of the lesser tarsus. The lesser tarsus is is bisected in theinfant using the followingtechnique:

1. A line is drawn from the distal medial talus to the medial base of the 1stmetatarsal, and its midpoint marked.2. A line is drawn from the calcaneus to the base of the 4th metatarsal, andits midpoint marked.3. A line is drawn connecting the two midpoints from 1 and 2, and this line isbisected.4. A perpendicular line is drawn at the midpoint of line 3, which is the finalreference line that is the bisection of the lesser tarsus.


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i. Radiographic findings consistent with a failed treatment:i. Forefoot is dorsiflexed on the rearfoot at the midtarsal jointii. Rocker-bottom deformityiii. Flat-topped talus (can be due to talar head ischemic necrosis fromcompression)

7. Congenital Deformities of the Forefoot:a. Overlapping lesser toesb. Juvenile hallux valgus:i. Treat with splintingii. Treat with surgery- (soft tissue/chondrotomy)c. Syndactyly (webbed toes)- usually 2nd and 3rd toe:i. Due to embryonic developmental arrestii. 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/tendonattachments)

e. Congenital short metatarsals:i. Short 4th metatarsal can be associated with pseudohyperparathyroidism orpseudopseudohyperparathyroidismii. Treat with metatarsal lengthening proceduref. Ectrodactyly (lobster claw foot): absence of 2 or more metatarsals and theirassociated phalanges.g. Long toes: Associated with Marfan's syndrome (also seen are visualproblems, ligamentous laxity, long fingers, and mitral valve prolapse)h. Edematous feet: Associated with Milroy's diseasei. Enlarged or giant toes (macrodactyly): Associated with vonRecklinghausen's disease (CT scan of CNS to check for neurofibromas)

Pediatric Radiology1. 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: cuboidiii. 1st bone to ossify after birth: lateral cuneiformiv. Last tarsal bone to ossify after birth: navicular at 3.5 yearsv. Calcaneal apophysis appears at age 7 yearsvi. Sesamoids appear at age 12 yearsb. Ossification at birth:i. Talusii. Calcaneusiii. Cuboid (can be absent in the premature baby)

NOTE* Functional digit articulates with metatarsal head properly and hasbetter blood supply


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iv. Metatarsalsv. Proximal phalangesvi. Middle and distal phalanges 2-4vii. Distal phalanx 1c. Age 3 months: lateral cuneiformd. Age 4 months: tibial epiphysise. Age 6 months: cuboid and lateral cuneiform articulatef. Age 7 months: talar neck appears, base of metatarsals wideng. Age 11 months: fibular epiphysis appearsh. Age 18 months: phalangeal epiphyses appeari. Age 24 months: medial cuneiform and ossification of epiphysis ofmetatarsal 1j. Age 30 months: intermediate cuneiform ossifiesk. Age 36 months: ossification of epiphysis of metatarsals 2, 3, and 4l. Age 3.7 years.: ossification of navicularm. Age 4.2 years: ossification of epiphysis metatarsal 5n. Age 4.9 years: alignment of tarsal and metatarsal bones

o. Age 6.7: ossification of calcaneal epiphysisp. Age 12 years: sesamoids appearq. Age 13 years: os trigonum and os vesalianum appearr. Age 14 years: fusion of epiphyses of distal phalanges of toes 2, 3, and 4s. Age 15 years: epiphyseal fusion of tibia/fibula, metatarsals 2/3/4, andphalanges 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 secondarycenters of ossification. Its etiology probably relates to some type of vasculardisturbance to the ossification center, during the time of their greatestdevelopmental 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 insports. On examination there is enlargement of the tibial tubercle, with amaximum area of tenderness at the insertion of the patellar tendon.

ii. Etiology: Tendonitis of the distal portion of the patellar tendon withsecondary hypertrophic new bone formationiii. X-ray findings: Soft tissue swelling anterior to the tibial tuberosity (acutestage), irregularity in the ossification center of the proximal tibial tubercle isa normal variation, late stages a prominent/irregular tibial tuberosity with orwithout a small particle of bone anterior and superior to the tibial tuberosity.iv. Differential diagnosis: Must R/O osteogenic sarcomav. Treatment: Restriction of excessive physical activities, severe casesimmobilization of the knee.

NOTE* Boys lag behind girls with regard to skeletal age


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b. Kohler's Disease (osteochondritis of the tarsal navicular):i. Clinical appearance: Affects boys (80%) 3-6 years old. Can be aspontaneous onset (pain and swelling over the navicular) or brought on byinjury. A limp (antalgic gait) may be present with the child walking on thelateral side of the foot.ii. Etiology: Abnormalities in ossification of the navicular from compression ofthe 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 tissueswelling around the bone.iv. Treatment: In mild cases stop strenuous exercises and use rigidorthoses. 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 (afterage 13). It is more common in females, and is usually unilateral affectingthe 2nd metatarsal head primarily (can affect others). Pain is localized underthe affected metatarsal head, with swelling and limitation of motion at them.p.j.ii. Etiology: Due to a vascular insufficiency from trauma to the epiphysealarea.iii. X-ray findings: Widening of the joint space with effusion and soft tissueswelling in the early stages. Later there is a flattening of the head of theaffected metatarsal, a narrowing of the joint space, and subarticularsclerosis. There is never any ankylosis.iv. Treatment: Orthoses to remove pressure from the metatarsal head inmild cases. For severe cases use a BK cast for 4-6 weeks, or if symptomspersist 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 commonin boys 10-11 with a cavus foot type. Complaints are pain in the heelespecially after rigorous activity. Pain is exacerbated by squeezing themedial/lateral epiphyseal margins of the calcaneus.ii. Etiology: Excessive traction on the calcaneal apophysisiii. X-ray findings: Multiple centers of ossification, a moth eaten appearanceof bone, and apophyseal sclerosis (all of which also can be seen in a normalapophysis)iv. Treatment: Cessation of rigorous physical activity, stretching of posteriormuscles, shock absorbing heel pad, and/or orthoses. If severe then a BK cast.

Pediatric Gait Patterns1. Parameters of Normal Gait:a. Early independent ambulator (1 year) characteristics:i. Wide base of gaitii. Prolonged hip and knee flexioniii. Arms abducted with elbows extended to increase stabilityiv. High cadencev. Low velocityvi. Short step length


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b. Toddler (1-2 years) characteristics:i. Narrowing base of gaitii. Reciprocal arm swingiii. Increased step lengthiv. Increasing velocityv. Mild foot dropc. 2 year old characteristics:i. Reduced external rotation during arm swingii. Decreased pelvic tiltiii. Knee flexion in early stanceiv. Knee extention in late stancev. Emerging heel strikevi. Disappearance of mild foot dropd. 3 year old (early mature gait) characteristics:i. High cadenceii. Low velocityiii. Increasing stride length with growth of limbiv. Increasing single support phasee. 7 year old characteristics:i. Decreasing cadenceii. Increasing stride lengthf. Full mature gait characteristics:i. Increased single support phaseii. Increased velocityiii. Increased stride lengthiv. Increased ratio of pelvic span to ankle spreadv. Decreasing cadence

2. Abnormal Gait Patterns:a. Spastic gait: Manifested by internal rotation and adduction of the entirelimb, with hip/knee/ankle in marked flexion. Seen with cerebral palsy, familialspastic diplegia, paraplegia, and hemiplegia.b. Dyskinetic gait: A constant movement abnormality with a high degree ofvariability from patient to patient and gait cycle to gait cycle. It ischaracterized by motion involving considerable effort, often with deliberate,almost concentrated step. Seen with cerebral palsy, Huntingtons chorea, anddystonia musculorum deformans.c. Ataxic gait: Characterized by a marked instability during single limbstance with an alternating wide/narrow base during double support. During

swing phase the limb will swing widely and cross the midline. Seen withmultiple 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 anassociated equinovarus foot type. Seen with Duchenne muscular dystrophy,limb-girdle muscular dystrophy, Beckers muscular dystrophy, spinal muscularatrophy, and congenital dislocated hips.e. Steppage gait: Gait exhibits a swing phase drop foot. Seen with CharcotMarie-Tooth, polio, Guillain-Barre syndrome, CVA, paralytic drop foot, and


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fascioscapulohumeral dystrophy.f. Vaulting gait: Gait changes include a high cadence, increased lateraltrunk movement, scissoring and instability from step to step, suggesting aloss of balance. Seen with myotonic dystrophy.g. Equinus gait: Gait exhibits a swing phase ankle plantarflexion with noheel contact. Seen with cerebral palsy, Charcot-Marie-Tooth, musculardystrophy, spinal muscular atrophy, schizophrenia, osseous block of theankle, and habitual toe walking.h. Festinating gait: Gait changes include loss of reciprocal arm swing,decreased velocity, shuffling, decreased stride length, and increasedcadence. Seen with Parkinson's disease.i. Trendelenberg gait: Stance phase of each step leads to a contralateraltiltof the pelvis with a deviation of the spine to the affected side. Seen withdislocated 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 toplay? More pronounced in rigid shoes?iii. Developmental history: as previously discussediv. Hospitalizations/ injuries v. Family historyb. Observation of gait:i. Angle of gait: in-toe or out-toe or rectusii. 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 upii. With the child lying down" and the hip and knee extended, rotate the

femur inward (estimate the number of degrees)

iii. Rotate the femur outward (estimate the number of degrees of motion)

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


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iv. Perform the same examination with the hip flexed an then with the kneeflexed (to eliminate soft tissue elements)

e. Average rotation of the hip joint:i. Up to 1 year old: twice external to internal rotationii. At 5 years old: internal = external rotationf. Internal femoral position/can produce an in-toe gait:i. Anti-torsion and retroversionExternal 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 yearsoldii. Normal transverse plane motion: birth/5-15, 0-5 at years old

iii. Pseudomalleolar torsion (pseudolock): excessive transverse planemotion at the knee can result in in-toe gait (usually 15-35)h. Examination of malleolar position (tibial torsion: add 5 to malleolartorsion):i. measure the malleoli with a goniometerii. 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 adductusii. Clubfootiii. Talipes varusiv. Metatarsus adductusv. Spastic posterior tibial ms.vi. Genu varumvii. Tibia varumj. Treatment:i. Not all cases warrant treatmentii. The cases that should be treated are those in which 8 of improvementwould not bring their feet into a straight-forward position,those children having difficulty walking, or a destructive foot typeiii. Manipulation of the soft tissues by the parentiv. Functional orthoses to control pronationv. 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 pseudolockviii. SurgeryPediatric Fractures1. Anatomical Considerations:a. Epiphysisi. Pressure epiphysis: At the articular surface, involved with growthii. Traction epiphysis: Not at the articular surface and not involved with

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


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growth (femoral trochanter, tibial tuberosity, calcaneus, base 5th metatarsal)b. Diaphysisc. Metaphysisd. Epiphyseal plate: Zone between the epiphysis and the metaphyseal plateMicroscopic appearance (multiple cell types)i. Resting cellsii. Proliferating cellsiii. Endochondral cellse. Points to remember:i. Matrix makes the plate the strongest at areas close to the epiphysis andmetaphysis.ii. The zone of provisional calcification, where cells are dividing andcalcification 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 theproliferating cell zone uninterrupted; thus there is usually no interference inbone growth, as long as circulation to the physis remains intact.iv. Diaphyseal blood supply will nourish the layer of endochondral ossificationwithout crossing the epiphyseal plate.v. Epiphyseal blood supply will enter through the joint capsule and throughthe perichondrium to the epiphysis zone area of the epiphyseal plate (2types: intracapsular & extracapsular).vi. When making a diagnosis a minimum of 3 views should be taken andbilateral x-rays should be taken.

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 malesb. Chance of epiphyseal fracture is 42% till age 16 in males and 27% infemales.c. Fractures at the epiphysis peak at 2 years of age and again between 11-14years of age.d. 13.4% of the fractures occur in the foot and ankle e. 21 % of the injuries

Note* The physis contains 3 parts:a. Zone of Growth: containing the dividing and resting cellsb. Zone of Maturation: for calcification

c. Zone of Transformation: for ossificationThe Zone of Ranvier is a groove surrounding the periphery of the physis andiscomposed of..a. Fibroblastsb. 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 ofthephysis proceeds in harmonyNote* Remember that the periosteum in the child is more vascular, thicker,

loosely attached and stronger than in the adult


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are sports relatedf. Pathological fractures should be taken into account occurring due to minortrauma in diseases such as: renal disease, cystic fibrosis, growth hormonedeficiency, diabetes mellitus, Turner's syndrome.

3. Important points to remember:a.Haversian canal system in children is more extensive as compared to thatof adults, especially in the metaphysis.b. Children's fractures can be of compression or tension type; in adultscompact bone fails in tension only.c. Incomplete failure in tension results in a greenstick fractured. In. children, the strongest skeletal segment is the periosteum, the weakestbeing the growth plate.e. Due to the strong periosteum one rarely sees open fractures in childrenIntermediate strength is the epiphysis which is protected by joint congruencyand cartilage.f. Capsule and ligaments are a continuation of the periosteum, which mostlybypasses the epiphysis, distributing forces to the growth plate andmetaphysis.

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

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

Type 1: complete separation of the epiphysis with no fracture of bone Type 2:fracture along the epiphysis then through the metaphysis producing atriangular fragment

Type 3: extends from the joint surface to the epiphyseal plate, along theplate to the peripheryType 4: extends from the joint surface to the epiphysis and plate and througha portion of the metaphysisType 5: severe crush injury and compression of the plate

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


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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


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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 (largemedial 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 theproximal 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 thegerminal 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 determineamount 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 notcross 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 3injury

treat same as Salter 3 tibialfor non-displaced and displaced, except thatadditional fixation is needed for the metaphyseal fragment (properanatomical reduction/alignment is necessary)

these are rare

possible growth disturbances


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vi. S-H Type 5: Tibial fractures

caused by severe axial loading across the plate resulting in multiplefracture lines

these fractures may lead to premature fusion across the whole platecausing 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 withprogressive 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 aftertrauma

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-traumaticgrowth patterns: symmetrical growth, initial/temporary growthstimulation, initial/temporary growth retardation, initial/ progressivegrowth retardation, and initial/permanent growth arrest.


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b. Dias and Tachdjian: Added a classification of physeal injuries based inLauge-Hansen and Salter-Harris. The first term describes the position of thefoot at the time of impact, and the second term refers to the direction ofthe 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

fragmentposteriorlyii. Supination-external rotation

Stage 1:Characterized by Salter 2 of the distal tibia Stage 2: Characterized by a short oblique fibula fracture above the distalfibula physisiii. 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 tibiaiv. 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 tibiotalarjoint with the metaphyseal fragment lateral

c. Juvenile Tillaux fracture:i. An avulsion fracture of the distal lateral tibial tubercle by the anteriortibiofibular ligament due to an external rotation force


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ii. This fracture is seen on an A-P view as a S-H type 3 fracture of the lateraldistal tibial epiphysis, involving from 20-50% of the width of the epiphysisiii. Usually occurs in ages 12-14, because of closure of the medial half of theepiphysis and not the lateral half

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

vii. Triplane fractures:

NOTE* Treatment is ORIF if displaced with lag screw technique from distallateral to proximal medial (can cross the physis since growth is alreadycompleted)

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


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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 ChildhoodLimp is an exaggeration or deficiency of normal gait which may be painful orpainless. It may be associated with paralysis, spasticity, contractures, loss of

supporting structures, limb length discrepancy, and ataxia. It should beconsidered to reflect serious disease until proven otherwise. Except in themost obvious causes, a complete review of history and general physicalexam is necessary and if indicated appropriate lab studies, x-rays, andconsultations. Looking at limp by age groups is helpful.1. The Beginning Walker:a. Congenital hip dislocationb. Trauma (always consider abuse)c. Septic joint (diagnosis urgent especially in the hip)d. Osteomyelitise. Synovitis

f. Neuromuscular disorders

2. The Walking Child:a. Congenital dislocated hipb. 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 percentagedevelop Legg-Perthes disease)e. "Growing pains"f. Legg-Calve-Perthes disease

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

SUMMARY OF TYPES OF LIMP

Age (Yr) Antalgic Paralytic Short Leg Contracture Loss of Support

Birth-4 Trauma, infection Cerebral palsy,spinalmuscularatrophy,

Congenital, coxavara,CHD, infection

Spina bifida,cerebralpalsy, CHID, Infec-

CHD, trauma,van, spine I:

5-10 Trauma,infection,rheumatoidarthritis,

Cerebral palsy,spinabifida, musculardys-

Spina bifida,trauma,CHD, Infection,rheumatoid

Trauma, CHD,Legg-Calve-Perthes dis-ease, infection,

Trauma, polio, infec-tion, muscular dys-trophy

11-14 Trauma,synovitis,slipped capitalfemo-ral epiphysis,

Musculardystrophy,polio, peripheralnerve trauma,CNS

infection, trauma,slipped capitalfemo-ral epiphysis, neo-plasm

Infection, trauma,Legg-Calve-Perthesdisease, slippedcapi-

Trauma, slipped capi-tal femoral epi-physis, inadequatetreatment, CHD

CHD, Congenital heart disease.


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Juvenile Hallux Valgus1. 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 columniii. Residual met adductusb. Hyperlaxity (hypermobile pes planus):i. Physiologicii. Pathologic: Down's and Marfan's syndromec. Adolescent:i. Advanced met primus varus secondary to

trapezoidal medial cuneiform

oblique 1st met-epiphyseal line oblique 1st met-medial cuneiform jointii. Associated hypermobile pes planusd. Neurologic:i. Equinovalgus: contracted achilles with overpull of the peronealsii. Spasticity of the adductor hallucise. Superimposed factors:i. Extrinsic: shoes, balletii. latrogenic

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

clinical findings.a. Akin procedure: for hallux interphalangeusb. Tendon sling with Modified McBridec. Lapidus procedured. Cotton procedure (sagittal plane opening wedge of medial cuneiform for1st metatarsal elevatus)e. Hemiepiphysiodesis at the proximal phalanx and base of the firstmetatarsalf. Proximal 1st metatarsal osteotomies (Austin, Mitchell) good up to 140 IMAg. Distal 1st metatarsal osteotomies

3. Complications:a. The most common complication seen with correction of juvenile bunion isshortening of the first metatarsal. This is a result of interruption of growth ofthe physis fromi. Base wedge osteotomiesii. Epiphysiodesis


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e. Calcaneal position: Most children have a pes planus on weight-bearing. Achild's calcaneus is normally everted at the onset of ambulation which canpersist till the age of 6-7 years old.

3.Off-

weight-bearing examination:a. Hip range of motion: External vs. internal rotation measured with the childsupine has about a 2:1 ratio for the first few years. The total ROM measuresmore than 1000. Both the amount of external rotation and the total ROMdiminishes over the first few years and essentially becomes symmetrical atthe age of 5-6 through adulthood. This is measured with a Martin'sgoniometer placed on the epicondyles of the femur. If a marked amount ofinternal hip rotation is noted compared with external rotation, theexamination should include evaluation of motion with the hip extended andhip 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 decreasesdrastically at age 3-4. In a normal child under the age of 3 there should be asymmetrical amount of internal and external rotation of the tibia relative tothe femoral segment. However, if there is 300 of external rotation availablefrom a resting position with minimal internal rotation this indicates that thetibia is being maintained in an internally rotated position (congenitally shorthamstring or medial head of the gastrocnemius)c. Tibial torsion: This is assessed by measuring malleolar position, bydetermining the amount of anterior rotation of the tibial malleolus relative tothe fibular malleolus (measured by a goniometer placed on the malleolei or

tractograph placed on the plantar aspect of the foot). At birth there is notibial torsion present, however, this gradually increases in an externaldirection through the first 7-8 years to a normal adult value of 13-18. Tibialtorsion is generally 5 greater than malleolar position.d. Ankle joint dorsiflexion: At birth there is unrestricted ankle jointdorsiflexion (can approach 75) , reduces to 20-25 by age 3, reduces to 15by age 10, and reduces to 10 by age 15. When obtaining this measurementthe subtalar joint is held in neutral position or the midtarsal joint will unlockthereby introducing additional forefoot dorsiflexion. If dorsiflexion is limitedwith the knee extended, retake the measurement with the knee flexed. Ifthere is limited ankle dorsiflexion with the knee extended but greater than

150 with the knee flexed, the child has a gastrocnemius equinus. If thelimitation is present with the knee extended and flexed then a gastroc-soleusequinus is most likely responsible (an osseous equinus is uncommon in thisage group)e. Subtalar joint range of motion: Since a child under the age of 3 has anapropulsive gait, measurement of the STJ ROM is not essential. Only after theage of 3 when a heel-toe propulsive gait is initiated, does a functionalorthoses become useful, and therefore so does the STJ measurement. Rangleof motion is accomplished by bisecting the calcaneus and measuring full

NOTE* Calcaneal eversion should reduce approximately 1 per year.Therefore a child with a calcaneal eversion of 6-7 should reduce to

perpendicular by the age of 7 (a rough estimate)


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eversion and inversion. This is generally more than the adult values. The footmust be measured in a slight dorsiflexed position for accuracy.f. Midtarsal joint range of motion: The STJ is placed in neutral position and theMTJ is locked (in this fashion the 2 axes of the MTJ cross each other and limitextraneous midtarsal joint mobility upon examination). A forefoot varus orvalgus deformity upon examination will not be outgrown, and any degree offorefoot deformity should be supported to prevent abnormal compensation

4. Weight-bearing examinationa. Relaxed and neutral calcaneal stance position: The calcaneal bisector onweight bearing should be noted. Abnormal calcaneal eversion in the child canbe due to compensated forefoot varus (frontal plane),compensated gastrocnemius equinus (sagittal plane), and internaltibial/femoral torsion (transverse plane).b. Tibia varum: The angle that the distal one-third of the tibia makes relativeto the ground with the STJ in neutral position is tibial varum (generally 0-5 inthe child)c. Genu varum/genu valgum, genu recurvatum: The child demonstrateschanges in frontal plane position at the genicular region at different ages . Ifexcessive genu varum is detected and does not reduce with time, thepossibility of Blount's disease or juvenile rickets should be investigated. Ifgenu valgum is noted and does not decrease with time, then functionalorthoses should be used to reverse the severe pronatory force to the feet. Aposterior 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 theage of 5, or any amount present at all after 5 should be checked forpathologyd. Limb length inequality: This is done by palpating the anterior superior iliacspine, and measuring to the tip of the medial malleolus. Repeatmeasurement 2-3 times consecutively for consistency. If there is asymmetryin their levels, further investigation is necessary

Corrective Casting in Infants1. Application of the cast:a. Only gentle force is exertedb. Webril is utilized and should be no more than 2 layers thick with 3-4layers at the posterior-of the heel and at the upper limit of the cast. It shouldbe wrapped under a slight stretch making a snug fit. It should extend one-half inch beyond the plaster

c. Use extra-fast setting plasterd. Babies usually require only 1 roll of 3 inch plaster and 2 inch rolls fornewborns

2. Calcaneovalgus deformity:a. The assistant grasps the thigh and toes and then holds the hip, knee, andfoot in the anteroposterior plane with the foot in equinusb. With the foot held in equinus, the metatarsal adducted, apply pressure inthree areas:


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i. The posterior aspect of the heelii. Over the talus mediallyiii. Laterally over the 5th metatarsal area

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

4. Talipes equinovarus:a. Apply 2-3 casts consecutively,, with the foot in "unlocked" equinus positionb. Apply three point pressure:i. Evert the heel by pressure mediallyii. Lateral counter-pressure over the talar head in an attempt to open up theT-C angle (to try to move the calcaneus laterally from beneath the talarhead)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 300b. The corrective force is exerted by holding the thigh stable and rotating thefoot to the end range of motion (avoid inversion or eversion while doing this)

The Toe-Walking ChildToe-walking may be a result of idiosyncratic or idiopathic factors with nopathological background, or can follow serious neuromuscular,psychological, and skeletal pathologies. Therefore, the etiology of habitualtoe-walking is determined by exclusion:1. Examination:a. Medical history: As aboveb. Gait Evaluation:

NOTE* Response to this should be a dramatic improvement in the transverseand frontal plane alignment. Later casts are applied with the forefoot to

rearfoot in a neutral position and the knee flexed to stretch the posteriorstructures (equinus is overcome by pulling down on the posterior of the heeland applying dorsiflexion pressure, making sure some of the pressure is onthe calcaneocuboid area). Being overzealous will result in a rocker-bottomfoot with the calcaneus in an equinus attitude.


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usefully applied to evaluate nonspastic short calf muscles. Clinically, a childwith a gastrocnemius soleus muscle equinus will stand with an abductedstance angle and will often exhibit a genu recurvatum and significantmidtarsal pronation1. Clubfoot: A deformity in which the leg and foot are said to resemble a club,and is associated with congenital hip dislocation, arthrogryphosis multiplexcongenita, spinal abnormalities, and neuromuscular disease. The form ofclubfoot that leads to toe-walking is talipes equinovarus.a. Shoe therapy: Rigid sole high top shoeb. Orthoses therapy: Heel lifts, gait plates, and knee-ankle-foot orthoses c.Short leg castingc. Auditory feedback: A method of cognitive muscle managementd. Surgical intervention: With a significant structural gastrosoleus muscleequinus

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