Some orthopaedic conditions in children

Dr. B.J.C.Perera

MBBS(Ceylon), 
DCH(Ceylon), DCH(England), MD(Paediatrics),FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, 
FCGP (Sri Lanka) 
Consultant Paediatrician

KEY POINTS

* The orthopaedic problems that occur in children may be trivial while others could be quite serious.

* Some children are born with noticeable bony abnormalities.

* In some of them walking is interfered with by some of these bony problems.

* Some bone and joint infections cause significant problems.

* All those more serious conditions need urgent medical attention.
There are quite a few conditions that affect the bones and joints in children. Some are congenital while others are acquired during life. Among the congenital defects, there are some bone problems that one may notice as obvious abnormalities. Others may not be that obvious or may present with features that are not seen with a direct anatomical relationship to the affected bones or joints. As time passes, one may notice that a child's growth is not taking place completely on the straight and narrow. Many young children exhibit problems such as flatfeet, toe walking, pigeon toes, bow legs and knock-knees in their first few years of life. Some of these conditions correct themselves without treatment as the child grows. Others that persist or become more severe may be linked to other conditions. Many minor orthopaedic conditions, just like dimples or cleft chins, are just normal variations of human anatomy that do not require treatment. Acquired bone and joint problems may be due to infective conditions, trauma, inflammatory diseases and tumours.

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Whether a baby rises from a crawl with a shaky first step or a very young child sprinting across the living room, chances are that the parents would be on the edge of their seats. It is also necessary to remember that a child's first steps usually are not picture perfect. Learning to walk takes time and practice, and it is common for kids to start walking with their toes and feet turned at an angle. When feet turn inward, a tendency referred to as walking "pigeon-toed" which phenomenon the doctors call "in-toeing". When feet point outward, it is called "out-toeing".

Most babies are born with flatfeet and develop the arches of the feet as they grow. But in some of them the arch never fully develops and that condition is known as "flat feet". Parents often first notice that their child has what they describe as "weak ankles." The ankles appear to turn inward because of the way the feet are planted. Flatfeet usually do not represent an impairment of any kind and suitable treatment should be considered only if it becomes painful. The use of special footwear such as high-top shoes are generally not recommended for all cases as it has been found that they do not really affect arch development. However, sometimes it is necessary to wear such appliances to try and reduce foot pain. Parents with flatfooted children sometimes say their children are clumsier than others but doctors say that flatfeet is not a cause for concern and should not interfere with the ability to play sports.

Toe walking is common among toddlers as they learn to walk, especially during the second year of life. Generally, the tendency goes away by age of two years, although it could persist in some children. Intermittent toe walking should not be a cause for concern. However, children who walk on their toes almost exclusively and continue to do so after about the age of two should be evaluated by a doctor. Persistent toe walking in older children or toe walking only on one leg might be linked to other conditions such as cerebral palsy or other nervous system problems. Persistent toe walking in otherwise healthy children occasionally requires treatment, such as casting the foot and ankle for about 6 weeks to help stretch the calf muscles.

In-toeing, or walking pigeon-toed with inwardly turned feet, is another normal variation in the way the legs and feet line up. Babies may have a natural turning in of the legs at about 8 to 15 months of age, the time around which they begin standing and walking. The medical name for this condition is femoral anteversion. Treatment for pigeon-toed feet is almost never required. Special shoes and braces commonly used in the past have never been shown to speed up the natural slow improvement of this condition. This, too, typically does not interfere with walking, running or sports and resolves on its own as children grow into teenage years and develop better muscle control and coordination.

Most toddlers toe-in or toe-out because of a slight rotation, or twist, of the upper or lower leg bones. Tibial torsion, as it is called, is the most common cause of in-toeing, occurs when the lower leg bone (tibia) is tilted inwards. If the tibia tilts outward, a child will toe-out. When the thighbone, or femur, is tilted, the tibia will also turn and give the appearance of in-toeing or out-toeing. The medical term for this is femoral anteversion. In-toeing can also be caused by metatarsus adductus, which is a curvature of the foot that causes toes to point inward.

The reason some children develop gait abnormalities while others do not, is somewhat unclear. Many experts think that a family history of in-toeing or out-toeing plays a role. Additionally, a cramping of the fetus in the womb during pregnancy could also have led to in-toeing or out-toeing. As a fetus grows, some of the bones have to rotate slightly to fit into the small space of the womb. In many cases, these bones are still rotated to some degree for the first few years of life. Many times this is most noticeable when a child learns to walk. As most children get older, their bones very gradually rotate to a normal angle. Walking, like other skills, improves with experience and thus children will become better able to control their muscles and foot position with time.

In-toeing and out-toeing gets better over time, but the change occurs very gradually. It is sometimes hard to notice. Therefore, doctors often recommend using video clips to help parents track improvement. Parents can record their child walking and then wait for about a year to take another video. This usually makes it easy to see if the gait abnormality has improved over time. In most cases, it has. If not, parents may need to seek expert medical help. In the past, special shoes and braces were used to treat gait abnormalities. However, doctors have noticed that these do not make in-toeing or out-toeing disappear any faster and many such appliances are now not used.

Most children show a moderate tendency toward knock-knees (medical name: genu valgum) between the ages of 3 and 6, as the body goes through a natural alignment shift. Treatment is almost never required as the legs typically straighten out with time. Severe knock-knees or knock-knees that are more pronounced on one side sometimes require treatment.

Bow leggedness with the medical name of genu varum is an exaggerated bending outward of the legs from the knees down. This can be an inherited condition and is commonly seen in infants. In very many cases, it corrects itself as a child grows. Bow leggedness beyond the age of two years or bow leggedness that only occurs in one leg but not the other can be the sign of a larger problem, such as rickets or Blount disease.

Rickets, a bone growth problem usually caused by lack of vitamin D leads to severe bowing of the legs and can also cause muscle pain as a result of the abnormal forces that are transmitted through the bowed legs. Rickets is much less common today than in the past. Rickets, when it occurs in children, is corrected by the administration of vitamin D but the bow legs may not be corrected only by using vitamin D. However, some types of rickets are due to genetic conditions or may occur as a result of kidney dysfunction. These will require more specialised treatment by an endocrinologist.

Blount disease is a condition that affects the tibial bone in the lower leg. Leg bowing from Blount disease is seen when a child is about 2 years old and can appear suddenly and become rapidly worse. The cause of Blount disease is unknown, but it causes abnormal growth at the top of the tibial bone at the knee joint. To correct the problem, the child may need bracing or surgery between 3 and 4 years of age.

One needs to get the child seen by a qualified doctor if one is concerned about the way a child walks. For a small number of children, gait abnormalities can be associated with other problems. For example, out-toeing could signal a neuromuscular condition in rare cases. A medical evaluation is necessary if any of the following are present :-

* In-toeing or out-toeing that does not improve by the age of three years.

* The child complains of pain or there is a limp.

* One foot noticeably turns out more than the other

* There are other features of developmental delays such as not learning to talk as expected.

* Gait abnormalities that worsen steadily rather than showing progressive improvement.

The doctor can then decide if more specialised examinations or testing should be done to make sure that the child gets proper care.

There are other important conditions that could affect the bones. One such disease is an entity known as osteomyelitis. Many children are pretty active and not always as careful as they should be. Minor scrapes and bruises that develop on their arms and legs will usually heal on their own but deeper wounds that are left untreated can become infected. In such situations, spread of the infection to the underlying bones lead to an important entity known by the medical term osteomyelitis. In certain other cases, even without an obvious overlying infection, osteomyelitis could occur as a result of infection spreading to the bones through the blood stream.

Children with osteomyelitis often feel severe pain in the infected bone and might have fever with chills, feel tired or nauseated,or have a general feeling of not being well. The skin above the infected bone may be sore, red, and swollen. It's often difficult to diagnose osteomyelitis in infants and young children because they do not always show pain or feel specific symptoms in the area of the infection. In teenagers who tend to develop osteomyelitis after an accident or injury, the injured area may begin to hurt again after initially seeming to get better.

If a has as fever and bone pain, the child needs to be seen by a doctor right away. Waiting is not recommended because if it is due to osteomyelitis, the situation can get worse within hours or days and become much more difficult to treat. The doctor will perform a physical examination and ask questions about recent injuries to the area that were painful. Blood tests might be done to see whether the white blood cell count is elevated (a sign of infection) and to look for signs of possible inflammation or infection in the body. An X-ray may be ordered. However, X-rays usually do not show signs of infection in someone who has had osteomyelitis for just a little while.

Treatment of osteomyelitis depends on the severity of the infection and whether it is acute (recent) or chronic (has been present for a longer period of time). The doctor may perform a needle aspiration, removing a sample from the bone to help identify the bacteria responsible for the infection, which will help determine the correct antibiotic to treat that particular infection. A child who's diagnosed with severe osteomyelitis may be admitted to the hospital for a short stay so that intravenous (IV) antibiotics can be given to fight the infection. Once the condition improves, the child could go home but may need to continue IV or oral antibiotics for several more weeks. In cases where a cavity or hole developed in the bone and pus (a large collection of bacteria and white blood cells) filled this area, a doctor will perform a surgical debridement. This is a procedure to clean the wound, remove dead tissue and drain pus out of the bone so that it can heal properly.

The easiest way to prevent osteomyelitis is to practice good hygiene. All cuts and wounds, especially deep wounds, should be cleaned thoroughly. To keep the wound clean afterward, one needs to cover it with sterile gauze or a clean cloth. One could apply an antibiotic cream too but the most important thing is to keep the area clean. Wounds should begin healing within 24 hours and completely heal within a week. A wound that is taking longer to heal or is causing the child extreme pain should be examined by a doctor.

There are quite a few conditions that affect the joints. Some of these are due to inflammatory conditions while others are caused by bacterial infection of the joints. Joint infection can cause painful swelling of the affected joints with fever. Some affected children could have chills and rigors as well. Such infections need to be seen and attended to by a qualified doctor as soon as possible. Several tests may be necessary including ultra-sound scanning, surgical aspiration of the joint and blood tests. Confirmed bacterial infections of the joints need protracted antibiotic treatment which often needs to be given intravenously in the early stages of treatment. It is very important to realise that inadequate treatment of such joint infections could lead to long-term, sometimes irreversible, chronic damage to the joints.

It needs to be stressed that all forms of abnormalities of bones and joints in children need to be seen and properly assessed by a qualified doctor. Some conditions many not need any further attention while others may need investigation and treatment. In certain cases treatment is urgent to try and cure the problem and also to prevent long-term problems. All medical institutions in our country are geared to deal with these problems and the smaller hospitals could advise the parents on how to get the problem attended to at larger institutions or transfer the patients to a bigger facility.

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