Common Paediatric Orthopaedic Conditions

Information for parents

Clubfoot
1
Clubfoot

Clubfoot, also known as talipes equinovarus (klompvoet in Afrikaans) is the most common congenital limb deformity and occurs in 1/1000 South African babies. There is a genetic component to developing this condition, but it is not inherited in a predictable fashion.

Clubfoot can be diagnosed during pregnancy by ultrasound scan, otherwise it will be diagnosed after birth by the presence of a typical clubfoot deformity.

Often babies feet look like they have clubfoot because of the way they lie in the uterus, but in the absence of true clubfoot, the feet are flexible and can be corrected.

Metatarsus adductus (pigeon toes) is another condition that is often mistaken for clubfoot. In metatarsus adductus, only the front part of the foot is skew and the rest of the foot is normal. It is still recommended to seek medical advice if your child has metatarsus adductus.

What to do if my baby is born with clubfoot?

It is important check the baby’s whole body to look for abnormalities of the spine, hips and other limbs. Clubfoot is usually an isolated condition but may be associated with certain other conditions such as spina bifida (myelomeningocele) and arthrogryposis.

Your GP or paediatrician should refer you to a paediatric orthopaedic surgeon or clubfoot clinic in your region as soon as possible. It is best to start treatment for clubfoot as soon after birth as possible, even as soon as day 1!

The most effective treatment for clubfoot involves the Ponseti method of serial casting. This entails weekly application of plaster casts that gradually correct the feet over a period of 6-8 weeks. This may be followed by a small procedure, an Achilles tenotomy, where the tight heel cord is cut. This procedure does not require a general anaesthetic. Most clubfeet will correct with this treatment process.

Once the feet are corrected, your child will have to wear braces for the next 2-4 years. These braces are worn full time from the first three months, and after that only at night and during naps.

SAPOS works closely with a local NGO, STEPS, that provide support for parents with clubfoot. STEPS is involved with our regional clubfoot clinics that are based at the major hospitals all over the country. To find your regional clubfoot clinic, click here.

There is wealth of information and resources on the STEPS website, which you access here.

Cerebral Palsy
Suzie CP
Cerebral Palsy

Cerebral Palsy, or CP, refers to a group of conditions caused by damage to the developing brain and literally means brain (cerebral) lameness or paralysis (palsy). CP can look very different from child to child, ranging from very mild symptoms such as a tendency to walk on the toes, to severely disabled children that are dependant for all their physical needs.

Cerebral palsy can also be associated with other problems, such as epilepsy, deafness and blindness.

Cerebral Palsy can be caused by something that happened during pregnancy, during the birth process or shortly afterwards. Sometimes the cause remains unknown and we know now that there are many genetic abnormalities that can lead to the picture of cerebral palsy.

Though the cause of CP and the damage to the brain is not reversable, many of the features are treatable. As these are complex conditions, a multidisciplinary team should be involved in the care of your child. This should include a paediatrician, physiotherapist, orthopaedic surgeon, neurosurgeon and, if needed, speech therapist and occupational therapist.

Orthopaedic surgeons work closely with these other specialities and our role is to correct fixed deformities of the bones, lengthen short muscles and sometimes transfer tendons to allow for more balanced muscle action.

Because every child with CP is different, treatment is tailored to what the specific child needs to optimise his or her function. Below we provide some information on the most common interventions used for children with CP, the indications, and what you can expect.

Physiotherapy and splinting

Physiotherapy and splinting are the first form of intervention for children with affected legs and arms that suffer from CP. When the child is young, increased tone or spasticity accounts for most of what we see and there is no need for orthopaedic surgery. At this stage, regular stretching, splinting and treatment that reduces spasticity is the best way to manage the tight muscles. Splints act as supports for unstable joints and weak muscles, and helps to keep the limbs, especially the feet, in a more functional position.

Treatment that reduces spasticity

For children with whole body involvement, oral medication such as baclofen and diazepam can reduce spasticity and make seating and care easier and more comfortable.

Botulinum toxin A, commonly known as Botox®, is an injectable agent that reduces spasticity locally. This may be indicated if only a few muscles are involved. Botox®’s effect lasts for approximately 4-6 months and it is especially useful to allow for stretching of tight muscles and strengthening of weak muscles.

Neurosurgical procedures such as selective dorsal rhizotomy (SDR), selective peripheral neurotomy (SPN) and intrathecal baclofen pumps provide more lasting spasticity relief. For more information on neurosurgical procedures for CP, click here.

Orthopaedic surgery

Orthopaedic surgery for CP can be divided into four groups. Muscle lengthening for shortened muscles, tendon transfers to balance unbalanced muscles, osteotomies to correct bony deformities and joint stabilising procedures.

The muscles that become short most often are the muscles of the calf and the back of the thigh (hamstrings). These muscles are often surgically lengthened to allow standing on flat feet and standing with a straight knee. Your orthopaedic surgeon will examine your child carefully to find out which muscles are short and will benefit from lengthening. Following muscle lengthening, the muscles will be weak and regular physiotherapy and splinting is necessary to rebuild the strength of the lengthened muscle.

Tendon transfers are commonly performed around the ankle and wrist to strengthen weak muscles and balance imbalanced muscles.

Osteotomy refers to a procedure where a bone is surgically cut, and the shape changed. The most commonly performed osteotomies in children with CP are osteotomies around the hip, thigh bone (femur) and shin bone (tibia). Once the shape of the bone is corrected, osteotomies are usually fixed with plates and screws on the inside. These plates and screws are made of surgical stainless steel or titanium and does not cause any negative effects whilst in the body. Your surgeon may decide to remove the plates and screws once the bone has healed.

Joint stabilising procedures are usually performed at the hip and foot. Children with CP, especially those that don’t walk, very often develop hip dislocations. This is when the ball of the hip joint moves out of the socket over time. A dislocated hip can become painful and it also makes it difficult to open the legs for washing and diaper changes, and it affects sitting. Once a hip has been dislocated for a long time, it becomes impossible to put the hip back in joint therefore it is best to prevent the hip form dislocating. Another commonly performed joint stabilising procedure is subtalar fusion. With this operation, the bones of the heel of the foot are fixed together to correct severe flatfoot.

Single Event Multilevel Surgery (SEMLS)

This refers to the concept of performing multiple procedures at once to lengthen all the short muscles and correct bone deformities in one sitting. This is extensive surgery, but it means that your child will only have to go though the recovery once, though it may take many months.

For support in your region and more information on services available, the links below may be useful.

 

Western Cape Cerebral Palsy Association https://wccpa.org.za

Cerebral Palsy Association, KwaZulu-Natal www.kzncerebralpalsy.co.za

Cerebral Palsy Association Eastern Cape www.cerebralpalsy.org.za

The United Cerebral Palsy Association of SA (Gauteng) www.ucpa.za.org

Malamulele Onward (Gauteng) www.malamuleleonward.org

Mpumalanga Association for Persons with Disabilities www.apdmpumalanga.org

Osteogenesis Imperfecta
Alime right femur lat
Osteogenesis Imperfecta

Osteogenesis imperfecta (OI), also known as brittle bone disease, is a condition that causes children’s bones to break or fracture easily. It is caused by abnormal or insufficient collagen type 1, which is major part of bone. OI is inheritable therefore if your child has is the condition, their children will also be at risk of being born with OI.

Children with OI may also have other characteristic features such as blue sclerae (sclerae are the white parts of the eye), abnormal brittle teeth, being short for their age, bowed legs and joint laxity.

A child with OI may have very mild disease, in which case the bones break easily, but the child is a normal size, has normal teeth and has no other problems. Children with severe disease break their bones very regularly, their limbs are bowed, and they are often short compared to children their age.

The treatment of OI is aimed at preventing fractures or breaks, correcting deformities, and improving function.

Calcium and Vitamin supplements are typically not helpful in the management of OI, although it is important to make sure that your child does not suffer form rickets, which can also cause brittle bones but is due to a deficiency of calcium and vitamin D in the blood.

Ask your treating doctor about the use of bisphosphonates. Bisphosphonates are a type of medicine that is most commonly used to treat older people with osteoporosis. This treatment can decrease the amount of fractures your child sustains and improve chronic pain.

Surgery for OI usually involves correcting deformity and inserting rods or nails inside the bones to keep them straight and protect them from fracturing again. Despite this surgery, the bones may still end or break again, but it is less common.

Children with OI tend to stop breaking their bones once they have reached adulthood.

For more support and to connect with other patients with OI, see brittlebonessa on Facebook.

Flatfoot
Feet
Flatfoot

Flatfoot describes a normal variation in the shape of the foot where the arch of the foot is low or collapsed. All children are born with flatfoot and the arch of the foot typically only starts to develop after the age of 2 years. Even after that, flatfoot is considered normal and should only be treated if there are symptoms.

Symptomatic flatfoot presents with foot and lower leg pain and ‘tiredness’.

Flat feet do not affect balance, sporting ability or posture. It has no late effects on the knees, hips or back and should be left untreated in most cases.

If the flatfeet are associated with symptoms, the first line of treatment is shoe inserts or arch supports. These shoe inserts can be bought at most pharmacies and custom made shoe inserts are not better than over-the-counter inserts. If this still does not relieve the symptoms, surgery may be indicated.

In certain cases, flatfoot can be caused by other underlying conditions. If the arch does not come back when your child stands on his/her toes or when the foot is hanging free, it is a stiff flatfoot and an orthopaedic opinion should be sought.

Bow-legs and knock-knees
straight by 8
Bow-legs and knock-knees

Bow-legs and knock knees

Toddlers often have bow-legs when they just start walking. This may be accompanied by in-toeing. In children under the age of 2, bow-legs are normal and part of the natural process of growing up. Not all children will have bow-legs though. Following the age of 2 years, children’s legs are usually straight, but they then tend to develop knock knees, this is most pronounced between the ages of 4 and 6 years. We like to say that children’s legs should be ‘straight by eight’.

If your child has bow-legs or knock-knees and are older or younger than the age ranges mentioned above, medical advice should be sought. Bow-legs and knock-knees can be caused by other conditions such as Rickets, which is a condition caused by too little calcium and Vitamin D in the blood.

In South-Africa, the most common cause of bow-legs is a condition called Blount disease. Blount disease is most common in overweight children, those that started walking early and those of black African descent. Blount disease is caused by abnormal or delayed growth at the inside part of the top of the shin bone (tibia) and is usually progressive. Surgery is always necessary to correct the legs in Blount disease.

In-toeing
Internal foot progression Adam Titus
In-Toeing
In-toeing is a very common finding in young children and can be caused by problems in the hips, femur (thigh bone), tibia (shin bone) or foot.

The most common cause of in-toeing in toddlers is internal tibial torsion, or turning in at the level of the shin bone. This usually resolves spontaneously by the age of 4-years, and no intervention is required.

After the age of 4-years, increased femoral anteversion, or turning in at the level of the thigh bone, is the most common cause of in-toeing. Again, this may resolve spontaneously by the age of 10-years.

Another cause of in-toeing is metatarsus adductus, a deviation of the forefoot towards the midline, also known as ‘pigeon toes’.

Usually, in-toeing does not require any treatment. Special shoes, braces or physiotherapy has not been shown to help, with the exception of metatarsus adductus.

Mild metatarsus adductus can be treated by stretching during early infancy, whereas more severe cases may need serial casting. A simple solution to mild or moderate metatarsus adductus is what we call ‘banana shoes’, or stated simply, wearing shoes on the wrong feet. For this to be successful, the shoes need to be fairly rigid so as to exert some pressure on the foot.

Surgery is indicated if the in-toeing does not resolve, causes functional problems such as tripping or difficulty with shoe wear, or rarely for cosmetic concerns.

Femoral or tibial derotation osteotomies are reliable options for addressing in-toeing due to increased femoral anteversion or tibial torsion. The bone is surgically cut and rotated to normal alignment, and then fixed with a plate and screws or an intra-medullary nail. For in-toeing that does not resolve due to metatarsus adductus, surgery to correct the alignment of the foot bones can be performed.

Hip dysplasia
Hip dislocation
Hip dysplasiac(DDH)

Hip dysplasia refers to underdevelopment of the hip joint and is most common in girls of Caucasian descent.

The hip is a ball-and-socket joint, in hip dysplasia, the socket does not develop properly and is shallow compared to a normal hip. More like a saucer than a cup. Sometimes, the hip may be completely dislocated, or out of joint.

Risk factors for hip dysplasia include female gender, family history of hip dysplasia and breech presentation. Hip dysplasia is also associated with certain syndromes.

If left untreated, hip dysplasia leads to early hip arthritis and pain, requiring hip replacement surgery at a young age. Untreated dislocated hip will lead to a short leg on the affected side, limping and lower back pain. Hip dysplasia always requires treatment.

Hip dysplasia is diagnosed by ultrasound and clinical examination in new-born babies. If you have any risk factors, ultrasound should be performed. In older children, X-rays of the hips must be done.

In new-born babies, treatment consists of a brace known as a Pavlik harness. This brace must be worn full-time with regular check-ups including ultrasound of the hip, to monitor the development of the hip joint. This treatment is successful in most cases, but if not, surgery may be required. Importantly, the sooner the hip is put back in joint, the better the expected outcome.

Hip dysplasia refers to underdevelopment of the hip joint and is most common in girls of Caucasian descent.

The hip is a ball-and-socket joint, in hip dysplasia, the socket does not develop properly and is shallow compared to a normal hip. More like a saucer than a cup. Sometimes, the hip may be completely dislocated, or out of joint.

Risk factors for hip dysplasia include female gender, family history of hip dysplasia and breech presentation. Hip dysplasia is also associated with certain syndromes.

If left untreated, hip dysplasia leads to early hip arthritis and pain, requiring hip replacement surgery at a young age. Untreated dislocated hip will lead to a short leg on the affected side, limping and lower back pain. Hip dysplasia always requires treatment.

Hip dysplasia is diagnosed by ultrasound and clinical examination in new-born babies. If you have any risk factors, ultrasound should be performed. In older children, X-rays of the hips must be done.

In new-born babies, treatment consists of a brace known as a Pavlik harness. This brace must be worn full-time with regular check-ups including ultrasound of the hip, to monitor the development of the hip joint. This treatment is successful in most cases, but if not, surgery may be required. Importantly, the sooner the hip is put back in joint, the better the expected outcome.

 
Scoliosis
Scoliosis5-1

Scoliosis

Scoliosis refers to an abnormal curvature of the spine and may be a result of many conditions. If your child has scoliosis, he or she must always be referred to an orthopaedic surgeon.

Scoliosis could be idiopathic, meaning that there is no specific underlying cause, or it can be as a result of another condition. This may be abnormal bony development, infections or even a leg length discrepancy. Your orthopaedic surgeon will request X-rays and other tests to determine the cause of the scoliosis and the most appropriate treatment.

For mild scoliosis, no treatment is indicated. If the abnormal curvature of the spine increases, bracing and later surgery may be necessary. I left untreated, severe scoliosis causes significant deformity, back pain, and lung problems.

For more information, visit www.spinesurgery.co.za