Category: Orthopedic

My son seems to be limping. Should I call my pediatrician?

Limping can be caused by something as simple as a pebble in her shoe, a blister on her foot, or a pulled muscle. But a limp also can be a sign of more serious trouble, such as a broken bone, infection, or a pulled muscle. For that reason, it’s important to have your pediatrician examine a child with a limp to make sure that no serious problems exist.

Some children limp when they first learn how to walk. Early limping can be caused by neurological damage. But any limp around the time your child begins to walk needs to be investigated as soon as possible, since the longer it goes untreated, the more difficult it may be to correct. Once walking is well established, significant sudden limping usually indicates one of several conditions: 

• A “toddler” fracture
• Hip injury or inflammation (synovitis)
• Previously undiagnosed developmental dysplasia (abnormal development) of the hip (DDH)
• Infection in the bone or joint
• Kohler’s disease (loss of blood supply to a bone in the foot)
• Juvenile idiopathic arthritis

Fractures

A “toddler” fracture is a spiral fracture of the tibia (one of the leg bones that extends from the knee to the ankle). It can occur with minor accidents such as when children trip, jump, or fall, or when they go down a slide in a n older child’s or adult’s lap with their feet tucked under them. Sometimes children can explain how the injury occurred, but usually they have difficulty recalling exactly what happened. At times an older sibling or child care provider can solve the mystery.

Infection

Hip problems that cause a limp at this age usually are due to a viral joint infection and need to be brought to the attention of your pediatrician. When a child has an infection in the bone or joint, she usually experiences a fever, swelling of the joint, and redness. If the infection is in the hip joint, the child will hold her leg flexed or bent at the hip and be extremely irritable and unwilling to move the hip and leg in any direction, although swelling and redness may not be obvious in this deep joint.

Hip Problems

Sometimes a child is born with a dislocated hip (DDH, developmental dysplasia of the hip) that that may not be noticed until she starts to walk. As one limb is shorter and less stable than the other, she will walk with an obvious limp.

Limping is a major reason that parents of children with juvenile idiopathic arthritis seek medical care. In a typical case, a child will not complain of being in pain. But she limps nevertheless, with this limping at its worst after waking in the morning or from a nap, and becoming less noticeable with activity.

Treatment

With minor injuries, such as a blister, cut, or sprain, simple first-aid treatment can be performed at home. However, if your child has just started walking and is constantly limping, your pediatrician should evaluate her. It is all right to wait twenty-four hours if your older child develops a limp since sometimes the problem will disappear overnight. But if your child is still limping the next day, or is in extreme pain, see your pediatrician.

X-rays of the hip or the entire leg may be necessary to make the diagnosis. If there is an infection, antibiotics should be started and hospitalization may be required. Intravenous (IV) antibiotics may be given in high doses to allow them to get to the joint and bone. If a bone is broken or dislocated, the limb will be placed in a splint or cast and the child will be referred to an orthopedist for evaluation and further management. It is also advisable to see a pediatric orthopedist if a congenital dislocated hip (DDH) is diagnosed.

I think my child has sprained her ankle. How can I tell for sure?

Sprains are injuries to the ligaments that connect bones to one another. A sprain occurs when a ligament is stretched excessively or torn. Sprains are less common in young children, because their ligaments are usually stronger than the growing bones and cartilage to which they are attached. Therefore, the growing part of the bone might separate or tear away before the ligament is injured.  

Types of Sprains  

In young children, the ankle is the most commonly sprained joint, followed by the knee and wrist. In a mild sprain (grade 1), the ligament simply is overstretched. More severe sprains can involve partial tearing of the ligament (grade 2), or complete tearing (grade 3).  

Signs and Symptoms  

The signs and symptoms of sprains in young children can be quite similar to those for fracture and include the following:  

• pain
• swelling around the joint
• inability to walk, bear weight, or use the joint  

When To Call The Pediatrician  

Call your child’s pediatrician if your child has a joint injury and is unable to bear weight or has excessive swelling or pain. Often the doctor will want to examine the child. In some instances, special X-rays may be ordered to rule out a fracture or a break. If there is a fracture or a break, your pediatrician may consult with or refer you to an orthopedist or sports medicine specialist.

Treatment  

When a sprain is diagnosed, treatment usually involves compression using an elastic bandage or immobilization with a splint. A walking cast may be necessary if the ankle or foot injury has been severe.  

Most grade 1 sprains will heal within two weeks without subsequent complications. Your child’s physician should be called any time a joint injury fails to heal or swelling recurs. Ignoring these signs could result in more severe damage to the joint and long-term disability.

Our spine is naturally curved in order to distribute the weight of the body. A side-view X ray of a soldier standing rigidly at attention would show the cervical spine in his neck arched slightly forward. The twelve thoracic vertebrae curve gently to the rear. Then the lumbar spine, which bears most of our upper-body weight, arches forward as it nears the pelvis.

About one in twenty-five adolescent girls and one in two hundred teenage boys develop scoliosis. Captured on an X-ray, their spines form, to varying degrees, a more pronounced S shape. When imaged from the back, a normal spine exhibits no curvature. A youngster is said to have scoliosis if her curvature is greater than ten degrees.

The condition can occur as a complication of polio, muscular dystrophy and other central nervous system disorders, but four in five cases among teenage girls are idiopathic—that is, of unknown cause. Very often, though, a family member will also have had scoliosis.

Symptoms Suggestive of Scoliosis May Include:

• Conspicuous curving of the upper body
• Uneven, rounded shoulders
• Sunken chest
• Leaning to one side
• Back pain (rare)

Scoliosis can develop quietly for months to years so it may only be picked up by the pediatrician during an examination of the teen’s back. Progression may occur quickly during the teen’s growth spurt. One in seven young people with scoliosis have such severe curvature that they require treatment.

How Scoliosis Is Diagnosed

• Physical examination and thorough medical history
• X-rays

How Scoliosis Is Treated

• Bracing: Many such cases never progress to the point that treatment is necessary. Follow-up visits are scheduled approximately every six months for those diagnosed with curves between fifteen and twenty degrees.

Curvature above twenty-five degrees may call for bracing. There are two main types of orthopedic back braces. The Milwaukee brace has a neck ring and can correct curves anywhere in the spine; the thoracolumbosacral orthosis (TLSO for short, thankfully) is for deformities involving the vertebrae of the thoracic spine and below. The device fits under the arm and wraps around the ribs, hips and lower back.

Scoliosis patients can expect to wear the brace all but a few hours a day until their spinal bone growth is complete; usually that’s about ages seventeen to eighteen for girls, and eighteen to nineteen for boys. The braces are more cosmetically appealing than they used to be and can be hidden easily under clothing. Having to wear an orthopedic brace interferes only minimally with physical activity. Only contact sports and trampolining are off-limits for the time being.

• Surgery: Posterior spinal fusion and instrumentation, the operation to surgically correct scoliosis, is typically recommended when the spine’s curvature is fifty degrees or more. The surgical procedure fuses the affected vertebrae using metal rods and screws to stabilize that part of the spine until it has fused together completely. On average, this takes about twelve months. Although teenagers who have the surgery still face some restrictions on physical activity, they can say good-bye to the brace.

Helping Teens Help Themselves

Only about 50 percent of young scoliosis patients wear their braces. Parents need to convey the importance of complying with the doctor’s instructions. At the same time, they should be sensitive to the tremendous impact the condition can inflict on a teenager’s body image, which at this age is inextricably entwined with self-identity and self-confidence. You might want to consider asking your pediatrician or orthopedist for a referral to a mental-health professional experienced in counseling children with chronic medical problems. A patient support group, like those run by the Scoliosis Association may also be helpful.

Children who walk with their feet turned in are described as being “pigeon-toed” or having “intoeing.” This is a very common condition that may involve one or both feet, and it occurs for a variety of reasons.

Intoeing during infancy

Infants are sometimes born with their feet turning in. If this turning occurs from the front part of their foot only, it is called metatarsus adductus.

Most commonly it is due to the foot being positioned in a certain way inside the uterus before the baby is born. You can suspect that metatarsus adductus may be present if:

• At rest, the front portion of your infant’s foot turns inward.
• The outer side of the child’s foot is curved like a half-moon.

This condition is usually mild and will resolve before your infant’s first birthday. Sometimes it is more severe, or accompanied by other foot deformities that result in a problem called clubfoot. This condition requires a consultation with a pediatric orthopedist, and there is extremely effective nonoperative treatment with early casting or splinting.

Intoeing in later childhood

When a child is intoeing during their second year, this is most likely due to inward twisting of the shinbone (tibia). This condition is called internal tibial torsion.

When a child between ages 3 and 10 has intoeing, it is probably due to an inward turning of the thighbone (femur), a condition called medial femoral torsion. Both of these conditions tend to run in families.

Treatment for intoeing

Some experts feel no treatment is necessary for intoeing in an infant under 6 months of age. For severe metatarsus adductus in infancy, early casting may be useful. Studies show that most infants who have metatarsus adductus in early infancy will outgrow it with no treatment necessary.

If your baby’s intoeing persists after 6 months, or if it is rigid and difficult to straighten out, your doctor may refer you to a pediatric orthopedist, who may recommend a series of casts applied over a period of 3 to 6 weeks. The main goal is to correct the condition before your child starts walking.

Intoeing in early childhood often corrects itself over time, and usually requires no treatment. But if your child has trouble walking, discuss the condition with your pediatrician, who may refer you to an orthopedist. In the past, a night brace (special shoes with connecting bars) was used for this problem, but it hasn’t proven to be an effective treatment.

Because intoeing often corrects itself over time, it is very important to avoid nonprescribed “treatments” such as corrective shoes, twister cables, daytime bracing, exercises, shoe inserts, or back manipulations. These do not resolve the problem and may be harmful because they interfere with normal play or walking. Furthermore, a child wearing these braces may face unnecessary emotional strain from her peers.

That being said, if a child’s intoeing remains by the age of 9 or 10 years old, surgery may be needed to correct it.

A pulled elbow (also known as nurse­maid’s elbow) is a common, painful injury generally among children under four years old but occasionally older.

Nursmaid’s elbow occurs when the tissue of the outer part of the elbow slips between the bones of the joint. This happens be­cause the child’s elbow joint is loose enough to separate slightly when their arm is pulled to full length (while being lifted, yanked, or swung by the hand or wrist, or if they fall on their outstretched arm). The nearby tissue slides into the space created by the stretching and becomes trapped after the joint returns to its normal position.

A nursemaid’s elbow injury usually doesn’t cause swelling, but the child will complain that the elbow hurts, or cry when their arm is moved. A child will typically hold his arm close to the side, with the elbow slightly bent and the palm turned toward the body. If someone tries to straighten the elbow or turn the palm upward, the child will resist because of the pain.

Treating nursemaid’s elbow

This injury should be treated by a pediatrician or other trained healthcare provider. Since elbow pain can also be due to a fracture, your pediatrician may need to consider this before the elbow is “reduced” or put back into place.

Your doctor will check the injured area for swelling and tenderness and any limitation of motion. If an injury other than nursemaid’s elbow is sus­pected, X-rays may be taken. If no fracture is noted, the doctor will move and twist and flex the arm gently to release the trapped tissue and allow the elbow to return to its normal posi­tion.

Once the doctor has moved the elbow back in place, the child will generally feel immediate relief and within a few minutes should be using their arm nor­mally without any discomfort. Occa­sionally, the doctor may recommend a sling for comfort for two or three days, particularly if several hours have passed before the injury is treated suc­cessfully.

If the injury occurred sev­eral days earlier, a hard splint or cast may be used to protect the joint for one to two weeks. Persisting pain after a reduction may mean that a fracture occurred that may not have been ap­parent at the time of initial X-rays.

Prevention

Nursemaid’s elbow can be prevented by not pulling or lifting your child by the hands or wrists, or swinging her by the arms. Instead, lift your child by grasping her body under the arms.

When children are born, adoring parents often joke about their new baby having 10 fingers and 10 toes. In reality, anything different is pretty rare (and not as bad as you might think). More common is seeing feet that point in different directions. Sometimes this is due to the baby being squished in a small space, for example. Other times it is from something that happened during the child’s development or as part of a genetic condition.

Causes & treatment for foot deformities in babies

The two most common foot deformities in newborns are metatarsus adductus and calcaneovalgus. Both are from how the baby’s foot was positioned and molded inside their mother. These conditions usually improve on their own without any treatment, and don’t cause any long-term problems.

Two other deformities, clubfoot and congenital vertical talus, look similar and may occur on one or both sides. However, these are serious congenital disorders that need prompt treatment by an experienced clinician.

Metatarsus adductus

Metatarsus adductus is a curve in the middle of the foot that occurs when the feet are folded inward. How crooked the foot looks is less important than whether the foot is flexible and can be straightened out if the examiner gently pushes it into a “normal” position.

Flexible metatarsus adductus usually improves on its own by 6-12 months old. There aren’t studies to show that stretching the foot during feedings or diaper changes helps, but it doesn’t hurt and is reasonable to try.

Feet that are stiff and don’t correct may benefit from casting. The need for surgery is rare, but can be done to straighten the foot if there are problems. Typically, surgery is done only if children have trouble fitting in or tolerating shoes, usually at around 3- to 4-years old.

Clubfoot

Children with clubfoot have metatarsus adductus, but the foot is stiff and has other differences such as a high arch. Clubfoot may occur in one or both feet. It is often diagnosed before birth by prenatal ultrasound. If not, the condition is readily noted at birth as a turned-in foot that cannot be simply placed in a normal position. Some clubfeet occur as part of a broader condition, such as spina bifida or arthrogryposis.

The treatment of clubfoot is generally very successful if treated by the Ponseti method starting in the first few weeks after birth. The Ponseti method, which is the international standard of care, involves several casts, generally one week apart, followed by Achilles tenotomy (sectioning of the Achilles tendon) in the doctor’s office. Then there is a brief period of more casting, followed by bracing for several years. It works very well unless families discontinue bracing too soon. When this happens, the clubfoot will return and possibly need surgery.

Calcaneovalgus

Calcaneovalgus foot is more or less the opposite of metatarsus adductus. The foot is pushed up and out. When the baby is born, it may be difficult to point the foot down all the way, but this improves without treatment over a couple months. It is not known if stretching helps, but it also probably doesn’t hurt. So, many doctors advise doing some stretching with feeding or diaper changes.

Surgery is usually only needed if the foot was pushed up enough to bend the shin bone backwards (posteromedial bowing) which is rare. The bowing will improve over a couple years on its own, but many children will have a leg length difference that may require surgery later in life. Until then, an insert in the shoe (heel lift) or building up the outside of the shoe helps even out the difference.

Congenital vertical talus

Children with congenital vertical talus also have a foot that bent up and to the outside. Similar to clubfeet, children with congenital vertical talus have a foot that is stiff and won’t correct. It is treated with surgery and casting.

Why does my pediatrician check my baby’s hips at each check-up?

Hip dysplasia (developmental dysplasia of the hip) is a condition in which a child’s upper thighbone is dislocated from the hip socket. It can be present at birth or develop during a child’s first year of life.

No one is sure why hip dysplasia occurs (or why the left hip dislocates more often than the right hip). One reason may have to do with the hormones a baby is exposed to before birth. While these hormones serve to relax muscles in the pregnant mother’s body, in some cases they also may cause a baby’s joints to become too relaxed and prone to dislocation.

Factors that may increase the risk of hip dysplasia include

• Sex – more frequent in girls
• Family history – more likely when other family members have had hip dysplasia
• Birth position – more common in infants born in the breech position
• Birth order – firstborn children most at risk for hip dysplasia

Detecting Hip Dysplasia

Your pediatrician will check your newborn for hip dysplasia right after birth and at every well-child exam until your child is walking normally.

During the exam, your child’s pediatrician will carefully flex and rotate your child’s legs to see if the thighbones are properly positioned in the hip sockets. This does not require a great deal of force and will not hurt your baby.

Your child’s pediatrician also will look for other signs that may suggest a problem, including

• Limited range of motion in either leg
• One leg is shorter than the other
• Thigh or buttock creases appear uneven or lopsided

If your child’s pediatrician suspects a problem with your child’s hip, you may be referred to a pediatric orthopedic specialist who has experience treating hip dysplasia.

Hip dysplasia is rare and in spite of careful screening during regular well-child exams, a number of children with hip dysplasia are not diagnosed until after they are 1 year old.

Some girls and boys complain of muscle aches around bedtime or wake up with pains in their legs and arms after sleeping for an hour or two. These aches are sometimes called growing pains. Although no one knows for sure what’s behind them, growth is not the cause; even at the peak of an adolescent growth spurt, a child’s rate of growth is too gradual to be painful.

Growing pains may consist of tenderness caused by overwork during hard exercise. Children don’t feel sore while they’re having fun; only later, when the muscles relax, do the pains come on.

What Parents Can Do to Help Lessen the Pain

You may not be able to prevent growing pains, but you can help your child lessen the aches.

• Call for periodic rest breaks during energetic play and encourage your child to take part in a variety of sports and activities. In this way, he’ll give different muscle groups a workout and avoid overstraining the same muscles day after day.
• A warm bath before bedtime may help soothe muscles and ease aches.
• When growing pains are bothersome, gently massage your child’s limbs.
• A dose of children’s acetaminophen or ibuprofen may be helpful.

When to Call Your Pediatrician

Call your pediatrician if your child has any of the following symptoms:

• Severe pain
• Swelling that doesn’t decrease or that grows worse after 24 hours, despite first aid with rest, ice or a cool compress, compression, and elevation (RICE) treatment
• Fever
• A persistent lump in a muscle
• Limp
• Reddening or increased warmth of the skin overlying the muscle
• Dark urine, especially after exercise (If severe enough, this may require emergency care.)

Babies are often born with flat feet, which may persist well into their childhood. This occurs because children’s bones and joints are flexible, causing their feet to flatten when they stand. Young babies also have a fat pad on the inner border of their feet that hides the arch. You still can see the arch if you lift your baby up on the tips of the toes, but it disappears when he’s standing normally. The foot may also turn out, increasing the weight on the inner side and making it appear even more flat.

Normally, flat feet disappear by age six as the feet become less flexible and the arches develop. Only about 1 or 2 out of every 10 children will continue to have flat feet into adulthood. For children who do not develop an arch, treatment is not recommended unless the foot is stiff or painful. Shoe inserts won’t help your child develop an arch, and may cause more problems than the flat feet themselves.

However, certain forms of flat feet may need to be treated differently. For instance, a child may have tightness of the heel cord (Achilles tendon) that limits the motion of his foot. This tightness can result in a flat foot, but it usually can be treated with special stretching exercises to lengthen the heel cord. Rarely, a child will have truly rigid flat feet, a condition that can cause problems. These children have difficulty moving the foot up and down or side to side at the ankle. The rigid foot can cause pain and, if left untreated, can lead to arthritis. This rigid type of flat foot is seldom seen in an infant or very young child. (More often, rigid flat feet develop during the teen years and should be evaluated by your child’s pediatrician.)

Symptoms that should be checked by a pediatrician include foot pain, sores or pressure areas on the inner side of the foot, a stiff foot, limited side-to-side foot motion, or limited up-and-down ankle motion. For further treatment you should see a pediatric orthopedic surgeon or podiatrist experienced in childhood foot conditions.

Idiopathic clubfoot is the most common serious musculoskeletal birth defect worldwide. In the United States, about one in 1,000 infants is born with a clubfoot (or clubfeet, as 40% of cases involve both feet).

Here’s what parents should know about clubfoot.

What does clubfoot look like?

An idiopathic clubfoot has a very high arch and turns inward toward the other leg, with the toes pointed down and backwards. The foot is quite stiff. The Achilles tendon, located behind the ankle, is tight.

What causes clubfoot?

The cause of idiopathic clubfoot is unknown (idiopathic means cause unknown). Genetic factors likely are involved, though, since there is a tendency for clubfoot to run in families. Idiopathic clubfoot is found in babies who have no other abnormalities.

Very rarely, however, clubfoot occurs as part of a syndrome or neurologic condition such as spina bifida.

How is clubfoot diagnosed?

Clubfoot may be discovered during prenatal ultrasound, usually at around the 20th week of pregnancy.

Occasionally a foot deformity seen during an ultrasound is a harmless positional abnormality, and not a true idiopathic clubfoot. For babies born with positional abnormalities, sometimes caused by crowding in the uterus, the feet are flexible. This kind of positional abnormality is often self-correcting.

Idiopathic clubfoot is diagnosed when the foot is examined at birth and found to be quite rigid. The deformity lasts into adult life unless treated.

How is clubfoot treated?

Fortunately, there is a very effective treatment for clubfoot: the Ponseti method. The treatment is named for Ignatio Ponseti, MD (1914-2009), who developed the technique over a number of years at the University of Iowa. The Ponseti method has three phases, casting, minimal surgery (Achilles tenotomy), and bracing.

Phases of the Ponseti method

• Phase one, the casting phase, should start soon (1-3 weeks) after birth. The casting technique is precise and should be performed by a physician (often a pediatric orthopedic surgeon) who is experienced with the Ponseti method. The casts are changed weekly until all elements of the deformity are corrected except a tight Achilles tendon. Usually, the first phase is complete after 5-7 casts.
• Phase two is a very minor surgical procedure, an Achilles tenotomy, required in 90% of cases. The tenotomy is generally done under local anesthesia in the office. Following the tenotomy a final cast is applied and left on for three weeks.
• Phase three is a prolonged period of bracing, full time for three months following casting and then nighttime only until the child is 4 to 5 years old. The brace is a bar with shoes or splints attached at shoulder width. The shoe or splint is turned out 60-70 degrees on the clubfoot side and 30-40 degrees on the normal side.

Working with your child’s doctors during the bracing

It’s not easy to keep an infant in a brace every night until age four years old. It is important to work closely with your child’s pediatrician and pediatric orthopedic surgeon to identify and solve any barriers to bracing.

In a small percentage of cases, the clubfoot deformity will come back (recur). Stopping the bracing phase too early is the most common cause of recurrence.

If the deformity comes back, the Ponseti casting is repeated and bracing started again. Occasionally, even when the bracing phase of the treatment plan is followed perfectly, the deformity will come back. If this happens, your child’s pediatric orthopedic surgeon may recommend a surgical procedure called an anterior tibial tendon transfer.

Beyond joint release surgery

Before the Ponseti method was accepted as the best treatment for babies with idiopathic clubfoot, pediatric orthopedic surgeons often treated clubfeet with extensive joint release surgeries. These surgeries dramatically corrected the clubfoot deformity in the short term. However, many of the children who were treated surgically developed pain and stiffness as they reached adulthood.

The anterior tibial tendon transfer that is occasionally needed to treat recurrent clubfoot deformity is considered part of the Ponseti method. It should not be confused with the joint release surgeries done in the past. It is extremely rare for a child treated with the Ponseti method to need a joint release surgery.

What is the outlook for a child born with a clubfoot?

The outlook for children who are born with a clubfoot and undergo Ponseti treatment, including the complete bracing phase, is excellent. They can be expected to wear normal shoes, participate in sports, and have every opportunity for a happy and productive life.