J A FIXSENABCj of Ito 7H B VALMAN

MINOR ORTHOPABDIC PROBLEMS

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Minor orthopaedic problems such as in-toeing, bow legs, knock knees, and

flat feet cause anxiety to both parents and doctors.In-toeing is nearly always due to one of three conditions: metatarsus

varus, which affects the foot; medial tibial torsion, which affects the lowerleg; and persistent femoral anteversion, which affects the whole leg. In

managing all these minor orthopaedic anomalies the whole child must beexamined to ensure that the orthopaedic problem is not part of a more

serious generalised disorder.

Metatarsus varus or adductus

Metatarsus varus or adductus, hookfoot or skewfoot, is very common. Itmay be noticed at or soon after birth but is most obvious and causes mostanxiety when the child starts to walk. At this stage the child fallsfrequently. Parents often ascribe the falls to the pronounced in-toeingrather than to the complex problem of learning bipedal gait. Metatarsusvarus can be distinguished from talipes equino varus as only the forefootis abnormal. The heel is in line with the leg and the foot can be flexed to90 or more.

Ninety per cent of all cases of metatarsus varus correct spontaneouslywithout treatment by the age of 3 to 4 years. Most of the remainingchildren will have no coniplaints about their feet; a few will showpersistent deformity, which will require treatment by plasters andoccasionally surgery. When advising parents to wait for natural resolutionin the face of obvious deformity it is important to explain three things:firstly, the natural history and high spontaneous recovery rate; secondly,the time recovery is likely to take; and thirdly, that if their child is the"odd man out" who does not correct then adequate and full correction ispossible and has not been jeopardised by waiting.

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Medial tibial torsion* : . :: ... .. : . . : ..~~~~~~~~~.. ... .. !.. ....::. .. ... ..........:..RR,R,R;

E z : ~~~~~~~~~~~~~~~~~~~~~~~~... ..... XEEpejiMedial tibial torsion is nearly always associated

with outward curving of the tibia, which is anexaggeration of the normal or physiological bowingof the tibia. In medial tibial torsion when the kneeis pointing forwards the foot is medially rotated20"-30° whereas in the adult the foot is normallyrotated outwards 0o-25o. Both the medial torsionand the bowing should correct spontaneously by theage of 3 to 4 years provided they are not associatedwith any other abnormality. No special shoes orSplints are necessary. Beware of marked unilateralbowing, which suggests an epiphyseal abnormality.Dietary rickets is still seen, particularly amongimmigrant children. Tibia vara, due to epiphysealgrowth abnormality, should be considered,particularly in West Indian and West Africanchildren, if the bowing is very pronounced and theangulation immediately below the knee.

Persistent femoral anteversion and retroversion

In persistent femoral anteversion the whole legturns in from the hip. The patellae look towardseach other-so called squinting patellae. The childcharacteristically sits between the legs. Todemonstrate the femoral neck anteversion the childshould be examined with the hips extended and theknees flexed. Internal rotation of the hip is greaterthan external rotation and can easily be seen andmeasured. 'In 8O0' 1 of these children the anteversionwill correct by the age of 8 years. It is doubtfulwhether any form of special shoe or splint caninfluence the condition. If there is severe persistentfunctional and cosmetic deformity after the age of8 femoral osteotomy is occasionally indicated.

Femoral retroversion (out-toeing) is the oppositecondition. The child lies or stands with the legsexternally rotated 900. There is often no internalrotation in extension at the hip. This conditioncorrects within a year of the child starting to walk.It is important to check the stability of the hipscarefully as congenital dislocation of the hip canalso cause external rotation.

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Knock knees

Seventy-five per cent of children aged 2 to 41 years have somedegree of intermalleolar separation. Up to 31 inches (9 cm) measuredwith the child lying down is acceptable. There is no evidence that shoemodification, splints, or exercises affect this condition. It is important tolook for pronounced asymmetry, short stature, and other skeletalabnormalities which may indicate a more serious problem. If the conditiondoes not correct spontaneously medial epiphyseal stapling at 10 to 11 yearsor corrective osteotomy at maturity is the treatment of choice.

Flat feet

There are two forms of flat feet: the first group are pain free and havenormal mobility and normal muscle power, and the second are painful,stiff, or hypermobile and show abnormal muscle power-that is, are weakor spastic.

It is important to remember that the normal foot is flat when the childstarts to stand. The medial arch does not develop until the second or thirdyear of life. Most children with flat feet will fall into the first group. Thesecharacteristics are commonly familial or racial. Treatment with insoles, shoemodification, or exercises is unlikely to make any difference to the shape ofthe feet. Shoe wear can be a problem and insoles or medial stiffening mayhelp. Surgery is rarely indicated. The second group is important as there iseither a local bony or inflammatory problem in the foot that needsdiagnosis and treatment or the flat foot is part of a more generalisedcondition such as severe generalised joint laxity, cerebral palsy, peronealspastic flat foot, or Down's syndrome.

joint laxity

Joint laxity should always be considered in children with a clumsy orawkward gait. The presence of three or more of the following are evidenceof definite joint laxity: in the arm, hyperextension of the wrist andmetacarpophalangeal joints, the thumb, or the elbow; in the leg,hyperextension of the knee or ankle. Laxity is frequently familial or it maybe part of a generalised disorder such as osteogenesis imperfecta,Ehlers-Danlos syndrome, or Marfan's syndrome.When counselling parents about minor orthopaedic problems it is

important to examine the patient fully, to explain the natural history of thecondition, and to check carefully for more serious disorders.

Mr J A Fixsen, MCHIR, FRCS, is consultant orthopaedic surgeon, Hospital for SickChildren, Great Ormond Street, and St Bartholomew's Hospital, London, and Dr HB Valman, MD, FRCP, consultant paediatrician, Northwick Park Hospital andClinical Research Centre, Harrow.

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