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Hip, knee and foot

Hip, knee and foot

Hip disorders

Developmental dysplasia of the hip (DDH)

Developmental dysplasia of the hip (DDH) is a condition of the hip joint where the child is born with, or develops, an abnormal hip. The normal hip is a ball and socket joint where the ball (femoral head) is located on the top of the thigh bone (femur) and sits in a round socket (acetabulum) that is part of the pelvis. DDH is a spectrum of disease ranging from slight uncovering of the ball by the socket to a hip that is completely dislocated. In newborns, treatment may involve a Pavlik harness to promote development of the hip joint. In older children, casting or surgery may be necessary to keep the ball in the socket and promote normal development of the hip.

Newborns are susceptible to DDH by tight swaddling techniques. It is recommended that when a newborn is swaddled the upper body can be wrapped tightly, but the legs should be free to allow proper hip flexion and abduction. Tight swaddling in a position where the hips and knees are straight and do not allow movement, has been shown to increase the risk for DDH.

Perthes disease

Legg-Calve-Perthes is a condition in which blood no longer reaches the ball part of the hip, causing the bone to stop growing and flatten. Eventually, blood flow is restored, dissolving the flattened part of the bone and replacing it with new bone. There is no known cause of this disorder. Treatment consists of observation that includes X-rays and keeping the newly growing bone centered in the hip socket. This helps the bone grow back in a properly round and smooth shape. We may prescribe physical therapy exercises to help keep the range of motion in the hip joint and assistive equipment for walking, such as crutches. Occasionally, we may have to place the child in Petrie (abduction) casts to keep the hip in the proper position while healing. Surgery is sometimes required to gain a better hip joint.

Adolescent hip pain

Slipped capital femoral epiphysis (SCFE)

Slipped capital femoral epiphysis (SCFE) is an acute condition requiring urgent attention. The top of the thigh bone, or femoral head, looks like a ball. An SCFE is when this ball slips off. Pain can be sudden or gradual and can be expressed as knee pain. The blood supply to the ball can be affected if the SCFE is left untreated. Treatment involves a short surgery to place a pin into the femoral head to prevent further slipping of the ball. Patients will usually say their pain is relieved once the surgery is over. After surgery, activities are restricted until X-rays demonstrate healing of the bones. SCFE is more common in boys. Although the cause is not fully understood, times of accelerated growth during puberty and being overweight are associated findings.

Femoral-acetabular impingement (FAI)

Femoral-acetabular impingement (FAI) is a condition that presents during adolescence as hip pain in active children. Typically, the pain is located in the groin and is due to a slight mismatch between the socket and the ball such that the ball hits or “impinges” on the socket during normal range of motion. The labrum (protective soft-tissue lining of the socket) or cartilage (joint surface) can be damaged in FAI causing hip pain. Evaluation involves a thorough history and physical exam, X-rays and possibly an MRI. Treatment consists of activity modification, physical therapy and possibly surgery.

Lower extremity conditions

Limb length discrepancy

Limb length discrepancy is a difference between the length of the arms or legs. Limb length discrepancy of the arms does not usually have an impact on how the arms function and usually requires no treatment. Children with limb length discrepancy of the legs may be treated using a shoe lift or shoe insert. Children with significant differences in leg length may need surgery for either epiphysiodesis (slowing the growth in the long leg) or Ilizarov (lengthening the bone in the short leg). Epiphysiodesis is a surgery to stop the growth at the epiphysis (end of the bone). It is performed on the longer leg, which allows the shorter leg to catch up in growth. The Ilizarov method is an external device (metal rings on outside of arm or leg) with small wires that go through the bone. Sometimes the device is referred to as a halo. The bone is separated by cutting it and then slowly lengthened. When the desired length is reached the metal ring and wires are removed, the limb is casted until the bone is fully healed, followed by physical therapy after cast removal. The process can take six to 12 months.

Genu varum (bowed legs) and genu valgum (knock-knees)

  • Bowed legs is a common condition in young children. In the first year of life, bowed legs are normal. Treatment is usually observation. We may take pictures of the child’s legs several months apart to observe the straightening process. Most children outgrow this condition. Bracing or therapy is not indicated for common bowed legs.
  • Knock knees is a common condition in young children. They usually outgrow it. Common treatment is observation and sometimes X-rays. We may take pictures of the child’s legs several months apart to see their progression. Rarely is surgery necessary.

Foot disorders


Clubfoot is a condition present at birth where the foot is contracted and turned inward. We use the Ponseti method for treating clubfoot. This consists of serial castings starting as soon after birth as possible. Most babies will have a minor surgical procedure called a tenotomy, followed by bracing with a foot abduction orthosis. Once corrected, older children are clinically observed and braced as needed. Rarely is there a recurrence of the clubfoot as the child grows.

Flat feet

Flat feet is a very common condition that usually does not interfere with the child’s comfort or ability to walk. Our orthopaedic specialists will monitor the child’s condition. If the flat foot persists and the child is complaining of pain, arch supports may be beneficial. Special shoes or inserts will not fix the flat foot. Surgical intervention is rare.

In-toeing (pigeon toes) and out-toeing

In-toeing (pigeon toes) and out-toeing are common concerns in children. The problem can develop just in the foot or can be from a slight rotation of the hip or the lower leg bone. Most children outgrow this without any treatment, special shoes, braces or exercises. Very rarely will a child need casting or a surgical procedure.

Congenital limb deficiencies and amputations

Congenital limb deficiencies and amputations can be caused by a variety of conditions such as: fibular deficiency, tibia deficiency, amniotic band syndrome and congenital amputation. A child may be born with a condition where the limb has a complete amputation or the child is born without a functional lower part of the arm/leg. A multidisciplinary team of surgeons, nurses, prosthetists and therapists evaluate and work with each child to create a solution that maximizes their individual function.