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Hip, knee and foot

Hip, knee and foot

Hip, knee and foot

Hip disorders

Developmental dysplasia of the hip (DDH)

This 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 a part of the pelvis. DDH is a spectrum of disease ranging from slight undercovering of the ball by the socket, to a hip that is completely dislocated. In the newborn period, 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 is 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, have been shown to increase the risk for DDH.

Perthes disease, or Legg-Calve-Perthes

This 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, including 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. Physical therapy exercises may be prescribed 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

Femoral-acetabular impingement (FAI)

This 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 which causes the ball to hit or “impinge” on the socket during normal range of motion. The labrum (protective soft-tissue lining to the socket) or cartilage (joint surface) can be damaged in FAI causing hip pain. Evaluation involves a thorough history and physical examination, X-rays and possibly an MRI. Treatment consists of activity modification, physical therapy and possibly surgery.

Slipped capital femoral epiphysis (SCFE)

This is an acute condition requiring urgent attention. The top of the thigh bone, or femoral head, looks like a ball. SCFE occurs when the 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 surgery to place a pin into the femoral head to prevent further slipping of the ball. Patients will usually experience relief from pain 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.

Lower extremity conditions

Amniotic band syndrome

This is a rare syndrome caused when thin strands of tissue form inside the amniotic sac, tangling around the baby while still in the womb. Pressure from the strands can affect the way the baby grows. While most bands affect only the outer layers of soft tissue, tighter bands may go all the way to the bone. Treatment is individualized based on the child’s specific needs, depending on where and how deeply the amniotic bands affected development.

Blount’s disease, also called genu varum or bowed legs

This 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.

Genu valgum, also called knock knees

This is a common condition in young children where the legs curve inward, which they usually outgrow. Treatment is usually 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.

Limb length discrepancy

This is a difference between the lengths of the legs. 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 to either slow the growth in the long limb or lengthen the bone in the short limb. Epiphysiodesis is a surgery to stop the growth at the epiphysis (end of the bone). It is performed on the longer limb, which allows the shorter limb to catch up in growth. The Ilizarov method (commonly used at Shriner’s Hospitals for Children — Lexington) involves surgical application of an external device (metal rings on outside of arm or leg) with small wires that go through the bone. The bone is surgically separated in the middle then slowly lengthened by gentle distraction of the rings. 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.

Osgood-Schlatter disease

This is a common cause of knee pain in children. It is an inflammation of the area just below the knee where the tendon from the kneecap attaches to the tibia, or shin bone. Treatment usually involves rest, over-the-counter medications and stretching, and strengthening exercises.

Foot disorders

Clubfoot

This is a condition present at birth where the foot is contracted and turned inward. The Ponseti method is used at Shriners Hospitals for Children Medical Center — Lexington to treat clubfoot. This method consists of serial casting to start as soon as possible after birth. 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

This is a very common condition that usually does not interfere with a child’s comfort or ability to walk. If flat feet cause discomfort, arch supports may be beneficial. Rarely is a surgical procedure needed.

In-toeing (pigeon toes) – also called out-toeing

These are common developmental variations in children. The condition can develop solely 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; so special shoes, braces or exercises are not indicated. Very rarely will any casting or surgical procedure be indicated.

Congenital limb deficiencies and amputations

This includes a variety of conditions such as fibular deficiency, tibia deficiency, amniotic band syndrome or 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 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.

   
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