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Hip, knee and leg

Hip, knee and leg

Hip, knee and leg

So many childhood aspirations are linked to the ability to walk straight and tall, run, and move gracefully. Performance depends on how well feet, legs, knees and hips function. The pediatric orthopaedic team at Shriners Hospitals for Children — St. Louis addresses the surgical and non-surgical needs of children so they can achieve their personal best. Babies born with clubfoot, a limb deficiency or hip dysplasia are among patients seen by the board-certified pediatric orthopaedic specialists at the St. Louis Shriners Hospital. Care also extends to children and adolescents who suffer accidental and traumatic injuries that impair function. The course of care is determined individually for each patient. In each and every case, the goal is to optimize function and put the child on the road to independence.

More about the hip, knee and leg conditions we treat:

Bowed legs

Blount’s disease (tibia vara) is a rare growth disorder of the tibia (shin bone) that causes the lower leg to angle inward, resembling a bowleg. Treatment for Blount’s disease may include bracing or surgery.

Genu varum (bowed legs) is a common condition in young children. In the first year of life, bowed legs are normal. Treatment is usually observation. Pictures of the child’s legs may be taken several months apart to observe the straightening process. Most children outgrow this condition. If necessary, a child may undergo a surgical procedure called guided growth where plates and screws are secured to the growth plate; or a surgical procedure called an osteotomy, which is a complex procedure that involves cutting the bone, adding or removing a wedge of bone, and realigning the bone.

Foot problems

Bunions are abnormal enlargements of the joint of the great toe. Taping or splinting of the foot, padded shoe inserts, anti-inflammatory medication or cortisone injections may treat bunions. Surgery may be necessary if conservative treatment doesn’t work.

Clubfoot/talipes equinovarus is a condition present at birth where the foot points downward while the toes and bottom of the foot point inward. We use the Ponseti method for treating clubfoot. This consists of serial casting, which starts 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. Physical therapy may be ordered. Once corrected, older children are clinically observed and braced as needed. Rarely is there a recurrence of the clubfoot as the child grows.

Metatarsus adductus is a common foot deformity noted at birth that causes the front half of the foot to turn inward. It may be either "flexible" (the foot can be straightened to a degree by hand) or "nonflexible" (the foot cannot be straightened by hand). Treatment, depending on the severity, can range from observation, stretching and manipulation exercises, casting or surgery. It is recommended that a diagnosis be sought and treatment begin as soon as possible after the child’s birth to ensure the best possible outcome.

Pes cavus (high arched feet) is a condition where the arch of the foot does not flatten with weight bearing. Treatment for pes cavus is corrective shoes with arch supports or insoles. Surgery may be necessary for severe cases only.

Pes planus (flat feet) is a very common condition that usually does not interfere with a child’s comfort or ability to walk. If the flat foot persists and the child is complaining of pain, shoe orthotics/inserts, braces or pain medication may be beneficial. Surgery is rarely needed.

Polydactyly is being born with extra fingers and/or toes. This deformity occurs during the development of the fetus. Polydactyly is treated with surgery to remove the extra digits.

Tarsal coalition is an abnormal connection of the two bones at the back of the foot, causing foot pain. There are several treatment options for tarsal coalition, including rest, shoe inserts/arch supports, boot or cast, or steroid injections. Surgery may be necessary to improve function and reduce pain.

Toe walking is a condition where a child walks on his/her toes without putting weight on the heel or any other part of the foot. It is common in toddlers and typically children outgrow it. If toe walking persists beyond age three it is suspicious for an underlying neuromuscular problem. If treatment is necessary, a child may undergo physical therapy, bracing, splinting, serial casting or surgery.

Vertical talus is a congenital foot disorder where the foot points upward, creating a rocker bottom. There are several treatment options for vertical talus, including casting, physical therapy and stretching or surgery.

Hip deformities

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 a part of the pelvis. DDH is a spectrum of disease ranging from slight under-covering 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, spica 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 where the hips and knees are straight not allowing movement has been shown to increase the risk for DDH.

Legg-Calve-Perthes is a condition where 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, 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 (stretching) exercises may be prescribed to help keep the range of motion in the hip joint. Assistive equipment for walking, such as crutches, may be necessary. Occasionally the child may need to be placed in casts or traction to keep the hip in the proper position while healing. Surgery is sometimes required, typically after the age of seven, to shape the hip joint and relieve pain.

Slipped capital femoral epiphysis is a condition when the upper end of the femur slips backwards in the hip socket, causing hip pain. Surgery may be necessary to prevent further slipping.

In-toeing gait

In-toeing (pigeon toes) and out-toeing are common developmental concerns in children. The problem 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; therefore special shoes, braces or exercises are not needed. Casting or surgical procedure is necessary for severe cases only.

Femoral anteversion is an inward twisting of the thighbone and causes the child's knees and feet to turn inward or have what is also known as a "pigeon-toed" appearance. It is typically detected when the child is four to six years old. Femoral anteversion has a very good prognosis. Many cases correct themselves as the child grows. Occasionally the doctor prescribes braces or special shoes. On rare occasions, femoral anteversion can be severe and surgery may be required to straighten the thighbone.

Tibial torsion is an inward twisting of the shinbones. Tibial torsion causes the child's feet to turn inward, or have a "pigeon-toed" appearance. It is typically seen among toddlers and has a very good prognosis. Many cases correct themselves as the child grows. On rare occasions, tibial torsion can be severe and surgery may be required to straighten the shin bones.

Knees

Osgood-Schlatter disease is an overuse injury in the knee area of growing adolescents. There are several treatment options for Osgood-Schlatter disease, including rest, ice, pain medication, physical therapy or a knee strap.

Patellar (knee) instability is a condition where the kneecap is unstable and can move out of place (dislocates). Treatments include physical therapy or immobilization (cast). Surgery may be necessary in order to stabilize the knee.

Limb length problems

Limb length discrepancy is a difference between the lengths of the arms or 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. Surgical options include epiphysiodesis (slowing the growth in the long leg), Ilizarov method (lengthening of the short bone) or a new technique using lengthening rods. 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. The bone is separated by cutting it and then slowly lengthened. When the desired length is reached, the metal ring and wires are removed and the limb is casted until the bone is fully healed, followed by physical therapy after cast removal.

Toes

Syndactyly is a condition in which the fingers/toes were not completely separated (webbed) during development. Some forms of syndactyly are inherited while some forms occur sporadically. Treatment of syndactyly varies by child; therefore a team of hand and foot specialists will decide a treatment path and will evaluate each child. Sometimes the hand functions well without surgery and sometimes surgery is required to separate the fingers and deepen the space between the fingers.

   
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