Normal and abnormal in Paediatric Orthopaedics; what should we do James Hunter Nottingham

Clinics and Team Kathryn Price Monday KRP1B James Hunter Tuesday JBH2B Dominik Lawniczak Tuesday DL22B Julian Chell Thursday JC34B Hip instability Tuesday Mark Batt Friday MEB5P Physio Clinic Friday JBH5P

Normal Growth Growth is predictable Boys half adult height aged 2 Tanner and Whitehouse Legs half adult length age 3 for girls 4 for boys (Paley)

Leg growth Proximal femur 15% Distal femur 37% Proximal tibia 28% cm/yr 0.6 1.2 0.7 Proximal femur 15% Distal femur 37% Proximal tibia 28% Distal tibia 20%

Normal Variation

Flat feet Flexible flat feet are normal 90 % at age 1 20 % of adults Associated with generalised laxity Doesn’t all “get better”

Flat feet

Flexible

Flat feet: Jack’s test

Flat feet ; red flags Pain Stiffness Peroneal spasm

Stiff

Flat feet; differential Infection Inflammation eg arthritis Tarsal coalition Tumours

Flat feet: tarsal coalition

Stiff

Flat feet: management Flexible flat feet are normal Orthotic if painful retain if effective First orthotic from shop or internet Treat other conditions on merit

Intoeing Persistent femoral anteversion Tibial torsion aka femoral torsion Tibial torsion Metatarsus adductus

Intoeing: examination Foot progression angle Range of hip movement Thigh-foot angle Inter-malleolar angle Foot curvature (from below)

Intoeing: examination

Intoeing: examination

Intoeing

Intoeing: W position

Intoeing: management Advice Torsional differences do not Reduce athletic performance Lead to degenerative changes Metatarsus adductus mostly resolves if flexible The only definitive management is osteotomy Bracing stresses joints

Metatarsus adductus

Bow legs

Bow legs

Salenius and Vankka

Bow legs

Bow legs Red flags Blount’s is physiological varus gone wrong Unilateral Progressive after age 3 Blount’s is physiological varus gone wrong Common in Overweight Early walkers US black population

Bow legs: Blount’s