FAQ Category: Child

As you know from personal experience, clubfoot is an unmistakable deformity present at birth. The foot is twisted (turned under and towards the other foot). The medical terminology for this position is equinus and varus.

Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

The medical term for clubfoot is Congenital Talipes Equinovarus. Congenital means that the condition is present at birth and occurred during fetal development. Clubfoot mainly affects three bones of the foot: the calcaneus (heel bone), talus (just above the heel bone), and navicular (bone next to the talus).

The standard treatment for a clubfoot deformity in infants and young children is the procedure you are probably most familiar with: the Ponseti Method. Developed by an Italian physician, the Ponseti Method involves manipulating (moving) the bones of the foot and ankle toward a neutral position of alignment. The bones are then held in place by a cast.

Each week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).

The reason this approach works is that manipulation stretches the still very flexible joint capsule ligaments, tendons, and muscles in infants and young children. The Ponseti method also corrects the abnormal relationships of the bones in the foot. By aligning the bones where they belong, this treatment even has the potential to reshape the bones so that they fit together as they should.

A corrective brace is worn after the Ponseti treatment is completed. Many studies over the years have shown that just wearing the brace is not enough to correct the abnormal ankle and foot alignment. Combining manipulation with immobilization followed by corrective bracing has the best results overall.

Relapse can occur and we know that relapses don’t recover on their own without intervention. Currently, poor compliance with abduction bracing is the only known risk factor. Changes in the brace angle and wearing schedule have already been implemented, which may account for the decline in relapse rates from even 10 years ago.

Treatment for late-relapses varies and can range from 1) observation only to 2) bracing, or 3) casting followed by bracing, 4) casting to prepare the feet for surgery followed by surgery then bracing, and 5) surgery. Most of the children (no matter how they were treated for the relapse) ended up having surgery to correct the deformity. The most common surgical procedure is a tendon transfer called TATT for tibialis anterior tendon transfer.

Research is needed to determine the best treatment for late relapses and to identify risk factors for relapse. Each case may require a slightly different approach depending on the age of the child, the type of initial treatment, and current symptoms/clinical presentation.

Although we have some general guidelines for range-of-motion measurements in adults, normative values for children of varying ages are not available. Normative values means you can find a chart with the expected measurements for each of these areas based on age and sex (male and female).

Other measures of things like grip strength, height, weight, head circumference, and even IQ (intelligence quotient) have normative values. When it comes to evaluating and treating hip problems in children, it would be helpful to know what is normal motion and what is not.

However, a recent study was done at Children’s Hospital of Philadelphia (CHOP) to determine what constitutes normal (versus abnormal) hip motion in normal, healthy children.. Hip measurements were taken of children who came to the hospital for treatment of a broken arm. There were no leg injuries or other compromising health conditions. There were 252 children involved in the study (that’s 504 hips to measure).

Measurements were taken in two positions lying down: supine (face up) and prone (face down). Measurements taken in the supine position included flexion, abduction (leg away from the midline), adduction (leg toward the midline), and rotations (internal and external). Extension and rotations were measured from the prone position.

In general, it appears that hip range-of-motion decreases as children get older. This effect is more obvious in boys than in girls. Differences between boys and girls at different ages are presented but the study was not designed to compare differences based on race (e.g., Whites, Blacks, Hispanics, Asians). That will be something future researchers may address. A graph showing the range and averages over time for each measured motion was included based on age and sex.

The information gathered in this study will help physicians evaluating children for problems such as slipped capital femoral epiphyses (SCFE), synovitis or other inflammatory hip problems, and femoroacetabular impingement (FAI). Such diagnoses depend on altered range-of-motion as a primary measure. To really help in the evaluation of all pediatric hip diseases, the additional information about differences based on race will be needed.

Until the values from this study can be repeated and confirmed, physicians and physical therapists measuring hip motion in children will continue to compare one side to the other looking for differences. With clinical experience taking these kinds of measures, health care professionals can usually tell when something is not ‘normal’. The gray areas where something isn’t quite right remain a challenge that will require additional testing and possibly imaging studies (e.g., X-rays, CT scans, MRIs).

You are most likely referring to a gadget called a goniometer. This two armed measuring stick is used to measure joint range-of-motion. It is actually a fairly reliable measuring tool based on studies that compare how close two (or more) people come using the same tool on the same child (and on other children).

Usually the goniometer is made of solid plastic or metal so there is very little give or flexibility in the tool itself. Each arm of the goniometer is lined up with preset bony landmarks. By using the same physical reference points from person-to-person, it’s easy to get a close approximation of the angle.

When the same therapist using the same tool measures the same person, there could be a little intra-rater difference. But for the most part, this will only differ by three to five degrees of motion. In the long-run and in the big picture, any significant changes over time will be easily recognized.

Goniometric measurements can be very useful aids in the initial assessment, determining a diagnosis, and later, making an evaluation of progress made. Evaluating children for problems such as slipped capital femoral epiphyses (SCFE), synovitis or other inflammatory hip problems, and femoroacetabular impingement often requires hip range-of-motion measurements for a clear diagnosis. And the goniometer is the best tool available for this task.

It sounds like your son may have a condition known as tarsal coalition. Tarsal coalition is the failure of the developing bones in the foot to properly form all the distinct, individual bones. The problem occurs most often in the midfoot (between the ankles and toes). Two or more bones form a bridge of bone between them or they fuse together. Males are affected more often than females though the reason for this remains unknown.

There may be no treatment required for some people with this condition. That’s because some children and teens don’t develop any symptoms until they are older. Some folks never experience any problems associated with tarsal coalition. But weight gain, an injury, or a sudden increase in activity can result in pain, stiffness, and/or a limp.

Conservative care is the first-line of treatment for bone deformities of this type. This can include orthotics (molded shoe inserts), nonsteroidal antiinflammatory medications, or steroid injections. Changes in activity can also provide some relief from symptoms.

Surgery is another treatment possibility but this is usually reserved for patients with foot pain that is intolerable and doesn’t go away otherwise. Usually, the bar of bone is removed and body fat or muscle is used to fill in the space. Packing the space left by bone excision (removal) is necessary so the bone doesn’t grow back in.

The prognosis is good for tarsal coalition when it is diagnosed early or when the affected individual is fairly inactive. There is usually a favorable outcome for patients with a foot that is fused in the neutral position. Fusion can occur naturally (be present as part of the condition) or can be done surgically.

The goals of all treatment are to reduce (eliminate if possible) pain and other symptoms, to correct ankle and foot alignment, and to restore full function of the foot and ankle complex. After surgery an orthosis (molded shoe insert) may be prescribed to support the foot and ankle. Results of surgical treatment vary depending on how many bones are affected, the type of surgery done, and whether or not complications occur during or after the procedure.

Good-to-excellent results are reported in 75 per cent of all surgical cases. The remaining 25 per cent may have less optimal results if there is an incomplete correction of the problem. Damage to nerves in the surgical area can result in unexpected problems. Even with a few bumps in the road, most children are back to full play and activities three to six months later.

Tarsal coalition is the failure of the developing bones in the foot to properly form all the distinct, individual bones in the midfoot (between the ankles and toes). Instead, two or more bones can form a bridge of bone between them or fuse together. Males are affected more often than females though the reason for this remains unknown.

This condition is usually congenital (present at birth) and there are inherited factors involved. Tarsal coalition can also develop after birth as a result of trauma, infection, or inflammation (e.g., arthritis). In some cases, tarsal coalition is part of a larger problem with other bony malformations.

The most obvious symptom of tarsal coalition is a rigid flatfoot. An X-ray or other imaging study provides a look inside the foot to confirm the diagnosis. CT scans are especially helpful to see exactly what’s going on. This information helps the surgeon know how to best treat the problem.

The condition can be asymptomatic (no symptoms present). Symptoms such as pain and stiffness don’t develop in children until the connecting tissue between the bones hardens or ossifies forming a bony bridge. Increased activity (e.g., sports or dance) involving the feet may aggravate the child, teen, or young adult. Sometimes it’s weight gain or repeated ankle sprains that bring on symptoms of pain, foot fatigue, or limping. Muscles in the foot may spasm in an effort to protect the foot adding to the discomfort.

Treatment is usually conservative (nonoperative) but surgery may be needed in some cases. Treatment and results depend on the severity of the condition, any complications that may develop, and activity level of the affected individual.

Children have remarkable healing abilities but sometimes their fast growth just isn’t enough. That’s the case with large gaps in bone caused by tumor removal or traumatic fractures. To help bridge the gap, a special technique called vascularized fibular periosteal graft can be used.

A fibular periosteal flap is a piece of bone taken from the fibula the smaller bone in the lower leg. A special tool called a periosteal elevator is used to lift the top layer of bone, which is then transferred to the site where it is needed.

The way in which the bone graft is placed in the defect depends on the underlying problem. For example, if a fracture hasn’t healed (called a nonunion), then the periosteal flap is wrapped around the two ends of the bone in a “J” pattern. If the gap is from bone (tumor) removal, then the flap is used to bridge the gap by attaching it from one side to the other.

If the bone is used in the same leg, then blood vessels to the bone can be taken at the same time. This is called a pedicled graft. If the bone graft is used anywhere else, the donor bone is taken without attached blood vessels (called a free flap). With a free flap, the surgeon must perform microsurgery to connect the bone graft to local blood vessels (at the site of placement).

Vascularized fibular periosteal graft is a reconstructive strategy that works for children because of their unique ability to grow fast. This type of tissue transfer is successful because the bone has strong osteogenic (bone growth) properties and angiogenic (formation of blood vessels) abilities. Both the donor site and the graft site heal quickly and without problems.

There was a recent report from Spain about a new surgical technique for complex, challenging cases like your daughter. They used a technique called vascularized fibular periosteal graft. Their report gives the results of a dozen children who received this treatment.

A fibular periosteal flap is a piece of bone taken from the fibula the smaller bone in the lower leg. A special tool called a periosteal elevator is used to lift the top layer of bone, which is then transferred to the site where it is needed.

If the bone is used in the same leg, then blood vessels to the bone can be taken at the same time. This is called a pedicled graft. If the bone graft is used anywhere else, the donor bone is taken without attached blood vessels (called a free flap). With a free flap, the surgeon must perform microsurgery to connect the bone graft to local blood vessels (at the site of placement).

Once the procedure has been completed, the wait begins. In places where the bone is close enough to the surface, it may be possible to palpate or feel the new bone growing. New bone forms a callus (bony knob) that will eventually be remodeled by the body’s own healing processes and become smooth once again.

The callus can often be felt two to three weeks after the bone graft procedure. Otherwise, serial (repeated) X-rays and CT scans can be used to assess results. Special ultrasound Doppler tests are used to monitor blood flow.

Using this new technique, the authors report success in all but one case. In the one case where it didn’t work, the blood vessel attached to the bone graft was twisted so blood was not getting to the graft site. A second surgery to repeat this technique was successful.

Healing time with progressive bone formation ranged between two and nine months. This is much faster than with allografts (bone from a donor bank). The length of time for bone to fill in the gap depended on the location of the problem (e.g., middle of the bone versus near the growth plate). The final bone union occurred in two stages: first along the outside (periosteal layer) and then the layers underneath forming the cortical (inside) layers.

The authors conclude that this new technique using periosteal bone (with or without blood vessels attached) is an effective way to stimulate fast bone growth in children. It’s not a method that is needed routinely but saved for children with complex bone loss too large to heal completely without some help.

Vascularized fibular periosteal graft is a new reconstructive strategy that works for children because of their unique ability to grow fast. This type of tissue transfer is successful because the bone has strong osteogenic (bone growth) properties and angiogenic (formation of blood vessels) abilities. Both the donor site and the graft site heal quickly and without problems. It may be one approach your surgeon wants to consider but there may be other more appropriate techniques recommended for your daughter’s situation.

Forceful and repeated actions associated with several sports can strain the immature surface of the involved joint for some athletes. The knee and elbow are affected most often. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. This condition is called osteochondritis dissecans (OCD).

In the past, this condition was called Little Leaguer’s elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, including gymnastics, weight lifting, and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

Treatment is determined by several factors including size of the lesion, age of the patient, and symptoms (e.g., severity of pain, swelling, loss of joint motion). The status of the affected cartilage (attached, partially detached, completely detached) is also considered when determining the best treatment approach.

For small defects that don’t involve loose fragments, conservative (nonoperative) care may be successful. The child or teen is advised to modify his or her activity and avoid putting strain and load on the joint. Activity reduction and modification may be required for several months or more.

If this treatment approach isn’t successful or if there is a large lesion with loose fragments, then surgery may be required. The goals of surgery are usually to decrease pain, increase motion, and return the athlete to a preinjury level of activity.

Surgeons have at their disposal several techniques that can be used. The simplest method is called debridement. The surgeon gently shaves away the damaged cartilage, removing any jagged edges and smoothing down the bone. If there are any loose pieces of cartilage or bone, these can be removed during the procedure. Large pieces of bone can be reattached with pins, wires, or screws. The surgeon can also drill tiny holes into the affected area to help stimulate a healing response.

The best surgical approach for this condition has not been identified. Studies show that early treatment is favored over a wait-and-see approach. Lesions seen early on X-rays have a fairly poor prognosis without surgery. More advanced imaging such as MRIs give the surgeon a better idea of the depth and extent of the defect when considering surgical intervention.

The surgeon may have the patient take part in formal physical therapy a few weeks after surgery. The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. Exercises are chosen to help improve elbow motion and to get the muscles toned and active again. At first, the elbow is exercised in positions and movements that don’t strain the healing cartilage. As the program evolves, more challenging exercises are chosen to safely advance the elbow’s strength and function.

Most patients will need to modify their activities after surgery. Most pitchers are unable to throw hard and without pain afterward. In general, most athletes with elbow OCD need to stop playing high-level sports due to lingering elbow pain and reduced elbow motion.

If symptoms come back again, patients must modify their activities until symptoms subside. They’ll need to avoid heavy sports activity until symptoms go away and they are able to safely begin exercising the elbow again.

You should be aware that surgery isn’t 100 percent successful. The various procedures don’t necessarily improve athletes’ chances for returning to high-level competition. Patients can lose the ability to fully straighten the elbow. And even after surgery, they are prone to elbow arthritis in early adulthood.

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to an elbow condition called “Little League elbow”. The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. The medical term for this condition is osteochondritis dissecans (OCD).

Elbow OCD affects the articular cartilage in the capitellum. The capitellum is a knob on the end of the humerus (your upper arm bone). The capitellum fits into the cup-shaped end of the radius (one of the two bones in the forearm that connects to the humerus).

The capitellum transmits two-thirds of all compressive forces across the elbow. Throwing athletes with an increased angle at the elbow (called valgus) put even more force and load through the capitellum. Overworked, poorly conditioned, and skeletally immature elbows are at increased risk for this condition.

OCD also affects the layer of bone just below the cartilage, which is called the subchondral bone. In advanced stages of OCD, the upper end of the radius, particularly the head of the radius, is also involved.

For small defects that don’t involve loose fragments, conservative (nonoperative) care may be successful. The child or teen is advised to modify his or her activity and avoid putting strain and load on the joint. Activity reduction and modification may be required for several months or more.

If this treatment approach isn’t successful or if there is a large lesion with loose fragments, then surgery may be required. The goals of surgery are usually to decrease pain, increase motion, and return the athlete to a preinjury level of activity. This is where advanced imaging such as MRIs and CT scans can be very helpful. X-rays are less expensive but aren’t as sensitive as MRIs for showing the depth and extent of the lesions.

Before and after MRIs can also help identify if and when the problem is healing as it should. Delays in healing or worsening of the condition need to be addressed sooner than later for the best results. The insurance company may reverse its decision with a letter of justification from the surgeon. This type of documentation explains the problem and why advanced imaging techniques such as MRI are needed.

If the company still won’t budge, you may have to consider paying out-of-pocket for the service. Most imaging companies will work with patients and their families to create a payment schedule that works for everyone.

When two bones in the ankle are formed without the normal separation between them but are held together by a bridge of bone, the condition is referred to as a coalition. The child is born this way but may not know it until later in life when the foot looks flat and ankle pain and deformity interfere with standing and walking.

The two most common bony coalitions in the ankle are formed by the talus and calcaneus bones (talocalcaneal coalition) and the calcaneus and navicular bones (calcaneonavicular coalition). The condition has been treated in the past with conservative (nonoperative) care (e.g., leg cast) or with surgery to fuse the ankle.

But more modern surgical approaches are now available. A recent article written by experts in this area, may help you. Six surgeons offer their insights, expertise, and results performing one of the newer techniques. The specific approach they took was to treat a talocalcaneal coalition by removing the bridge of bone between the two bones. Then a piece of fat (taken from the patient’s buttocks or abdomen) was placed in the space left by the resected bone. Fat implantation of this type is referred to as a fat graft interposition.

Overall results were measured using a test called the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score (AOFAS). The AOFAS provides a way to measure three areas: pain, function, and alignment. Each child was followed for at least one full year. Before and after X-rays and CT scans were also compared.

Only one of the 49 feet was rated “poor” on the AOFAS. The majority (85 per cent) had good-to-excellent results. Ankle range-of-motion and mobility were much better for 92 per cent of the group. One fourth of the group did require additional surgery to further correct ankle alignment. In a small number of cases (two patients), the first surgery was considered a failure and a second (revision) surgery was needed to repeat the procedure.

Comparing these results to other studies where patients’ ankles were fused, the authors point out that this bone resection and fat graft implantation is just as successful (if not more so) than the fusion. The hope is that long-term studies will show less arthritis from this condition (a typical response to the ankle fusion). These patients will continue to be followed to see if results hold or if there is a gradual but steady decline in function and alignment over time.

A bony bridge connecting two bones together as you described is referred to as a coalition. The two most common bony coalitions in the ankle are formed by the talus and calcaneus bones (talocalcaneal coalition) and the calcaneus and navicular bones (calcaneonavicular coalition). The condition has been treated in the past with conservative (nonoperative) care (e.g., leg cast) or with surgery to fuse the ankle.

Cast immobilization for this condition is no longer recommended as the first-line of treatment in children. And once the condition has been discovered (or revisited as in your case) in adults, conservative care is no longer appropriate. Two surgical approaches are now available. The first is an arthrodesis or fusion procedure. The bones around the two bridged bones would be fused to the coalition to create a more stable ankle.

A second alternate surgery can be done to remove the bridge of bone between the talus and the calcaneus. Then a piece of fat (taken from the patient’s buttocks or abdomen) was placed in the space left by the resected bone. Fat implantation of this type is referred to as a fat graft interposition. With this approach, patients with talocalcaneal coalitions may be spared early arthritic changes in the ankle.

After either the surgical procedure, patients are put into a short leg cast for three weeks. They are usually allowed to walk on the foot right away as much as they can tolerate. When the cast comes off, a supportive athletic shoe is advised. Following the bone resection and fat implantation procedure, physical therapy may be prescribed to help you regain motion, strength, and alignment.

Studies suggest that additional surgery may be needed after to coalition removal in order to further correct ankle alignment. It has been suggested by experts in this area that two separate conditions are often present: the talocalcaneal coalition discussed and a hindfoot deformity referred to as hindfoot valgus.

Additional surgeries to further correct the ankle alignment by correcting the valgus deformity may be recommeded. Length of time completing the treatment and rehab process with the first surgery and then subsequent procedures can take months to years. The information provided here is just a general overview and may not apply to you. Your surgeon is the best one to advise you based on your own individual situation.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calvé-Perthes disease in honor of the three physicians who each separately described the disease. In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals.

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. The closer to normal the femoral head is when growth stops, the better the hip will function in later life. The way that surgeons achieve this goal is using a concept called containment.

Treatment can be nonoperative but if this fails, then surgery may be needed to realign the hip and achieve containment. Sometimes it is necessary to surgically dislocate the hip during the procedure. Doing so gives the surgeon a better idea of the full extent of hip deformity and the knowledge needed to realign the bones. Surgical dislocation comes with a few extra problems to watch out for such as damage to the nerves or blood vessels in the area.

Dysplasia means the hip socket is too shallow to hold the femoral head in place. Partial or complete hip dislocation is often the result. Surgery to realign the femoral neck and femoral head and to reshape the hip socket may be required.

In both Perthes and hip dysplasia, a particular procedure called femoral osteotomy is often used to regain a more natural hip anatomy. In the case of Perthes disease, the lack of blood supply can make the procedure one notch more difficult than reconstruction for hip dysplasia. But fortunately in today’s more modern approach, MRIs can be used to map out the pathway and location of the blood vessels to the hip. This careful assessment can help the surgeon minimize complications.

With any surgery (no matter how simple, minor, or complex), there are always potential problems or “complications.” It is the surgeon’s responsibility to make sure the patient or patient’s family is fully informed of these possibilities. The fact is that complications do occur but the majority of patients come through surgery just fine without any adverse effects.

Thanks to the wonderful benefits of MRIs, surgeons now have a map of the location, number, and pathway of blood vessels in the hips of children with Perthes disease. The blood supply to this area of the hip is called the vascular safe zone. Knowing where this vascular safe zone is located allows the surgeon to avoid disrupting it when surgically dislocating the child’s hip.

In a recent study from Children’s Hospital in Boston, surgeons found that children with Perthes disease who had surgery to correct the problem had fewer blood vessels compared with children who had a similar surgical procedure for developmental hip dysplasia. Most of the blood vessels in the children with Perthes disease inserted into the femoral neck through a very narrow pathway.

Operating within the vascular safe zone (and avoiding further disrupting the arteries bringing blood to the femoral head) when performing a surgical dislocation to correct the hip problem is important in preventing additional problems. Careful planning is required for this type of reconstructive surgery, including knowing where the vascular safe zone is located. With this knowledge, your surgeon will be able to minimize the risk of bleeding during the procedure.

Occasionally, a child will learn to walk up on toes rather than the more typical heel-toe pattern we are used to seeing. It’s not really something to be concerned about unless it continues as the child gets older. Children who are still toe walking after age two should be evaluated more closely by their pediatrician or perhaps even referred to a specialist such as an orthopedic surgeon.

There are many possible causes for this type of persistent gait (walking) pattern. The list includes muscular dystrophy, cerebral palsy, autism, spina bifida, and even schizophrenia. Other possible causes have been reported such as a general (“global”) developmental delay, leg length difference, or a neurologic disorder known as Charcot-Marie-Tooth disease.

Most of the time, the condition is referred to as idiopathic, in other words: cause unknown. The diagnosis may take some time as the physician examines the child, considers the history, and conducts some specific tests. The calf muscle will be tested for tightness called a contracture. A neurologic exam will be performed.

Although toe walking in young children can be a sign of a true developmental problem, most of the time, it is not. That’s when it’s referred to as idiopathic toe walking. Idiopathic toe walking is just one of those things adults can’t explain and kids outgrow. In cases where it persists past age two, efforts should be made to lengthen the calf muscle. This can be attempted first with a conservative approach with surgery as the backup plan. Children with an underlying neuromuscular or neurologic cause for their toe walking may be treated differently.

Depending on your relationship with your adult children (the parents of the child), you may be able to at least bring up your concern. It’s possible they have already been to the doctor’s for this but don’t want to worry you. Asking if the pediatrician has said anything about the cause of the walking pattern may open the door for further communication.

Occasionally, a child will learn to walk up on toes rather than the more typical heel-toe pattern we are used to seeing. It’s not really something to be concerned about unless it continues as the child gets older. Children like your son who are still toe walking after age two should be evaluated more closely by their pediatrician or perhaps even referred to a specialist such as an orthopedic surgeon.

There are many possible causes for this type of persistent gait (walking) pattern. The list includes muscular, neurologic, neuromuscular, and anatomic causes. Sometimes it’s something as simple as a slight leg length difference (one leg shorter than the other). It can be a sign of a general (“global”) developmental delay.

Most of the time, the condition is referred to as idiopathic, in other words: cause unknown. The diagnosis may take some time as the physician examines the child, considers the history, and conducts some specific tests. The calf muscle will be tested for tightness called a contracture. A neurologic exam will be performed.

More advanced testing such as EMGs (electromyography) of the muscles and computerized gait analysis may help identify unusual patterns of muscle activation. In the case of true idiopathic toe walking where there is no neuromuscular or neurologic problem, treatment depends on the age of the child. For example, children who have not reached their second birthday may just be observed carefully. It is possible that over time, the child will start to walk more normally.

After age two, the condition of the muscles is checked. If there is no contracture (muscle tightness with loss of lengthening), the child may be helped by stretching exercises. Casting the leg or wearing a special brace may help as well. When the muscle is contracted and the ankle cannot move past neutral, then surgery to lengthen the muscle may be advised. Surgery may also be required when conservative care with stretching and bracing or casting hasn’t worked.

Although toe walking in young children can be a sign of a true developmental problem, most of the time, it is not. That’s when it’s referred to as idiopathic toe walking. Idiopathic toe walking is just one of those things adults can’t explain and kids outgrow. In cases where it persists past age two, efforts should be made to lengthen the calf muscle. This can be attempted first with a conservative approach with surgery as the backup plan. Children with an underlying neuromuscular or neurologic cause for their toe walking may be treated differently.

Trigger finger and trigger thumb are conditions affecting the movement of the tendons as they bend the fingers or thumb toward the palm of the hand. This movement is called flexion. Trigger thumb is much more common than trigger finger among babies and young children.

In children, trigger thumb or finger is an acquired (not congenital or present at birth) condition. In other words, like your daughter, the child isn’t born this way but instead, develops the condition early on. A common anatomic cause of trigger thumb is a mismatch in the size of the flexor tendon and the pulley.

The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone.

To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule.

Trigger thumb or finger in children is not from overuse, trauma, or injury (those are more common causes in adults). And in children, the thumb is more likely to be fixed or stuck in what is referred to as a flexion contracture rather than a true triggering mechanism. Flexion contracture means the child cannot actively (or sometimes cannot even passively) straighten the thumb.

No one really knows the reason why some children develop these triggering digits. There are plenty of theories but no actual scientific evidence to explain it. There may be some linked to habit (constantly holding the thumb in a bent or flexed position). A static position can cause build up of synovial tissue and a break down of the natural tissue. The end result is a thickening of the tendon sheath as the body tries to heal itself.

Trigger finger and trigger thumb are conditions affecting the movement of the tendons as they bend the fingers or thumb toward the palm of the hand. This movement is called flexion. Trigger thumb is much more common than trigger finger among babies and young children.

the tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone.

To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

Triggering is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule.

In children, trigger thumb or finger is an acquired (not congenital or present at birth) condition. In other words, the child isn’t born this way but instead, develops the condition early on. A common anatomic cause of trigger thumb is a mismatch in the size of the flexor tendon and the pulley.

Trigger thumb or finger in children is not from overuse, trauma, or injury (those are more common causes in adults). And in children, the thumb is more likely to be fixed or stuck in what is referred to as a flexion contracture rather than a true triggering mechanism. Flexion contracture means the child cannot actively (or sometimes cannot even passively) straighten the thumb.

No one really knows the reason why some children develop these triggering digits. There are plenty of theories but no actual scientific evidence to explain it. Likewise, little is known about the natural history of trigger thumbs/fingers. And that is what you are asking about.

Natural history refers to what happens over time without treatment. As with many other orthopedic problems in children, there are a significant number of children who experience a gradual healing or resolution of the condition. This type of spontaneous recovery takes up to two years and is unpredictable. In other words, there’s no way to tell which children will “grow out of it.”

The majority of children do not grow out of it and require surgery to remove the nodule holding the tendon back, to release the stuck pulley mechanism, or to cut the tendon or lining around the tendon. This last treatment technique is used when the tendon isn’t gliding inside the tendon sheath like it should.

At this time, expert opinion is that conservative (nonoperative) care should be tried first to see if the problem resolves spontaneously. Six months of splinting (keeping the thumb or finger straight at night while sleeping) is another possible approach.

Families should not wait more than two years for a natural healing to occur before considering surgery. And there is some limited research suggesting that surgical release is better done sooner than later (e.g., by age three rather than waiting five or six years). Your orthopedic surgeon is really the best one to evaluate the child and advise you.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calve-Perthes disease in honor of the three physicians who each separately described the disease.

In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines what problems the condition will cause in later life. This condition can lead to serious problems in the hip joint later in life.

Until recently, all treatment (operative and nonoperative) was focused on a concept called hip modeling. The goal of treatment has been to mold the femoral head back into a round (spherical) shape and keep it in the hip socket (acetabulum). According to several large studies, the results of this approach have been only “modestly successful.”

Less than half the children treated for Pethes disease end up with a spherical, well-contained femoral head. And no one has been able to identify why some children respond to treatment while others do not. Some experts think there is a need to work more with the cause of the problem (loss of blood to the hip, impaired healing, altered biology) rather than just the effects of the disease (femoral head necrosis, deformity, and collapse).

Improved understanding of the pathogenesis of this condition is starting to open doors. New avenues for research centered on pathologic-based rather than symptom-based treatment are being explored. The hope is to find some way to prevent Perthes from developing in the first place. A second goal is to treat the condition quickly and successfully when it does occur, thus preventing some of the long-term effects today’s generation with Perthes will suffer later in life.

Most of the newer information comes from experimental studies on pigs and dogs. It’s looking more and more like a complex problem with multiple causal factors — not just one effect. The new theories include ischemic injury leading to changes in the mechanical properties of the articular (joint) cartilage, change in mineral (calcium) content of the bone, disruption of the growth plate, and an impaired repair process.

With this new understanding comes an effort to rethink our current treatment approaches using hip modeling. For example, it is believed that putting load on the deformed hip will make the problem worse. So sometimes are restricted from weight-bearing activities in order to reduce the load on the hip. But whether or not this treatment strategy really makes a difference is unknown. Studies to investigate the effect of weight-bearing versus non weight-bearing in treating Perthes are needed.

New avenues for research centered on pathologic-based rather than symptom-based treatment are being explored. The hope is to find some way to prevent Perthes from developing in the first place. A second goal is to treat the condition quickly and successfully when it does occur, thus preventing some of the long-term effects today’s generation with Perthes will suffer later in life. It may turn out that hip modeling is still the best way to go but experts hope to find more specific treatment that will yield better short-term and long-term results.

You are right: one hundred years ago, three physicians (Drs. Legg, Calvé, and Perthes) reported on a bone condition in children’s hips they named after themselves: Legg-Calvé-Perthes disease (Pethes for short). Perthes is caused by a spontaneous loss of blood to the femoral head (round ball of bone at the top of the thigh bone). Necrosis (bone death), then collapse of the hip, and early arthritis are the natural results of this condition.

Since that time, there have been ongoing efforts to understand the cause(s) of this disease and find ways to treat it successfully. Until recently, all treatment (operative and nonoperative) has been focused on a concept called hip modeling. The goal of treatment has been to mold the femoral head back into a round (spherical) shape and keep it in the hip socket (acetabulum). According to several large studies, the results of this approach have been only “modestly successful.”

Less than half the children treated for Pethes disease end up with a spherical, well-contained femoral head. And no one has been able to identify why some children respond to treatment while others do not. Some experts think there is a need to work more with the cause of the problem (loss of blood to the hip, impaired healing, altered biology) rather than just the effects of the disease (femoral head necrosis, deformity, and collapse).

In the last few years, there has been some breakthrough in research on animals that might help humans. Most of the newer information comes from experimental studies on pigs and dogs. It’s looking more and more like a complex problem with multiple causal factors — not just one effect. And with this new understanding comes an effort to rethink our current treatment approaches.

One new approach being studied is the use of antiresorptive therapy to combat the excess bone resorption. Medications known as bisphosphonates are being used in investigational (animal) studies. These drugs inhibit or prevent bone cells from being broken down. The optimal type of drug (local injection versus systemic application), amount of drug (dosage), timing of drug use (based on child’s age), and duration of drug therapy remain to be determined.

Another potential therapeutic option is called bone anabolic therapy. With this type of treatment, bone stimulating proteins called bone morphogenetic protein (BMP2) are used to speed up bone growth. The substance is injected into the hip to improve bone healing and preserve the round shape of the femoral head.

Studies using BMP2 for Perthes have all been done on animals with no studies on children yet. Long-term results and safety issues must be explored first before children could receive these new, as yet still experimental treatments.

Your surgeon is really the best one to give you all the information you need for a decision like this. But we may be able to offer some things to consider when talking with him or her.

As you have probably seen from the X-rays, the forearm has two bones (radius and ulna). Fractures of one or even both of these bones are among the most common childhood fractures. Most of the time these types of breaks are clean and simple. The physician can line the bones back up without surgery.

The child wears a splint or cast for four to six weeks while the bone remodels and heals. And quite honestly, if the child has not yet completed his or her full growth and has not yet reached skeletal maturity, the bone does a remarkable job healing and even restoring normal anatomy.

There are problematic forearm fractures that require recognition and special treatment. In the simplest of cases, the bones are displaced (separated). There may be a hidden dislocation along with the fracture that doesn’t show up on a plain X-ray.

Or there could be a fracture with bone rotation so the ends no longer line up as they should. Putting the arm in a cast without realigning the bones could result in permanent loss of wrist and forearm motion. Sometimes one or both of the bones break and leave the bone at an angle. This type of deformity won’t realign on its own. To add to that list, there could be cases where the forearm fracture affects the alignment of the elbow.

The surgeon will make every effort to identify the type of fracture and any other associated soft tissue or joint injury. It is especially important to look for damage to the ligaments, blood vessels, and/or nerves. Complete diagnosis may require additional imaging using computed tomography scans (CTs) or magnetic resonance imaging (MRI).

The child’s age makes a big difference in planning treatment. Children up to age eight will have the capacity to heal, repair, and remodel angular deformities of the bones up to 15 degrees. X-rays will help determine the skeletal age of maturity and show how much more growth is left. If the child is within a year or two of full skeletal maturity, then he or she should be treated as an adult.

Closed reduction (realignment without surgery) is acceptable for many of the younger children. But open reduction with internal fixation (ORIF) is often required when there are unusual circumstances or complications. A flexible titanium rod may be placed down through the length of the fractured bone. Metal plates and/or stainless steel pins may be used until union occurs.

Most surgeons will advise minimal surgical intervention if it is clear surgical correction is not required. Surgeons treating children with forearm fractures are vigilant in watching for complications that can leave the child with permanent deformities or loss of motion.

Careful evaluation at the time of the injury AND close observation during healing, recovery, and follow-up are essential to recognize fractures that may need corrective surgery. Elbow joint instability (due to ligamentous damage or dislocation), malunion, and excess bone angulation require special surgical management.