Neonatal leg and foot abnormalities

Question 1

Developmental dysplasia of hip

Answer 1

Detected by:

• clinical examination (Ortolani and Barlow tests)
• and ultrasound examination (ideally 6 wks)

Most cases are treated successfully by abduction bracing with a Pavlik harness or splint

Open reduction may be required

Question 2

Bow legs (genu varum)

Answer 2

Most are physiological:

• which are symmetrical
• improve with age

Toddlers are usually bow-legged until 3 yrs

Monitor intercondylar separation (ICS): distance between medial femoral condyles

Refer when ICS >6 cm, not improving or asymmetric

Question 3

Knock knees (genu valgum)

Answer 3

Most are physiological:

• children are usually knock-kneed from 3–8 yrs.

Running is awkward but improves with time.

Monitor intermalleolar separation (IMS):

• distance between medial malleoli

Refer when IMS >8 cm

Question 4

In-toeing

Answer 4

The three main causes of in-toeing stem from problems at three levels:

1. foot
2. tibia
3. femur

Metatarsus varus:

• Presents at birth with sole of foot bean shaped.
• Advise against prone nursing.
• Associated with DDH so check hips.
• Refer 3 mths after presentation if not resolved.

Internal tibial torsion:

• Presents as toddler 1–3 yrs.
• Observe and measure.
• Refer 6 mths after presentation if problematic
• but usually resolves spontaneously.

Medial femoral torsion:

• Presents later (3–10 yrs) as ‘inset’ hips.
• Some children like to sit in ‘W’ position.
• Rarely need surgery.
• Refer after 8 yrs if concerned.

Question 5

Postural variance of lower limbs

Answer 5

Question 6

Out-toeing

Answer 6

Infants have restricted internal rotation of hip due to an external rotation contracture

Exhibit a ‘Charlie Chaplin’ posture between 3 and 12 mths—up to 2 yrs

Child weight bears and walks normally

No treatment required as spontaneous resolution occurs.

Discourage the prone sleeping position

Surgery may be necessary in older children.

Question 7

Club foot (congenital talipes equinovarus)

Answer 7

Most abnormal-looking feet in infants are not a true club foot deformity;

• the majority have postural problems such as talipes calcaneovalgus
• metatarsus varus and postural talipes equinovarus.

Such conditions are usually quite mobile and mild, and all resolve spontaneously without treatment.

True club foot deformity is usually stiff and severe and requires orthopaedic correction.

Question 8

Flat feet (pes plano valgus)

Answer 8

The majority are physiological.

All newborns have flat feet but 80% develop a medial arch by their 6th birthday.

Perform the ‘tiptoe’ test when the arch usually appears, indicating flexibility.

No treatment is required unless painful and stiff.

Question 9

Curly toes

Answer 9

Usually the 3rd toe curls inward under the 2nd toe.

Ignore until 2 yrs but refer to have any severe deformity corrected by flexor tenotomy.