pediatric disorders

1. ASSESSMENT AND EVALUATION
TOOLS FOR PAEDIATRIC
CONGENITAL AND ACQUIRED
DISORDER
PRESENTED BY
G. MONISHA DEVI
MPO 1 ST YEAR

2. INTRODUCTION
• Leg and foot problems in childhood are common causes of parental concern
• Rotational problems include intoeing and out-toeing.
• Intoeing is most common in infants and young children. Intoeing is caused by metatarsus adductus,
internal tibial torsion, and femoral anteversion.
• Out-toeing is less common than intoeing and occurs more often inolder children. Out-toeing is
caused by external tibial torsion and femoral retroversion.
• Angular problems include genu varum (bowleg) and genu valgum (knock knee). With pes planus
(flatfoot), the arch of the foot is usually flexible rather than rigid.

3. • A history and physical examination that include torsional profile tests and angular
measurements are usually sufficient to evaluate patients with lower extremity abnormalities.
• Most children who present with lower extremity problems have normal rotational and angular
findings (i.e., within two standard deviations of the mean).
• Lower extremity abnormalities that are within normal measurements resolve spontaneously as
the childgrows.
• Radiologic studies are not routinely required, except to exclude pathologic conditions

4. HISTORY AND PHYSICAL EXAMINATION
• For the physical examination, the lower extremities should
be fully exposed, and the child may need to wear shorts, a
diaper, underwear, or a gown
• The child’s height and weight with growth percentiles
should be reviewed because normal growth
reduces the likelihood of systemic conditions
• The musculoskeletal examination should include evaluation
for hip dysplasia, leg length discrepancy, and joint laxity
assessment of passive range of motion and rotational
positioning of lower extremities (i.e., torsional profile) and a
gait analysis
• TheFoot progression angle measurements will have positive
values with out-toeing and negative values with intoeing

5. Pertinent History for Children with Lower Extremity Abnormalities
Understand parental concerns - gait, function, appearance, duration, and progression
Patient history - prenatal and birth history, developmental milestones
Family history - complete orthopedic family history of pathologic rotational or angular
deformities and interventions required
Signs/symptoms - gait problems, issues wearing shoes, limping, tripping, falling
Sitting habits - the W sitting position is common in children with increased femoral
anteversion
However, there is no evidence that sitting habits cause or worsen
orthopedic lower extremity problems

6. physical examination in children with lower extremity abnormalities
• Screening examination
Component Findings Possible diagnosis
Height and
weight
Plot on appropriate Centers for Disease Control and
Prevention or World Health Organization growth chart
Abnormal measurements may suggest
pathologic conditions (e.g., rickets, metabolic
bone disease)
Facial
appearance
Abnormal facies Genetic disorders
Skin
Warmth or redness Septic arthritis Ecchymosis Fracture,
nonaccidental trauma Masses; sacral pits, dimples, hair
patch; congenital lesions (e.g., café au lait spots)
Spina bifida, neurofibromatosis
Spine Flexion and extension of the spine Scoliosis, lordosis, dorsal kyphosis
Neurologic Neurologic abnormalities Developmental delay

7. • Focused Musculoskeletal examination
Component Findings Possible diagnosis
Torsional profile • External and internal hip rotation
• Thigh-foot angle
Measurements more than 2 standard
deviations outside the mean may suggest
femoral anteversion or retroversion, or
internal or external tibial torsion
Angular measurements • Intercondylar distance: with medial malleoli touching,measure distance
between the femoral condyles
• Intermalleolar distance: with femoral condyles touching, measure distance
between the medial malleoli in sitting position
Measurements more than 2 standard
deviations outside the mean may suggest
genu varum or valgum
Evaluation for limb
asymmetry and joint
laxity
• Measure leg lengths for asymmetry
• Assess range of motion
• Asymmetry may be due tocontracture,
cerebral palsy, perinatal stroke,
intracranial mass, neuromuscular
disorder, fracture, or septic joint
• Joint laxity can mimic or worsen
torsional or angular deformities and
contributes to pes planus, hip dysplasia,
and dislocated patella
Foot Heel bisector line Lateral C shape, tight heel cord Metatarsus adductus
Gait analysis 1.Observe child standing for loss of medial foot arch ,
2.Trendelenburg sign,
3.Observe child’s gait for intoeing and out-toeing, and measure foot progression
angle: apply dusted chalk or sanitizing gel to child’s bare feet, have child walk
on strips of examination paper,
4.Assess for W sitting position
Pes planus
Hip dysplasia, leg length discrepancy
Internal or external tibial torsion, femoral
anteversion or retroversion
Femoral anteversion

8. Clinical Conditions Lower limb abnormalities in children can be grouped
broadly into three categories
1. Rotational
2. Angular
3. Foot variations

9. ROTATIONAL
INTOEING
• Intoeing, an inward pointing foot, is the most common rotational condition in
children. The three major causes of intoeing are metatarsus adductus, internal
tibial torsion, and femoral anteversion
• The etiology of intoeing is suggested by the age at the onset of symptoms.

10. METATARSUS ADDUCTUS.
• Metatarsus adductus is the most common congenital foot abnormality and
usually resolves spontaneously by one year of age
• Physical examination reveals medial deviation of the forefoot relative to a
normal hindfoot,
lack of a tight heel cord, a convexity or C shape of the lateral aspect of the foot,
and a concave medial border of the foot
Severity is determined by the heel bisector line. The foot should be assessed for
flexibility to rule out rigid deformities(e.g., metatarsus varus)

12. INTERNAL TIBIAL TORSION.
• Internal tibial torsion is a common normal rotational variant. It is the most common cause of intoeing,
usually presenting in toddlers. The child walks with patellae facing forward and feet pointing inward,
producing an internally rotated
• thigh-foot angle and negative foot progression angle on torsional profile.
Internal tibial torsion usually resolves spontaneously by five years of age.
Braces, night splints, shoe modification/wedges, other orthotics, and serial casting are not recommended for
this condition.
• Residual internal tibial torsion has not been shown to cause degenerative joint disease or disability and,
thus surgery is rarely indicated Surgery may be considered in patients older than eight years who have a
severe residual deformity
(thigh-foot angle more than three standard deviations above the mean [i.e., greater than 15 degrees internal
rotation]) and severe functional or cosmetic abnormality that is not expected to self-correct

13. TORSIONAL PROFILE. MEASUREMENTS MORE THAN 2 STANDARD DEVIATIONS OUTSIDE THE MEAN ARE
CONSIDERED ABNORMAL (I.E., A DEFORMITY). MEASUREMENTS WITHIN THE NORMAL RANGE DO NOT
REQUIRE SUBSPECIALTY CONSULTATION.

14. FEMORAL ANTEVERSION.
• Femoral anteversion is the most common cause of intoeing in school-aged children and is most severe
between four and seven years of age
• Physical examination focuses on assessment of internal and external rotation of the hip. Increased
internal rotation (60 to 90 degrees) with reduced external rotation (10 to 15 degrees) is diagnostic of
femoral anteversion.
• The patellae and feet appear to point inward (known as squinting or kissing patellae), resulting in a
clumsy, circumduction gait.
• Children with femoral anteversion often sit in the W position (Figure 8) for comfort rather than sitting
cross-legged

15. • Surgical intervention is indicated for children older than eight years with severe functional or cosmetic
abnormality secondary to persistent femoral anteversion greater than 50 degrees and internal rotation
greater than 80 degrees

16. OUT-TOEING
• Out-toeing, an outward pointing foot, is less common than intoeing. It is caused by external tibial
torsion, femoral retroversion, and pes planus
• External Tibial Torsion. External tibial torsion usually presents between four and seven years of age
when the tibia externally rotates during normal growth and worsens into a deformity. Physical
examination reveals a positive foot progression angle and a thigh-foot angle greater than 30 degrees

17. FEMORAL RETROVERSION.
• Femoral retroversion is common in newborns because of contracture of the hip from intrauterine positioning. It is
diagnosed when the feet of a prewalking child are rotated outward by nearly 90 degrees (i.e., Charlie Chaplin
appearance).There is a markedly decreased hip internal rotation and increased external rotation on torsional profile
• Femoral retroversion typically improves during the first year of walking.9 Persistence after three years of age
warrants radiography of the pelvis, hips, and lower extremities and referral to an orthopedist.11 If femoral
retroversion is diagnosed after eight years of age, it may be associated with a slipped capital femoral epiphysis.
• Femoral retroversion results in osteoarthritis and increased risk of lower extremity stress fracture
• Surgical consultation should be considered for children with persistent femoral retroversion at three years of age5
however, the average age for surgical correction with osteotomy is 10 years of age

18. SKEW FOOT
• Skewfoot is a congenital birth defect, meaning that it is present at birth.
• It is very similar to metatarsus adductus, in which there is a “bend” in the middle of the foot and the foot
curves inward.
• The difference with skewfoot is that the hindfoot is also misaligned. This can lead to a “C” or “Z” shape in
the foot.
• On close inspection, an almost “corkscrew” alignment of the foot is evident. The forefoot is in adduction
with some degree of supination, whereas the hindfoot is in abduction with significant valgus. A key finding
is lateral displacement of the navicular on the talus.

19. • Berg described simple and complex types of skewfoot, based on whether the calcaneocuboid joint was
similarly displaced
Divides the condition into four subtypes:
Simple MTA: MTA.
Complex MTA: MTA, lateral shift of midfoot.
Skew foot: MTA, valgus hindfoot.
Complex skew foot (serpentine foot): MTA, lateral shift,
valgus hindfoot

20. • Treatment ranges from serial casting to surgical correction. Although Berg believes that milder forms of
skewfoot can be corrected with serial casting, Peterson in a review of the world literature, reported that
all authors found nonoperative treatment to be unsuccessful. It has been suggested that a skewfoot results
from improper manipulation and casting of MA
• Virtually all of the shoe modifications and orthoses used for treatment of simple MA have the potential to
worsen heel valgus. No specific corrective orthosis is available for skewfoot. A foot orthosis (FO) can be
custom molded to accommodate the foot shape for pain relief

21. FLATFOOT
• “The term flatfoot is commonly used to describe a nebulous mixture of anatomical variations as well as a
small core of pathological conditions”.
• There is no universally accepted classification system or definition of pediatric flatfoot.
• Because of this lack of standardized semantics, there is confusion in the literature regarding this subject;
some authors fail to make the distinction between normal variations and pathological conditions. This
aspect in turn leads to confusion about treatment.

22. FLATFOOT POSTURE
• Flatfoot is physiologic in newborns and toddlers. Toddlers pronate their feet when learning to walk to
improve their base of support and gain more stability. Flatfoot is very common in young children and is
considered to be an anatomical variant of ligamentous laxity that does not require treatment
• Six years appears to be the critical age for development of the longitudinal arch. The arch has a natural
tendency to continue to develop beyond 6 years; numerous studies have demonstrated that the prevalence
of flatfoot is higher in 6-year-olds compared with 10-year-olds.
• This suggests that closed-toed shoes may inhibit the natural development of the longitudinal arch.

23. FLEXIBLE FLATFOOT
• Flexible flatfoot is a condition in which the foot has a normal medial longitudinal arch and normal heel
alignment when suspended and not weight bearing but collapses into a flat pronated posture with calcaneal
valgus with weight bearing
• Sometimes the flatfoot posture arises primarily through the arch itself, with pronounced flexibility and sag
through the naviculocuneiform and tarsometatarsal joints.
• The flexibility often can be demonstrated by passively dorsiflexing the great toe, which should improve the
height of the arch.
• In addition, if heel valgus and flattening of the arch correct to slight heel varus with a normal arch during
tiptoe stance, the child probably has a flexible flatfoot.

24. • Heel cord contracture occasionally is seen with flexible flatfoot and may be a primary cause of the foot
posture. On the contrary, heel cord contracture can also develop secondary to the persistent pronated,
valgus heel position.

25. RIGID FLATFOOT
.
• A rigid flatfoot has no medial longitudinal arch despite its position. On physical examination, a rigid flatfoot
lacks normal flexibility
• This condition is uncommon in children and should prompt a search for an underlying diagnosis such as
inflammatory arthritis, occult fractures, tumors, and abnormal tarsal bones.
• A thorough neurologic examination is recommended, especially if the rigid flatfoot is unilateral.
• Treatment of rigid flatfoot depends on the underlying diagnosis; orthoses may or may not be part of the treatment
plan. In general, orthoses are not expected to correct the deformity in rigid flatfoot. Orthoses may be used to
cushion the foot or accommodate the foot shape to relieve pain.

26. FREIBERG INFRACTION
• In 1914 Freiberg specifically used the term infraction to describe a painful condition of the metatarsal
head, indicating that he believed that trauma was the cause.70 The cause of Freiberg infraction remains
unknown, but trauma, repetitive stress, and vascular compromise have been proposed.
• The condition presents as pain and swelling directly at the involved joint, most classically at the second
metatarsophalangeal joint. The other metatarsals are less commonly involved. Symptoms usually begin
in adolescence, more often in females
• Freiberg infraction progresses to subchondral bone collapse, arthritis, and osteophyte formation, resulting
in a painful rigid metatarsophalangeal joint.

27. • Nonoperative treatment attempts to redistribute weight across the forefoot and limit stresses across the
involved metatarsal head. Metatarsal pads, a variety of foot orthotics, and sole modifications can be
effective for pain relief, but no comparative studies document any effect on the ultimate outcome.

28. TARSAL COALITION
• Tarsal coalition is a common cause of rigid deformity of the hindfoot and can also be associated with
flatfoot. The incidence of tarsal coalition has been reported to be between 2% and 13%, with roughly
half of patients having bilateral coalitions
• The most common coalitions involve the talocalcaneal and calcaneonavicular bone. Ossification of the
coalitions typically occur between the ages of 8 and 12 years for calcaneonavicular coalitions and 12
and 16 years for talocalcaneal coalitions.

29. • There appears to be equal incidence between males and females
• Tarsal coalitions become problematic when the hindfoot develops a rigid valgus deformity and can result
in painful muscle spasms of the foot evertors because of a stretch reflex arc
• Subtalar motion is significantly restricted in the coalitions, and there can be compensatory movements in
the surrounding tissues resulting in recurrent sprains of the ankle ligaments
• Physical examination often reveals an equinus ankle, valgus hindfoot, low arch, and pronated forefoot.
Palpation can reproduce pain at the subtalar joint, which also has limited range of motion. It is critical to
identify whether the patient has a flexible or rigid deformity.

30. • During the toe raise test a heel with rigid tarsal coalition will remain everted or vertical. Another useful
maneuver is the “step-forward” Hubscher maneuver: while the patient is standing, tension is generated
in the plantar fascia by dorsiflexing the great toe with leg external rotation.
• This will restore an arch in a flexible/reducible foot and will fail to produce an arch in a rigid foot

31. ACCESSORY NAVICULAR
• An accessory navicular (AN) bone is an anatomic variant that has been classified
into three types
• Type 1 is characterized by a distinct ossicle that is contained within the posterior
tibial tendon (PTT). Type 2 is a larger ossicle that is adjoined to the navicular by
a synchondrosisattachment.
• Type 3, known as a conuate navicular, is fully fused to the navicular bone and
protrudes medially. Because the PTT inserts on the navicular, repetitive stress
can be a source of pain, particularly in young athletes.
• AN has been shown to predispose to PTT tendinopathy, tears, and painful
navicular syndrome

32. • The AN protrudes medially in the arch of the foot and can be mistaken for flatfoot. The degree of
flatfoot radiographic parameters in AN does not predict symptomatology.
• Asymptomatic AN may be observed, but imaging of the symptomatic foot can be pursued.
• The degree of flatfoot radiographic parameters in AN does not predict symptomatology.90
Asymptomatic AN may be observed, but imaging of the symptomatic foot can be pursued. CT can reveal
cortical irregularity, sclerosis along the synchondrosis, or direct damage to the AN. MRI can be
particularly useful, because in addition to bony edema and increased signal within the synchondrosis, it
can also evaluate for concomitant PTT pathology.

33. • Conservative treatment often consists of relative rest until symptoms improve. Occasionally,
corticosteroid injections or immobilization for 2 to 3 weeks is required.
• A soft navicular pad or an insert with a soft medial wedge can be can be prescribed to reduce the chance
for recurrent symptoms. These orthoses may mitigate the tension on the PTT.
• Rigid arch support should be avoided, because it would simply increase the pressure on the ossicle.
• For refractory cases, the primary surgical method is to excise small ossicles or fuse large ossicles.91
Surgical correction for refractory cases is very often curative with excellent or good functional outcomes

34. KOHLER DISORDER
• Kohler disorder of the tarsal navicular is an uncommon but characteristic source of medial midfoot pain
in children 4 to 7 years old. It is more common in boys than in girls.
• The cause is unknown but presumably is related to a combination of mechanical stress at the time of
ossification and vascular compromise with elements of avascular necrosis.
• Radiographic changes in the tarsal navicular mimic the avascular, fragmentation, and regeneration
phases of Legg-Calvé-Perthes disorder of the hip. The condition is self-limited. Final healing almost
always includes some minor diminution of the size of the navicular compared with the uninvolved
contralateral side.

35. CLUBFOOT
• Clubfoot, or congenital talipes equinovarus (CTEV), is one of the most common congenital limb
deformities and has an incidence between1 : 250 and 1 : 1,000 live births, with the higher values
attributed to certain racial and ethnic groups.
• Despite the relative severity of this common deformity, outcomes are usually very good and result in
normal or near-normal function after completing treatment
• About 20% of cases are associated with other congenital abnormalities, and 50% of cases are bilateral.
The exact cause of CTEV remains unclear; some environmental component is suspected, but family and
ethnic predilection suggest a genetic inheritance pattern as well.

36. • Examination of the affected limb(s) reveals the characteristic rigid hindfoot equinovarus, severe
adduction, supination, and cavus deformity of the midfoot and forefoot.
• This constellation of findings results in medial navicular and cuboid subluxation, which directs the first
ray obliquely to become adjacent to the medial aspect of the tibia.
• The subtalar joint is subluxated, and the calcaneus is often internally rotated and displaced from the
heel pad because of the equinus deformity
• The foreshortening of the skeletal framework results in plantar, medial, posterior soft tissue
contractions. CTEV can be distinguished from severe MA and skewfoot by the rigid equinus positioning.
CTEV is associated with hypoplasia of the calf musculature and possible leg length discrepancy in
unilateral cases

37. • Historically, corrective manipulation has been achieved with bracing, stiff taping, or casting. In patients
younger than 2 years, frequent stretching, active assisted movement, and maintenance of positioning via
taping is described by the French functional method and has been shown to be fairly effective.
• The Kite technique begins with nonoperative manipulation around the calcaneo-cuboid joint and uses
long leg casting to hold the foot in the desired position. Studies of the Kite method have shown that 50%
to 75% of patients will still require major surgical intervention
• The Ponseti method, initially described in the 1950s, has become the treatment of choice in recent
years.98-100 Outcomes of the Ponseti method have been very positive, and studies have shown that
when there is strict adherence to the principles of the method, major surgery can be avoided in almost all
cases

38. • Only nonoperative treatment is indicated, and activity restrictions and selective use of cast
immobilization are recommended. Various orthoses have been suggested to relieve pain and keep these
young patients active, but no literature supports one orthosis over another

39. CONGENITAL VERTICAL TALUS
• Congenital vertical talus (CVT) is a rare deformity that goes by many names, including congenital convex
pes valgus, rocker-bottom foot, and Persian slipper foot.
• CVT is a rare disorder, with the exact incidence unknown. It can be idiopathic or associated with a
genetic or neuromuscular disorder. Physical examination reveals that the heel is in fixed equinus, with
the forefoot dorsiflexed and everted. The arch is convex, and the head of the talus is prominent
medially in the sole.
• Overall, the foot has a rocker-bottom appearance, and it is rigid and uncorrectable. A true CVT cannot
be passively reduced with simple manipulation. If the talonavicular joint can be readily reduced and the
ankle can be readily manipulated out of equinus, the deformity probably is either a calcaneovalgus
positional deformity or the “oblique talus” of a severe flatfoot.

40. • Radiographic confirmation of this diagnosis requires a lateral view of the foot in maximum plantarflexion.
• The navicular will not be ossified in an infant, so direct visualization of the talonavicular relationship
is not possible. However, in true CVT a line drawn through the long axis of the talus will project plantarward to the
ossific nucleus of the cuboid.
• Treatment of CVT begins with passive manipulation and holding casts, which stretch the soft tissues.
Traditionally, actual realignment of the bones by closed means was not expected. This deformity almost always
was believed to require surgical correction.
• A casting regiment pioneered by Dobbs et al.119 advises gradual reduction of the talonavicular joint by
manipulations suggestive of a “reverse Ponseti” method. This regimen minimizes surgery, requiring only pin
fixation of the talonavicular articulation with percutaneous heel cord release.

41. • Orthoses usually are advised after surgery to passively maintain correction. No literature supports the use
of one orthosis over another. FO, supramalleolar orthosis (SMO), and AFO designs that incorporate
support of the medial longitudinal arch are acceptable.

42. CALCANEOVALGUS FOOT
• Calcaneovalgus foot is a common positional variation among newborns and must be differentiated from
CVT.
• The incidence of calcaneovalgus probably is much greater than the reported 1 : 1000 live births because
it ordinarily resolves spontaneously and therefore may never attract medical attention.
• It is common in the firstborn of young mothers and is believed to be the result of intrauterine packing.
No inheritance patterns are known.
• The forefoot is abducted and dorsiflexed with the dorsum lying against the anterior leg, and the heel is in
valgus. In severe cases, the ankle cannot readily be plantarflexed much beyond neutral. Overall,
• however, the foot is flexible. The heel and forefoot can be passively corrected into varus, and the entire
foot can be moved as a unit into plantarflexion and dorsiflexion through the ankle joint.

43. • This flexibility and the position of the heel in valgus rather than equinus distinguish calcaneovalgus from
congenital vertical talus. Radiographs are typically not necessary, but the maximum plantarflexion lateral
view can be reassuring.
• Congenital posteromedial bowing of the tibia is sometimes associated. It initially can cause some
diagnostic confusion, because a normal foot can have the cosmetic appearance of calcaneovalgus when
significant posteromedial bowing is present. Treatment of a calcaneovalgus foot begins with passive
stretching.
• If the ankle cannot be easily plantarflexed beyond neutral, retention taping, casting, or bracing is
indicated. A molded AFO with the ankle positioned in plantarflexion and the foot in adduction is often
used.
• No literature supports one orthosis over another.

44. CAVUS DEFORMITY
• Cavus deformity is characterized by an excessively high arch resulting from a varus deformity of the
hindfoot and a plantarflexed equinus deformity of the forefoot, especially the first metatarsal. This
deformity almost always is secondary to an underlying neurologic dysfunction in the spinal axis or the
peripheral nerves. Accurate diagnosis of potential underlying causes is essential.
• Shoe modifications and orthoses are rarely effective to modify the deformity. The cavus is invariably
rigid and progresses according to the underlying neurologic condition. Additionally, sensory deficits are
common and limit any bracing opportunities
• The usefulness of orthoses is limited to accommodation of the deformity for relief of pain and protection
of the soft tissues.

45. • An AFO can prevent recurrent ankle sprains and may be appropriate depending on the causative
neuromuscular disorder. Plantar callosities and symptoms related to abnormal pressure may be relieved
by use of an arch support or metatarsal pad.
• Rocker modifications of the shoe sole can help accommodate for loss of ankle and midfoot motion.
They are customized to the individual patient for relief of symptoms and preservation of function. No
meaningful outcome studies of orthotic management are available.

46. TIBIA VARA (BLOUNT DISEASE)
• Blount’s classic review of tibia vara was published in 1937. Tibia vara characteristically presents as a
progressive bowing deformity, resulting from disorderly growth of the proximal medial physis and
metaphysis of the tibia. Infantile (early onset) and adolescent (late onset) forms are described. Only the
infantile type is discussed here; orthotic management for adolescent tibia vara is ineffective.
• Children with tibia vara initially present with bowlegs that do not spontaneously improve within the
expected physiologic timeframe. Most children are obese, and many are early walkers.
• Common associated findings included ligamentous laxity, a lateral thrust at the knee in stance, and a
palpable “beak” at the proximal medial tibia.

47. • Treatment depends on the age of the patient and the radiographic stage of the disease. Orthoses are
recommended for treatment of patients younger than 3 years
• Bracing aims to provide a force at the medial side of the proximal thigh and medial malleolus with an
opposing lateral support at the knee. Control of flexion of the knee and rotation of the leg is desirable.
• Blount brace, an A-frame brace, or a specifically constructed KAFO can be used
• Beginning at about age 3 years or when a physeal bar has presented on the medial aspect of the
proximal tibia (Langenskiold stage III), treatment invariably requires surgery. Multiple surgeries are
usually required to correct the angular, rotational, and length deformities.

48. TIBIAL BOWING
Lateral Tibial Bowing
• Lateral tibial bowing is a normal physiologic variation during the first year of life. It reaches its
maximum angulation between 18 and 36 months, in association with physiologic bowing of the entire
lower extremity. Treatment is observation to differentiate this condition from pathologic conditions,
especially infantile tibia vara.

49. Anterior Bowing
• Anterior bowing of the tibia may be associated with an absent or hypoplastic fibula. Dimpling of the
skin of the anterior leg usually defies more fibular involvement. This condition is commonly called either
fibular hemimelia or postaxial hemimelia and includes a spectrum of abnormalities of the lateral aspect
of the limb. International Organization for Standardization (ISO) terminology incorporates a description
of the components, which can be quite variable. The main problem here is tibial shortening, which may
require correction by a contralateral epiphysiodesis or a limb-lengthening procedure. No specific
orthotics are recommended.

50. Posteromedial Bowing
Posteromedial bowing is associated with a calcaneus or calcaneal valgus foot deformity, triceps surae
weakness, extension contracture of the ankle, and anisomelia.
Spontaneous improvement of the angulation occurs with growth, so operative correction should be
delayed.
Limb shortening is a problem and often is progressive Initial treatment is nonoperative and generally
consists of passivestretching to relax the tight anterolateral soft tissues at the ankle. Casting and
bracing with custom-molded AFOs are sometimes recommended, but no outcome studies or
significant published series document the effectiveness of these treatments.

51. • Anterolateral Bowing
• Anterolateral bowing of the tibia virtually always represents the mildest expression of pseudarthrosis of
the tibia. As such, it should be considered a precursor to frank pseudarthrosis. Anterolateral bowing, with
or without pseudarthrosis, is associated with neurofibromatosis in more than 50% of patients
• One notable exception to these generalizations is the anterolateral bowing associated with duplication of
the great toe, which seems to have a more benign natural history.
• As soon as this condition is recognized, support of the limb with a cast orthosis is indicated to prevent a
fracture, because these fractures often never heal properly. For a young infant, orthotic management
begins with a nonarticulated plastic KAFO.
• As the infant begins to stand and walk, the addition of an anterior molded panel to create a total contact
orthosis is recommended. Older infants and young children are treated with an articulated KAFO,
whereas a high AFO may suffice for an older child.

52. IDIOPATHIC TOE WALKING
• Toe walking is believed to be a normal occurrence in the development of a tandem heel-toe gait
pattern.
• However, persistent toe walking beyond 2 years of age does merit further evaluation, because it may
be a sign of an underlying neuromuscular or developmental abnormality, such as cerebral palsy (CP),
congenital muscular dystrophy, or autism.
• If no underlying abnormality is discovered during this evaluation, persistent toe walking after 2 years of
age is termed idiopathic toe walking
• The cause of ITW remains unknown

53. • Caregivers should be asked about the age at which toe walking began, variability of toe walking,
proportion of time spent toe walking, whether the child is able to stand flat on his or her feet, and
whether the child has any complaints of associated pain.
• The history should also include questions regarding muscle tone, neurogenic bowel and bladder,
language delays, and sensory processing difficulties

54. • The physical examination should focus on a detailed musculoskeletal and neurologic examination,
including observation of the gait pattern with and without shoes and preferably wearing shorts to allow
an unobstructed view of the lower extremities.
• When observing gait, the practitioner should note whether the child is able to walk with heel strike; it is
not uncommon for children to walk with a normal gait pattern when they know they are being observed,
especially in a physician’s office.
• Thus it is important to also spend time observing the child’s natural gait pattern before or after the child
knows that their gait is being evaluated.
• The musculoskeletal and neurologic examination should include assessment of strength, coordination,
muscle tone, reflexes, sensation, and range of motion in the hips, knees, and ankles. The examination
should also include inspection of the spine and lower extremities for cutaneous abnormalities, pelvic
asymmetry, leg-length discrepancy, and foot deformities

55. • Diagnostic testing for ITW may include electromyography (EMG) and formal gait analysis.
• Both Policy et al.147 and Rose et al. found that EMG could be helpful in differentiating ITW from toe
walking in spastic diplegic CP.
• Both studies demonstrated that children with CP had consistent coactivation of their gastrocnemius–
soleus complex and quadriceps muscle with active and resisted knee extension, whereas children with
ITW did not demonstrate this muscle coactivation pattern.

56. REFERENCE
• Rerucha CM, Dickison C, Baird D. Lower extremity abnormalities in children. American family
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• https://orthotextbook.com/skewfoot-pediatric/
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