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Some psychology may aid orthopedic therapy.

STANFORD, CALIF. -- The most common complaints from parents about a child's musculoskeletal condition stem from usually benign causes that don't need treatment, but addressing them can help alleviate parental anxiety.

Listen to the parents. Acknowledge their concerns by saying something affirmative like, "I see what you mean," advised Dr. James G. Gamble, professor of orthopedic surgery at Stanford University.

After examining the child, educate the parents about the rotational or angular conditions you find in the child's legs and feet, and get parents actively involved in stretching or massaging the child's limbs. Offer to follow up with them later, he suggested at a pediatric update sponsored by the university.

He calls this approach OP, for orthopedic psychotherapy. "We use a lot of OP in our clinic," he said.

Recognizing the difference between physiological and pathological conditions of the hips, knees, legs, and feet will let physicians know when to refer to a specialist and when to otherwise handle parental complaints. Dr. Gamble reviewed the most common rotational and angular conditions in children that raise concerns about the feet, legs, and knees:

* Pigeon toes. Scientifically called metatarsus adductus, this condition presents between birth and 6 months of age, typically as a foot with a concave medial border, a convex lateral border, and a deep plantar crease. Also known as "kidney bean foot," it can be confused with clubfoot.

Looking at the bottom of the foot, imagine the heel as an oval, and bisect it with an imaginary line that extends up toward the toes. On a normal foot, the line would bisect the gap between the second and third toes. The more the line is toward the last little toe, the more severe the metatarsus adductus.

Check to see if the foot is rigid or supple, because rigidity can be a sign of skewfoot and may require surgery. Finally, check ankle range of motion; limited dorsal flexion may indicate clubfoot or other problems that might need surgery, he said. Also, check the hips, because children with metatarsus adductus have an increased incidence of dislocation.

Refer patients with foot rigidity, limited dorsiflexion at the ankle, or extremely anxious parents to an orthopedic surgeon, Dr. Gamble said.

For metatarsus adductus alone, treatment starts with OP and stretching. Casting may help if there's rigidity. Splints or special shoes are an option, but there's no good evidence that any of these treatments change the natural history. About 90% of cases resolve with time. In the other 10%, metatarsus adductus remains but is asymptomatic and does not increase the risk for bunions or other problems in adults.

* Tibial torsion. Look at the backs of the legs and feet as the child is prone or on a parent's lap, and if the foot is internally rotated or (less commonly) externally rotated, the child has internal or external tibial torsion (also called tibial rotation or version). This is typically seen between 6 months and 3 years of age.

The mainstays of treatment are OP and benign neglect, Dr. Gamble said. Very rarely would he consider surgery or orthotics, and then only in cases of neuromuscular problems such as spina bifida or cerebral palsy or trauma, he said.

* Bowlegs or knock-knees. Parents typically get concerned about bowlegs or knock-knees (genu varum or genu valgum) when infants begin to stand and cruise. These conditions typically present between 6 months and 3 years of age.

To differentiate bowlegs from internal tibial torsion, have the child placed supine or sitting with knees in extension. Place the patella in a neutral position and cover the lower leg and foot with your hand. If you see no bowing in the tibial-femoral angle, but when you look under your hand, the foot is turned in about 70 degrees from the distal leg, the condition is not at the knee; it's at the tibia. This is tibial torsion, not genu varum.

If the legs are more angled than bowed, consider the possibility of rickets, vitamin D deficiency, or Blount disease. An x-ray is warranted only if the condition is unilateral or rapidly progressing, or the patient has asymmetric leg length or a limp. Dr. Blount advised referring to an orthopedist for an x-ray.

"We may want to get special views," he explained.


San Francisco Bureau
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Title Annotation:Clinical Rounds
Author:Boschert, Sherry
Publication:Pediatric News
Date:Oct 1, 2008
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