Developmental orthopaedics. III: Toddlers

The most common orthopaedic problems seen in toddlers are: (1) in-toeing due to femoral torsion, internal tibial torsion, talar torsion (persistent medial deviation of the neck of the talus), or metatarsus adductus; (2) genu valgus (bow-leg) and genu varus (knock-knee); and (3) pes valgus (flat-feet). In most cases these conditions will resolve spontaneously, as has been substantiated by a number of published studies. However, a small percentage of the disorders will persist if untreated. To prevent the deformity from becoming established and irreversible, treatment must begun while the patient is still young. Therefore the orthopaedist needs objective criteria to select those children in whom the deformity is likely to persist and who thus require prompt management. If femoral torsion persists, it becomes fixed by the time the child reaches eight years of age. Surgery is the only definitive treatment which can be offered, although gait training by augmented feedback methods may result in correcting by increasing the range of external rotation of the hip. Internal tibial torsion or talar torsion usually resolve spontaneously before the children reach seven years of age. However, in 8 per cent of cases in-toeing persists; it is cosmetically objectionable in the adult. I advise simple brace treatment in infants up to the age of 18 months if the medical deviation of the foot from the mid-sagittal plane is greater than 10 degrees. Because metatarsus adductus corrects spontaneously in many cases, some authors suggest that this condition should not be treated. However, I think it is prudent to use serial plaster-casts for infants under eight months of age in whom the deformity is moderate or severe. If treatment is withheld while the patient is observed, and if spontaneous correction does not occur, the deformity will become fixed and correctable only with surgery. Genu valgus and varus correct without treatment in the majority of patients. However, some cases of genu varus appear to develop into the progressive form of the disorder, Blount's disease. When the varus femoral-tibial angle exceeds the norm for age, early treatment with the Danish night-splint appears to prevent the development of this serious disease. 'Flat foot' (pes valgus) must be defined carefully by physical and radiographic examination. Treatment and radiographic examination. Treatment might be considered only for those feet classified as pes valgus with plantar flexed talus of 50 degrees or more. For children with this disorder between the ages of two and six years, a corrective moulded plastic shoe-insert may help to improve the abnormal anatomy while natural ligamentous tightening occurs.