Orthopaedics

Intoeing (pigeon toed) is common in children and is often considered a normal part of development. Your child's gait pattern will improve over time without the need for treatment. Most children that intoe stop doing so by the age of 8 to 10 years. It is extremely rare to operate on this condition.

What is intoeing? 

Intoeing develops from one of three areas: the foot, the knee, or the hip:

• Foot (metatarsus adductus). This is the most common cause of intoeing from birth to two years of age. It is believed to be caused by the positioning of the baby's foot in the uterus or from family history. If the foot is flexible and can be gently pulled into the correct position, no treatment is necessary. If the foot is rigid, and your child is under eight months of age, your doctor may recommend casting

• Knee (tibial torsion). This is usually noticed during the second year of life after the child has started walking. The shinbone (tibia) is slightly twisted or rotated causing the foot to turn inward. This may be caused by the positioning of the baby's foot in the uterus or from family history. It is also related to bow legs and gets better as the bow legs improve with growth

• Hip (femoral anteversion). Children between the ages of three and seven may walk with their kneecaps pointing inward. This is caused by a slight rotation of the top of the hip bone (femur) in the socket of the hip. This is very common especially in girls aged between 3 and 7 years.

Out-toeing usually occurs during the first year of life. It is due to the position of the hips within the uterus and will resolve without treatment.

What is the treatment for intoeing?

The best treatment is observation. You can take pictures each year of your children standing and then compare the progression of the straightening process. In very rare instances a bone cutting operation to correct rotation can be done after the age of 12-14 years if at that stage the child is close to fully grown, intoeing is still severe and has still not resolved.

Facts about intoeing

• Intoeing is common in children
• There are no braces, cables or orthotics that will make the slightest bit of difference.  Many years ago these were used but it has been proved that they are NOT effective 
• Falling is part of learning to walk and is not exclusively caused by intoeing
• Intoeing will not affect your child's ability to walk, or run or play even if it persists into adulthood.

In the first 12 months of life, bowed legs are common. The legs naturally bow outward and begin to straighten as the baby grows. By age four, it is common to see knock knees or genu valgum. The child walks or runs with his knees very close together, perhaps even touching when walking.  Usually between the ages of seven to ten the legs become straight. 

Mild knock knees may persist into adulthood. A family history is common.  In some cases, the knock knees are due to injury to the soft growth areas in the bones near the knees. Very rarely it can be caused from infection in the bone or arthritis of the joint. Despite understandable concern, knock knees do not usually cause problems in later life. Most cases do not require treatment.

What is the treatment for knock knees?

For most children, the treatment is observation, allowing time and growth to correct the legs. You might want to take a photograph of your child standing and then another photograph several months later to follow the straightening process. There are no braces, cables or orthotics that will make the slightest difference. Only rarely is surgery needed (after 10 years of age) to help correct the leg shape through a technique called guided growth. Generally surgery is performed for cosmetic reasons and not because of medical necessity.

Facts about knock knees

• Knock knees may continue into adulthood but should not cause any problems
• Children with knock knees can participate in sports
• Bracing will not correct the normal growth pattern of knock knees.

In the first 12 to 24 months of life, bowed legs are often normal. The legs naturally bow outward and begin to straighten as the baby grows. By age four, it is common to see the child become knock kneed and then by age seven to ten the legs become straight again.

Bow legs often runs in families. In rare cases the bowing may be due to an abnormal growth plate at the top of the shin bone (tibia) at the knee, infection, or a specific medical condition. Your doctor will explain the cause to you. If the bowing is not equal on both legs or, if your child is older than 24 months, your doctor may want to take an x-ray of the legs. This will help decide if treatment is necessary. Very occasionally this condition may require treatment to prevent future problems.

What is the treatment for bowed legs?

The treatment will probably be simple observation. You may want to take a photograph of your child and then, several months later, take a second photograph to compare and to follow the straightening process. For the rarer causes of bowing, the treatment might be bracing or even surgery if the child is older.

Facts about bowed legs

• Early walking does not always cause bowed legs
• Bowing that occurs as part of development does not require bracing nor surgery
• Bowed legs will not affect your child's ability to walk, run or play.
• Sometimes bowing of the legs occurs if your child does not have enough vitamin D. Your family doctor can check this for you.

Tuesday, Thursday and Friday afternoons.

Developmental dislocation of the hip (DDH), also known as congenital hip dislocation, dislocatable hip or developmental dysplasia, refers to a range of conditions in which the head (ball) of the hip bone does not fit appropriately into the hip socket at birth.

• The socket may be too shallow
• The ball may move in and out of the socket
• The ball may have come completely out of the socket

No one knows why this happens. It is more common in:

• First born children
• Females
• Breech babies
• Babies with a family history of Hip Dysplasia

It is very important to have a doctor, midwife or Plunket nurse test for this condition within the first few days after your baby is born.

The condition tends to worsen as the child grows and if not treated, may result in the child learning to walk with a limp or unusual waddling gait. As an adult, the condition could cause severe pain, early arthritis and may require hip replacement surgery at a young age. This is what we hope to avoid by treating DDH.

Symptoms are generally not noticeable in infants but may include:

• lack of symmetry to the creases in a baby's thighs, buttocks, groin
• one leg appearing shorter than the other
• one leg appearing less mobile or flexible than the other
• toddler who walks with a limp or waddling gait.

Babies should be screened at birth for DDH by the doctor (or sometimes the midwife) and they will perform certain movements of the baby's hip joint (Ortolani and Barlow tests). If they are suspicious that there could be a problem, then diagnosis can be confirmed by ultrasound scan or X-ray if the baby is more than 4 months old. Sometimes it is dificult to detect hip problems just by examining the baby and that is why tests may be recommended by your GP such as ultrasound or X-ray.

Treatment depends a lot on your child's age and what the ultrasound or X-rays shows us about the hip. There are many different ways to treat DDH. They include:

• Observation with repeat ultrasound or X-rays
• A harness or brace
• Surgery followed by a cast or brace.

It is normal to worry about how the treatment will work for your child. Not all cases of DDH are the same and some are more difficult to treat than others, however the good news is that the majority of cases have a good result from treatment.

Treatment is not always straightforward and it does carry some risk however this will be discussed with you in detail by your Orthopaedic Surgeon and our Nurse Specialist team.

If you are concerned your child may have DDH please see your family doctor. They can refer you to our service if they have concerns. Often an Xray is required before we see your child but this will be discussed with you by your doctor.

Referral Recommendations for Antenatal Detection of Congenital Talipes Equino Varus (CTEV)/Clubfoot:

In our experience, families of a child with a potential diagnosis of Congenital Talipes Equino Varus (CTEV)/Clubfoot during their antenatal anatomy ultrasound scan, are often less anxious when good quality and timely information is provided and when families are directed to reliable sources of information.

Parental education plays an important part in the success of the CTEV/Clubfoot treatment process. Early treatment is important and families who are well informed about the potential diagnosis and treatment process make a smooth transition from delivery to the start of treatment.

More frequently, identification of CTEV/Clubfoot is detected on the antenatal anatomy ultrasound examination. However, the likelihood of false positives and false negatives should be discussed together with the possibility that the condition may be associated with other anomalies.

When CTEV/Clubfoot is initially detected, a referral should be made to your local Fetal Medicine Unit for a more detailed scan to look for the presence of potential associated anomalies.

It is important to discuss with the family that confirmation of the actual diagnosis of club foot can only occur after the baby is born.

The prevalence of CTEV/Clubfoot is 1 to 6 per 1000 live births in New Zealand and is twice as common in boys as girls. In around 50% of the cases both feet are affected.

The birth prevalence varies among different ethnic groups. The highest rates are seen in individuals of Maori and Polynesian ethnicity and the lowest in Asian populations.

Some families prefer to be prepared and armed with as much information on what to expect, the treatment and what will happen following the birth of their baby. Families should be reassured that CTEV/Clubfoot is a treatable condition and that the Ponseti Method is the current recommended gold standard treatment. A dedicated Ponseti clinic is run weekly here at Starship Children’s Health. At Starship Children’s Health, the antenatal education is done by the Advanced Paediatric Physiotherapist and Paediatric Orthopaedic Nurse Specialist.

If the family have any further questions and/or would like an antenatal appointment, we would be happy to accept a referral.

Please use eReferral system, or send/fax the referral to:

Central Referrals Office on – Fax (09) 638 0402 – Attention Paediatric Orthopaedic Department

Botulinum Toxin A is a type of toxin that is injected in small quantities into spastic (stiff) muscles to help them relax, thereby allowing movements to become more controlled. Botulinum toxin also increases the stretch of the muscle to encourage longitudinal growth.

It is most commonly used to treat spasticity in calf, hamstring and groin muscles and makes it easier for a child to perform movements such as putting their heels on the floor when walking and placing their legs apart.

Botulinum toxin is injected under a light anaesthetic and usually begins to work 2-3 days after the injection. The effects will last for 3-5 months.

Side effects of the treatment include: initial abnormal walking and falls, temporary soreness at the injection site, temporary changes in bowel and bladder control and a feeling of weakness, malaise (feeling unwell) and a mild fever for several days.

It is important to know that most children who develop Perthes disease have been very active and are often very involved in sporting activities. To manage their symptoms it is usually necessary to take them out of competitive and impacting sports for a period of time and this can have a major psychological effect on the child.

Perthes disease does heal and the reason for restricting activities is so that your child will have a better functional hip for sports in the longer term. Giving your child timeframes is very important so that they realise that they will eventually be able to return to the activities they enjoy. It is necessary to explain this to your child's friends, teachers, and coaches.

Hand service:

Dr Terri Bidwell (Orthopaedic Surgeon)
Mr Murray Beagley (Plastic Surgeon)

Referrals
Acute: Phone registrar on call 021 938 154
Non-Acute: E-referral or Central Referral Fax Line (09) 307 8906

The Children’s Hand Team at Starship is a combined Orthopaedic and Plastic Surgical Service. We provide treatment for:

• Acute hand injuries including finger and hand fractures, lacerations, nailbed injuries, wrist injuries. We do not take whole finger or hand replants, these are done at Middlemore Hospital. Please wrap the digit in a damp cloth and then place in a bag of ice and present as quickly as possible to the Middlemore ED.
• Common hand conditions such as: Ganglion, Trigger thumb, problems as a result of previous injuries
• Congenital hand differences including patients with missing digits or parts (symbrachdactyly, congenital band syndrome), patients with extra digits (polydactyly), patients with other arm differences such as radial dysplasia, hypoplastic thumb, ulnar dysplasia, cleft hand, macrodactyly.
• Birth Brachial Plexus injuries
• Cerebral Palsy - the cerebral palsy clinic is located at the Wilson Home but is part of the Starship service.

STARSHIP CLINICAL GAIT ANALYSIS SERVICE

PUBLIC SERVICE

The Starship Clinical Gait Analysis Service is provided jointly by Starship Children’s Health, AUT University and Waitemata District Health Board. The clinic is a national service that provides assessments for both children and adults from all over New Zealand. The assessment team is made up of orthopaedic surgeons, physiotherapists and biomechanists

The Gait Analysis Service provides a detailed assessment of walking and movement. It gives precise information about a person’s walking pattern and what is happening in their joints when they walk. The assessments are carried out over 2 days and may include the following:

• Medical, birth and developmental history
• Measurements of lower limb joint movement and muscle strength
• Walking endurance test (6 minute walk test)
• 3D motion analysis
• Plantar pressure assessment
• StepWatch Activity monitor

Results from the assessments are used by doctors and surgeons to help plan treatment or surgery.

Common conditions assessed:

• Cerebral palsy
• Idiopathic toe walking
• Acquired or traumatic brain injury
• Spinal cord impairment
• Neuromuscular conditions

Locations for assessments:

The assessments are carried out over 2 days. You must attend on both days.

Day 1:

Wilson Centre

1 St Leonards Road

Takapuna 0622

Auckland

Day 2:

AUT University

North Shore Campus

Akoranga Drive

Northcote

Auckland

Please allow 3 hours for each day.

Consultants:

Professor Susan Stott

Dr Nichola Wilson

Referrals:

Referrals to the Starship Gait Analysis Service must come from an orthopaedic or paediatric consultant. Referral information should include reason for referral, relevant medical and surgical history, expectations from assessment and current patient contact details. Referrals are sent to the Paediatric Orthopaedic service via central referrals at ADHB: centralreferrals@adhb.govt.nz