The main thing is to check whether they’re stiff or flexible. Flexible flat feet are a normal variant and orthoses won’t make any difference. If the foot is stiff and painful, orthotics might help though a comfortable soft trainer is likely to be of more help, and surgery is occasionally needed.
Normal in babies. Refer if still present over the age of 3 years.
Extremely common between 3 and 6 (75% of children between 3 and 5 have them). Look for asymmetry or progressive deformity.
Perthé’s and SUFE
SUFE is more urgent of the two. Perthé’s is not an emergency but requires an outpatient appointment ‘as soon as possible’ as it causes anxiety (this is not totally helpful in negotiating OP waiting lists, but it’s something).
Diagnosis of exclusion, and should only be made after checking inflammatory markers, X-ray and ultrasound. Hip pain associated with fever or inability to weight-bear should always be urgently referred to exclude septic arthritis.
Curly toes and overriding toes
Curly toes aren’t usually a problem although the nails may rub. If they do need surgery, this is best done before the age of 10.
Overriding fifth toes will need surgery if they rub, though they may respond to massage if started early. If they need surgery it’s best done by school age.
Overriding second toes are rarely a problem but can occasionally need tendon release.
Developmental dysplasia of the hip
Note that this (or ‘primary dysplasia’) is the term which has replaced CDH, as it also covers unstable hips that aren’t actually dislocated. Ortolani’s and Barlow’s have sensitivity and specificity >60% on the first day after birth, which is still not brilliant. Asymmetrical skin creases are not significant but limited abduction is and should be referred. Asymmetrical gait requires detailed examination (including neurological) to figure out the problem.
If this is causing pain but no actual giving way/dislocation, referral should be to a rheumatologist or children’s physio rather than an orthopaedic surgeon. Giving way or dislocation should be referred to orthopaedics.
Do a neurological examination, as cerebral palsy is the most common pathological cause (and can also cause tiptoe walking). Also, look at the feet with the child prone – the lateral border of each foot should be straight or should easily straighten with a gentle push. If this isn’t so, then the child should be referred, but this is rarely necessary for intoeing as the orthopaedic causes usually correct themselves.
Remember that the provoking activities will typically be pain-free with the pain occuring only after activity. Pain and tenderness should be localised to the tibial tuberosity. It’s important to exclude referred pain from a hip problem as a possible differential diagnosis, and to check spine and thigh as well.
(From Pulse on-line learning module, Fabian Norman-Taylor, consultant orthopaedic surgeon from London clinic)