Sophisticated ultrasound probes nowadays are able to pick up lots of conditions during pregnancy and it comes always as a shock if indeed your baby has been diagnosed with a clubfoot deformity. However, the Ponseti-method ideally started the 1st week of life after birth is a highly successful treatment based on weekly cast changes for 6-8 weeks, possibly a very small procedure at 2-3 months (Achilles tendon release) and then a brace with a bar and pretty normal shoes up until walking age around 12 months. Occasionally, a tendon transfer is needed with 6 weeks of casting at the age 3-4 years. However, a good looking foot with a great ability to dance or play football is possible as has been shown in the last 50 years that this method has been used.

For some reason - still unexplained - during pregnancy or even after (hence developmental and not congenital) the hip joint comprising of socket and hip ball does not develop as it should. A Yin / Yang relationship is needed and if one or the other turns away both underdevelop resulting in a shallow steep small socket and a small twisted deformed hip ball. Time is of the essence and the sooner things are picked up e.g. with proper clinical exam, ultrasound ( up until age 6 months) or radiographs (after 4-5 months) the sooner proper treatment is instituted and the greater success rate and lesser chance for need of future surgery. Initial mainstay of treatment is the application of a stirrup harness (Pavlik) for several weeks. If this fails, a closed or open reduction of the hip dislocation in theatre under short general anaesthesia is needed followed by a special pelvis/hip/leg plaster cast on for 6 weeks to 3 months. Usually a successful outcome follows but 'some hips do what they want whatever we do' especially in some families. Treatment becomes in those (fortunately rare) instances more complicated . Early screening is the key but nevertheless some children slip through the net! If in doubt, ask your doctor!

Between the age of 4 and 8 years, the hip joint can become very irritated usually after a preceding viral illness (2 weeks) and your child might develop a painful limp. He/she should not be really ill at all (fever suggests something more sinister like an infected joint) and after a thorough clinical exam, an ultrasound, radiographs and usually a blood sample, the diagnosis 'irritable hip' or transient synovitis can be made. A short course of non-steroidal anti-inflammatory medication usually does the trick. As far as we know, there are no long-term consequences of 'transient synovitis'.

This is very serious condition usually affecting adolescents between 10 and 14 years of age still for unknown reasons. Possibly due to accelerated growth the growth plate enlarges, becomes stressed and develops a stress fracture. Gravitational forces create a huge split and like tectonic plates the surrounding bony structures start to shift resulting in pain in the groin (but sometimes only in the knee!) and limping. This is not a simple sprain which usually settles after 5-7 days. If and when your teenager continues to complain, he should be seen and examined. Radiographs of the hip are needed and the amount of 'slip' (hence the name slipped capital femoral epiphysis) determined. Prompt treatment is needed and usually surgery under general anaesthesia involving stabilization of the stress fracture with pins or screws is indicated. If nothing is done and if the slip is very severe, very disabling osteo-arthritis can occur requiring fusion or joint replacement at a young age. Once the growth plate has fused (between 14 and 17 years), there is no further risk for breakage of the metalwork and high impact sports can be resumed again!

For some reason - yet unknown - the blood supply to the hip ball can become interrupted in children between 4 and 10 years of age resulting in fragile bone and cartilage compression and deformity. Pain in the groin and limping develops requiring prompt attention. Radiographs give a good idea of the extent of collapse determining treatment such as observation, traction, physiotherapy, splinting, bracing and even surgery. Fortunately, in most children the socket adapts to the deformed shape of the hip ball and if some decent fitting (or congruency) can be achieved, the hip joint should be good for at least 30 / 4o years. After that, a hip joint replacement might be required in severe osteo-arthritis.

Perthes Association: Helpline Number 01483 306637
Email: help@perthes.org.uk

Knee pain in children for several days without any particular injury can be anything from overuse inflammation (Osgood-Schlatter's), cartilage damage (osteo-chondritis dissecans), transient membrane inflammation, joint infection (septic arthritis), entrapment of a congenital membrane remnant (plica) to a hip condition with referred pain pattern.
A thorough clinical exam and appropriate imaging studies are critical for a prompt diagnosis and the right treatment. If in doubt, ask your doctor !

www.orthogate.org/patient-education

Intoeing/outtoeing www.orthogate.org/patient-education

Flat feet/tiptoeing www.orthogate.org/patient-education

www.orthogate.org/patient-education

Dear Parent/Guardian/Carer

Before you come for a consultation, you may like to know what to expect.

Because the problem of children's bones, joints and muscles are different from those of adults, a new group of specialists has emerged in the past 25 years, known as paediatric orthopaedic surgeons. We train in general orthopaedics and then take years of further training to focus on children's orthopaedic problems.

The definition of normal is wide

Children have survived for million of years. They are hardy. Most conditions are self-righting or unimportant. The result is that many children coming for consultation are fundamentally normal and require no treatment. I will try to explain that the definition of normal is quite wide. You may have set your heart on having an athlete for a child and find it hard to discover that this is not the case. You may find it hard to accept that a child is flatfooted, round-backed, or bowlegged and that there is nothing abnormal about this and that some children grow out of it, or that there is no simple treatment. Some will not change and will probably look like their parents. There is nothing that can or should be done for these children.

There is no magic for minor problems. It is my policy to leave these things alone and not prescribe a placebo treatment. I will explain them and try to put them in perspective for you. My aim is to prescribe treatment that is appropriate and to guard you from unnecessary and ineffectual treatment.

Parents often say that they think that a child will blame them later for not doing something about a problem when they were small. Children are such wondering beings that it should not be difficult to focus on their strengths rather than on their weaknesses. Children are not small adults, they are special. They stumble and fall and trip and are flatfooted and complain of aches and pains and want to be carried.

Some children require treatment
Another group of children need more than explanations - they need treatment. I will explain the different options of treatment. Sometimes you and I will choose to start with simple methods first. If these are not enough, we will be prepared to go onto something more elaborate.

My real skill is sorting out children who would benefit from an operation and then doing it well and providing care until the benefit is seen.

If a child needs an operation, we will have to talk about possible complications. Some will be serious and some trivial. Most are rare. You must know about these in order to come to a decision about whether to go ahead with the treatment. We may both find it a difficult discussion.

Some children are difficult to diagnose

Sometimes a child will come up with a problem that is hard to diagnose. Tests are done and shed no light. This does not mean that the child's problems are psychosomatic - though you will be asked questions with this in mind. It means that no diagnosis can be made with the tools available. The tests will rule out a serious disease so that your mind can be set at rest somewhat. The chances are that the symptoms will disappear without anyone becoming wiser. The child will be followed up to see if anything turns up.

Prevention is more important than treatment

You may think that the main function of a doctor is to diagnose and treat diseases. In fact, preventing diseases is even more important. Children are healthier today because of preventative medicine. In the days before antibiotics and immunisation, parents worried about infection - infections were the greatest threat to a child then but as one problem is solved, the next on the list assumes a new importance. Today, accidents and a negative lifestyle pose the greatest risk to the life of a child.

You can help to reduce the risk of accidents. Teach road safety. Use seatbelts in cars, buy a bike helmet, do not let your child play out in the street, have window guards on high-rise windows, and practice water safety. These are areas for effort rather than worrying over minor problems.

Prevention is a parents best policy.

Some children have long-term problems

Some children have long-term problems, such as cerebral palsy or spina bifida. The plan will be to do as much as can be done and not give up. There is always something. We will need the skill to change what can be changed, the patience to accept what cannot be changed, and the wisdom to know the difference. You will need to find positive factors to focus on and put on a cheerful face, because children tend to mirror their parents attitudes. They will laugh if you laugh, and they will be sad if you are sad.

Oh The Waiting!

You may be upset now because you are waiting longer than you expected. There is often a lot of waiting around when you come to the hospital and for this I apologise. Waiting is irritating. You may think that it is only patients who wait, but the doctors do it every day too - waiting for tests and x-rays, tracking children around the hospital, waiting for the operating room, holding phones that say 'hold', and then sitting around on emergency call on weekends. If we could get rid of the waiting, we would. As some have said, it is always possible to find a doctor without a waiting list but who would want to see him or her? Perhaps you should be cheered that many other patients value the service that you seek.

Patients go through a clinic like traffic goes along the motorway. A small hold-up causes delays for all. What can you do? Tell your child a story, read to them, get a newspaper to read or talk to the person sitting next to you.

You may want me to answer questions and be disappointed because I do not have an answer for each one. Medicine has nothing to say about many things.

You may expect me to be able to forecast the future. It is not simply the outcome of disease that will influence a child's future; there are many other factors involved, especially the parents' handling of the situation.

You may want another opinion; I will help you obtain one and will send x-rays and notes to assist you.

I will try to stay positive and cheerful because I want to make your visit a cheerful experience for you and your child. Visiting a doctor may be stressful at times, but it should become a good memory.

With best wishes

Mr J G V Neyt FRCS MD

www.posna.org (Paediatric Orthopaedic Society of North America)