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Update_July2013: Orthopaedics - Normal abnormalities in childhood


Jai Chitnavis

MA, FRCS, FRCS(Ed), Royal College of Surgeon`s Research, Fellow, Nuffield Orthopaedic Centre, Oxford, UK.

Christopher Bulstrode

MA, MCh, FRCS(Orth), Clinical Reader and Consultant in Trauma and Orthopaedic Surgery, John Radcliffe Hospital, Oxford, UK.

Some orthopaedic problems in childhood are part of the child`s normal musculoskeletal development, but others are due to epiphyseal dysplasias and neurological deficits. In this article, the authors describe normal orthopaedic abnormalities in childhood and identify when children should be referred for an orthopaedic opinion.

Certain features of a child`s normal musculoskeletal development can worry parents. Many of these features involve the legs and most children will grow out of the features. However, a few abnormalities, including some epiphyseal dysplasias and neurological deficits, will not disappear and it is important to exclude them.

General practitioners then have the difficult task of explaining the nature of these normal `deformities`, and reassuring parents. A follow-up appointment is sometimes enough, but a specialist opinion is often necessary for a definite diagnosis and management plan.1

Curly toes

Curly toes are very common, and are often inherited. The outer three toes are usually involved (Figure 1). Curly toes usually do not need treatment, but some children with a fixed deformity develop pressure symptoms. The risk of developing such symptoms is lower if the toes can be straightened passively. Strapping curly toes do not alter their natural history. However, parents should be aware that surgery is possible for symptomatic curly toes.2

Figure 1: Curly fourth toes. Treatment is only necessary if the toes are symptomatic.

Over-riding toes

The most common form of over-riding toe is the fifth toe over-riding the fourth, but other variations exist (Figure 2). These deformities are permanent and often cause local irritation and thickened skin.

Figure 2: Thickened skin in a patient with an overriding fourth toe.

Strapping the over-riding toe is not an effective therapeutic measure. Surgery can be used to correct it.

Flat feet

Ignorance about postural causes for low medial arches helped many people escape military service in the past. As a result, there is a tendency to associate flat feet in children with physical handicap.

The medial longitudinal arch does not develop until children are 2-3 years old. Before this age, all children have a fat pad which gives them a `flat foot`. It is easier to distinguish non-pathological, postural flat feet (Figure 3) when a child starts walking. Pathological flat feet are much less common and can be secondary to:

  • cerebral palsy;
  • peroneal spastic flat foot;
  • down`s syndrome.

Postural flat feet are pain-free, supple and have good muscle power. The medial arch can be displayed by asking the child to stand on tip-toe (Windlass test) or to hyper-extend the big toe. Pathological flat-feet are often painful, weak and have abnormal tone (either stiff or lax). The arch cannot be actively recreated.

Figure 3: Loss of medial arches in a child with non-pathological flat feet. The arches can be demonstrated by asking the child to stand on tip-toe.

There is no evidence that children with non-pathological flat feet require special shoes, in-soles or physiotherapy. Children who are thought to have serious pathology need specialist orthopaedic assessment.2-4


Parents often mistakenly blame in-toeing for their children`s clumsiness in learning to walking. As many as 10 percent of 2-5 year olds are thought to have in-toe. Of these, 40 percent will develop a walking pattern which has a small degree of in-toeing.1 In most cases the main problem is excessive shoe wear. The feet of in-toeing children tend to flail sideways when they run - parents concerned by this can be reassured that many champion athletes were in-toed as children!

In-toeing may be caused by:

  • misshapen feet, eg metatarsus varus (`hook foot`);
  • normal feet being turned inwards by causes higher up the leg, eg internal rotation of the femoral shaft (femoral anteversion), which causes the whole leg to twist inwards, or the tibia twisting inwards (internal tibial rotation).2

Metatarsus varus

This common abnormality, which may be apparent at birth, is usually evident by the time the child begins to walk. It involves a medial or varus displacement of the metatarsals (Figure 4). The heel is normal and the foot can be dorsiflexed beyond 90 degrees. This differentiates it from club-foot. About 90 percent of cases resolve by 4 years of age. It is impossible to identify the 10 percent which will not resolve.

Figure 4: Medial displacement of the metatarsals in a child with bilateral metatarsus varus.

Passive stretching of the foot was advocated in the past, but is no longer thought to be effective. Parents should be aware that surgery is possible and that the results are usually good.2,3

Internal tibial torsion

In-toeing in a toddler is usually secondary to an internal twist or torsion of the tibia. The child`s parents may be worried about an inwardly turned foot and bowed leg. On closer inspection, the feet are medially rotated, but the patellae point forward. If this is symmetrical and the child is otherwise normal, the torsion is physiological and will correct itself by 4 years of age. There is no need for splints or special shoes.3,4

Persistent femoral anteversion

In femoral anteversion, the femoral head and neck point forwards in the same direction as the patellae. This is normal in a newborn baby. The head and neck of the femur usually spiral as the bones grow, and the anteversion decreases to a maximum of about 15 degrees in adults. Any delay to this process results in persistent femoral anteversion.

A child with femoral anteversion has to internally rotate the femurs to keep the femoral head in the acetabulum. This results in the whole leg turning inward, and the patellae facing each other (`kissing patellae`; Figure 5a) and feet in-toeing. When they run, their feet tend to fly outwards. Children with femoral anteversion prefer to sit with their feet spread laterally, knees bent and hips internally rotated (the so-called `W` position; Figure 5b).

Figure 5: Persistent femoral anteversion a) `Kissing patellae`. b) Children with persistent femoral anteversion often sit in the `W` position, with their feet spread laterally, knees bent and hips internally rotated.

On examination, children with persistent femoral anteversion have limited external rotation of the hips with their legs extended, but internal rotation may exceed 90 degrees. Conservative measures are not usually effective, but parents should encourage their child to sit normally.

Eighty percent of cases resolve by the time the child is 8 years old. However, anteversion gets worse when the cause is pathological, eg secondary to cerebral palsy. These children may need femoral osteotomy when between 8 and 10 years old.2,3


Out-toeing is less common than in-toeing. The main causes are, in many ways, the opposite of those predisposing to in-toeing.

Femoral retroversion

The femoral head and neck point backwards relative to the patellae, so the child must externally rotate their leg to engage the head of the femur in the acetabullum. This mimics the `Charlie Chaplin` stance. The whole leg is affected in femoral retroversion, so the patellae and feet are turned outwards. The medial longitudinal arch is reduced and the child appears flat-footed. On examination, internal rotation is limited.

Children with dysplastic hips occasionally present with femoral retroversion. It is therefore important to look for hip instability when examining them. Femoral retroversion rarely requires surgery, as most cases resolve within a year of the child starting to walk.1-3

External tibial torsion

A child`s tibia usually twists outwards, from a degree of internal rotation to external rotation. If external rotation of the developing tibiae is excessive, the feet will be out-toed even though the patellae point inwards, resulting in `squinting patellae`. Although external tibial torsion may result from cerebral palsy or polio, most cases are developmental and resolve as the child grows.2

Calcaneovalgus foot

In calcaneovalgus foot (`banana foot`) the forefoot and heel point laterally. The foot looks curved (like a banana) when it is examined from below. Most cases are bilateral and associated with external tibial torsion. The deformity is thought to be secondary to the way the foot was positioned in utero. Almost all cases recover with time and passive stretching does not alter the natural history.1


Parents are sometimes concerned about a rounded back and shoulders in the adolescent child. Roundback is a painless condition which can be corrected by posture. The kyphotic curve is often long and smooth and there may be a family history of the same condition.

However, if there is co-existing backache and the kyphosis is sharp or cannot be removed by postural adjustment, the child should be investigated at an orthopaedic clinic. A lateral radiograph might reveal vertebral wedging suggesting Scheuermann`s disease (adolescent kyphosis, Figure 6).1

Figure 6: Painful thoracic kyphosis in an adolescent with Scheuermann`s disease.

Knock-knees and bow-legs

The femur spirals inwards and the tibia twists outwards during growth. As a result, most children drift from being slightly bow-legged under 2 years old to being knock-kneed between 2 and 7 years old. However, most children`s legs have straightened by the time they reach their teens.1


Knock-knees are defined by the inter-malleolar separation when the legs are placed together (Figure 7). Between 2 and 5 years old, 75 percent of children have at least 2.5 cm separation. In most children, this disappears by the time they are 7 years old.

Figure 7: Knock-knees (genu valgum) usually disappear by the time a child is 7 years old.

Most cases of knock-knees are symmetrical, with both legs showing an apparent deformity. Rarely, one leg will be more involved than the other. This may be due to epiphyseal dysplasia, especially if associated with short stature.

Some children with excessive joint laxity can hyper-extend at the knee. They demonstrate apparent knock-knees when they do this, but this disappears if the legs are kept straight at the knee. Surgical options in children with true knock-knees include stapling the inner femoral or tibial epiphyses, or a femoral osteotomy. This is usually performed between 10 and 11 years old.3,5


Bow-legs are defined by the distance between the femoral condyles when the malleoli are placed together and the patellae point forwards. Mild bow-legs are common in infancy, and are often secondary to internal tibial torsion.

Children with unilateral bowing or excessive bilateral bowing are much more worrying. Possible causes include an epiphyseal dysplasia or rickets. All children with an inter-condylar gap greater than 5cm, or with unilateral curvature, need investigating.5


Several normal abnormalities of childhood worry parents. Most of these involve the lower limb. Although the majority are transient features reflecting growth and the development of upright gait, a small proportion result from disorders such as cerebral palsy and epiphyseal dysplasia. Management should be aimed at excluding serious underlying disease and reassuring parents where appropriate. If this is not possible, the child needs to be referred for a specialist orthopaedic opinion.

Practical Points

  • Over-riding toe deformities are permanent and often lead to local irritation. Corrective surgery is often unsuccessful if the fifth toe is involved.
  • Postural flat feet are painless and supple, with good muscle power. The medial arch can be displayed by asking the child to stand on tip-toe. Pathological flat feet are painful and weak, with abnormal tone. They require specialist assessment.
  • Approximately 10 percent of children between 2 and 5 years old in-toe. Causes of in-toeing include metatarsus varus, internal tibial torsion and persistent femoral anteversion.
  • Most children are slightly bow-legged under 2 years old, and knock-kneed between 2 and 7 years old. Surgery for children with true knock-knees is usually performed between 10 and 11 years of age.
  • Children with bow legs and a femoral intercondylar gap greater than 5cm, and all children with unilateral curvature need orthopaedic referral.
  • Children with roundback, backache and kyphosis which is not removed by posture, should be referred for an orthopaedic opinion.

References available upon request


Posted on Tuesday, August 13 @ 10:14:26 SAST by E-Doc
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