Vertical talus is a congenital foot disorder, meaning it is present at the time of birth. It appears as an extreme case of flatfoot and may affect one or both feet. Though vertical talus is not painful for a newborn or young child, it can lead to serious problems and discomfort later in life. The talus is a small bone that connects the foot and leg, and sits between the heel bone (calcaneus) and the two bones of the lower leg (tibia and fibula). The tibia and fibula work with the talus to form the ankle joint. In vertical talus, the talus has formed in the wrong position and other foot bones have formed on top of the talus. As a result, the foot typically points up and the bottom of the foot is stiff with no arch.

Causes and risk factors

The exact cause of vertical talus is not known, though it is often associated with the following conditions:

• Arthrogryposis
• Spina bifida
• Neurofibromatosis
• Other neuromuscular diseases

Symptoms

Vertical talus is a foot disorder that’s usually diagnosed at birth, or before, if it is visible on an ultrasound.

Treatment

Vertical talus will not resolve itself and requires medical attention. It is important for vertical talus to be treated early before the deformity has time to progress. If your child learns to walk with an abnormal foot, painful problems can develop. Nonsurgical treatment options for vertical talus include:

• Stretching or casting
• Physical therapy

If the deformity does not correct with conservative treatment, surgery is usually required. Your pediatric orthopedic surgeon will put the bones in the correct position and fix any issues with the tendons and ligaments supporting the bones. A brace or special shoe may be recommended to prevent the deformity from returning. With treatment, you can expect your child to have a stable and functional foot.

The arch of the foot helps to support us when we stand up or walk. Most children are born with very little arch in the feet. As they grow, develop, and begin to walk, the soft tissues along the bottom of the feet tighten and begin to shape into an arch. When the arch in the foot is not present, the condition is known as flatfoot. There are two types of flatfoot: flexible flatfoot and rigid flatfoot. In flexible flatfoot, the arch is present when the foot is not bearing any weight, but disappears when standing or walking. In rigid flatfoot, the arch is never present, whether bearing weight or not.

Causes and risk factors

Flatfoot is caused by abnormal foot development and can be hereditary.

Symptoms

Some children with flatfoot may have no symptoms, and children with flexible flatfoot often outgrow the condition eventually. Flexible flatfoot is typically not painful, while rigid flatfoot may cause pain during regular activities. See your pediatric orthopedic surgeon if your child experiences:

• Recurring foot pain, particularly in the heel or arch area
• Pain that worsens with activity
• Swelling along the inside of the foot

Treatment

Children with flexible flatfoot usually outgrow the condition as their foot ligaments continue to develop. Treatment for flatfoot is only necessary if your child begins to experience pain or discomfort from the condition. Nonsurgical treatment options include:

• Physical therapy and stretching exercises
• Shoe inserts, such as arch supports
• Supportive, well-fitting shoes
• RICE treatment

Occasionally, flexible flatfoot can become rigid instead of correcting with growth. These cases may require surgical treatment to repair tendons or ligaments, or correct bone abnormalities.

Cavus foot is a condition in which the foot develops an unusually high arch. Because of the high arch, an excessive amount of pressure is placed on different parts of the foot while standing or walking. This condition usually develops slowly during the adolescent years, and may be present in one or both feet.

Causes and risk factors

Most commonly, children develop cavus foot due to a nerve or muscle condition such as cerebral palsy, spina bifida, muscular dystrophy, or clubfoot. These conditions cause some muscles to be weaker than others, and unbalanced muscles work unevenly. Cavus foot may also occur due to an injury to the nerves in the leg or spinal cord. It may also be caused by an inherited structural abnormality.

Symptoms

The most obvious symptom of cavus foot is a very high arch in the foot, even when standing. Children may also experience the following symptoms:

• Calluses or blisters on the side, heel, or balls of the feet
• Bent toes (hammertoes) or flexed toes (claw toes)
• Pain when walking or standing
• Unstable feet due to the heel tilting inward, which can lead to frequent ankle sprains

Treatment

The first step of treating cavus foot is to determine the underlying cause. If linked to a neurological or muscular condition, it will likely worsen over time. In the very early stages or with mild cases of cavus foot, surgery may not be necessary. Non-surgical treatment options include:

• Shoe inserts, such as arch supports
• Shoe modifications
• Bracing

If conservative treatment does not relieve pain and improve stability, your pediatric orthopedic surgeon may recommend surgery.

Sinding-Larsen-Johansson syndrome is characterized by inflammation of the kneecap (patella) at its lowest point in the area of the growth center. This is the site of origin of the patellar tendon. There is traction on the kneecap at this point due to the action of the large, powerful thigh muscle (quadriceps), as well as with deep bending of the knee. The injury is usually due to repeated stress or vigorous exercise.

Common signs and symptoms

• Slightly swollen, warm and tender bump below the kneecap
• Pain with activity, especially when straightening the leg against force (such as with stair climbing, jumping, deep knee bends, or weightlifting) or following an extended period of vigorous exercise in an adolescent
• In more severe cases, pain during less vigorous activity

Causes

Sinding-Larsen-Johansson syndrome results from stress (a single sudden incident or repeated) or injury of
the lower patella that interferes with development, causing inflammation. This may be inflammation of the
cartilage of the growing patella, death of tendon cells from repeated stress, or pulling off of the lining of the
patellar bone.

Risk factors

• Overzealous conditioning routines, such as running, jumping or jogging
• Being overweight
• Boys between 10 and 15
• Rapid skeletal growth
• Poor physical conditioning (strength and flexibility)

Preventative measures

• Appropriately warm up and stretch before practice or competition
• Maintain appropriate conditioning
• Thigh and knee strength
• Cardiovascular fitness
• Exercise moderately, avoiding extremes
• Use proper technique
• Flexibility and endurance
• Maintain ideal body weight

Treatment

Mild cases can be resolved with a slight reduction in activity level, whereas moderate to severe cases may require significantly reduced activity (12-16 weeks) and even immobilization (cast/brace) at times. Initial treatment consists of medications and ice to relieve pain, stretching and strengthening exercises, and modification of activities. Specifically, kneeling, jumping, squatting, stair climbing, and running on the affected knee should be avoided. The exercises can all be carried out at home for acute cases. Chronic cases often require a referral to a physical therapist or athletic trainer for further evaluation or treatment.

Uncommonly, the affected leg may be immobilized for 6 to 8 weeks (in a cast, splint, or reinforced elastic knee support). A patellar band (brace between the kneecap and tibial tubercle on top of the patellar tendon) may help relieve symptoms. Rarely, surgery is needed (if conservative treatment fails) in the growing patient. In addition, surgery may be necessary after skeletal maturity if the ossicle becomes painful.

Download Sinding-Larsen-Johansson Syndrome patient information

The spine is made up of small bones called vertebrae, which are stacked on top of one another. The bones connect to create a tube that protects the spinal cord. Spondylolysis is a common cause of low back pain in adolescents that is caused by a crack or stress fracture in one of the vertebrae. The injury most commonly occurs in the lower spine and can occur on one or both sides of the vertebrae.

Causes and risk factors

Spondylolysis is commonly seen in young athletes who participate in sports that involve ongoing stress on the back, such as gymnastics, football, or weight lifting. Spondylolysis can occur in people of all ages, but children and adolescents are most susceptible as their spines are still developing. Genetics may also play a role in spondylolysis. Some people are born with vertebrae that are thinner than usual, which may make them more vulnerable to fractures.

Symptoms

Many patients with spondylolysis do not have any symptoms. The condition may not be discovered until an x-ray is taken for an unrelated reason.

If symptoms are present, the most common are:

• Back pain similar to muscle strain
• Pain that radiates to the buttocks or back of the thighs
• Pain worsens with activity and improves with rest

Treatment

For most children with spondylolysis, the condition will improve with conservative treatment. The first step is usually a period of rest from sports or other strenuous activities. Other nonsurgical treatment options include:

• Anti-inflammatory medications to help reduce swelling and relieve pain
• Physical therapy exercises to improve flexibility and strengthen muscles
• Bracing to limit the movement of the spine and allow fractures to heal

Surgery is not required for spondylolysis, but may be necessary if the condition progresses into spondylolisthesis.

Download and Print Educational Information About Spondylolysis

The hip is a ball-and-socket joint. The rounded head of the upper femur (thighbone) fits firmly into the socket of the pelvis, and together they make up the hip joint. The socket is lined by a layer of articular cartilage known as the labrum. The labrum aids in stability of the hip joint and acts as a cushion to reduce friction and distribute force evenly. Sometimes different injuries or structural abnormalities can lead to a tear in the labrum.

Causes and risk factors

Hip labral tears can be caused by degenerative or traumatic factors. Typically, tears in the labrum are caused by sports or other activities that involve the hip, such as soccer, ballet, football, ice hockey, or golf. Hip labral tears can also be associated with other conditions of the hip such as hip dysplasia or hip impingement.

Symptoms

• Occasional sharp pain in the hip or groin area
• Stiffness and/or limited range of motion of the hip
• A locking, clicking, or catching sensation in the hip joint
• Pain with certain movements such as getting into or out of the car
• Sometimes patients experience no pain or symptoms while at rest

Treatment

Treatment for a labral tear depends on the severity of your symptoms. Many people will recover fully with conservative treatment, while some cases may require surgery. Nonsurgical treatment options include:

• Anti-inflammatory medications to relieve pain and control swelling
• Physical therapy exercises to help with strength, stability, and range of motion
• Rest from activities causing symptoms

Generally, if conservative treatment does not relieve symptoms within 3-6 months, surgery may be recommended. If the labrum does not heal on its own, a minimally invasive surgery is usually performed arthroscopically to repair or remove damaged tissue.

Spica casts (body casts) are used to treat femur fractures in younger children in order to avoid surgery or the placement of metal. They are also used for children who are born with hip dysplasia to maintain the position of the hip.

Cast placement

Spica casts are often placed in the operating room or in a similar setting while a child is sedated or under anesthesia. This is because the cast takes time to put on properly and care must be taken to place it in a way that it will do its intended job.

The cast will cover the lower part of the belly and waist and include one or both legs. The cast is left open between the child’s legs so that toileting and cleaning can take place. The reason for the cast will determine how long a child will need to be in it. In the case of hip dysplasia, for example, children may need to be in the cast for 12 to 18 weeks. In this case, the doctor may change the cast every six weeks.

Dealing with the cast

Cast Tips

• Watch the edges of the cast for signs of skin problems such as redness, abrasions or sores. Sharp edges can be filed down with a nail file. Padded edges can be protected with tape (duct tape works great).
• Discuss how to clean your child with your doctor- it often depends on the materials used to make the cast.
• In general, do not put anything down inside the cast. Things may get stuck or cause sores or scratches not visible because of the cast.

Clothing

A lot of clothing is not necessary as the cast will cover much of the body. Larger clothing will often fit over the cast (big t-shirts, long night shirts, or loose dresses). Break away pants can work well for older children. Clothes may be adapted by splitting along the seams and attaching Velcro strips to fasten around the cast. The toes and foot can be covered with a sock when cold.

Diet

• Avoid food or drink that may trigger diarrhea..
• Smaller, more frequent meals may avoid bloating and tightness of the cast

Toileting and diapering

• For children in diapers, tuck a smaller sized diaper into the front and back of the cast, under the cast edges. Then place a larger diaper over the cast to hold the inside diaper in place. This will help contain any mess.
• Positioning the child and the cast on a slight incline (head up) will allow gravity to encourage urine and stool to flow down into the diaper. The crib mattress can be slightly elevated on one end to facilitate positioning on an incline.
• The diaper should be checked frequently during the day (at least every 2 hours) and at least once overnight (every 4 hours). The diaper must be changed whenever soiled to prevent the cast from becoming soiled and to avoid diaper rash.
• With each diaper change, check for skin irritation, redness, blisters, or pressure spots.
• For older children, a bedpan and handheld urinal can be used. A wash cloth between the cast and skin may help prevent urine from leaking into the cast.

Bathing

• Give your child a sponge bath daily. Be careful not to get the cast lining wet.
• Avoid lotions, powders, and oils under the cast or around the cast edges. Powders tend to cake up and irritate the skin. Lotions and oils soften the skin and this may lead to a pressure spot from the cast.

Comfort, positioning and activity

• Provide activities to entertain your child, such as books, crafts, board games, etc. Place things within reach to keep them entertained.
• A hair dryer on a cool setting may help with itching or dampness; powders or creams are not recommended inside the cast.
• Pillows, cushions, or a bean bag can be used to prop up your child into a sitting position during the day. Changing the child’s position every 2 hours will help avoid a pressure sore.
• Protect the heels from pressure at all times, even if the feet are included inside the cast.

Transportation

• Special car seats or harnesses are often needed to fit the cast and child safely. The hospital may be able to assist with car seats.
• A stroller or wagon with pillows in the bottom may be useful for smaller children. A reclining wheelchair is helpful for larger, older children.

Download and Print Perthes Disease Educational Information

The hip is a ball-and-socket joint. The rounded head of the upper femur (thighbone) fits firmly into the socket of the pelvis, and together they make up the hip joint. In newborns and children with developmental hip dysplasia (DDH), the hip joint has not formed normally and the ball of the femur is loose in the socket. This usually means the hip is very easily dislocated.

Causes and risk factors

DDH tends to run in families, and is more common in:

• The left hip
• Girls
• Firstborn children
• Babies born in the breech position
• Family history of DDH
• Oligohydramnios patients (low levels of amniotic fluid)

Symptoms

DDH is most often present at birth, though it may develop during the first year of childhood. Some babies born with DDH may not present any symptoms initially.

Common signs of DDH include:

• Legs are different lengths
• Uneven skin folds on the thigh
• Less mobility or flexibility on one side
• Limping, walking on the toes, or waddling gait

Treatment

When DDH is diagnosed at birth, it can usually be treated conservatively with good results. If the condition is not diagnosed until a child begins walking, treatment can be a little more complicated.

Nonsurgical treatment options include:

• Harnesses to hold the hip in the proper position while allowing free movement of the legs
• Bracing or casting are used if a firmer material is needed to keep the joint in the proper position

In some cases, the pediatric orthopedic surgeon will need to reposition your child’s femur into the right position, and apply a cast to hold the bones in place. This procedure is performed while the child is under anesthesia. Surgery to correct DDH is sometimes necessary to realign the hip.

Download and Print Developmental Hip Dysplasia Educational Information

Perthes disease is a childhood condition of the hip that occurs when the blood supply to the rounded head of the femur is temporarily disrupted. The rounded head of the femur fits into the hip socket and helps make up the hip joint. If the bone does not have an adequate blood supply, it begins to die and over time will break down and lose its round shape. As time passes, the body will eventually restore blood supply to the bone and the bone will begin to heal. New bone cells will gradually replace the dead bone, but this process may take several years. If the ball of the femur is no longer round after it has healed, it can cause pain and stiffness.

Causes and risk factors

The underlying cause of the temporary disruption of blood flow to the femoral head is still unknown. The disease commonly affects children between the ages of 4 and 8, and is more common in boys than girls.

Symptoms

One of the earliest signs of Perthes disease is a change in the way your child walks or runs. This often is most apparent during sports or other activities; the child may have a limp, limited motion, or develop a different running style. Other common symptoms include:

• Pain or stiffness in the hip, groin, thigh, or knee
• Pain that worsens with activity and gets better with rest
• Muscle spasms around the hip

Treatment

The long-term prognosis for children with Perthes disease is generally good. The goal of treatment is to relieve pain and other symptoms, protect the hip joint, and restore normal function of the hip joint. If left untreated, Perthes disease can lead to complications in adulthood, such as early onset arthritis. There are several treatment options for Perthes disease, and your orthopedic surgeon will consider several factors including age, degree of damage, and stage of the disease.

Nonsurgical treatment options for Perthes disease include:

• Observation through periodical x-rays
• Anti-inflammatory medications
• Limiting activity and avoiding high impact activities
• Physical therapy
• Casting and bracing

Your doctor may recommend surgery to re-establish proper alignment of the hip joint if the damage is severe. Generally speaking, most children return to their daily activities without major limitation after 18 months to two years of treatment.

Download and Print Perthes Disease Educational Information

When hip pain, stiffness, and limited range of motion keep you from your daily activities, you may need a full joint replacement. For patients with arthritis, the most common source of debilitating hip pain, the goal of hip replacement is to restore function and decrease pain. According to the American Academy of Orthopedic Surgeons (AAOS), hip replacement was first performed in 1960 and is one of the most successful operations in all of medicine.

Anatomy

The hip is a ball and socket joint. The socket is formed by part of the pelvic bone (acetabulum) and the ball is formed by the femoral head at the top of the thighbone (femur). The surfaces of the ball and socket are covered by a slippery tissue called articular cartilage. Normally, the cartilage coating over the bones makes the joint move smoothly and provides an additional shock-absorbent cushion. Arthritis occurs when the cartilage surface wears out and you begin rubbing bone on bone. This can cause pain, stiffness, and decreased motion to the hip joint.

Evaluation

An orthopedic surgeon will give you a thorough evaluation that includes your medical history, a physical exam to test hip mobility, strength, and alignment, and imaging tests such as x-ray or MRI to see the amount of damage in your hip.

Total Hip Replacement Surgery

Your doctor may recommend surgery if conservative treatment methods have not relieved your hip pain or allowed you to continue with daily activities. Total hip replacement surgery involves the removal of the arthritic surfaces of the hip joint and replacing them with total hip implants. The implants are designed to replicate the hip joint and are made with metal, polyethylene (a durable plastic), and/or ceramic. This allows the joint to move smoothly again.

Joint replacement is a major decision, and at The Center, your orthopedic surgeon will provide you with as much information as possible to choose the right procedure for you. Our surgeons stay current with advances in anesthesia, surgical techniques, and technology to offer both outpatient total joint replacement and total hip replacement with Makoplasty.