CHILDREN'S CONDITIONS I TREAT
Here I have given an overview of the sort of issues I treat in children. It is not intended as an exhaustive list, neither as a proxy for sound medical advice.
If you are unsure please get in touch for more advice about the best way forward to help your child in your time of need.
Any limb that is not shaped optimally for it’s function can be said to be malaligned. Sometimes this can be quite marked, at other times it is a mild issue that creates problems over time. This can be an obvious malalignment when you look the someone standing or can be harder to spot and can include differences in the rotation or “twist” in a limb.
Limb malalignment can have many causes- the common causes in children are either as a result of trauma or injury, infection or as a result of problems with limb growth and development. If these problems are not addressed in childhood they can carry through in to adulthood and result in needing more input in adult life or an accumulation of problems through age. One example of a childhood problem that can be treated in childhood but also has significant adult effects is Blount’s disease:
e.g. Blount’s disease
This is a disorder of the growth plate in the upper inner tibia (the bone below the knee). It results in changes in the angle at the knee and results in bowing of the leg that gradually gets worse as people grow. In many countries and populations it is neglected in childhood as it does not necessarily cause pain, but the damage to the knee in the long term can be very severe. Realigning the limb, even if the joint has started to be damaged correcting the limb alignment can preserve the knee for a long time, and makes any future work on the knee easier and last longer.
Limb Length Difference
Limbs usually grow the same length. If you look at 100 people, on average 70 of them will have a leg length difference- they just don’t know about it! A difference of up to 1.5cm can be tolerated throughout life without noticing it at all. Above this some people start to notice effects on either their back, hips or knees and can look for treatment. Much more than 2.5cm and the effects are more noticeable and there is better evidence for treatment. Having said that I have found that some patients with a combination of a mild rotational malignment and a very small length difference of even just 1cm can feel significant impact from this. Treating the two elements can lead to a big difference in how they feel.
The management of different leg length differences can be broken down into simple steps including internal shoe lifts, external shoe modifications or length modifying procedures (lengthening or shortening). Often the best use for each patient is best discussed on an individual basis.
Of course, we should never forget the impact that arm length difference can make to people’s life. For many people it causes little functional problems but can be a major cause of cosmetic or body image concerns if there is a difference in the arms.
The causes of limb length differences in children are similar to those for malalignment. They are usually the result of trauma or injury, infection or as a result of a syndrome or growth disorder. If these are not addressed properly during childhood people can end up with the adult accumulation of undiagnosed problems that will cause pain. A good example of this is Hemi-hypertrophy, which has been described in more detail below:
Sometimes the two sides of the body can grow at different rates. It is actually fairly common and can be quite mild. Although both the arm and leg on the affected side can be longer in length, it is often only noticeable in the leg. Treatment is usually given in the form of shoe lifts, or if noticed at the correct time, smaller surgery in childhood to stop the growth in the longer leg can equalise the limb lengths.
Occasionally the thickness of the arm or leg can also be different. This is harder to treat but can be discussed with a plastic surgeon if it becomes a problem in any way.
Trauma and Post-Traumatic problems
Children injure themselves a lot (!) Given that fact, the majority of injuries they sustain are fairly minor. However, if they do fracture a limb you want the best possible advice and management for your child. Children can get quite specific injuries that adults don’t get and can need specialist treatment to give the best long-term outcome. There is a fine balance between conservative treatment without surgery and surgical treatment that may be unnecessary.
Even in the best hands fractures (or breaks- they are the same thing) can result in problems such as healing in the wrong shape (mal-union), not healing (non-union) or infections after surgery. These can result in the limb looking and functioning abnormally, resulting in pain or limitation in how much people can do.
For a quicker and longer lasting recovery you need treatment by an expert with the knowledge and understanding of how to achieve results in the most reliable way. Limb reconstruction surgeons are often the few in each region who are trained in advanced techniques that can save limbs after injury and give you comprehensive treatment options.
This is slightly different to limb malalignment. In this case the limb can remain the correct shape overall, so the arm or leg looks ok, but the angle of the joints causes pain and limited movement because they are set wrong. It is a bit like having the wheels on your car out of alignment. Of course, it can be associated with limb malalignment also and this is where the advice of an expert in limb alignment analysis and treatment becomes crucial to avoid having multiple operations or having operations that don’t give the required result.
The causes of joint malorientation are similar to the other areas above i.e. new injury or trauma, or the ongoing result of childhood problems such as injury, infection or congenital disorders. This time we have the spotlight on infections:
e.g. Growth plate infection or injury
The growth plate is an area of cartilage near the ends of long bones. As children grow, the cartilage turns into bone, which determines the length and shape of the mature bone. The growth plates often also form the joints at the ends of the bones.
Injury here can result in the bone growth slowing down or stopping. If the whole growth plate stops you often land up with a limb the “correct” shape but short. If part of it stops then the limb will be misshapen resulting in malalignment or joint malorientation. Either of these, if severe enough can also result in poorly formed or shaped joints that go on to cause pain or stiffness in later life.
e.g. Meningococcal septicaemia
This is a very severe infection affecting children and young adults especially badly. It is caused by the bacterium Neisseria Meningitidis and when it gets in the blood stream can cause Septicaemia (blood poisoning) leading to a severe illness including loss of blood supply to skin, muscle and vulnerable parts of the skeleton in small children who still have a lot of growing to do. This can cause major problems with bone shape and length throughout childhood and the effects can be lifelong.
Bone Infection (Osteomyelitis) and Joint Infection (Septic Arthritis)
Infection can result when bacteria or fungi get in to a bone. Bone infections can occur after a trauma, injury or previous surgery. Children are particularly susceptible to bone and joint infection from blood borne organisms that may not cause problems in adults, and don’t necessarily need to have had an injury or surgery to get an infection in the bone.
Bone infections can appear quickly or develop over a long period of time. If they’re not properly treated, bone infections can leave a bone or a joint permanently damaged, resulting in pain, long term leaking wounds or limitation in function. It is an area that limb reconstruction surgeons are very familiar with and can give you a comprehensive treatment plan for the long term.
A controversial topic to many, but height problems are real. The world is really designed in a very certain way that does not easily take in to account the needs of all members of our society.
Many people who have concerns about their height have been born with a skeletal dysplasia that limits how much their body can grow, others are unhappy with their height for a variety of personal, social, psychological or career reasons.
The options for treating height problems have changed dramatically in the last few years specifically. It is becoming easier to add height to patients, although there are still significant risks.
One of the bone shape diagnoses that can affect height in adulthood is Achondroplasia:
This is the most common type of short stature affecting how the arms and legs develop leading to either different shaped limbs or an overall reduction in height that some people find unsatisfactory. Due to the nature of the problem and size of the limbs treating the limb shape in childhood can need repeated surgery and careful planning. This is best undertaken with someone who can give a long term view on the timing of surgery and how to minimise the physical impact of repeated surgery balanced with the psychological aspects of a lifelong condition.
Limb Dysplasia (Hemimelia and Focal Deficiencies)
This really is a family of fairly disparate disorders that can cause any of the issues we have mentioned above. The impact on each individual in terms of the “expression” of the problem varies hugely and the treatment needs are bespoke for each person. I have split them up below with a flavour of each type of problem, but very much feel this is an area better discussed in person.
Fibular Dysplasia (hemimelia)
Children who have fibular hemimelia are born with a short or missing fibula (the outer “small” bone in the lower leg). The other bones in the leg, ankle, and foot can be affected too. Fibular hemimelia is the most common congenital dysplasia.
Children with fibular hemimelia present with three typical problems. Limb length difference because the tibia on the affected side grows at a slower rate than the tibia on the opposite side; foot problems related to the abnormal ankle joint and possible missing parts of the foot and; knee or limb malalignment which typically has a valgus (knock knee) appearance.
Tibial Dysplasia (hemimelia)
This is characterised by a shortened or absent tibia and presents as a shortened leg with knee and ankle problems. Most often they cause the knee to remain in a slightly bent position (flexion) and the ankle to point inwards (varus). There is also typically instability of the ankle and/or knee joints due to the ligaments holding the joint in position being absent.
Femoral Dysplasia (PFFD and CFD)
Congenital deformities involving the femur consist of a spectrum of disorders and it can be given quite a few different names. Proximal femoral focal deficiency (PFFD), also known as congenital femoral deficiency (CFD), is a rare birth defect that affects the pelvis, and the part of the femur nearest the hip (proximal). It may affect one side or both, with the hip being misshapen and the leg shortened. The affected limb does not grow properly, so the length difference between the two limbs will continue to increase throughout childhood.
Humeral, Radial and Ulnar Dysplasia
The same pattern of problems can affect the upper arm or forearm leading to malaligned arms or an elbow and wrist that is difficult to get in to a useful position. Again bones can be missing and treatment is best as a team with specialist children’s limb reconstruction and hand surgeons.
Skeletal Dysplasias including Osteogenesis Imperfecta
Skeletal dysplasias, are a group of disorders characterised by abnormalities of cartilage and bone growth, resulting in abnormal shape and size of the skeleton and disproportion of the long bones, spine, and head. Commonly seen skeletal dysplasias include achondroplasia, osteogenesis imperfecta, hypochondroplasia and exostoses. We have discussed achondroplasia further above. Some other examples are discussed here:
This is when you get “extra” bits of bone forming, usually around the ends of long bones close to the joints. It can run in the family (hereditary) or be the result of a new gene change as an embryo. The commonest problems are pain from the lumps when they get knocked or tendons flick over them, although some can cause limb alignment or length changes also.
OI or “brittle bone disease” as it can be known is a fairly common form of dysplasia. Again it can look very different between different individuals, and can run in families or happen new. In the mildest forms it causes bones to break during lighter activites than normal, but otherwise people manage well. At the other end of the spectrum people can struggle with regular breaks, a lot of pain and multiple poorly shaped bones. Sometimes we find that placing rods inside the bones helps protect them from fractures and prevent the bad shapes that can develop. This needs to be undertaken with careful consideration and as part of a wider multi-disciplinary team to give the best care overall. As part of the national OI management team at Great Ormond Street I can advise you at any stage of your child’s care as to the best way forward.
Whilst not terribly common, this abnormal development of the bones near the wrist can be treated very simply if found early, or can need more complex surgery to correct the shape of the wrist. Commonly attributed to an extra tether of connective tissue in the forearm, the problem can run in families or can happen de novo. If left unchecked people can end up with very poorly shaped wrists by the end of childhood leading to early changes in the joint that lead to pain and stiffness and needing further operations in adult life.
Slipped Epiphysis (SUFE or SCFE)
Slipped Upper (or Capital) Femoral Epiphysis occurs in adolescent hips. Many times it occurs silently and only gets noticed later in life on xrays for another reason. When it does present as it occurs it often gets missed for a while as a groin strain or a sprain, or even a knee injury before being found.
I found the best way of describing what is happening is to imagine the top of the thigh bone as an ice cream cone and imagine the ice cream is slipping off the side.
If caught early treatment can be through a fairly minor operation to put a screw in to the top of the femur and stop it from slipping off more. If left for a while or if it has been creeping along quietly in the background a bigger operation to realign the hip properly may be needed. As an expert in paediatric limb problems I can offer the full range of options for urgent management of this condition to give your child the best outcome whilst avoiding repeated surgery.
If a SUFE is the ice cream falling off then Perthes is the ice cream simply going soft and melting! A hip problem mainly affecting young boys between 3 and 8 it usually presents with an insidious onset limp, pain and stiffness in the hip. As it goes through the stages of the disease there are different priorities, the over-arching one being to try and keep that ice cream nice and round in the same shape as the “cup” of the hip. The rounder the hip stays the better they do in the long term. Most of this can be managed with physiotherapy and close follow up, but the ability to make a strong surgical decision in this difficult disease with no consensus on treatment is valuable to having all the options available for a good outcome in later life.
Hip Dysplasia (DDH)
Hip dysplasia is the commonest form of hip problem. Commonly running in families but especially female, first born, breech presentation with a family history and a lack of water around the baby, it is an eminently treatable condition. If picked up early in life (within the first few weeks) it can often be treated very successfully with simple harness or bracing treatment. The older they get the more involved treatment can be, although it can still be highly successful. I learnt how to treat children’s hip disorders from some of the best in the world and am well versed in the different methods of treatment and what is appropriate for your child.
Clubfoot (talipes) is a condition that commonly occurs when the foot is curved inwards while the baby is in the womb. Sometimes it occurs as part of other problems with limb development or with poorly separated bones in the foot. The condition does not always result in decreased limb length, but requires treatment usually by manipulation followed by a series of plaster casts to move the foot into the correct position (Ponseti technique). This is then held in place until the age of 5 using splints or a “boots and bar” mainly at sleep and nap times.
If these methods do not work, then surgery may be considered either to move tendons to help preserve the corrected foot shape or bigger surgery to achieve a good foot shape for walking.
Some bones are either never formed properly, or within the first couple of years of life fracture through normal movement at a site where the bone hasn’t developed normally. This happens commonly around the collar bone (clavicle) or the shin (tibia).
When pseudarthrosis of the tibia is present at birth, it is known as congenital pseudarthrosis of the tibia (CPT). The bone tries to heal abnormally with fibrous tissue between the broken ends. This can lead to difficulty with the shape of the bone, its ability to allow comfortable walking or taking part in sports. It often results in a length difference between the two legs that needs to be corrected along with trying to get the bone to heal.
Popliteal Ptergyium Syndrome (PPS)
This is a very rare genetic condition of unknown cause. It usually shows up as webbing of joints like the knees, ankles, and elbows. This webbing causes problems walking and doing everyday tasks because the muscles are held in positions that are hard to maintain and are always fighting themselves to work. It is a hard problem to live with and needs specialist knowledge to take care of properly. Correcting the pterygium is fairly high risk and best undertaken as a team with specialist children’s limb reconstruction and plastic surgeons.
Vascular malformations are very common. They can range anywhere from a small “birth mark” to whole limbs or even half the body being affected. They can get inside joints, cause problems around them, make limbs grown long or short or take up space in bones that really should be packed full of nice honeycomb bone.
It is a specialist area in it’s own right, and the best services are made up of Dermatologists, Radiologists and Surgeons to take a rounded approach to managing the problem. There are few centres around the world who can manage them well and our unit at Great Ormond Street and the Wellington Hospital in London can manage these difficult cases for children or adults.