Flatfoot in children: how to approach?

Although the exact incidence of flatfoot in children is unknown, it is very common and is, in fact, one of the most common conditions seen in pediatric orthopedic practices. All children are born with flat feet, and more than 30% of neonates have a calcaneovalgus deformity of both feet. This condition is not painful and generally resolves without treatment; very rarely is corrective casting necessary. For the pediatrician evaluating flatfoot, it is important to differentiate between flexible and nonflexible [rigid] flatfoot, and to classify the condition as painful or painless. Most children who present to a pediatrician for evaluation of flatfoot will have a flexible flatfoot that does not require treatment. On the other hand, other conditions that do require treatment, such as congenital vertical talus, tarsal coalition, and skew-foot often present as nonflexible flatfoot. Surgical management is rarely indicated for a true flexible flatfoot. The longitudinal arch of the foot is not present at birth and slowly develops during childhood, usually by about age five or six. It is a process that occurs throughout growth and is not affected by the presence or absence of external arch support. Sometimes the arch takes even longer to take shape, but this still usually does not cause any problems. A variety of tendon transfers and reconstructive procedures have been advocated, but none has proved uniformly successful. Nor have any of the various types of supports ever been shown to change the arch architecture. It should be borne in mind that painful flexible flat foot requires treatment, often with several types of shoe inserts and supports and as a last resort by operative procedures. Although parents are often concerned about pediatric flatfoot, the child is usually found to be asymptomatic, and no treatment is indicated. In most instances, the best treatment is simply taking enough time to convince the family that no treatment is necessary

Rotational deformities of the lower limb in children

Rotational deformities are common lower extremity abnormalities in children. Rotational problems include in-toeing and out-toeing. In-toeing is caused by one of the three types of deformity: metatarsus adductus, internal tibial torsion, and increased femoral anteversion. Out-toeing is less common than intoeing, and its causes are similar but opposite to those of intoeing. These include femoral retroversion and external tibial torsion. An accurate diagnosis can be made with careful history and physical examination, which includes torsional profile [a four- component composite of measurements of the lower extremities]. Charts of normal values and values with two standard deviations for each component of the torsional profile are available. In most cases, the abnormality improves with time. A careful physical examination, explanation of the natural history, and serial measurements are usually reassuring to the parents. Treatment is usually conservative. Special shoes, cast, or braces are rarely beneficial and have no proven efficacy. Surgery is reserved for older children with deformity from three to four standard deviations from the normal