Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept.

BACKGROUND: A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones. DESCRIPTION: The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa. PURPOSE: This paper is a review article of this concept and of its physiopathological applications.

Closed reduction in late-detected developmental dysplasia of the hip: indications, results and complications.

PURPOSE: The aim of the study was a review of the literature in order to evaluate the results and complications of closed reduction in late-detected developmental dysplasia of the hip (DDH). METHODS: This study consisted of an analysis of the literature relative to late-detected DDH treatment options considering hip congruency, rates of re-dislocation and of avascular necrosis. RESULTS: Gradual closed reduction (Petit-Morel method) appears to be an effective method concerning joint congruency restitution. Dislocation relapse and avascular necrosis are more efficiently prevented with closed versus open reduction. The tendency for spontaneous correction of acetabular dysplasia decreases if closed reduction is performed after 18 months of age. Patient age at the beginning of traction should be considered for the prognosis, with a lower rate of satisfactory results showing after the age of 3 years. CONCLUSION: In our opinion, the Petit-Morel method is a suitable treatment option for children aged between six months and three years with idiopathic DDH.

Is non-operative management of childhood neurologic cavovarus foot effective?

INTRODUCTION: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE: IV.

Congenital dislocation of the knee at birth - Part I: Clinical signs and classification.

INTRODUCTION: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period. HYPOTHESIS: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria. MATERIAL AND METHODS: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III. CONCLUSION: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors.

INTRODUCTION: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis. MATERIAL AND METHODS: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees. CONCLUSION: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the hip: optimal screening strategies in 2014.

A prospective multi-centre nationwide study of patients with congenital dislocation of the hip (CDH) diagnosed after 3 months of age was conducted with support from the French Society for Paediatric Orthopaedics (Société Française d'Orthopédie Pédiatrique [SoFOP]), French Organisation for Outpatient Paediatrics (Association Française de Pédiatrie Ambulatoire [AFPA]), and French-Speaking Society for Paediatric and Pre-Natal Imaging (Société Francophone d'Imagerie Pédiatrique et Prénatale [SFIPP]). The results showed inadequacies in clinical screening for CDH that were patent when assessed quantitatively and probably also present qualitatively. These findings indicate a need for a communication and educational campaign aimed at highlighting good clinical practice guidelines in the field of CDH screening. The usefulness of routine ultrasound screening has not been established. The findings from this study have been used by the authors and French National Health Authority (Haute Autorité de Santé [HAS]) to develop recommendations about CDH screening. There is an urgent need for a prospective randomised multi-centre nationwide study, which should involve primary-care physicians.

The surgical treatment of children with congenital convex foot (vertical talus): evaluation of midtarsal surgical release and open reduction.

In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder). Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%). The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus. Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Outcomes of modified Dega acetabuloplasty in acetabular dysplasia related to developmental dislocation of the hip.

UNLABELLED: Developmental dislocation of the hip (DDH) is frequently, even after reduction, associated with residual acetabular dysplasia. Various surgical techniques are used to correct this, one of which is Dega acetabuloplasty. This osteotomy technique has, however, rarely been assessed in this particular indication. The present study therefore sought to describe the technical details, report clinical and radiological results, and present limitations. HYPOTHESIS: Unlike reorientation osteotomy in children, Dega acetabuloplasty does not lead to a high rate of acetabular retroversion at the end of growth. PATIENTS AND METHODS: Sixteen Dega acetabuloplasties in 15 patients were assessed on joint range of motion, limp, lower limb length discrepancy and impaired everyday activity, pre-operatively and at end of follow-up. Hips were classified following Wicart et al. (2003). Radiologic assessment comprised Wiberg angle and acetabular index, pre- and post-operatively and at follow-up. Acetabular retroversion was analyzed by crossover sign, and hips were classified following Severin. RESULTS: Median age at surgery was 3 years (range, 1.1-12.2 years) and 10 years (6.4-17.8) at end of follow-up. At end of follow-up, all hips were pain-free and classified as Wicart A, and all activities were allowed. Radiologically, hips were classified as Severin I, II or IV, in 11 (68.5%), 4 (25%) and 1 (6.5%) cases respectively. Wiberg angle rose from a mean 3.3° (-30° to 30°) to 23° (10° to 38°) and acetabular index fell from a mean 31° (25° to 45°) to 20° (5° to 30°) with surgery, and both continued to improve over follow-up: 26° (12-45°) and 13° (3-24°) respectively (P<0.05). Acetabular retroversion was found in 2 of the 10 hips with Y cartilage fusion. DISCUSSION: Modified Dega acetabuloplasty was effective in correcting acetabular dysplasia in DDH. Functional and radiological results were good, with a low rate of acetabular retroversion (2/10), unlike with other techniques. LEVEL OF EVIDENCE: Level IV. Therapeutic study.

Pathogeny and natural history of congenital dislocation of the hip.

Based on a review of the literature, the authors have made a critical study of several etiological factors. Endogenous factors such as acetabular dysplasia, increased anteversion of the femoral neck, and capsular laxity support the genetic theory but are neither constant nor necessary and are only facilitating factors. The major factor seems to be a mechanical one linked to the position in the uterus: hyperflexion with adduction and external rotation constituting the dislocating foetal posture combined with abnormal pressure on the greater trochanter and leading to expulsion of the head upward and backward. This theory can explain the natural history of C D H which is first, at birth a hip instability followed by two possible evolutions: either persistent luxation becoming irreducible or spontaneous stabilisation leading sometimes to complete healing or to residual abnormalities (subluxation or dysplasia). This concept suggests practical conclusions: the importance of an early diagnosis, the selection of the signs of the hip at risk, the pattern of prevention, the role for non-clinical investigations, the principles of the treatment based on postures, the indications for the different types of treatment.

The talonavicular and subtalar joints: the "calcaneopedal unit" concept.

The talonavicular (TN) joint and the three subtalar (ST) joints are linked anatomically and functionally. Together they form the subtalar joint complex, where movement occurs between the calcaneopedal unit (CPU) (entire foot except the talus) and the talotibiofibular unit (talus held tightly by the ankle mortise). Many are unaware of the TN joint's dual membership: it is a component of the subtalar joint complex (talocalcaneonavicular joint) and also the transverse tarsal joint (with the calcaneal-cuboid joint). The anatomy of the articulating surfaces, movement of the CPU when unloaded, shifts and changes in CPU shape with weight bearing, application to clinical tests and X-ray interpretation, and the pathophysiology applications to pes cavovarus, pes planovalgus and congenital talipes equinovarus (club foot) will be reviewed here. The CPU concept corresponds to a horizontal segmentation of the foot. This is a useful supplement to the two other segmentation methods: frontal (hindfoot, midfoot and forefoot) and sagittal (medial and lateral columns). This horizontal segmentation solves the issues with the ST joint complex, which straddles the hindfoot and midfoot, and also the issues with the dual membership of the TN joint. This concept makes it easier to understand foot deformities, better interpret the clinical and radiological signs and deduce logical treatments.

Flatfoot in children and adolescents. Analysis of imaging findings and therapeutic implications.

INTRODUCTION: Pes planovalgus (PPV) is a complex three-dimensional deformity of which routine radiographs provide only a two-dimensional analysis. HYPOTHESIS: Angles and other radiographic parameters of the foot in children and adolescents, when studied on both the dorsoplantar and the lateral view, can be used to establish a radiographic classification system for PPV that provides useful therapeutic guidance in clinical practice. MATERIALS AND METHODS: A retrospective single-centre study was conducted on 65 feet in 35 patients aged 7 to 18 years and having adequate ossification. All patients had a clinical diagnosis of idiopathic or neurologic PPV and available weight-bearing dorsoplantar and strict lateral radiographs. We excluded pes planus due to tarsal coalition, congenital bone deformities, or overcorrection of talipes equinovarus (n=25). All possible axes were drawn and angles measured after an evaluation of interindividual agreement. RESULTS: We identified four patterns of PPV: subtalar pes planus (n=16) with marked subtalar valgus and longitudinal sag predominating at the talonavicular joint, midtarsal pes planus (n=12) without subtalar valgus but with marked midtarsal abduction and sag predominating at the cuneonavicular joint, mixed pes planus (n=28) with subtalar valgus, midtarsal abduction, and sag at both the talonavicular and cuneonavicular joints, and pes planocavus (n=9) with sag of the medial arch and cavus deformity of the lateral arch. CONCLUSION: This original classification system provides therapeutic guidance by helping to match the surgical procedure to the nature and location of the deformities. LEVEL OF EVIDENCE: Level IV.

Neuro-orthopaedic evaluation of children and adolescents: a simplified algorithm.

Orthopaedic surgeons are often the first physicians to evaluate paediatric patients in the event of delayed walking, gait abnormalities, or parental concern about motor abilities. Therefore, orthopaedic surgeons must be thoroughly familiar with the normal neurodevelopmental stages. Neurological disorders are often first recognised during an orthopaedic evaluation. Minimal neurological abnormalities should be taken as warning signs that require additional investigations. Consequently, the evaluation must follow a strict protocol, even in children referred for apparently trivial functional disorders. We have developed an original physical examination protocol in which the largest possible number of signs is sought in each body position to ensure that the examination is both systematic and rapid. About ten minutes are required when all findings are normal. This protocol is extremely helpful for identifying the cause of the problem that motivated the evaluation or for reassuring the child and family. The main causes of paediatric orthopaedic disorders are cerebral palsy, spinal dysraphism, myopathies, peripheral neuropathies, motor neuron diseases, and intraspinal tumours. In some instances, no definitive diagnosis can be established clinically. In this situation, appropriate orthopaedic treatment can be initiated, although considerable caution is in order when establishing the indications. The cause may be detected only much later, when the clinical manifestations become more prominent.

Paralytic congenital talipes equinovarus of unknown origin: A new entity. Multicenter study of 42 cases.

BACKGROUND: Paralysis of the lateral and/or anterior leg muscles can lead to relapse of treated talipes equinovarus. HYPOTHESIS: The muscle function impairment is due to isolated permanent paralysis, and early palliative tendon transfer may prevent recurrence of the deformity. MATERIAL AND METHODS: Forty-two cases of congenital talipes equinovarus that recurred after conservative therapy were reviewed after a mean follow-up of 10 years. In 39 cases, second-line surgery was performed (posteromedial release, n=33; and muscle transfer, n=26). Outcomes were evaluated clinically. RESULTS: Separating the cases into two groups, based on whether muscle transfer was performed, showed a statistically significant difference: muscle transfer intended to restore eversion and/or dorsal flexion of the foot was associated with significantly better functional outcomes. DISCUSSION: In addition to providing etiological insights, the identification of paralysis in patients with talipes equinovarus can influence treatment decisions, depending on the nature of the muscle deficiencies, with the goal of preventing recurrences. Early muscle transfer to restore eversion and/or dorsal flexion of the foot may provide the best functional outcomes by minimizing the need for soft-tissue release. LEVEL OF EVIDENCE: IV, retrospective multicentre study.

Is there a link between osteofibrous dysplasia and adamantinoma?

Because of the relative frequency of osteofibrous dysplasia (OFD) and the gravity of adamantinoma, it is important to know whether there is a link between these two entities. A young boy had been followed from the age of 5 years for OFD of the right tibia. At the age of 10, biopsy performed because of pain, revealed OFD-like adamantinoma. Surgery was undertaken, with en bloc proximal tibial resection of 14 cm and reconstruction by free vascularized fibula and internal fixation. This observation illustrates the risk of evolution of OFD-like adamantinoma, showing the same unfavorable evolution as classic adamantinoma. Strict surveillance is mandatory in OFD, with systematic biopsy in case of onset of pain or increased tumor volume.

Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer.

INTRODUCTION: One possible sequela of obstetric brachial plexus palsy (OP) is impaired external rotation (ER) of the shoulder which, in addition to its functional consequences, can generate a posterior humeral head subluxation or dislocation. The goal of the present study was to assess medium-term clinical and radiological results of release of the subscapularis muscle with transfer of the latissimus dorsi and teres major muscles. PATIENTS AND METHODS: From 1985 to 1995, a continuous series of 32 OP patients underwent subscapularis muscle release, associated in 24 cases to muscle transfer. Mean age was 2.5 years (range, 1-9.2 years). Shoulder function was assessed by measurement of passive ER and graded according to the modified Mallet classification at 1, 5 and 10 years' follow-up or before revision. The evolution of the glenohumeral deformity was assessed on CT images of glenoid retroversion and the humeral head subluxation (% of humeral head covered), before and 5 years after surgery. RESULTS: Mean postoperative follow-up was 9.5+/-5.6 years. Treatment brought significant improvement in passive ER (mean preoperative and 1-year follow-up values: -10 degrees and 52 degrees, respectively). This explained the good modified Mallet score at 1 year: mean=18.4/25. Subsequent significant progressive degradation was noted: 10 years postoperatively, mean ER amplitude and modified Mallet score were respectively 13 degrees and 15.8. The CT study showed correction of the glenoid retroversion (mean preoperative and 5-year follow-up values: 29 degrees and 18 degrees, respectively), and of the humeral head subluxation (mean preoperative and 5-year follow-up values: 25 and 39%, respectively). Surgical revision was indicated six times (five patients): two latissimus dorsi and teres major transfers (not performed initially) and four derotational humeral osteotomies. Three-quarters of the patients who did not initially have muscle transfer had to be reoperated or else showed ER insufficiency at last follow-up. DISCUSSION AND CONCLUSION: Surgical treatment produces objective functional gain, even if this diminishes over time. Moreover, it prevents or corrects posterior subluxation of the shoulder. It is indicated when passive ER amplitude is negative. It seems advisable to associate release to muscle transfer. LEVEL OF EVIDENCE: Level IV Retrospective study.

Congenital pseudarthrosis of the tibia: an atypical proximal location.

UNLABELLED: Proximal location of congenital pseudarthrosis of the tibia (CPT) is uncommon, and its management challenging, risking to end in amputation. We here report a case of proximal CPT managed in a limb-sparing perspective and followed up until the end of growth. A 17-year-old girl presented with type-1 neurofibromatosis and proximal CPT. Initial X-ray showed severe pseudarthrosis of the tibia with bone atrophy, 12-cm shortening and femorotibial and femoropatellar dislocation. Inter-tibiofibular graft and fibular tibialization were performed. At end of follow-up (age 33 years), fusion had been obtained. For orthoprosthetic and cosmetic reasons, a Boyd amputation of the tarsus was performed when the patient was 22 years of age. The functional result was very good, with 0-100 degrees knee mobility. CPT, when proximal, completely disorganizes the knee joint, which is otherwise usually unaffected by this pathology. To achieve a good result, a limb-sparing treatment should combine correction of the tibial axis and of the dislocation of the knee, fibula osteosynthesis and bone graft. LEVEL OF EVIDENCE: Level IV retrospective

Recurrent club-foot deformity following previous soft-tissue release: mid-term outcome after revision surgery.

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds. The results were independent of the age at which revision was undertaken.

Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years.

The treatment of developmental dysplasia of the hip diagnosed after the first year of life remains controversial. A series of 36 children (47 hips), aged between one and 4.9 years underwent gradual closed reduction using the Petit-Morel method. A pelvic osteotomy was required in 43 hips (91.5%). The patients whose hips did not require pelvic osteotomy were among the youngest. The mean age at final follow-up was 16.1 years (11.3 to 32). The mean follow-up was 14.3 years (10 to 30). At the latest follow-up, 44 hips (93.6%) were graded as excellent or good according to the Severin classification. Closed reduction failed in only two hips (4.3%) which then required open reduction. Mild avascular necrosis was observed in one (2.1%). The accuracy of the reduction and associated low complication rate justify the use of the Petit-Morel technique as the treatment of choice for developmental dysplasia of the hip in patients aged between one and five years.

[Congenital dislocation of the hip: current concepts as a preliminary for diagnosis and treatment]. / La luxation congénitale de hanche. Les faits, les signes, les mots. Etat de l'art.

Congenital hip dislocation has been regularly reviewed, in the wake of important progress made over the last thirty years, and more precisely in the field of clinical and ultrasonographic screening, as well as in early treatment. The search of a consensus on the best screening methods (who? how?) should start from one initial point: a thorough knowledge of anatomical, clinical, pathological and therapeutic definitions and concepts underlying this far-reaching question. This is the purpose of the present review of current ideas (from a historical perspective). The two authors, members of French Society for Paediatric Orthopaedics (SOFOP), have extensively researched this subject and contributed to the implementation of national "good practice".

[Protective limp]. / Boiterie.

Limping in a child is a frequent reason for consultation, sometimes as an emergency. A distinction should be made between a protective limp, to avoid painful weight bearing, and an equilibration limp, which corresponds to an adaptation to a disturbance of muscular activity with a neuromuscular or osteoarticular origin. Etiological analysis of a protective limp is essentially based on the history and examination. Further radiological or biochemical investigations contribute to the diagnostic process and are essential in limps of recent onset. Broadly speaking, in children aged between one and two years, the main etiological hypothesis, in terms of frequency and potential seriousness, is osteoarticular infection, although fractures are also common. In children aged between three and eight years, osteoarticular infection should be sought as a priority. The diagnosis of acute transient synovitis (irritable hip) should only be made after excluding other conditions including benign bone tumours (such as ostioid osteoma), malignant tumours, inflammatory monoarthritis, primary osteochondritis of the hip, trauma with or without fracture, apophysitis, leukemia, etc. The diagnosis of acute transient synovitis should be questioned if the condition persists for more than seven days. After the age of nine years, the diagnosis that is important not to miss is proximal femoral epiphysiolysis, because this condition can have serious implications for the future function of the hip. The other diagnoses already cited remain possibilities. Finally, a psychogenic aetiology, tendinitis, or sprain should not be considered in children, and they risk delaying the diagnosis of a potentially serious condition. The aetiology of an equilibration limp is based on a precise clinical examination, aimed at detecting orthopedic or neurological pathology, which will direct further investigations.