Have you ever been concerned about a young child who appears to have knock-knees or bowlegs? What about a youngster whose feet appear to turn inward or outward instead of pointing straight ahead? Parents often worry about the appearance of a child’s legs or feet, but the good news is that these problems usually resolve on their own.
Pediatric orthopedic surgeons are specialists in childhood bone growth and development. At HSS, we often see children whose legs aren’t perfectly straight or whose feet turn inward. These are common concerns among parents, and they should never feel bad about bringing their child to a specialist for a second opinion. Most of the time, we find that everything is normal, and many parents just need reassurance.
Normal Growth and Development
A lot of children’s legs aren’t perfectly straight, and most of the time it’s a normal part of growth and development. Babies are born with a bowlegged appearance, but by the time they’re 18 months old, their legs usually become straight. Then as they grow and begin walking, from 18 months to 3 or 4 years old, most children’s legs look somewhat knock-kneed, which is normal as well.
In general, children don’t develop normal leg alignment until they’re 5 to 7 years old. Even then, many children’s legs aren’t perfectly straight and some variation is normal.
Some children appear to be pigeon-toed, a condition referred to as “in-toeing.” This is caused by too much turning in of the hips or the shin bones. “Out-toeing,” in which the feet turn outward, is much less common. Parents are often concerned, but are reassured to learn that most children will outgrow this by age 6 or 8, and it rarely requires treatment. We encourage the family to be patient and let Mother Nature take its course. Surgery for in-toeing or out-toeing is rare and reserved only for very severe cases.
When to See a Pediatric Orthopedic Surgeon
Parents often wonder if they should see a specialist. Certainly, if a young child has a severe bowleg deformity that seems to be getting worse and worse by age 2, a visit to a pediatric orthopedic surgeon would be in order. As for knock-knees, if a child’s legs still appear this way at age 9, he or she may not be following normal bone growth patterns and treatment may be recommended. Parents are also advised to see a doctor if a child is limping or experiencing leg pain.
Although poor leg alignment often resolves spontaneously, in some cases, treatment is needed. Sometimes a pediatric orthopedic surgeon will see a child for follow-up visits over several months to see how growth is progressing. The doctor may order x-rays and blood tests to make sure an underlying medical condition isn’t affecting bone growth. In the event there is a problem, the sooner it’s diagnosed and treated, the better.
Why Treatment is Important
Fortunately, very good minimally invasive treatments for mild to moderate knock-knee or bowleg deformities can correct the problem. Treatment is not only important to improve the appearance of a child’s legs; it also enables the youngster to avoid problems later on.
Poor leg alignment puts significant stress on a joint, causing the cartilage to wear out. So by the time people are in their 30s or 40s, they may have developed knee arthritis. Imagine that the front end of your car is out of alignment and your tires wear unevenly. The same thing happens to your knee joints.
If a child does have a problem with leg alignment, an early diagnosis increases the chances that bracing or a minimally invasive technique will correct the condition without the need for major surgery. For children who are bowlegged, bracing can usually correct the problem in 6 to 9 months.
Sometimes surgery is needed for knock knees or bowlegs, and the minimally invasive technique has revolutionized the correction of these deformities. The procedure, performed on an outpatient basis, entails placing a tiny one-inch square titanium plate on one side of the child’s growth plate. This is an area of smooth cartilage at the end of the body’s long bones where growth occurs. Within a few weeks, the youngster is back to normal activity, and his or her legs become straight within a year. We then remove the plate.
If the deformity is very severe or the child is too old for bracing or a minimally invasive procedure, major surgery may be needed in which we straighten the bone. After a short hospital stay, the child uses crutches for a while, and recovery generally takes a couple of months.
A Difference in Leg Length
Although not as common as bowlegs or knock-knees, a leg length discrepancy is another condition that pediatric orthopedic surgeons treat. A slight variation in leg length isn’t very rare and usually doesn’t cause problems. But when the difference starts approaching an inch or more and one leg is visibly shorter than the other, it can be hard on a child. It can affect balance and the way a youngster walks. It may eventually lead to pain in his lower back, knees or hips.
A child can be born with a leg length inequality, or it can result from an infection or injury. The difference can be a couple of inches, or even more, causing a noticeable limp if the youngster doesn’t wear a shoe lift. The good news is that pediatric orthopedic surgeons have a variety of treatments to lengthen the shorter leg, or shorten the longer leg.
The goal of any treatment is to attain equal leg length when the child’s growth is complete. It’s not the difference at age 3 that’s most important. We’re concerned about what the difference will be when the child becomes a teenager and finishes growing. Pediatric orthopedic surgeons have the specialized training and expertise to predict the leg length discrepancy. That information is vital to develop an appropriate treatment plan, and several options are available.
The latest advance in treatment is a magnetic lengthening rod that is implanted into the shorter leg bone. An external magnet is placed on the child’s leg several times a day to lengthen the rod a tiny bit at a time. This enables the bone to get longer and longer until the short leg catches up to the longer leg and they are both the same length.
Childhood fractures are fairly common, and prompt diagnosis and treatment are essential.
It’s important to consult a specialist in pediatric orthopedics, as our treatment of a child’s fracture is much different from the way adult fractures are handled. A leg fracture in a youngster that’s improperly treated, for example, could cause one leg to be shorter than the other, especially if the growth plate is involved.
Prompt treatment is critical because there’s only a narrow window of time to make sure the bone is in the best position to heal correctly. The biggest problem we see is a child who was first brought to an adult orthopedic surgeon who may or may not understand the nuances of how a child’s fracture needs to be addressed. A delay in treatment can potentially lead to poor results.
The good news is that with prompt and appropriate treatment, most childhood fractures heal well without complications.
Dr. John S. Blanco is a pediatric orthopedic surgeon at Hospital for Special Surgery’s Lerner Children’s Pavilion. He specializes in scoliosis correction (anterior and posterior), clubfoot correction, pediatric fracture management, and management of neuromuscular conditions. Throughout his career, Dr. Blanco has published numerous articles on a variety of topic including scoliosis, pediatric fracture management, slipped capitol femoral epiphysis and cerebral palsy.