Top Ten Lower Extremity Conditions In Pediatric Patients

Pediatric patients can suffer from a variety of conditions, both symptomatic and asymptomatic. These authors present their experience in treating conditions such as hallux valgus, plantar warts and flatfoot in children.

When a child is complaining of pain in his feet or legs, most parents are not sure if the child has an actual problem or may be seeking more attention from his parents. In contrast, some children have a painful foot or leg problem, and do not complain at all. It is common that a parent will try to treat the problem with home remedies or take the patient to a pediatrician. Sometimes when a patient sees a pediatrician for a lower extremity issue, the pediatrician is not sure where to refer the patient. The doctor may consider a dermatologist, a physical therapist, a general orthopedic surgeon or, more frequently, a podiatrist.

Our goal is to help educate the foot and ankle specialist with pearls on treating pediatric foot and ankle disorders and diseases. We have been in private practice for 20 years and see a large volume of pediatric patients. Every day, we see something new and we are always learning from our experiences. The medical literature has featured very little in the past 20 years on the treatment of pediatric pathologies in the foot and ankle, and quality research is desperately lacking.

One of our professors many years ago emphasized to us that it is vital to learn from your mistakes and critical to learn from the mistakes of others as you will not have enough time in your career to make them all yourself. Many treatments have emerged in the past 20 years for pediatric foot and ankle pathologies. Some of these treatments have proven to be ineffective and some have changed the way we practice medicine of the foot and ankle.

Keys To Addressing Ingrown Toenails
Ingrown toenails are sometimes present in infants but are most common in teenagers. At times, adolescent patients will neglect their toenails. Sometimes, they pick at them or cut them incorrectly, which may cause an infection. Trauma and the use of cleats for sports may also cause the nail to become incurvated.

If the nail is mildly incurvated and there is an infection, it is possible that the problem may resolve with a slant back debridement of the nail, oral antibiotics and warm water soaks with Epsom salts or diluted betadine. If the nail is severely incurvated with an abscess or the nail is penetrating the skin, then a nail procedure is necessary.

If you are treating an infant, a total nail avulsion is usually easier and more effective than a partial nail avulsion. Giving an anesthetic injection will be more painful than removing the nail. Simply do the nail removal quickly while the child is sitting on his or her mom’s lap. Usually, children will cry but are comfortable after a few minutes. Let the child’s mom know this will be hard to watch but it will be the easiest and least painful method. With an infant, we recommend a nail avulsion and giving the nail a chance to grow back. If the problem becomes a recurrent one, then a nail matrixectomy with the infant under anesthesia at the hospital may be necessary.

When treating an infected ingrown toenail in a child, it is vital to rectify the nail permanently. Urgent care or emergency room physicians often perform temporary nail avulsions but the recurrence rate is more than 80 percent in our experience. We recommend a partial nail matrixectomy with phenol or alcohol for the affected borders. It is very unusual that the whole nail is dystrophic, which would warrant a total nail matrixectomy.

The anesthetic injection in a child is always a challenge. Keeping the child calm before the injection is the most important part. We often use topical lidocaine/prilocaine (Emla) or a lidocaine-based anesthetic cream prior to the injection. We also try to let patients listen to music to make the experience easier for them. In the past, we used a CO2 laser or excised the matrix with sharp dissection and suturing. Both of these methods have revealed a higher recurrence rate than the use of phenol and alcohol, and children sometimes would develop painful scar tissue.¹

What You Should Know About Pediatric Plantar Warts
There are more than 30 different types of verrucae. Warts on the bottom of the foot are much more resistant to treatment than warts on other parts of the body. Plantar warts usually result from walking barefoot around a swimming pool, on the beach or outdoors where these microscopic viruses are on the ground. These skin lesions are usually painful with lateral compression, have discontinuous skin lines and show punctate bleeding upon debridement. Topical OTC medications and liquid nitrogen are often painful, and we have found they have a less than 25 percent success rate.

In cases of multiple plantar warts, we often recommend oral zinc sulfate 220 mg bid or oral cimetidine, both of which have proven to be effective in resolving the warts after one to three months of treatment. Unfortunately, not all children can swallow a pill nor do they always remember to take the medication.

Our initial treatment plan for plantar warts includes sharp debridement and the application of topical Salinocaine cream (Premier Medical). This cream is a combination of concentrated salicylic acid and benzocaine. One can apply this cream under occlusion with moleskin or adhesive tape. Patients can leave it on and keep it dry for five to seven days. Follow this with sharp debridement in the office.
Alternately, patients can apply the cream under occlusion at home before going to sleep and remove it in the morning. This treatment does not usually cause pain and will keep the child active during the treatment process. It may require two to three debridements to resolve the wart. The patient usually presents every two weeks until the veruccae resolve. We have found the combination of sharp debridement and topical cream works well more than 50 percent of the time. One can use topical cream concomitantly with oral zinc sulfate or cimetidine if multiple warts are present.

If the wart is persistent after the use of Salinocaine or oral medications, we recommend the use of topical cantharidin with occlusion, typically after debriding the skin growth. We recommend keeping the site dry for three to four days and then having the patient return to the clinic for surgical excision under local anesthesia. If the child is extremely anxious, one can perform the surgical excision in the hospital or surgery center with the child under anesthesia. One may use cantharidin by itself or in a combination with 30 percent salicylic acid and 5% podophyllum. This topical medication will create a blister and one should apply it under occlusion with a pressure relief pad. The foot can sometimes be very painful for the first three days if patients are walking on it. Sometimes crutches are necessary if there are multiple warts or if the wart is in a weightbearing area.

Upon performing surgical excision, topical medication lifts the epidermal layer and subsequent surgical debridement easily enables one to determine the depth of the excision needed. The stalk of the veruccae will be clearly visible and one should sharply debride the stalk down to the base. We recommend applying phenolic acid to the base of the wart after excision in order to kill any remaining microscopic cells of the benign skin neoplasm. Dressings should include an antibiotic ointment, a non-adherent dressing and gauze for padding. Typically, the post-op wound will heal in one to two weeks and the patient should be able to return to full activities two weeks after the initial treatment. We have found this treatment works well more than 75 percent of the time. In rare cases of recurrence, surgical excision with an elliptical biopsy is recommended.

In the past, we have attempted many other methods of treatment for plantar warts but these modalities proved to be less effective or caused other complications. Prior use of topical medications, including topical salicylic acid patches, fluorouracil (Efudex) ointment and others, revealed less than a 50 percent success rate and we found it often required numerous sharp debridements. The use of bleomycin injections has a high success rate in our hands but the medication is very expensive, has a short shelf life and the insurance companies often do not provide adequate reimbursement for this modality. In addition, the medication requires a painful injection and may require a second debridement with anesthesia to resolve the verrucae. We do not recommend bleomycin injections for children.

The use of CO₂ laser is very effective but often creates a large wound, which will take over one month to completely heal. The post-op wound is often painful and may limit weightbearing for more than three weeks. The laser also requires an anesthetic injection for excision and may result in painful scar tissue as the depth of the laser is sometimes difficult to control. In addition, the plume of smoke during debridement may be hazardous to the doctor, even when using a mask. This method is no longer recommended.

When Tinea Pedis Arises In Kids
Tinea pedis is the most common skin problem in children. Athlete’s foot often appears as interdigital, vesicular or in a moccasin distribution. There may be a scaling presentation, maceration or cracks in the spaces between the toes. Pruritus is the primary symptom although kids will frequently not tell their parents about it. Boys will often wear their shoes all day and if they exercise, they will walk around with wet socks, which contributes to the problem.

Treatment begins with changes in shoe gear and encouraging the child to use an antifungal powder or spray in the shoes daily. Topical treatment usually includes daily use of 2% naftifine gel (Naftin, Merz Pharmaceuticals), which dries quicker than creams, particularly between the toes. For rare severe cases in teenagers, oral terbinafine (Lamisil, Novartis Pharmaceuticals) 250 mg may be required daily for one to two months.

Resolving Pediatric Onychomycosis
Fungal toenails are not usually painful in children but are very upsetting to teenage girls and their parents. It is also common in boys who may not cut their toenails regularly or often wear wet socks due to sweating or exercise.

Topical treatments are often effective after mechanical debridement by a foot specialist. After debridement of the affected nails, once-a-day application with topical efinaconazole 10% (Jublia, Valeant Pharmaceuticals) solution or topical tavaborole (Kerydin, PharmaDerm) is often effective. The challenge with topical medications in children is adherence. Patients need to apply these medications daily for six to nine months until a new nail has grown.

In persistent cases in children 12 and over, we will prescribe oral terbinafine 250 mg daily for three months, which usually works well. It is our preference to use topical medications initially as they are often effective without side effects.

We do not use laser therapy for onychomycosis in our practice due to concerns of recurrence.

Recurrence of onychomycosis is always possible regardless of treatment. The weekly use of topical antifungal shoe sprays or antifungal powders is essential once the fungal toenail problem resolves.

How To Treat Crossover Toes
In childhood, curly toes are the most common toe problem. Children inherit this dominant trait and it most often involves the third or fourth toes. It is often a bilateral problem. There is a flexion deformity of the proximal interphalangeal joint with or without flexion of the distal interphalangeal joint. The toe often rotates laterally, goes into varus and may shift under the adjacent toe.

The deformity is usually flexible prior to the age of 12 and we can often treat it with pads and/or daily taping. Some studies have revealed a 25 percent spontaneous improvement with time.² We do not recommend a tenotomy of the affected tendons to the toes unless the toes are painful and if conservative care has not led to improvement after one year of treatment. If the deformity persists, the surgeon should repair the hammertoe in the same manner as he or she would for an adult once the bones have reached skeletal maturity between ages 14 and 16.

A Guide To Treating Hallux Valgus With Bunion Deformity
Adolescent bunions are far more common in females and are usually hereditary. Most children do not complain about pain related to the bunions but parents are often worried about the deformity progressing. Treatment should initially include wearing more supportive shoes, wider shoes and custom orthotics. Custom orthotics will help decrease stress on the first metatarsophalangeal and first metatarsocuneiform joints, and slow down the progression of the bunion deformity.³

If a bunion is painful in a child after conservative care, one should consider surgical repair. Soft tissue procedures and epiphyseal stapling have proven to us to be ineffective procedures over the years with temporary improvement only. In our opinion, surgical repair is ideal after skeletal maturity of the first metatarsal between the ages of 12 and 15. When a child is younger than 12, there is extensive ligamentous laxity and open growth plates, which increase the risk of recurrence. Over the years, we have seen a high recurrence rate with bunion procedures on patients under age 14. We always encourage parents to wait until the first metatarsal is fully mature, if possible, for a better long-term result.

Have New Advances In Custom Orthoses Reinvented Our Approach To Pediatric Flatfoot?
A flatfoot deformity may result in arch, ankle, knee, leg or back pain in the pediatric patient. The abnormal pronation affects the balance of the lower extremity and places abnormal stress on the body proximally. Several studies have reported that a permanent increase in arch height can occur both clinically and radiographically with the use of shoe modifications and orthotics.^4,5

In our practice, we have seen significant structural improvement to the arch clinically in more than 50 percent of children who receive custom orthotics prior to the age of 8 years old. In children older than 8 years of age with a flatfoot deformity, we may see a mild improvement in the shape of the foot but we can almost always resolve the symptoms related to the deformity, and minimize the progression of the deformity. New advances in custom orthotics with three-dimensional scanners, inverted techniques and the ability to change the shape of the orthotic device with the use of computers have changed the way we manage this problem in children. It is very rare that surgical repair is needed.

In the past, surgical reconstruction of flatfoot deformities was very common in the symptomatic foot. This may have included subtalar joint implants, calcaneal osteotomies and rearfoot fusions to help reconstruct the shape of the foot. Patients should utilize custom orthotics for at least six months prior to the physician considering surgical repair for the pediatric flatfoot unless the deformity is too severe and the foot will not fit on an orthotic device.

Pertinent Considerations With Intoed Gait
Parents often notice their child’s toes and legs turning in, and may notice that the child may be tripping more than other kids the same age or more than their siblings. When parents ask other doctors about the problem, a common response may be “they will grow out of it.” According to some studies, spontaneous resolution of intoed gait occurs more than 80 percent of the time.^6,7 Unfortunately, by the time children are 6 to 8 years old, if they still have intoed gait, it will be more challenging to correct and may lead to a permanent deformity.

There are many causes of intoed gait in children including fetal position in utero, metatarsus adductus, abnormal femoral torsion, abnormal tibial torsion, genu varum and abnormal pronation of the rearfoot.

It is important to consider closed kinetic chain internal rotation of the leg. This causes pronation of the rearfoot and midfoot, or external rotation of the foot on the leg.⁸ Individuals with unresolved internal femoral or tibial torsion generally function with their foot in a pronated position as long as the range of motion for such compensation is available.^9,10

When a child presents with abnormal intoed gait, we evaluate the child weightbearing as well as non-weightbearing. Intoed gait may often be more pronounced in gait or while the child is running. Our treatment plan consists of addressing the primary source of the intoed gait. The most common etiology is abnormal femoral torsion. Young children often sit on their feet or sit in a “W” position, which encourages the deformity. Advising the parents to encourage their children to sit with the legs forward or crossed in front of them will encourage a natural stretch to the abnormally tight hip musculature.
The use of supportive shoes and orthotics will also encourage the foot to stay balanced or supinate in gait, which will help prevent abnormal internal rotation of the leg. Most children do not walk in a normal heel to toe gait until the age of 4. Therefore, we do not recommend custom orthotics until 4 years of age. We often use prefabricated Kiddythotics (ProLab Orthotics) for children less than 4 years of age.

How To Address Pediatric Metatarsus Adductus
Pediatric metatarsus adductus is a congenital transverse plane deformity that occurs at the Lisfranc tarsometatarsal articulation. Clinically, the forepart of the foot is adducted. The incidence is three in 1,000.¹¹

The success of conservative treatment for this deformity depends on the patient’s age when treatment begins. If the deformity is flexible, we can often treat the deformity with conservative management. However, if the deformity is rigid, surgical repair is often required. When the child initially presents, we use the Crawford classification system.¹²

There are three types of metatarsus adductus.

Type 1. This type is very flexible and the forefoot will correct past neutral into a slightly overcorrected position. This does not require treatment unless the deformity persists past 2 years of age. When the child begins to walk, we will encourage the parents to have him or her use a shoe on the opposite foot. If the child is over 2 years old, we will use Bebax shoes nightly and readjust the settings as needed monthly for six to 12 months.

Type 2. In this type, there is partial flexibility and the deformity does not correct to neutral even with passive stretching. The use of shoes on the opposite foot and Bebax shoes nightly are necessary. Prior use of bars and braces has been less effective and our patients have not tolerated these as much as the Bebax shoes. In addition to Bebax shoes being less restraining, we can correct in the transverse and frontal planes if needed. We have also found that the old Denis Browne bars may contribute to rearfoot valgus so we do not use them anymore.

There are some patients in whom the deformity will improve with conservative care except for the hallux adductus. This is usually due to the tight abductor hallucis muscle, which may require an open surgical recession. It is rare that this is needed.

Type 3. This deformity is rigid and does not correct to neutral even with passive stretching.

If the child is less than 1 year of age, we will perform serial plaster casting for six to eight weeks. After two months, patients will use Bebax shoes for at least one year while sleeping. The Bebax shoes are essential after cast correction as recurrence after casting is reportedly as high as 30 percent.¹³

If the rigid deformity persists, one may need to consider surgical repair, which may include a medial soft tissue release of the adductor hallucis and the first metatarsocuneiform joint. Metatarsal base osteotomies are often needed for the rigid deformity. We recommend waiting until the child is at least 9 years of age to perform this procedure so the bones will be more skeletally mature.

Tackling Growth Plate Injuries
When a child walks into your office, the most common cause of limping is growth plate injuries. These injuries may be caused by trauma, overuse during sport activities or abnormal biomechanics.
Over the past three years, we have performed a study on growth plate injuries in children.¹⁴ The study included 80 patients with growth plate injuries of the foot and ankle. There were 51 patients with calcaneal apophysitis. Other common injuries included navicular epiphysitis, distal tibia epiphysitis, fifth metatarsal epiphysitis and distal metatarsal epiphysitis.

Treatment usually consists of gel heel pads for the calcaneal injuries, ice, oral anti-inflammatories and rest. If the patient is limping, then a controlled ankle motion (CAM) walker or cast immobilization is necessary for two to four weeks. If the patient has a resting calcaneal stance position with calcaneal eversion greater than 6 degrees, we recommend custom orthotics until skeletal maturity.

Dr. Feit is the President of Precision Foot and Ankle Centers. He is in private practice in Torrance and San Pedro, Calif.

Dr. Kashanian is in private practice in Los Angeles and Torrance, Calif.

References

1.     Murray WR, Bedi BS. The surgical management of ingrowing toenail. Br J Surg. 1975; 62(5):409-412.
2.     Turner PL. Strapping of curly toes in children. Aust NZ J Surg. 1987; 57(7):467-470.
3.     Coughlin M. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995;16(11):682-697.
4.     Bleck EE, Berzins UJ. Conservative management of pes valgus with plantar flexed talus, flexible. Clin Orthop. 1977; 122:85-94.
5.     Bordelon RL. Correction of hypermobile flatfoot in children by molded inserts. Foot Ankle. 1980; 1(3):143-150.
6.     Fabry G, McEwen GD, Shands AR Jr. Torsion of the femur: A follow up study in normal and abnormal conditions. J Bone Joint Surg. 1973; 55(8):1726-1738.
7.     LaGasse DJ, Staheli LT. The measurement of femoral anteversion: A comparison of the fluoroscopic and biplane roentgenographic methods of measurement. Clin Orthop Relat Res. 1972; 86: 13.
8.     Volpe RG. Evaluation and management of intoe gait in the neurologically intact child. Clinics Pod Med Surg. 1997; 14(1):57-85.
9.     Hutter CG, Scott W. Tibial torsion. J Bone Joint Surg. 1949; 31A(3):511-518.
10.     Sharrard WJ. Intoeing and flat feet. Br Med J. 1976; 1(6014):888-889.
11.     Wynne-Davies R. Family studies and the cause of congenital clubfoot. J Bone Joint Surg. 1954; 46B:445.
12.     Crawford AH, Gabriel KR. Foot and ankle problems. Orthop Clin N Am. 1987; 18(4):649-666.
13.     Bleck EE. Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatr Orthop. 1983;3(1):2-9.
14.     Feit E, Kashanian A. Treating overuse injuries in adolescent athletes. Podiatry Today. 2015; 28(1):35-38.

For further reading, see “Keys To Managing Common Pediatric Foot Fractures” in the June 2014 issue of Podiatry Today, “Treating Overuse Injuries In Adolescent Athletes” in the January 2015 issue, “Point-Counterpoint: Asymptomatic Pediatric Flatfoot: Should You Treat It?” in the December 2014 issue or “How To Address Pediatric Intoeing” in the January 2007 issue.

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