First Steps and Differential Diagnosis
For any orthopedic concern in a child, a systematic evaluation is essential:
- Detailed Anamnesis: Age, onset, duration, pattern (constant/intermittent, day/night), relieving/worsening factors, trauma, family history, developmental milestones.
- Complete Physical Examination:
- Observation of gait and posture.
- Inspection for symmetry, deformities, swelling, redness.
- Palpation for pain or masses.
- Assessment of joint range of motion (active and passive).
- Basic neurological evaluation.
- Consider the Physiological: Many orthopedic variations in children are part of normal development (e.g. flexible flatfoot, genu varus/physiological valgus, growing pains). Explaining this to parents is key.
- Search for Red Flags: Pay particular attention to warning signs that require immediate referral (see next section).
Attention! Red Flags
These signs and symptoms in any pediatric orthopedic condition require an URGENT referral to a specialist:
- Persistent, unilateral or progressive pain.
- Pain that wakes the child up at night and does not improve with common pain relievers.
- Pain associated with fever, weight loss, fatigue, night sweats.
- Severe or sudden limitation of joint movement.
- Joint swelling, redness or heat.
- Claudication or inability to bear weight.
- Acute or progressive deformity.
- Marked or new asymmetry.
- Neurological signs (weakness, numbness, changes in reflexes).
- History of high-energy trauma or suspected abuse.
1. Developmental Dysplasia of the Hip (DDH)
DDH is a developmental abnormality of the hip joint, which can range from capsular laxity to complete dislocation. Early detection is crucial for effective treatment.
Key Findings:
- Limitation of hip abduction.
- Asymmetry of skin folds (buttocks, thighs).
- Positive Ortolani and Barlow maneuvers (in neonates).
- Apparent shortening of the limb (Galeazzi sign).
- Claudication in children who walk.
When to refer to an orthopedist?
- Any clinical suspicion (Ortolani/Barlow +, abduction limitation).
- Abnormal hip ultrasound (in children under 4-6 months).
- Abnormal hip x-ray (in older than 4-6 months).
- Significant risk factors (family history, breech presentation, oligohydramnios) even with normal examination.
2. Congenital Clubfoot (PEVC)
Complex malformation of the foot involving equinus (plantar flexion), varus (inversion), forefoot adduct, and cavus. Requires early treatment to avoid functional deformities.
Key Findings:
- Foot turned inward and downward, which is not corrected with gentle manipulation.
- Small, raised heel.
- Deep skin folds on the inside of the foot and ankle.
- Rigidity.
When to refer to an orthopedist?
- All newborns with suspected true PEVC (not benign positional foot).
- As soon as possible, ideally in the first week of life, to start treatment with the Ponseti method.
3. Internal and External Tibial Torsion
They are rotations of the longitudinal axis of the tibia. Internal tibial torsion is a common cause of intoeing, while external tibial torsion is less common.
Key Findings:
- Internal: Feet pointing inward when walking, especially visible when running. Decreased thigh-foot angle (negative).
- External: Feet pointing outwards. Increased thigh-foot angle (positive).
- Generally bilateral and symmetrical.
- Asymptomatic in most cases.
When to refer to an orthopedist?
- Severe torsion that affects walking or causes frequent falls.
- Marked asymmetry between the extremities.
- Persistence beyond 8-10 years of age.
- Associated pain or functional limitation.
- Severe external torsion (less common to resolve spontaneously).
4. Genu Varus (Legs in O) and Genu Valgus (Legs in X)
They are physiological variations in the alignment of the legs that are normal at different stages of development. Genu varus is common in infants and genu valgus in preschoolers.
Key Findings:
- Genu Varo: The knees are apart when the ankles come together. Physiological until 18-24 months.
- Genu Valgus: The knees are brought together while the ankles are apart. Physiological between 2-5 years, with resolution around 7-8 years.
- Generally symmetrical and progress toward normal alignment.
- Not painful.
When to refer to an orthopedist?
- Marked asymmetry between the extremities.
- Associated pain or functional limitation.
- Progression of the deformity after the expected age of resolution.
- Persistent varus after 2 years or that gets worse.
- Persistent valgus after age 7-8 or worsening.
- Short height for age.
- History of rickets or other metabolic bone diseases.
5. Scoliosis
Lateral curvature of the spine, often with rotation of the vertebrae. The most common is adolescent idiopathic scoliosis.
Key Findings:
- Asymmetry in the height of the shoulders, scapulae or hips.
- Prominent ribs on one side when leaning forward (Adams test).
- Unbalanced trunk.
- Most of the time asymptomatic, not painful.
When to refer to an orthopedist?
- Any suspicion of structural scoliosis (positive Adams test).
- Progressive curvature.
- Associated back pain (especially in young children).
- Neurological signs.
- Curve > 10 degrees on x-ray.
- Early onset scoliosis (<10 years).
6. Congenital Muscular Torticollis (CMT)
Contracture of the sternocleidomastoid muscle that causes tilting of the head to one side and rotation to the opposite side.
Key Findings:
- Tilting the head towards the affected side and rotating the chin towards the opposite side.
- Palpable nodule or thickening in the sternocleidomastoid (not always present).
- Facial asymmetry or associated plagiocephaly.
- Limited range of motion of the neck.
When to refer to an orthopedist?
- Lack of response to conservative physiotherapy after 3-6 months.
- Severe contracture or significant stiffness.
- Significant facial asymmetry or severe plagiocephaly.
- TMC that persists beyond one year of age.
- Suspected other causes of torticollis (neurological, bone).
7. Common Fractures in Children (General)
Children have more elastic bones and thicker periosteum, resulting in unique fracture patterns. The remodeling capacity is high, but physeal fractures require special attention.
Key Findings:
- Pain, swelling, deformity, functional impotence after trauma.
- Sensitivity to palpation.
- Crepitation (not always present, avoid looking for it).
- In young or non-verbal children, irritability, non-use of the limb.
When to refer to an orthopedist?
- Any fracture with significant displacement or unacceptable angulation.
- Fractures involving the physis (growth plate) - Salter-Harris Classification.
- Intra-articular fractures.
- Open fractures (require urgent attention).
- Stress fractures (suspected excessive activity or inadequate nutrition).
- Suspected child abuse.
- Fractures of the spine or pelvis.
- Fractures of the femur or tibia in neonates/infants (high risk of abuse).
- Any fracture that the pediatrician is not comfortable managing or immobilizing properly.
8. Flexible Flat Foot
It is the absence or flattening of the medial longitudinal arch of the foot, which is corrected by standing on tiptoe or by placing weight on the heel. It is physiological in early childhood.
Key Findings:
- Absent or flattened medial arch when standing with weight.
- Normal appearance of the arch when not carrying weight or when performing the "Jack" maneuver (passive extension of the big toe).
- Generally bilateral and asymptomatic.
- Heel valgus (deviated outwards).
Initial Management by the Pediatrician:
- Observation and reassurance to parents if asymptomatic and flexible.
- Encourage activities that strengthen the muscles of the foot (walking barefoot, picking up objects with your fingers).
- The routine use of corrective insoles is not recommended.
When to refer to an orthopedist?
- Persistent pain in the foot or calf associated with flat feet.
- Stiffness of the foot or lack of arch flexibility (suspected rigid flatfoot).
- Marked asymmetry between both feet.
- Deformity that is progressive or worsens with age.
- Limitation of physical activities.
- History of family history of symptomatic or rigid flat feet.
9. Growing pain
Growing pain is a benign, intermittent and recurring pain that affects the lower extremities, common in children between 3 and 12 years of age. It is characterized by not being associated with any underlying pathology.
Key Findings:
- Bilateral and recurrent pain, predominantly nocturnal or evening.
- It affects the thighs, calves or behind the knees.
- There is no joint pain, swelling, redness or limitation of movement.
- Soothe with massage, heat or simple pain relievers (paracetamol, ibuprofen).
- The child is asymptomatic during the day.
- Completely normal physical examination between episodes.
Initial Management by the Pediatrician:
- Reassure parents about the benign nature of the pain.
- Gentle massages in the affected area.
- Local heat application.
- Administration of common analgesics (paracetamol, ibuprofen) as needed.
When to refer to an orthopedist?
- Unilateral or localized pain in a joint.
- Pain that interrupts daytime activities or play.
- Pain associated with fever, weight loss, fatigue, skin rashes.
- Pain that does not improve with common pain relievers.
- Presence of swelling, redness, heat or limitation of movement in a joint.
- Claudication or weakness.
- History of trauma.
- Abnormalities on physical examination.
10. Osgood-Schlatter disease
It is an osteochondritis of the anterior tibial tuberosity, caused by repetitive traction of the patellar tendon at the site of bone insertion during periods of rapid growth and activity.
Key Findings:
- Localized pain in the tibial tuberosity (just below the knee).
- It increases with activity (running, jumping, climbing stairs) and decreases with rest.
- Swelling and tenderness on palpation in the tibial tuberosity.
- A palpable lump in the area.
- More common in active children and adolescents, between 8 and 15 years old, especially males.
- It is usually unilateral, but can be bilateral.
When to refer to an orthopedist?
- Very intense or persistent pain that does not improve with rest and conservative management.
- Inability to carry out regular sports activities.
- Warning signs such as fever, significant redness, severe limitation of knee movement.
- Diagnostic doubt or suspicion of other pathologies (tumors, infections, fractures).
- Persistence of symptoms after the growth peak has ended.