Orthotics and Paediatrics

Paediatric orthotics covers a huge range of disabled and able bodied children.

 

It can range from children with mild flat feet to children with a severe reduction in mobility.    Conditions Seen:   Flat feet/overpronation Cerebral Palsy Spina Bifida Down Syndrome Congenital Talipes Equinovarus (CTEV) or Club Feet

 

 

Flat Feet

 

To understand flat feet you must first understand the normal foot type. The normal foot has a normal sized arch: during gait the normal foot lands on the outside of the heel and then rolls inward slightly to absorb shock. It’s the foot that is most efficient during activities.  

 

 

Pronation is the normal inward rolling of the foot when the foot initial hits the floor during walking and is a natural shock absorbing process for the body. Flat feet or over Pronation is when the foot rolls inwards excessively and will cause the foot to flatten excessively, placing stress and pressure on the tissues and ligaments of the foot.  

 

 

The flexible flat foot is the most common seen in children. When weight bearing the foot and ankle tends to roll in (over pronates) too far. When the foot over pronates the foot rolls in and place the arches under increased strain. During the arch collapse the ligaments, tendons, joints and muscles of the foot are strained.  

 

 

When the foot is excessively pronating and causing problems like sore ankles, feet and knee when standing or exercising, it these cases arch supports are essential to restore the foot structure. During this arch collapse the ligaments, tendons, joint and muscles of the foot are strained under the excessive load. It is this repetitive stress place on the joints, soft tissue structure that over time can cause injury. Early signs of overpronation are muscle fatigue when walking or standing and tired aching legs. In young children some of the early signs of over pronation are not waning to walk and always wanting to be picked up and carried.  

 

 

• Cerebral Palsy

The term cerebral palsy refers to a group of motor disorders resulting in muscular in-coordination and loss of muscle control. Generally, Cerebral Palsy (CP) is described as an injury, which occurs to the brain before, during or after birth that cause physical or mental damage. The damage is done so by a lesion, in the cerebral or motor area of the brain, which inflects paralysis or weakness to certain limbs. The name Cerebral Palsy itself describes where and what affect a lesion does to a human. Cerebral is the motor section of the brain and palsy being short for paralysis or ‘loss of motion or sensation in a living part or member’.  

 

 

There are many physical (motor) disabilities that a CP child must deal with such as dislocated hips, scoliosis and contracture of muscles which is a constant tightening pull of the muscles, i.e. Achilles tendon, Hamstrings etc. These contractures can lead onto other deformities such as equinus feet, knee joint recurvatum (hyperextension) and flexion deformities among others. The severity of such deformities and whether they appear to affect the lower or upper limbs or both, depends on the type of cerebral palsy present.  

 

 

Apart from treating the physical impairments as an orthotist, as well as physical impairment, sensory and intellectual impairments may also be present. Hearing loss such as sensorineural hearing loss (damage to the cochlea (inner ear)) and conductive hearing loss (damage to the ottis medis (middle ear)) are quite common in cerebral palsy patients. Visual impairment is also a common occurrence in patients with CP, squinting and lack of visual perception being just two of many. Other such problems that are encountered would be constipation, gastroesophageal reflex (vomiting), difficulty with chewing, sucking and swallowing and bladder problems among others. Again these all depend on the severity of the lesion.  

 

 

Orthotic treatment is an essential part of cerebral palsy patients rehabilitation as 85% of patients are prescribed some sort of orthotic device. The main aim of treatment is to facilitate and encourage mobility with simultaneously attempting to prevent the progression of deformity.   

 

 

• Spina Bifida

Spina bifida is a Latin term meaning ‘split spine’. It is a name given to a group of birth defects, which interfere with the development of the central nervous system.  

 

 

The condition originates from the ectoderm (layer of cells from which the brain and spinal cord develop). The ectoderm originally resembles a flat group of cells running down the middle of the embryo. This flat sheet changes and folds to form a groove eventually coming together to form a tube from which the brain and spinal cord develops. This structure is called the neural tube and when formed it sinks into the embryo and is covered by a layer of skin. The closure of the neural tube occurs around the thirtieth day after fertilisation. The spinal vertebra then begins to form around the neural tube. If there is interference and the neural tube fails to close properly a neural tube defect will occur. These defects include Spina Bifida.  

 

 

There are two forms of Spina Bifida, myelomeningocele and meningocele. Myelomeningocele is the most common and most severe form of cystic Spina bifida and is seen in 80-90% of patients. This is were the abnormal spinal cord is exposed and is not properly developed. Due to this there is always some degree of paralysis and loss of sensation below the damaged vertebra. The damage depends on what level and amount of damage occurred, bowel and bladder problems often occur. 

 

 

Memingocele occurs in the remaining 10-20% of patients. In meningocele a sac has formed that contains the meninges and cerebro-spinal fluid. Development of the spinal cord may be affected but impairment is usually less severe than myelomeningocele. 

 

 

Spina Bifida Occulta is said to occur in 5-10% of the normal adult population. It is determined by the absence of one or more spinous processes radiologically. This is limited to the lumboscral region and the abnormality is covered by skin, which may show abnormal pigmentation, a hairy patch or dermal sinus. In most cases this condition is asymptomatic.  

 

 

• Down Syndrome

Down syndrome is a genetic disorder characterised by mental retardation, dysmorphic facial features and a host of structural abnormalities. It is so called after Dr. John Langdon Down, an English physician 1828-1896.  Down syndrome has an incidence of 1 per 600 live births (approx). It has a widely recognised characteristic appearance. The head may be smaller than normal, and abnormally shaped. Prominent facial features include a flattened nose, protruding tongue and almond shaped and upward slanting eyes. The hands are short and broad with short fingers and often have a single palmar crease. The feet are also short and wide demonstrating flat feet or over pronation when weight bearing.

 

 

Congenital heart defects and gastrointestinal abnormalities are relatively common and may require major surgery shortly after birth.

 

 

Foot wear and orthotics are often required due to the short and broad foot shape which can make footwear difficult to fit.

 

 

 

 

• Congenital Talipes Equinovarus (CTEV) or Club Feet

Congenital Talipes Equinovarus (CTEV) is a deformity that is recognisable at birth and is present in 1-1.5% out of 1000 live births. It is twice as common in males as females. The deformity can be mild or severe and can affect one or both feet, 50% cases affect both feet. In most cases CTEV is idiopathic, (disease/condition in which the cause is unknown that arises spontaneously). However, CTEV can occur from abnormalities in the womb during pregnancy, from drugs, inherited syndromes or genetic abnormalities. It may also be secondary to various neuropathies or myopathies.

 

 

The affected foot or feet will be obviously different as the structure of the foot and ankle is altered. The talus bone which joins the foot and ankle is an abnormal shape with CTEV and is spun towards the inner border of the foot, whereas it should point straight down. The large tibialis posterior tendon is usually very tight causing a pulling affect of the heel bone inwards.

 

 

In cases where CTEV is unilaterally (one foot), the CTEV foot is more than likely smaller by 2-3 sizes; therefore shoes of the same size cannot be worn. This difference remains throughout life. When CTEV is unilaterally, the affected leg can occasionally be shorter and the calf muscle is thinner compared to the non affected side.

 

 

The corrective treatment for CTEV is a method known as the Ponseti Method, which was developed in the 1950’s by Dr. Ignacio Ponseti. “Parents of infants born with clubfeet may be reassured that their baby, if otherwise normal, when treated by expert hands will have normal looking feet with normal function for all practical purposes. The well-treated clubfoot is no handicap and is fully compatible with a normal, active life” – Dr. Ponseti.

 

 

The principle of the treatment is of repeated stretching and plastering. Every week the baby’s feet are stretched, and that stretch is maintained throughout the week by plaster of Paris. During the course of that the week the tissues relax a little and that allows further stretch to occur the following week. Gradually the foot is brought round to a more normal position. This repeated process if done over a period of between 6 weeks to 3 months. Hopefully if everything goes well, the foot will be fully corrected, however surgery intervention is required in some cases. This correction than needs to be maintained this is done by placing the baby into what is called boots and bar. The boots and bar are worn full times for a further 3 months and following this then at night time and nap time until the child is 3 or 4 years old. It is impossible too over-stress the importance of wearing these boots and bar, even if at the beginning the baby does not like them. Without them relapse is almost certain.

 

 

 

 

As the child grows, footwear and ankle foot orthosis (AFO) may be required at different stages throughout the child’s development to maintain a good position until the child has reached skeletal maturity.