Pediatricians and family practitioners often have to make judgments concerning actual or presumed problems of the feet and legs in infants and children. The frequency and natural history of these problems is such that referral to orthopedic consultants is not always appropriate. In most instances the problems presented require no treatment, others can be managed easily without consultations, and only a few require the services of an orthopedist.

The ped in pediatrics and orthopedics is derived from the Greek word paidios, meaning child, not from the Latin pedalis or French ped, meaning foot. Therefore pediatrics is the medicine (Greek iatrike) of the child, and orthopedics is the straightening or correction (Greek orthos) of deformities in children. Orthopedics has expanded its scope well beyond this initial thrust; nevertheless the orthopedist and the pediatrician are concerned with many problems involving the feet and legs of children.

Practitioners use certain terms to describe positional variations of the lower extremities and are often used in the nomenclature of specific orthopedic conditions.

In general, the joint that is primarily involved in the condition constitutes the first word; the subsequent word or words relate to the positioning of the extremity relative to the midline of the body. For example, coxa vara is a condition of the hip (coxa) that results in a deviation of the leg toward the midline (varus position). The orthopedic terms in BOX 183-1 have special reference to abnormalities of the feet and legs.

• Abduction: deviation away from the midline of the body
• Adduction: deviation toward the midline of the body
• Calcaneus: foot dorsiflexed, placing the heel below the level of the toes
• Cavus: medial longitudinal arch of the foot elevated
• Equinus: foot plantar flexed, placing the toes below the level of the heel
• Pes: the foot
• Planus: medial longitudinal arch of the foot flattened
• Talipes: congenital deformities of the foot that, if untreated, result in walking on the ankle (talus)
• Torsion: excessive or abnormal twisting along the long axis
  • Internal torsion: excessive or abnormal inward twisting
  • External torsion: excessive or abnormal outward twisting
• Varus: medial or inward deviation of one segment of an extremity relative to the proximal (previous) segment
• Valgus: lateral or outward deviation of one segment of an extremity relative to the proximal (previous) segment
• Version: physiologic or normal twisting along the long axis
  • Inversion: physiologic or normal twist inward
  • Eversion: physiologic or normal twist outward
  • Anteversion: physiologic or normal twist forward
  • Retroversion: physiologic or normal twist backward

The foot takes the shape of the shoe, not vice versa. Improperly fitted or manufactured shoes may be the primary cause of acquired foot deformities and problems. Shoes that do not fit properly can deform an otherwise-normal foot, resulting in hammertoes, hallux valgus, bunionettes, corns, and, ultimately, the need for surgery.

Parents often ask the physician when their child should begin wearing shoes and what kind of shoe should be worn. In answering these questions, the reasons for wearing shoes must be borne in mind. The shoe has two functions, the most important of which is protecting the feet from trauma and extreme temperatures. Protection implies comfort; therefore the shoe must fit properly to prevent discomfort to the foot. The 2nd function of the shoe is to provide style. Older children will often sacrifice comfort for style despite parental or medical advice to the contrary.

Support to the foot and ankle is not a function of the shoe except when a pathological condition is present. Athletes in all sports that place the feet and ankles under severe strain wear low shoes that have soft uppers. Ski boots are worn not to support the foot and ankle but to make them one with the ski, to ensure response to movements originating in the knee and lower leg. Babies and toddlers usually wear ankle-high shoes, not to provide support to the foot and ankle but to make removing the shoes more difficult for the child.

Style is the only reason for a baby to wear shoes at all until the child begins walking outdoors or is taken out in cold weather. Some babies may gain a certain degree of stability from hard-sole shoes when beginning to stand, but this circumstance has not been shown to enhance learning to walk. In fact, shoes that are rigid prevent foot motion and may diminish the development of the intrinsic musculature of the feet. Properly fitting shoes that have flexible, smooth soles and soft uppers should be recommended initially and subsequently. They need not be expensive. Toddlers can go barefoot in a protected environment, such as indoors. Sneakers are perfectly adequate for summer wear and for winter indoor wear for older children, but toddlers may stumble in sneakers, which can stick to the floor during the stance and step-off phases of the toe-to-heel gait that typifies this age group.[1] [2]

Determining the proper fitting of shoes involves no great science. Given that the foot widens while standing and through the day, these measurements should be made later in the day, with the child standing, and should apply only to the time the shoes are newly acquired. Both feet should be measured, given that one foot is often larger than the other, and the shoes should be fitted to the larger foot. The counter should hug the heel snugly; the length should allow a fingerbreadth (½ inch) between the tip of the great toe and the toe box. (BOX 183-2 describes the parts of the shoe.) The foot should fit snugly into the widest part of the shoe; but the width should not crowd the ball of the foot and should allow the toes to extend without wrinkling the upper. While still in the store, parents should have the child walk in the shoes to ensure comfort. The shoes should not be expected to stretch to fit. If shoes do not fit, then they should not be purchased. Shoes in good condition can be handed down from one child to another.

The frequency with which shoes should be changed depends on the rate of growth of the feet, the quality of the shoes, and the degree of their use. Parents are usually able to tell when shoes become too small (or rather, feet become too large) without professional advice. The toes will be felt to press against the toe box, and getting the shoes on or having the child keep them on will be increasingly difficult.

Lightweight cotton, nylon, or wool socks that adjust to the length and width of the foot present no problem in the attainment of maximal foot comfort for children of all ages.

• Last: the wooden or metal form on which a shoe is constructed. Shoes for regular use are built on a straight last; shoes designed to deviate the forefoot outward are built on an out-flare last; those designed to deviate the forefoot inward are built on an in-flare last. Actually, most shoes sold for general use in the United States have an adducted forefoot last rather than a truly straight last.
• Sole: the part of the shoe that covers the ventral surface of the foot. It consists of the outsole, usually made of firm leather, rubber, or synthetic material that comes in contact with the surface on which the shoe is placed and the insole, made of soft leather or synthetic material that comes in contact with the plantar surface of the foot.
• Heel: elevates the rear portion of the shoe. It is also made of leather, rubber, or synthetic material. It is usually absent in the shoes of infants and toddlers. The heel may be low and flat (common sense), somewhat higher (military), or more elevated and tapered (Cuban or high). The Thomas heel is of medium height and has a forward medial extension.
• Shank: the part of the sole between the forward most edge of the heel and ball of the foot. A narrow flat piece of steel is sometimes placed between the inner and outer soles to prevent flexion of the shank of the shoe.
• Counter: firm material placed above the heel between the outsole and insole and provides a shelf for the rear portion of the foot. It may be extended forward on the medial aspect of the shoe to provide added support to the instep.
• Upper: the top of the shoe. It may be made of leather or a variety of other materials. The upper of low shoes (Oxfords) rises to a point below the malleoli; the upper of high shoes extends above the malleoli.
• Toe box: the front end of the upper that accommodates the toes. It is often made of a firm material to also protect the toes.
• Welt (or vamp): the part of the upper attached to the sole.

Physicians who provide primary care for children from birth through adolescence encounter a variety of positional deformities of the legs and feet. The distinction between a pathological and functional cause must be made. The former should be referred to an orthopedist for treatment. When a pathological deformity of the legs or feet is diagnosed, the physician should look for other congenital anomalies, especially those involving the skeletal system.

The lower extremity rotates medially during the 7th fetal week, bringing the great toe to midline. With growth, femoral anteversion gradually declines from 30 degrees at birth to 10 degrees at maturity, leading to lateral rotation of the lower extremity during growth (Figure 183-1). Most functional deformities of the legs and feet are self-correcting in time, through this normal developmental progression of the lower extremity, even without treatment. This characteristic must be considered in weighing the results of any treatment prescribed. Studies of functional deformities, analyzing treated versus untreated paired control patients, have demonstrated the relative ineffectiveness of various treatments for these conditions, when analyzing treated versus untreated paired control patients. Therefore most clinicians choose to observe these conditions while children grow out of them.[3] [4] [5]

Figure 183-1 Positional deformities of the foot and ankle. A, Varus. B, Valgus. C, Equinus. D, Calcaneus. (Tachdjian MO. Pediatric Orthopaedics. Philadelphia, PA: WB Saunders; 1977. Copyright © 1977, Elsevier, with permission.)

Hallux valgus is a common problem. In a child with hallux valgus (Figure 183-2), the great toe is deviated laterally to overlap the second toe, and the first metatarsal bone is deviated medially, causing a prominence to form on the medial aspect of the metatarsophalangeal (MTP) joint. A bursa forms over the area as a result of the constant irritation and inflammation, forming a painful bunion. Some degree of foot pronation (flat feet) associated with the condition may be found.

Many factors come into play to cause the problem, including foot structure, which may or may not be hereditary, and use of narrow stylized shoes that crimp the toes. Most cases of hallux valgus are mild and asymptomatic and do not need treatment. Patients should be counseled in wearing shoes with plenty of toe room and no heels. If flatfoot is present, then a shoe insert to correct the foot pronation may help prevent progression of the disease. In the more severe cases, surgical correction may be needed.

Figure 183-2 Common toe anomalies.

Hammertoe occurs at the proximal interphalangeal joint (PIP) (see Figure 183-2). In an infant, hammertoe is usually hereditary; in the older child, it usually results from faulty shoe wear. Most cases of hammertoe are mild, cause no pain, and can be left alone. Parents should make sure that the child has roomy shoes that allow the toes to stretch. In the more severe cases, at an older age, surgical correction may be needed.

Mallet toe occurs at the distal interphalangeal joint (DIP) (see Figure 183-2). Most cases of mallet toe are mild and need no treatment. When a corn develops over the deformity, shaving and padding will help. In the more severe cases, surgical correction can be performed.

Claw toe involves all joints of the toe—hyperextension of the MTP joints and flexion at both the PIP and DIP joints (see Figure 183-2). Claw toe is a rare condition but usually occurs in conjunction with a cavus foot, present in neuromuscular diseases such as Charcot-Marie-Tooth disease or myelomeningocele.

In a child with a curly toe 4th or 5th toe is usually flexed downward and twisted underneath the adjacent toe (see Figure 183-2). Curly toe is quite common in infancy and childhood. If curly toe does not cause symptoms, then no treatment is needed; if the condition is severe and causes irritation with shoe wear, then surgical transfer of the toe flexor may correct the problem.

Polydactyly, the presence of an extra digit, usually the great toe or 5th toe (see Figure 183-2), may exist as an isolated finding or as part of a more extensive syndrome of congenital anomalies (5% of cases). The family history of the same anomaly is often found. If the extra toe is not causing problems with walking and shoe wear, then no treatment is needed. Vestigial digits can be ablated by suture ligation. If the duplication occurs in the little or big toe and sticks out prominently, then difficulty with shoe wear is common. In these cases, surgical excision will remove the problem. Surgery is typically performed after 9 to 12 months of age.

Syndactyly, the presence of webbed digits (toes) (see Figure 183-2), may also exist as an isolated finding or as part of a more extensive syndrome of congenital anomalies (5% of cases). A family history of the same anomaly is often found. Syndactyly is quite common and rarely causes problems. The interconnection between two or more toes can vary from thin skin to a bony attachment (synostosis) between parts of the phalanges. Unlike in the fingers, in which surgical separation is needed to obtain finer hand functions, syndactyly in the toes does not need treatment. The growth differential between the involved toes tends not to be significant.

Whereas a bunion forms on the great toe, the less common bunionette occurs at the fifth MTP joint. When a bunionette develops, the bursa over the lateral aspect of the fifth MTP joint gets prominent and inflamed and painful. If padding does not help relieve the discomfort of a bunionette, then surgical correction is needed.

Clubfoot is a pathological deformity that causes the leg and its appended foot to resemble a clubbing instrument. Two varieties of clubfoot have been identified. The more severe talipes equinovarus is a condition in which the heel and forefoot are inverted, the forefoot is adducted, and the entire foot is plantar flexed. Figure 183-3 shows bilateral clubfoot in a newborn; Figure 183-4 shows an untreated right clubfoot. Talipes calcaneovalgus is characterized by eversion of the heel and forefoot, abduction of the forefoot, and dorsiflexion of the entire foot (Figure 183-5). Both forms occur in approximately 1 of every 200 live births, are bilateral in 50% of the cases, and affect boys almost twice as frequently as girls.

In the newborn period, functional deformities of the feet secondary to in utero positioning will often mimic both varieties of clubfoot. These functional deformities can be differentiated readily from clubfoot based on flexibility of the foot. The functionally deformed foot can be brought easily to a neutral position and even overcorrected, which is not possible when pathological deformities are present.

Figure 183-3 Bilateral talipes equinovarus in a newborn. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-4 Untreated talipes equinovarus in a 3-year-old child. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-5 Bilateral talipes calcaneovalgus. The left foot is held dorsiflexed and the right plantar flexed to show the range of ankle movement. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Although many theories have been offered about the etiology of clubfoot, none has been proved. Most cases are idiopathic and occur in an otherwise-normal infant. If a family has a child with clubfoot, then the incidence in subsequent siblings is 3% to 4%. If 1 parent and a child have clubfoot, then subsequent children have a 25% chance of having clubfoot.

Clubfoot is characterized by 4 distinct components: (1) plantar flexion (equinus) of the ankle, (2) adduction (varus) of the heel (hindfoot), (3) high arch (cavus) at the midfoot, and (4) adduction of the forefoot.

When clubfoot is present, associated neurologic, muscular, or other skeletal anomalies should be sought. Neuromuscular clubfoot is a deformity associated with disorders such as arthrogryposis, meningomyelocele, and congenital constriction band syndrome.

Radiographic examination is required at the time of diagnosis and periodically during treatment to delineate the pathological finding and to guide management.

Treatment is with casting immediately on initial diagnosis; 2 to 4 months of manipulation and casting is usually required for correction. Recurrence is common after correction by manipulation alone; therefore prolonged casting is usually required. Recurrence after casting is most common within the first 2 to 3 years but may still happen up to age 5 to 7 years. Surgical correction (tenotomies, muscle transplants, and arthrodeses) may be required in severe cases, when conservative management fails or as a result of recurrence when the child is older. Recurrence is much less likely after surgical correction. Even with successful treatment the affected foot will be smaller and less mobile than a normal foot. Early initiation of therapy will increase the success rate of manipulative or conservative management and will therefore decrease the need for surgical intervention. Functional deformities are self-correcting and require no treatment.

Much confusion surrounds the incidence and management of deformities of the forefoot because 3 different deformities are characterized by adduction of the forefoot: talipes varus (Figure 183-6), in which the entire foot is inverted and the forefoot is adducted; metatarsus varus (Figure 183-7), in which the forefoot is inverted and adducted while the hind foot and heel are in the normal position; and metatarsus adductus (Figure 183-8), in which the only finding is adduction of the metatarsals at the tarsometatarsal joints. The combined incidence of these 3 forefoot adductive deformities is in the neighborhood of 1 per 100 live births (the most frequent musculoskeletal congenital malformation), with metatarsus adductus being the most common and talipes varus the least common.

Talipes varus and metatarsus varus have been considered lesser degrees of clubfoot and are fixed deformities of the foot that require early treatment. The medial border of the foot is concave, with a widening of the space between the 1st and 2nd toes and a high medial longitudinal arch. The lateral border of the foot is convex, and the base of the 5th metatarsal bone is prominent.

Figure 183-6 Bilateral talipes varus. The entire foot is twisted inward on its longitudinal axis, and the forefoot is adducted. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-7 Bilateral metatarsus varus. The forefoot is inverted and adducted, the great toe is widely separated from the second toe, and the lateral border of the foot is convex. The hindfoot is in a neutral position. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-8 Metatarsus adductus. The forefoot is adducted but not inverted. (Ferguson AB. Orthopedic Surgery in Infancy and Childhood. 4th ed. Baltimore, MD: Williams & Wilkins; 1981. Reprinted by permission of Lippincott Williams & Wilkins.)

Metatarsus adductus can be associated with hip dysplasia (2% of cases); therefore a thorough hip evaluation is essential. A history of a crowded intrauterine environment, such as uterine fibroids, bicornate uterus, multiple gestation or oligohydramnios is often associated with metatarsus adductus.

The severity of metatarsus adductus may be graded by the heel bisector method. Normally, a line bisecting the heel falls between the 2nd and 3rd toes. The metatarsus adductus is considered mild if line falls through the 3rd toe, moderate if between the 3rd and the 4th toes, and severe if between the 4th and 5th toes. Flexibility of the forefoot should be assessed. A flexible foot might be defined as one in which the 2nd toe can be easily brought in line with or past the heel bisector.

In babies with limited flexibility of the forefoot, radiographic examination is necessary to rule out talipes varus and metatarsus varus.

When evaluating metatarsus adductus in the primary care physician's office, placing the child in a standing position on a copy machine and taking a photocopy of the soles of the feet is an easy way to assess the heel bisector position. Although it is somewhat subjective, this low-cost, no-risk method allows for tracking of the progression or improvement of the condition over time.

Metatarsus adductus is a functional deformity and requires no treatment because it corrects spontaneously, usually during the first year. Talipes varus and metatarsus varus are fixed deformities of the foot that require early treatment. Treatment consists of serial casting, long-leg splints that abduct the forefoot, or both. Abduction stretching exercises and out-flare last shoes may be used as an adjunct to cast treatment but should not be relied on as the only therapy. Primary care physicians see metatarsus adductus frequently and observe its resolution without treatment, whereas orthopedists are more likely to see talipes varus and metatarsus varus through referrals, sometimes unfortunately in late infancy when treatment results are less satisfactory.

Pronation is an outward rolling of the foot with eversion of the heel and eversion and abduction of the forefoot. Flexible foot, relaxed foot, fatfoot, and flatfoot (pes planus) are other terms used to describe this condition, leading to considerable confusion.

Certain congenital anomalies involving the bones of the foot produce flattening of the medial longitudinal arch and eversion of the forefoot (planovalgus). These anomalies include vertical talus, accessory tarsonavicular, and fusion of one or more of the tarsal bones (tarsal coalition).

Accessory tarsonavicular is a normal anatomic variant. A secondary center of ossification forms in the medial portion of the tarsonavicular at the attachment of the posterior tibialis tendon. This ossification becomes more prominent and symptomatic during adolescence, either from its size or from repetitive sprains of the fibrous attachment of the ossicle to the navicular. Tarsal conditions are not usually detected until late childhood or adolescence, when they produce pain with walking and inability to invert the foot. Two types of tarsal coalitions have been identified: (1) calcaneonavicular coalition, which involves the calcaneus and the navicular bones; and (2) talocalcaneal coalition, in which the calcaneus is coalesced to the talus.

Almost all children develop some degree of pronation during the early stages of weight bearing. Most infants have flexible flatfeet. Typically, the condition is transient, resolving with normal growth and development in 97% of children, usually before 2½ years of age. A family history may be found in children with flat foot that persists beyond the usual time of physiological resolution.

Symptoms, including aching of the feet and legs, muscle cramps in the calves at night, easy fatigability, and reluctance to participate in strenuous activity, are uncommon but may occur. Symptoms result from the strain caused by the child's continual attempt to shift weight bearing laterally toward the center of the foot, bringing about some degree of toeing-in. Persistent pronation without symptoms occurs in some children who may have a family history of pronation and often demonstrates ligamentous laxity or hyperextensibility of other joints, including the knees, elbows, wrists, and thumbs.

The incidence of pes planovalgus is unknown. Vertical talus is very rare. Accessory tarsonavicular is fairly common; 14% of adolescents experience symptoms according to 1 study. Tarsal coalitions are bilateral in 50% of patients, probably occur in 1% of the population, and are usually hereditary. They may be found in other family members who are asymptomatic but have no hindfoot motion.[6]

The Achilles tendon is seen to curve inward, and the medial longitudinal arch of the foot, observed without weight bearing, disappears on standing. These changes occur because a wide-based stance is assumed for balance (accentuated by bulky diapers), causing the weight to be borne on the medial aspect of the feet (Figure 183-9). Laxity of the ligaments supporting the feet contributes to pronation. When symptoms do occur, the clinician should look for associated conditions, such as obesity, neuromuscular disorders, and structural abnormalities above the level of the ankle.

Vertical talus and accessory tarsonavicular can usually be detected in the newborn by the presence of a bony prominence on the medial and plantar aspects of the foot, with limitation of plantar flexion and inversion of the forefoot.

Tarsal coalitions are not usually detected until late childhood or adolescence, when the initially fibrous or cartilaginous bar connecting the hindfoot bones becomes ossified, producing pain with walking and an inability to invert the foot. The foot is held in a pronated position with eversion of the forefoot. The peroneal tendons stand out prominently when attempts are made to invert the foot. Calcaneonavicular coalition tends to develop between 9 and 13 years of age, whereas talocalcaneal coalition develops later, typically 13 to 16 years of age. The foot is held in a pronated position, with eversion of the forefoot. This condition, commonly called spastic flatfoot, is not related etiologically to simple pronation.

Figure 183-9 Pronation. A, Viewed from behind, the hindfoot is everted. B, Viewed from in front, the forefoot is everted and abducted. (Sharrard WJW. Paediatric Orthopaedics and Factures, 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Flexible flatfoot (pes planus) does not require any imaging in most cases. If pronation is persistent beyond 2½ years of age, if symptoms are present, if flexibility is limited, or if a suspicion of planovalgus exists, then radiographic examination may be necessary.

Pronation is transient in most children, usually disappears before 2½ years of age, and requires no treatment. In children in whom it persists, treatment is not necessary unless symptoms occur. Most cases of physiologic, flexible pes planus only require parental reassurance.

When symptoms do occur, they may be alleviated by use of corrective shoes that have a long medial counter and a Thomas heel. Support to the medial longitudinal arch with a flexible felt, rubber, or leather pad placed beneath the inner sole may help. Wedges that are ⅛- to 3/16-inch thick applied to the medial aspect of the heel and the lateral aspect of the sole of the shoe are sometimes helpful. Steel arch supports placed within the shoe rarely are required. If neuromuscular disorders (eg, tight heel cords) are present, then heel cord–stretching exercises may be beneficial in reducing discomfort.

Treatment in most cases of pes planovalgus is symptomatic with orthopedic shoes. Surgical correction is required only for accessory tarsonavicular or tarsal coalition if symptoms cannot be relieved through conservative means (only approximately 10% of cases) and is usually performed in adulthood. Vertical talus usually requires surgical correction early in infancy.[7]

Pes cavus (cavus foot deformity) is an equinus deformity of the forefoot relative to the hindfoot, producing a high medial longitudinal arch (Figure 183-10). It is referred to as clawfoot when associated with flexion deformities of the toes.

Figure 183-10 Pes cavus, viewed from the outer side. The height of the medial and lateral longitudinal arch is abnormal. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Pes cavus is seen in muscular dystrophy, peripheral neuropathies, and disease of the spinal cord, brainstem, and cerebral cortex. Cerebral palsy, meningomyelocele, poliomyelitis, Charcot-Marie-Tooth disease, and Friedreich ataxia are examples of conditions of neurologic origin that produce pes cavus as a late manifestation. Because of the variety of conditions in which pes cavus is seen and its variability as a manifestation of some of these, incidence in the general population is not known. A family history of pes cavus should be sought because many of the conditions producing this deformity are inherited.[8]

The primary pathological condition is neuromuscular rather than bony, with weakness or paralysis of the intrinsic muscles of the foot and its dorsiflexors, leading to the deformity over time. Pes cavus is therefore not seen at birth and usually does not develop clinically until late childhood or adulthood, depending on the underlying neuromuscular disease. A high-arched foot characterizes the deformity. Pes cavus takes one of two forms: (1) cavovarus, in which the calcaneus is inverted with tightness of the heel cord; and (2) calcaneocavus, in which a high arch with normal heel alignment is present, usually from weakness of the calf muscles resulting in increased ankle dorsiflexion and increased plantar flexion of the forefoot.

Radiographic examination may be necessary, especially if surgical management is under consideration.

Early treatment includes exercises designed to strengthen the affected muscles and application of metatarsal pads to the innersoles of the shoes or metatarsal bars to the outer soles. Surgical correction of the fixed deformities, including plantar fasciotomy, tendon transplants, osteotomies, and arthrodeses, may be required later.

Walking on the toes or the ball of the foot is a variation of normal gait for many children between 10 to 18 months of age as they begin to walk. This variation usually progresses to a toe-heel gait and eventually to the normal heel-toe gait pattern within 3 to 6 months.[9]

Some children, when asked to walk normally, can simply put their heel down on the ground before their toes. However, as soon as no one is observing them, they revert to toe-walking because it is habitual (idiopathic toe-walking). Cerebral palsy is commonly associated with toe-walking that persists beyond 2 years of age. A congenitally short tendocalcaneus causes persistent toe-walking even though the child can toe-heel and heel-toe walk. These latter gaits are awkward and are less comfortable for children until 6 to 8 years of age, when their toe-walking disappears.

Children with idiopathic or habitual toe-walking have a history of normal development. A family history of persistent toe-walking may be found. As with pes cavus, certain rare muscular, peripheral, spinal, and central neurologic diseases should be ruled out when toe-walking persists beyond 2 years of age.

Children with idiopathic or habitual toe-walking have a normal examination. A thorough neurologic examination is required to rule out cerebral palsy or other associated neuromusculature system disorders.

Radiographic examination is not indicated in most cases of toe-walking. Neuroimaging is necessary if the toe-walking is acquired (develops after a period of normal gait) to rule out intracranial lesions.

The only treatment required for either idiopathic or habitual toe-walking is reassurance.

However, in the child who continues to toe-walk beyond 2 years of age, a dorsiflexion-assist ankle-foot orthosis may be of benefit.[9] [10] [11]

Genu varum (bowed legs) is an angular deformity at the knee with the tibia adducted (varus) in relation to the femur. Genu valgum (knock-knees) is characterized by alignment of the knee with the tibia abducted (valgus) in relation to the femur.

Genu varum (bowed legs), when extreme or unilateral, may result from a variety of underlying conditions: rickets, dyschondroplasia, osteogenesis imperfecta, osteochondritis, Blount disease (tibia vara), or injury to the medial proximal epiphysis of the tibia. Extreme degrees of physiologic bowing of the legs may occur in the young child and resolve over time without treatment (Figure 183-11).

Genu valgum (knock-knees) is often associated with pronation and is more apt to be marked in the child who is overweight. The degrees of knock-knee can be gauged by measuring the distance between the medial malleoli when the child is standing with the knees approximated (Figure 183-12). Injury to the lateral proximal tibial epiphysis can cause unilateral genu valgum (Figure 183-13). As with extreme bowing, underlying generalized diseases of the bone can cause marked bilateral genu valgum.

Figure 183-11 A, Extreme physiological bowing of the legs at age 18 months. B, Spontaneous resolution over time (age 7 years). (Sharrard WJW. Paediatric Orthopaedics and Fractures. Oxford, NY: Blackwell Scientific; 1971. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-12 Marked degree of physiological genu valgum. At age 11 years the distance between the medial malleoli measured 4 inches. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-13 Unilateral genu valgum caused by previous injury to the lateral aspect of the right proximal tibial epiphysis. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

A history of uterine crowding during fetal development can be associated with extreme cases of genu varum or genu valgum. Prior trauma or a variety of endocrine, metabolic, or bone abnormalities may result in pathological degrees of bowing or knock-knees.

From birth until 18 months of age, a distinct physiological bowing of the lower extremities of 10 to 15 degrees is normal. Bowing is followed by a transitional period over the next year or so, during which continued growth results in a knock-knee pattern of 10 to 15 degrees, which assumes prominence by age 3 to 4 years. Knock-knee persists until later childhood or early adolescence when a balancing and straightening occur spontaneously. Physicians must be aware of this normal developmental pattern to avoid unnecessary treatment of mild to moderate degrees of bowed legs and knock-knees. However, marked degrees of these conditions require investigation to rule out underlying disease that can result in permanent deformity.

Genu varum (bowed legs), when extreme or unilateral, requires radiographic examination to exclude rickets, dyschondroplasia, osteogenesis imperfecta, osteochondritis, Blount disease (tibia vara), or injury to the medial proximal epiphysis of the tibia.

Simple observation and reassurance are all that are required for physiological genu varum and genu valgum, given that these conditions spontaneously correct 99% of the time. When identified, underlying etiologies of extreme varus or valgum deformities must be effectively treated to improve angulation. Treatment of severe bowing or knocking of the knees caused by underlying disease is determined by the nature of the condition and may include wedge osteotomy or epiphyseal stapling.

In-toeing (pigeon toe) is a condition in which the foot turns inward more than expected during walking or running relative to the line of progression. Out-toeing (slew foot) occurs when the foot turns outward more than expected during walking or running relative to the line of progression.

Toeing-in and toeing-out are frequently seen at all ages and are caused by a variety of conditions affecting the feet, ankles, legs, knees, and hips. In-toeing is more common than out-toeing and is more likely to be caused by benign conditions. Protective or compensatory shifting of the body weight to the middle or outside of the foot in pronation and knock-knee, both normal developmental stages, is the most common cause of toeing-in and corrects itself in time. Developmental bowing of the legs, also self-correcting, may lead to temporary toeing-in. Talipes equinovarus and metatarsus varus are associated with toeing-in. Spasticity of the internal rotator muscles of the hip, as seen in cerebral palsy, produces toeing-in, as does anterior maldirection of the acetabulum.

Toeing-out is seen with calcaneovalgus and pes planovalgus. Flaccid paralysis of the internal rotator muscles of the hip results in toeing-out. Posterior maldirection of the acetabulum produces toeing-out.

The remaining causes of both conditions are related to internal or external torsion of the tibia and femur. In general, with toeing-in, if the child's patellae are noted to be rotated inward (kissing knees) while walking, then the underlying problem is above the knee; if they face straight forward, then the underlying problem is below the knee.[12]

Parents often notice excessive inward or outward toeing-in infants or toddlers. Excessive in-toeing is more common than out-toeing and is more likely to be caused by benign conditions that usually represent variations of normal development from excessive rotations of the femur, the tibia, or both. In children, in-toeing does not usually cause pain or interfere with development or stability of gait. Therefore understanding the natural progression of femoral and tibial torsion, as well as the changes that occur in hip rotation, is essential for primary care physicians to reassure and advise parents about these common conditions.

Finding older family members with histories of these rotational anomalies is not uncommon. In many instances, a history of a parent who was treated as a toddler with an orthotic device for these conditions can even be found.

Inward rotation of the femur at the femoral neck (femoral anteversion) is greatest at birth (approximately 40 degrees) and gradually declines to adult values of 10 to 15 degrees by age 8 years.

The best position in which to assess the rotation of the lower extremities is with the child in the prone position, the hips fully extended, and the knees flexed to 90 degrees. To measure hip rotation, the lower leg is used as a pointer and the legs are rotated through the axis of the hip joint (Figure 183-14 and Figure 183-15). Until 1 or 2 years of age, the clinical measurement of hip rotation is limited by the physiological tightness of the hip joint capsule, therefore underestimating the degree of femoral anteversion. After the age of 18 to 24 months, measurement of hip rotation is a close approximation of bony femoral rotation, averaging 50 degrees of internal rotation and 40 degrees of external rotation.

The easiest way to assess tibial rotation is to measure the thigh-foot angle, the axis of the foot relative to the axis of the thigh (see Figure 183-16 and Figure 183-17). The normal thigh-foot angle ranges from 0 to 30 degrees of external rotation; therefore an internal thigh-foot angle indicates internal tibial torsion. By age 2 years, children typically walk with the foot turned out relative to the line of progression. A thigh-foot angle of 10 to 15 degrees is normal in adults and older children.

Figure 183-14 Starting position for measuring hip rotation with the hip extended while the child is in the prone position. (Reprinted with permission from Joint Motion Method of Measuring and Recording. Rosemont, IL, American Academy of Orthopedic Surgeons, 1965.)

Figure 183-15 Internal rotation. (Reprinted with permission from Joint Motion Method of Measuring and Recording. Rosemont, IL, American Academy of Orthopedic Surgeons, 1965.)

In-toeing and out-toeing rarely require imaging studies. Evaluation using gait analysis may help in differentiating the cause of the abnormality for individuals with extreme in-toeing or out-toeing.

Families must be reassured about the natural history of rotational variations in the femur and tibia. Most children will simply outgrow their variant. An orthopedic or neurologic evaluation should be made if a child has severe in-toeing or an unsteady gait (especially while running), causing stumbling as the toes catch on the back of the trailing leg. A referral may also be advised if a child's condition does not follow the expected physiologic progression with growth.[13] [14]

Infants and children often assume certain positions during sleep or while sitting for long periods (watching television) that lead to positional deformities of the femur, tibia, or feet.

Sleeping in the prone, knee-chest position with the legs internally rotated may lead to anteversion of the femoral neck, internal tibial torsion, and varus of the forefoot; having the legs externally rotated may lead to valgus of the feet; and having the legs in a neutral position may lead to equinus of the feet and toe-walking. Sleeping in the prone position with the legs extended and rotated inward may lead to anteversion of the femoral neck, internal tibial torsion, and varus of the forefoot; having them rotated outward may lead to retroversion of the femoral neck and valgus of the feet. Sleeping in the frog-leg position prone or supine may lead to retroversion of the femoral neck and valgus and abduction of the feet.

Sitting in the reversed tailor position with the feet internally rotated may produce anteversion of the femoral neck, internal tibial torsion, and varus of the forefoot; having the feet rotated externally may produce anteversion of the femoral neck and valgus of the feet.

When these sleeping or sitting positions occur in conjunction with the positional deformities listed, and when they raise concern, some effort can be made to change the positional sleeping or sitting habit. Success, however, is not often attained.

Although in-toeing or out-toeing may reflect a variety of underlying orthopedic diseases, no evidence has been found suggesting that in-toeing or out-toeing of developmental origin leads to any functional disabilities if left uncorrected.[15]

Tibial torsion is a rotation of the tibia on its longitudinal axis relative to the transverse axes of the knee and ankle joints.

Pathological degrees of internal and external tibial torsion are found only in association with deformities of the feet, ankles, knees, and hips or as a result of improperly applied casts, braces, or Denis Browne splints.

The incidence of internal tibial torsion is 12% at birth, gradually diminishing to near 0% at 2 years of age.

During fetal life, the tibia is rotated inward on its longitudinal axis relative to the transverse axes of the knee and ankle joints. At birth, it reaches a neutral position. External tibial torsion develops in most babies shortly after birth and is almost universal by age 2 years, reaching 20 degrees of lateral torsion by the time walking is fully established and 23 degrees by adulthood.

The degree of internal and external tibial torsion can be determined by observing the relative position of the medial and lateral malleoli while the child is sitting on the edge of a table or chair with legs dangling, the patellae facing forward, and the feet in their relaxed position. The medial malleolus is placed posterior to the lateral malleolus in internal tibial torsion and anterior to it in external torsion.

Figure 183-16 Thigh-foot angle: normal range. (Alexander IJ. The Foot: Examination and Diagnosis. New York, NY: Churchill Livingstone; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-17 Bilateral internal tibial torsion. (Alexander IJ. The Foot: Examination and Diagnosis. New York, NY: Churchill Livingstone; 1990. Copyright © 1990, Elsevier, with permission.)

The degree of torsion can be measured exactly either radiographically or with special instruments but is not required in most cases.

Treatment of primary internal tibial torsion is not required in most cases. Occasionally, if a child trips on his or her feet and falls frequently, or if parents are unduly concerned over toeing-in, then passive stretching exercises (externally rotating the foot at the ankle), corrective shoes (Thomas heel, longitudinal arch pad, inner-heel, and outsole wedges), or application of torque heels may be prescribed. Denis Browne splints should not be used without orthopedic consultation because they may create abnormal stress on the hip joint. Derotation osteotomy of the tibia rarely is required and then almost always when tibial torsion is associated with other orthopedic anomalies of the lower extremity. The primary care physician can usually observe children with tibial torsion. A referral is important if the child has extreme rotation, significant asymmetry of the torsion, a sudden proximal tibial deviation, or a condition that does not follow the typical pattern of improvement with growth.

Femoral torsion is the rotation of the proximal portion of the femur on its longitudinal axis in relation to the transverse plane of the knee. Femoral anteversion is the extreme twisting of the femoral neck anteriorly relative to the femoral condyles. Femoral retroversion is the extreme twisting of the femoral neck posteriorly relative to the femoral condyles.

In utero and postnatal positioning of the legs and hips produces stresses that bring about these rotational deformities of the femoral neck. The true incidence of anteversion and retroversion is not known, but the former is much more common and occurs twice as frequently in girls as in boys.

Femoral anteversion produces kissing knees, toeing-in, and a clumsy gait. With the patella in neutral position, the greater trochanter of the femur lies posterior to the lateral, longitudinal midthigh line. External rotation is decreased and internal rotation of the hip in extension is increased (normally 35 to 45 degrees for both). External rotation of the hip in flexion is normal, however. The findings in retroversion are the opposite of those found in anteversion of the femoral neck. Imaging is only required in cases of extreme anteversion or retroversion.

A simple measure that can be employed by the primary care physician early on for parental concern over toeing-in is to have the child learn to sit in the tailor, modified lotus, or Indian-style sitting position. The use of Denis Browne splints is contraindicated, and corrective shoes are of no value.

Most femoral torsion deformities correct themselves by 7 years of age. If they do not follow the typical pattern of improvement with growth, then an orthopedist should be consulted because the persistence of these deformities may lead to degenerative arthritis of the hip joint. Referral for evaluation should also be made if a child has extreme rotation, especially when associated with difficulty walking or running, or when significant asymmetry of the anteversion exists. Orthopedic treatment consists of the use of a bivalve lower-trunk and leg cast during sleeping hours or, in rare cases, a derotation osteotomy of the middle or lower femoral shaft.

Toe anomalies:

• Most toe anomalies are asymptomatic cosmetic defects and do not require referral. Referral to a podiatrist or orthopedist may be indicated if the anomaly leads to pain or uncomfortable shoe wear or ambulation and if these symptoms do not respond to conservative management.

Clubfoot:

• Immediate referral to an orthopedist should be made on diagnosis of clubfoot.

Metatarsus varus:

• Forefoot has limited flexibility.
• Condition appears to be progressing or is not improving with growth.

Pronation:

• Limited flexibility or a suspicion of planovalgus
• Persistence of pronation beyond 2½ years of age
• Symptoms are present that are not relieved through conservative management

Pes cavus:

• All individuals with pes cavus should be referred for evaluation by a neurologist, physiatrist, orthopedist, individually or in collaboration.

Toe-walking:

• Toe-walking that persists beyond 2 years of age
• A child who has an abnormal neurological history or examination

Bowed legs and knock-knees:

• Severe, asymmetric, or unilateral genu varum or genu valgus
• Condition that does not follow the expected physiologic progression with growth

Toeing-in and toeing-out:

• Severe in-toeing
• Unsteady gait (especially while running) that causes stumbling
• Condition that does not follow the expected physiologic progression with growth

Tibial torsion:

• Extreme rotation (especially when associated with difficulty walking or running)
• Significant asymmetry
• Sudden proximal tibial deviation
• Condition that does not follow the typical pattern of improvement with growth

Femoral anteversion:

• Extreme rotation (especially when associated with difficulty walking or running)
• Significant asymmetry of the femoral anteversion
• Condition that does not follow the typical pattern of improvement with growth, by 7 years of age

• Orthopaedic Connections: Shoes (fact sheet), American Academy of Orthopaedic Surgeons (orthoinfo.aaos.org/topic.cfm?topic=A00143&return_link=0).

• Cerebral Palsy Program—Cerebral Palsy; a guide for care (book), Alfred I. DuPont Institute (gait.aidi.udel.edu/res695/homepage/pd_ortho/clinics/c_palsy/cpweb.htm).
• Diagnosis and Treatment of Pediatric Flatfoot (guideline), Harris EJ, Vanore JV, Thomas JL, et al (www.guideline.gov/summary/summary.aspx?ss=15&doc_id=6517&nbr=4086).
• Essentials of Musculoskeletal Care, 3rd edition (book), American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (www.aap.org/bookstore).
• Wheeless' Textbook of Orthopaedics (book), Duke Orthopaedics (www.wheelessonline.com/).

• American Academy of Orthopaedic Surgeons (orthoinfo.aaos.org/menus/children.cfm).
• American Orthopaedic Foot and Ankle Society (www.aofas.org/i4a/pages/index.cfm?pageid=1).
• National Library of Medicine and the National Institutes of Health: Medline Plus (medlineplus.gov).
• Orthoseek (www.orthoseek.com).
• Pediatric Orthopaedic Society of North America (www.posna.org).

• Craig CL, Goldberg MJ. Foot and leg problems. Pediatr Rev. 1993;14(10):395-400.
• Greene W. Essentials of Musculoskeletal Care. 3rd ed. Rosemont, IL: American Academy of Orthopedic Surgeons; 2005.
• Herring JA. Tachdjian's Pediatric Orthopaedics. 3rd ed. Philadelphia, PA: WB Saunders; 2002.
• Staheli LT. Fundamentals of Pediatric Orthopedics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.

1. American Academy of Orthopaedic Surgeons (AAOS). Shoes. Available at: orthoinfo.aaos.org/brochure/thr_report.cfm?thread_id=15&topcategory=foot. Accessed August 10, 2007.
2. Bleck EE. The shoeing of children: sham or science? Dev Med Child Neurol. 1971;13(2):188-195.  [PMID:5562861]
3. Craig CL, Goldberg MJ. Foot and leg problems. Pediatr Rev. 1993;14(10):395-400.  [PMID:8255821]
4. Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Physician. 2003;68(3):461-468.  [PMID:12924829]
5. Scherl SA. Common lower extremity problems in children. Pediatr Rev. 2004;25(2):52-62.  [PMID:14754927]
6. Pfeiffer M, Kotz R, Ledl T, et al. Prevalence of flat foot in preschool-aged children. Pediatrics. 2006;118(2):634-639.  [PMID:16882817]
7. Harris EJ, Vanore JV, Thomas JL, et al. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. 2004;43(6):341-373. Available at: www.guideline.gov/summary/summary.aspx?ss=15&doc_id=6517&nbr=4086. Accessed August 10, 2007.  [PMID:15605048]
8. Duke Orthopaedics. Pes cavus: Charcot-Marie Tooth. Wheeless' Textbook of Orthopedics. Available at: www.wheelessonline.com/ortho/pes_cavus_charcot_marie_tooth. Accessed August 10, 2007.
9. Sala DA, Shulman LH, Kennedy RF, et al. Idiopathic toe-walking: a review. Dev Med Child Neurol. 1999;41(12):846-848.  [PMID:10619285]
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11. Tidwell M. The child with the tip-toe gait. Int Pediatr. 1999;14(4):235-238.
12. Kling TF, Hensinger RN. Angular and torsional deformities of the lower limbs in children. Clin Orthop Relat Res. 1983;176:136-147.  [PMID:6851317]
13. Dietz FR. Most torsional variations of tibia, femur resolve spontaneously. AAP News. 2000;16(1):35.
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Figure 183-1 Positional deformities of the foot and ankle. A, Varus. B, Valgus. C, Equinus. D, Calcaneus. (Tachdjian MO. Pediatric Orthopaedics. Philadelphia, PA: WB Saunders; 1977. Copyright © 1977, Elsevier, with permission.)

Figure 183-2 Common toe anomalies.

Figure 183-3 Bilateral talipes equinovarus in a newborn. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-4 Untreated talipes equinovarus in a 3-year-old child. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-5 Bilateral talipes calcaneovalgus. The left foot is held dorsiflexed and the right plantar flexed to show the range of ankle movement. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-6 Bilateral talipes varus. The entire foot is twisted inward on its longitudinal axis, and the forefoot is adducted. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-7 Bilateral metatarsus varus. The forefoot is inverted and adducted, the great toe is widely separated from the second toe, and the lateral border of the foot is convex. The hindfoot is in a neutral position. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-8 Metatarsus adductus. The forefoot is adducted but not inverted. (Ferguson AB. Orthopedic Surgery in Infancy and Childhood. 4th ed. Baltimore, MD: Williams & Wilkins; 1981. Reprinted by permission of Lippincott Williams & Wilkins.)

Figure 183-9 Pronation. A, Viewed from behind, the hindfoot is everted. B, Viewed from in front, the forefoot is everted and abducted. (Sharrard WJW. Paediatric Orthopaedics and Factures, 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-10 Pes cavus, viewed from the outer side. The height of the medial and lateral longitudinal arch is abnormal. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-11 A, Extreme physiological bowing of the legs at age 18 months. B, Spontaneous resolution over time (age 7 years). (Sharrard WJW. Paediatric Orthopaedics and Fractures. Oxford, NY: Blackwell Scientific; 1971. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-12 Marked degree of physiological genu valgum. At age 11 years the distance between the medial malleoli measured 4 inches. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-13 Unilateral genu valgum caused by previous injury to the lateral aspect of the right proximal tibial epiphysis. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Figure 183-14 Starting position for measuring hip rotation with the hip extended while the child is in the prone position. (Reprinted with permission from Joint Motion Method of Measuring and Recording. Rosemont, IL, American Academy of Orthopedic Surgeons, 1965.)

Figure 183-15 Internal rotation. (Reprinted with permission from Joint Motion Method of Measuring and Recording. Rosemont, IL, American Academy of Orthopedic Surgeons, 1965.)

Figure 183-16 Thigh-foot angle: normal range. (Alexander IJ. The Foot: Examination and Diagnosis. New York, NY: Churchill Livingstone; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-17 Bilateral internal tibial torsion. (Alexander IJ. The Foot: Examination and Diagnosis. New York, NY: Churchill Livingstone; 1990. Copyright © 1990, Elsevier, with permission.)