The Pocket Podiatry Guide: Paediatrics

321 Pages·2010·15.617 MB·English

by  Ian Mathieson (ed.)

Paediatrics
Angela Evans
PhD, GradDipSocSc, DipAppSc
University of South Australia, Australia
Series Editor
Ian Mathieson
BSc(Hons), PhD, MChS
Senior Lecturer, Wales Centre for Podiatric Studies,
University of Wales Institute, Cardiff, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2010
For the many children and parents
with whom it is and has been my
privilege and pleasure to consult, and
for the university students from whom
I have been fortunate to learn, and to teach.
Publisher: Sarena Wolfaard
Development Editor: Nicola Lally
Project Manager: Kerrie-Anne McKinlay
Design: Stewart Larking
Illustration Manager: Gillian Richards
Illustrator: Cactus
First published 2010, © Elsevier Limited. All rights reserved.
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ISBN 978-0-7020-3031-4
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Foreword
The publication of Pocket Podiatry: Functional Anatomy in summer 2009
carried a foreword that claimed it was the first of a series that would build
into a comprehensive clinical guide. One text does not make a series
however and, whilst basic clinical sciences are vital in that they underpin
clinical practice, they cannot claim to be a true clinical discipline in their
own right. Therefore the publication of Pocket Podiatry: Paediatrics not
only represents the point at which the concept of a series comes to frui-
tion but also the point at which it moves firmly into the clinical domain.
We do so under the guidance of Dr. Angela Evans who writes about the
clinical management of a patient group with whom most podiatrists have
some contact but with whom relatively few truly specialise – children. Dr.
Evans’ text is highly informative – both academically and practically – and
is written in a lucid, accessible style which conveys her real enthusiasm
for and genuine insight to the subject. After dealing with basic issues
including: an approach to the consultation; accounts of embryology and
ontogeny; developmental biomechanics; and the development of gait, a
series of specific conditions are discussed. These are diverse and include
growing pains, clubfoot, metatarsus adductus, verrucae and the osteo-
chondroses. A critical approach is adopted reflecting contemporary
knowledge and evidence. As such this book provides invaluable informa-
tion which will facilitate clinicians to develop an evidence based service.
For example, details of various valid and reliable diagnostic aids are pro-
vided and chapters discussing specific conditions include evidence based
treatment guidelines. I found this text both clinically informative and thor-
oughly engaging throughout. I am grateful to Dr. Evans for undertaking
this project with such professionalism and commitment. I believe that you
will find Pocket Podiatry: Paediatrics to be the genuinely informative and
useful clinical companion it was designed to be.
lan Mathieson
Cardiff, UK, 2009
Preface
This book is intended for undergraduate podiatry students but may well
be of interest to a broader range of clinicians. Following Chapter 1, which
addresses the clinical consultation with children, the book is basically
constructed in three parts. Chapters 2–6 provide a necessary foundation
to foot development and growth. Chapters 7–12 cover common paedi-
atric foot/gait conditions and in addition to descriptive accounts, address
clinical intervention from the perspective of an evidence-based medicine
framework. It is important that intervention be justifiable and well thought
out rather than applied because it is available or habitual. This is equally
true of non-intervention. The third part, Chapters 13–15, is general in
nature, with much of the content derived from my clinical experience.
Here, I have attempted to merge currently available research evidence
with clinical evidence, as reflects contemporary health care and from my
worlds of both research and clinical practice.
The current research into children’s foot posture should see contem-
porary research findings implemented within the realm of clinical practice.
Specifically, the oft experienced dilemma of the flat-footed child can be
more clearly understood, assessed and managed. The paediatric flat foot
proforma is a helpful approach to directing concerns about children with
flat feet. Having completed a doctoral thesis in the area of children’s leg
pain (growing pains) and foot posture, I am acutely aware, as both clini-
cian and researcher, how important it is to have an effective merging of
research findings into clinical practice if the public are to be recipients of
‘best practice’.
This small text is in no way a definitive book nor exhaustive for the
primary topic of paediatric podiatry. From the outset, I most strongly urge
and encourage readers to regard this as a stepping off point of departure,
from which many other paediatric, orthopaedic, medical, sociological and
current research resources need also be consulted. Though covering a
limited number and array of topics, this book will, I hope, prove useful
nonetheless.
I am indeed grateful for the opportunity to have compiled this book
and would like to thank Robert Edwards, my commissioning editor from
Elsevier, for presenting this challenge. My grateful thanks are also due to
my UK colleague Ian Mathieson, series editor, for his very helpful advice.
I am indebted to Nicola Lally, Development Editor at Elsevier, Oxford, for
her patience and assistance in seeing this book to its fruition. I wish to
sincerely thank my colleagues, Margaret Carty and Michael Harding, for
allowing me to use their children as photographic subjects and the many
publishers who have granted permission for designated figure use. Addi-
tional thanks are due to Melissa McCaig, for preliminary draft proofreading
and suggesting the chapter specific definition of terms.
Angela Margaret Evans
Adelaide, South Australia, 2009
1
C H A P T E R
Chapter contents
Introduction 1 Consulting with
Milestones 1
Do you like children? The  children
crucial element of 
authenticity 2
Thoughts as to why children 
cry 3
Children who are not crying may
still be frightened 4 Introduction
Sensitivity and the ‘three Fs’ 4
1. Fearful 4 Children are not a homogeneous group. In par-
2. Flexible 5
allel to their physical development, children are
3. Feisty 5
simultaneously growing psychosocially. It is
Courtesy 5
very important to recognize this fact when con-
The concept of ‘scaffolding’ 6
sulting with children, as they are not just scaled
Building rapport through 
down adults. An appreciation of the stages of
parents/carers 8
Special needs of special  children’s psychosocial development is both
children 9 fascinating and necessary if one is to enjoy
Engaging with ages and clinically successful consultations. By this, I
stages 9 mean a consultation which achieves its clinical
end, be this assessment or treatment, and one
which is a good experience for the child,
parent/carer and clinician. To do this is both
challenging and gratifying.
Milestones
Just as we have a set of expected milestones
for physical development, those of us consult-
ing with children require a similar knowledge of
what is expected for ages and stages from a
psychosocial perspective. Acknowledging that
we are podiatrists, we require what may be
termed a working knowledge of paediatric psy-
chology and social science to enhance our
clinical encounters with children of all ages.
Table 1.1 outlines the main psychosocial
stages of development, which it is useful to
appreciate (Miller 1993).
1
2 ConsultIng wIth ChIldren
table 1.1 The development of psychosocial stages across the life span,
according to Erikson*
Stage Age Concern Clinical relevance
1 Birth to 1 year Trust vs Mother is usually primary; keep her
mistrust close and all will be well. Be authentic
and consistent with infants
2 2–3 years Autonomy vs Important for children to ‘succeed’ in
shame, doubt the consult; help them to do the right
thing by being clear and sensitive
3 4–5 years Initiative vs guilt Role models are important at this
stage; be a good one
4 6 years to Industry vs Children are keen to do things well;
puberty inferiority inform and acknowledge their efforts
5 Adolescence Identity and This is a potent stage – blooming and
repudiation vs exciting for some, awkward and
identity diffusion uncomfortable for others; be gentle
(a grunt can be a socially acceptable
whimper)
6 Young adult Intimacy and Relationships are important; expect
solidarity vs boyfriends/girlfriends to accompany, so
isolation include them
7 Middle adult Generativity vs Busy careers, often raising their own
stagnation and children; be clear and efficient (and
self-absorption on time)
8 Late adult Integrity vs The die is cast – positively or
despair negatively. Be realistic and positive and
prepared to listen for some real
wisdom
*The development theorist Erik Erikson (a student of Freud) divided the life span into eight basic stages.
An awareness of these stages is very useful and the first five apply directly to the paediatric domain. The
clinical relevance column is sourced from this author’s experience.
do you like children? the crucial element
of authenticity
I genuinely like children and enjoy their company. Children are extremely
perceptive and can pick out a phony from the start. Such falsity arouses
their suspicions that all is not well and induces fear and apprehension.
This is quite justifiable and no amount of pandering and hollow words or
gestures can fool these astute little people. The consultation will be, at
Thoughts as to why children cry 3
best, an experience the child is pleased to see finish and at worst a
frightening, traumatic event.
Some people just are not suited to working with children and it is
painfully apparent. The lack of warmth, engagement and basic respect is
almost palpable, as is the wariness, doubt and fear of the child, expressed
more or less covertly by different children at different ages.
thoughts as to why children cry
Basically, children cry when they are not happy. This can be for a variety
of reasons and while as clinicians (as opposed to the children’s parents/
carers) we are not always able to identify the specific cause, we are able
to consider the likely factors at play.
Children largely cry when they are:
• unwell
• tired
• anxious
• hungry
• scared.
Key Concepts
While distressing for everyone, a crying child gives ample opportunity
for us to respond. There is nothing subtle about it and no excuse for
missing the cue
However, there’s crying and then there’s crying. Personality, socialization,
cultural background and fear will all play their part in how and when a
child cries. While there are no hard and fast rules, I am often less con-
cerned by a child who cries loudly and obviously as it is impossible to
miss their distress and therefore easier to manage it. In general, it is a
matter of slowing down and taking time to allay the child’s fears. Children
who have recently had their inoculations may not understand that this
‘doctor’ is just going to look at them walking. Play and explain, do not
rush the pace (depending upon the age) and things will almost always
settle down well. Children do not want to have a bad time any more than
you do, but they are usually very honest about it. Respect their honesty,
be honest in return and you will have a great time together. So often
children are then reluctant to leave, which is a ‘gold star’ for you as a
clinician, as is the overheard and unsolicited ‘that was fun’, or ‘I like her’,
on the way out.
1
4 ConsultIng wIth ChIldren
Children who are not crying may still be frightened
Please look out for these children, the stoic, reserved type who is trem-
bling on the inside. As stated above, the child’s personality, socialization,
culture and fear will merge to influence how, where, when and with whom
they express their feelings. It is the same for us. Our personality, socializa-
tion, culture and fear will influence how we perceive others and relate to
them, especially with children.
sensitivity and the ‘three Fs’
This is a model that is very helpful when working with children, especially
in the clinical setting where encounters are fairly brief, often unfamiliar and
relatively intrusive.
Using the three Fs (Lally et al 1990) can help to avoid many otherwise
likely pitfalls that can result in children being upset and mar the whole
consultation. Especially valuable at the initial consultation, screening chil-
dren’s basic modus operandi (psychosocially) informs and directs aware
adults. Recognizing and appreciating a child’s fundamental style takes
practice and it is important to realize that each F may be either overt or
covert. The main tenets of the three Fs are:
1. Fearful
The child is basically wary and apprehensive, especially of new people,
experiences and places. Anxiety is a dominant emotion and feeling. Eye
contact with you may be brief or absent.
Overt
The child is obviously crying and clinging to a parent/carer. The pitch of
the cry is scared, not angry (these subtle differences are easy to hear
after a while).
Covert
The child puts on a brave face and complies. Their body language is
‘louder’ if you ‘listen’, e.g. blank expression, downcast eyes, and a stoop
of the shoulders.
It is easy to mistake this quiet child for a flexible child and presume
they are coping better than they are. Missing the cues from these ‘easy’
children can result in more overt fear and distress.