The common skeletal problem in children 常見的小兒骨骼問題
I. Bow leg I. Bow leg 弓形腿,“O” 形腳
– Babies are born with physiologic bow legs. This is normal at birth. The knee becomes straight at around the age of 2, then bends out afterward. Maximum bending out angle occurs at about age 3. It then gradually reduces and becomes stabilized at age 9.
– 初出生的嬰兒都是有少許“O”形腳，這現象是正常的， 外觀上嬰兒的膝部好像是向內翻的，此角度約於兩歲時 便會變直，內翻繼而變得相反的向外翻而最明顯外翻的 時間約發生於三歲時，此後，外翻的角度會慢慢減少並 會於九歲時停止。
Bowlegs not only cause cosmetic problems but may also lead to pain. When the knee is in varus, the inner side of the knee joint will be over-stressed. In such a situation, the ankle will then be forced to varus. The weight-bearing point of the sole will shift to the outer side causing the development of callosity. Shoe wear is therefore easily broken.
“O” 形腳不但影響外觀，患者膝關節內側會受力過大而引 致痛楚，因膝部變形而踝關節和足部會被迫內翻，著地 點會集中在腳底外側而引起皮膚硬化，鞋的外側亦很快 被磨損。
As bow legs improve with growth, there is no urgency for treatment. The doctor will observe the change regularly. Strengthening exercises for the knee, such as cycling and stepping up and down, can improve the stability of the knee, and thus provides better support. The physiotherapist will measure the knee alignment at regular intervals. Should there be any deterioration of the condition, the patient will be advised to seek medical consultation for further investigation.
由於“O”形腳是會隨着年齡而改變，所以一般沒有治療的迫切 性，醫生一般都會定期觀察骨骼的變化。一些強化膝關節的 運動如踏單車和踏樓梯可增強膝關節的穩定性，從而提供更 佳的保護。 物理治療師會定期量度膝關節的角度，如發覺變形惡化，患 者需要見醫生作進一步檢查。
2. Flat feet 扁平足
Physiological flat feet are present in babies and toddlers. With normal development, the foot arch will gradually develop and mature at around age 6. Flat feet may persist after age 6 in children who have familial flat feet, lax joints, or pathological flat feet such as congenital bone disease. Flat feet are frequently seen in children with hypotonia. This is because low muscle tone will lead to inefficiency of the muscle pulls that hold the normal foot arch.
嬰兒及小童的足弓由於未發展成熟一般都比較扁平，經正常 的生長，足弓會漸漸發展並約於六歲時成形，如有家族遺 傳，韌帶過鬆或其他足科病變 (如先天性足關節融合 )的 問 題，足弓便不會形成。扁平足亦常見於肌肉張力低的小童， 由於他們的肌肉處於低張的狀態，足弓便沒有足夠的承托。
Functional problem 功能障礙:
Flat feet 扁平足
medial foot pain 足內側疼痛
inability to hop 不能單腳跳
poor running or jumping 跑步或跳動困難
easy tiredness 容易疲勞
The heel cord of flat feet will be shortened as a result of a malalignment of the foot bones. The shorter the heel cord, the more deformity has resulted. Therefore patient needs to do stretching exercises and massage to stretch out the tight heel cord (figure 6). Moreover, the calf muscles will be weakened as a result of mal-aligned muscle pull. Therefore strengthening these muscles is also important.
扁平足患者因足部變形而引致後跟縮短，情況持續可能加重足部 變形而引致扁平足惡化。因此患者需做按摩及後跟伸展運動。再者患者的小腿和脛後肌會因足部變形而變得無力，因此 患者亦需要訓練此組肌肉。
There are many small muscles at the foot and they may also help to support the foot arch. Therefore strengthening exercises for these small muscles such as walking on the beach (figure 9) or griping a towel with toes (figure 10) may be beneficial. 足弓的承托也靠足部的小肌肉輔助，因此，小肌肉的運動也 可以幫助足弓的形成。例如在沙灘上步行(圖9)或用腳抓毛巾 (圖10)。
In severe cases, orthotic treatment (figure 11) can restore the mal-alignment and the heel valgus improves.
When choosing shoes, parents should select shoes with arch support. The shoe materials should not be too hard or too soft. The size of the shoe must be just fit and should not be too large or too small. A pair of oversized shoes will lead to easy tripping and the arch support will not fit the child either.
家長選購鞋時必須注意選擇有足弓承托的鞋，鞋身及鞋底不宜 過軟或過硬，也不應選過大的鞋，過鬆的鞋不但不能正確承托 足弓，還會因過長過重的關係而引致孩子容易絆倒。
3. In-toeing walk “入”字腳
Children below the age of 5 may walk with mild in-toeing. The majority of them are usually due to poor sitting posture such as “ W”-sit on the floor .
五歲以下的小童可能出現 “入” 字腳走路的情況，大部份成因都 是由於坐姿不正確(如以 “W” 形坐在地上).
A. Deformity at the thigh bone (femur) 股骨內旋
Children below the age of 5 may walk with mild in-toeing. The majority of them are usually due to poor sitting posture such as “W”-sit on the floor (figure 13) and increased femoral anteversion angle (an angle formed between the femoral neck and the knee axis, figure 14). With normal skeletal development, this angle will gradually decrease and become normalized. However, this angle will not decrease in case of pathological condition and/or abnormal posture. The larger the anteversion angle, the more the in-toeing.
五歲以下的小童可能出現 “入” 字腳走路的情況，大部份成因都 是由於坐姿不正確(如以 “W” 形坐在地上，圖13)及股骨內旋， 即股骨頸與膝關節縱軸形成的角度(圖14)，隨著骨骼的生長， 此角度會漸漸減少至正常水平，假如因股骨病變或坐姿不正， 此角度便不會減少因而引致“入”字腳。
Figure 15 shows a clinical test for femoral anteversion. The tester rotates the child’s hip in both internal and external rotations and compares the difference. If femoral anteversion is increased, there is excessive internal rotation of the hip and reduced external rotation.
圖15顯示股骨內旋的臨床檢查，檢查者將患者的髖關節向內及 外旋轉，然後比較兩者的差別，如骰骨內旋過大，髖關節內旋 幅度會過大而外旋則過小。
B. Internal rotation of tibia
脛骨 (即小腿骨 )扭入
The tibia bone may be deformed and internally rotated as happened in a poor sitting posture in situation A. Regular assessment is needed.
Stretching out any tight soft tissues may improve the situation and gradually normalize this deformity.
C. Forefoot adduction 前掌內收
Forefoot adduction may also contribute to the in-toeing. It may be caused by inheritance or inborn.
Functional problem 功能障礙:
In-toe walking not only causes an awkward walking pattern but also leads to easy falling as feet are easily catching each other.
Furthermore, since the muscle pulls are not in the original mechanical advantage positions, these muscles are weakened and children may find difficulty in running and jumping.
Stretching for left hip 左髖關節的伸展運動
Treatment for in-toeing mainly focuses on stretching out tight hip structures. Figure 18 shows stretching for the left hip and figure 19 shows stretching both sides to increase the flexibility of external hip rotation.
治療目的在於增加髖關節外旋的活動性。圖18顯示左髖關 節的伸展運動以增加髖關節外旋的角度。圖19顯示兩邊髖 關節同時進行的伸展運動。
（資料來源 Information Sources: “https://www3.ha.org.hk/tmh”）