Cause

There is no one cause of congenital dislocation of the hip (CDH). Genetic factors seem to play a part, as it is more common in girls than in boys, and especially in daughters of mothers who themselves had CDH as babies. The posture of the baby in the womb also seems important, so that it is more common in breech presentations (where the baby is born legs first instead of the usual head first).

Clinical features

Often there are no easily detectable signs of CDH in infancy. Sometimes the skin creases in the thighs are asymmetrical. Parents may notice when changing the nappy that one thigh is restricted in its movement, and cannot be laid all the way back on the table. Later, an abnormal position of the leg on the affected side may be noticed, and the leg itself may be shorter than the other due to dislocation. There may be a delay in walking, or the child may walk with a limp or with the pelvis tilted to one side.

During the doctor’s examination of a newborn baby, both hips are carefully checked for any signs of dislocation. Several tests are performed specifically to detect CDH or an unstable hip. On examination of your baby’s hip a faint click may be heard (‘clicky hips’), which may be due only to stretched ligaments and simply requires monitoring. If this click is accompanied by an abnormal movement of the hip, the diagnosis of congenital hip dislocation is likely.

Investigation

A very careful physical examination of both hips should be done in the first few-days of life, and repeated at 6 weeks of age. In experienced hands, this should detect most cases of CDH. Sometimes an X-ray of the hip may be helpful, and ultrasound is being increasingly used.

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Babies often appear to have flat feet because the soles of their feet are filled with pads of thick fat. The fatter the baby, the flatter the feet look. Once babies start walking, this arches become more defined because the ligaments and muscles start more working more, and by the age of 3 years, the feet acquire their final shape. After this age, a child who has flat feet will wear down the heels of his shoes on the inner sides very quickly. The entire surface of the sole of the foot is in contact with the ground, and the arches are not visible. This occasionally causes the child pain, especially when playing sport. Children with flat feet do not need any treatment. In particular, there is no need for arches, supports or special shoes. If flat feet persist into adult life, arches may reduce the wear on shoes.

HEELS, PAINFUL

This condition is especially common in older children and young adolescents. Sometimes it is caused by a strain of the achilles tendon where it attaches to the bone of the heel. Pain is usually experienced after sport. Usually no treatment is necessary, because the condition improves with age and eventually disappears. Raising the heel of the shoe on the affected side sometimes helps. The child should be encouraged to continue playing sport.

The other cause of painful heels is a bony spur (calcaneal spur) on the back of the heel bone, which rubs against the bottom or back of the shoe. The overlying skin becomes reddened and bruised. Treatment consists of inserting a small pad in the shoe to protect the affected area. Occasionally surgery is needed to chip off the bony protrusion.

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Cause

The cause of growing pains is uncertain. They are said to be related to exercise, but this is not always so, and in most cases there are no known precipitating events.

Clinical features

The child complains of aching or a burning sensation in the legs — in the thighs, calves, feet or joints. The pains can also occur, though far less commonly, in the arms or other parts of the body. They usually occur at night, and sometimes wake the child from sleep, but are also common in the daytime. They are rarely severe enough to interfere with daily activity. In most children, the pain or discomfort is transient, irregular and unpredictable — it tends to come and go. The natural history is for growing pains to get better over time.

Investigations

No investigations are usually necessary. Occasionally the doctor will order an X-ray or blood test to exclude other conditions, such as a fracture or inflammation.

Treatment

There is no specific treatment for growing pains. Massaging the affected area may help. Occasionally a mild analgesic is given to the child, but mostly all that is necessary is reassurance and the general measures described above. There is no need to restrict activity.

When to see your doctor

See your doctor if you suspect that there is something more serious going on — if the pains are very severe and persistent, if there is a limp, or an affected part is tender or feels hot.

Prevention

There is nothing that can be done to prevent growing pains.

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Undisplaced fracture in which the break does not interfere with the alignment of the bone fragments, so that the two ends remain in contact with each other. Open fracture in which one end of the broken bone is exposed to the outside through the skin, and is thus susceptible to becoming infected.

Clinical features

The area around the fracture usually becomes swollen and sometimes there is an obvious deformity visible. The child may hold his arm or leg perfectly still because even the slightest movement increases the pain.

Investigations

The diagnosis of a fracture should always be confirmed by an X-ray.

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Teeth grinding

This is relatively common in children, often occurring at night during a child’s sleep. Sometimes it is due to stress or anxiety. In many cases grinding of teeth is the result of a temporary problem of alignment (malocclusion) between upper and lower teeth, during the period when the child is losing his milk teeth and acquiring his permanent teeth. The poor fit between the teeth may cause discomfort of the jaw which is relieved by grinding the teeth. In severe cases, the teeth may be damaged, with the enamel being worn down. If grinding of the teeth is severe or persistent, you should obtain advice from your dentist.

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Vitamin Ê occurs in green vegetables, and also some of the bacteria which normally live in the bowel manufacture this vitamin which we absorb and use.

An excess of Vitamin Ê has not been shown to cause any serious side-effects.

Vitamin C, or ascorbic acid, has occupied a lot of interest recently, not only for its effect in preventing the common cold but because of its actions generally in human nutrition.

Vitamin Ñ is widely distributed through many foodstuffs. The green vegetables, citrus fruits and potatoes contain considerable quantities.

This vitamin is necessary for the proper development of connective tissue in the body, especially the coverings of blood vessels.

Lack of ascorbic acid produces scurvy, with bleeding in the gums and other soft tissues, failure of wound-healing, and poor resistance to infection.

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The veins contain valves which allow oneway flow only, towards the heart and also break the blood up into smaller columns.

Flow of blood in the veins is mainly due to the action of the muscles, compressing the blood and forcing it onwards, towards the heart.

Negative pressure in the chest, on breathing, does tend to “suck up” the blood and aid its return.

The veins and arteries have nerves supplying the muscle in their walls, which maintain contraction of these vessels, so that there is a certain natural tone.

Sometimes an emotional cause, such as a fright, or bad news or the sight of blood, acting through the nervous system, causes the blood vessels to lose tone. They dilate, and the blood then tends to stagnate or pool in the abdomen and lower limbs.

The venous return to the heart is impaired, the blood pressure falls, an inadequate volume is pumped to the brain, the person feels giddy, nauseated, the vision goes grey and then black, the person is pale and sweaty and then consciousness is lost.

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In some cases, a more extensive operation, removing all the lymph glands in the pelvis as well, is done. Irradiation of the area is often combined with operation and cytotoxic drugs may be used.

Cancer of the body of the uterus is less common and occurs at an older age than cervical cancer. Most women who develop it are postmenopausal.

This is usually accompanied by bleeding or a discharge. Any bleeding from the vagina after the change of life must be investigated. It isn’t always due to cancer but that diagnosis must be excluded before any other is considered.

Promiscuity and multiple pregnancies are not risk factors for this cancer. But the use of oestrogen, the female hormone, is a definite part of its cause. The symptoms of the menopause, the hot flushes, the dry vagina, the lethargy and depression are believed to be due to a reduction in the amount of circulating oestrogen.

Giving oestrogen tablets or injections can relieve these symptoms. This drug, if taken regularly, can prevent osteoporosis or the thinning of the bone which occurs in older women.

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