What Causes Rectal Prolapse?

Patient Presentation
A 22-month-old female came to the emergency room with increasing abdominal pain over the past few days and now she was have intermittent crying spells. She had a history of chronic constipation treated with polyethylene glycol which she hadn’t been taking for a while. Her mother said she had not had a bowel movement in several days and had noticed her abdomen becoming larger overall. She denied any blood or mucous in the diaper. She also had no diarrhea, emesis, fever, or abnormal urine. She hadn’t been eating or drinking as much and wasn’t awakened by the pain.

The pertinent physical exam showed a female who was crying. She was afebrile and her weight was at the 50% and tracking previous weights. HEENT, heart and lungs were normal. Her abdomen was rounded and protuberant. She would cry during the examination but did not seem to have any particular location for pain and had no guarding. There was no specific hepatosplenomegaly but there were obvious fecal masses on exam. She had a normal anal wink and no hemorrhoids or anal fissures noted. The hymen was intact without discharge. The resident was in the process of ordering a work-up for abdominal pain with abdominal radiograph and blood work, when she started to really scream and passed an ~8 cm hard ball of stool. The mother and nursing staff quickly called the resident as her rectum was now emanating from her anus.

The diagnosis of rectal prolapse was made with healthy pink tissue circumferentially located ~1.5 cm from the anus with the anus being quite patulous. The child did not seem bothered specifically by the mass but was whimpering. The attending emergency room physician was called and he felt the prolapse would probably resolve, but was more concerned about the patulousness of the rectum. A surgical consultation was called. The surgeon was delayed an hour and by this time the prolapse had resolved and the patulousness had markedly improved. The child was also calmer. The examination at this time showed a decreased but still slightly rounded abdomen. There was a normal anal wink and enlarged rectal vault on exam. The surgeon recommended aggressive treatment for constipation and warned the mother that this could potentially occur again as the child obviously had additional stool burden that needed to be passed. Specific instruction on how to digitally replace the prolapse was given to the mother and she was told to attempt it once if needed and then to come to the emergency room if this did not resolve. The patient was to follow up with her regular doctor in 2-3 days.

Discussion
Rectal prolapse is defined as a herniation of the rectum through the anal verge. In children it is also usually mucosal prolapse and not full thickness. Partial or mucosal prolapse usually is seen as radial folds occurring 1 – 2.5 cm from the anal verge. Full thickness will protrude more than 5 cm. It affects genders equally and occurs most commonly in children under age 4. This is due to vertical course and low position of the anus, looser supporting tissues and less muscular support. These children are more likely to have prolapse but are less likely to have it recur. After age 4 the rectum takes the adult shape and more posterior position which lowers its occurrence. However, in older children it is more likely to recur.

Presentation is usually during defecation and is usually painless but patients may feel the mass or have a feeling of incomplete defecation or tenesmus. The prolapse looks like a beefy red mass. As prolapse usually resolves, having the patient perform a Valsalva maneuver or squat may reproduce the prolapse. Prolapses that do not resolve may become edematous, with bleeding and ulceration sometimes occurring. This also makes reduction more difficult. Rectal prolapse can be, but rarely is incarcerated.

Treatment includes spontaneous resolution as noted. Digital replacement is often the next step and may require take several minutes to allow the tissues to become less edematous and remain in place. Some have used sugar to reduce the edema similar to its use for stoma prolapse and edema. For recurrences requiring more treatment, injection sclerotherapy is a common first-line therapy, followed by more invasive surgical management if needed.

Treatment of the underlying cause is obviously important. Constipation is a common problem in any age group. In the young pediatric age group, caregivers should be instructed to treat with medications to allow passage of frequent soft stools (e.g. polyethylene glycol), adequate fluid intake avoiding sugar sweetened beverages, increased fiber which may require specific supplementation, and proper positioning for toileting. Families may not realize that having a foot stool placed under the feet not only allows the child to gain access to the toilet, but also put the child into a bent-kneed position which is an optimal position for the body to perform defecation. Underlying treatable causes of constipation should also be considered such as hypothyroidism

Learning Point
Many of the causes listed below are because of increased abdominal pressure and lack of rectal support. Lead points or general edema may develop leading to rectal prolapse. Chronic malnutrition and diarrhea decreases the ischiorectal fat which leads to decreased rectal support.

Causes of rectal prolapse includes:

  • Increased abdominal pressure
    • Constipation – most common reason
    • Coughing, intractable
    • Emesis, intractable
    • Iatrogenic – high ventilatory pressure
  • Idiopathic
  • Allergy
    • Cow’s milk protein
  • Anatomic
    • Cloacal anomaly
    • Hirschsprung’s disease
    • Imperforate anus
    • Short gut syndrome
  • Diarrhea illness
    • Inflammatory bowel disease
  • Infection
    • Bacteria – Clostridium difficile, Salmonella, Shigella
    • Viral – Cytomegalovirus
    • Parasitic
  • Intussception with lead point
    • Peutz-Jegher syndrome with polyp
    • Rectal polyps
    • Ulcerative colitis with pseudopolys
  • Malnutrition
    • Celiac disease
    • Cystic fibrosis – very common before newborn screening but less common currently
  • Neurologic
    • Meningomyelocoele
    • Psychological – studies show a large number of patients with concomitant psychological problems and rectal prolapse
      • Autism
      • Defecation dysfunction
      • Psychiatric illness
  • Other
    • Bladder stone
    • Ehler-Danlos syndrome
    • Medications
    • Pelvic masses
    • Solitary rectal ulcer syndrome
    • Trauma

Questions for Further Discussion
1. What causes constipation? A review can be found here

2. What is different or the same for hemorrhoid and rectal prolapse presentations? A review can be found here
3. What treatment and followup would you recommend if you saw this child 2-3 days later?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Constipation and Anal and Rectal Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Cares K, El-Baba M. Rectal Prolapse in Children: Significance and Management. Curr Gastroenterol Rep. 2016;18(5):22. doi:10.1007/s11894-016-0496-y

Cares K, Klein M, Thomas R, El-Baba M. Rectal Prolapse in Children: An Update to Causes, Clinical Presentation, and Management. Journal of Pediatric Gastroenterology and Nutrition. 2020;70(2):243-246. doi:10.1097/MPG.0000000000002546

Saadai P, Trappey AF, Langer JL. Surgical Management of Rectal Prolapse in Infants and Children. Eur J Pediatr Surg. 2020;30(05):401-405. doi:10.1055/s-0040-1716725

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are Some Mast Cell Disorders?

Patient Presentation
A 4 month-old male came to clinic for his health maintenance appointment. The parents had no concerns. The patient had been noted to have a single brown lesion on his trunk a couple weeks after birth that would get larger and have some mild erythema around it, and then resolve. The dermatologist thought that it was a solitary mastocytoma and he was started on an antihistamine medication. The parents said that they had not noted any other changes other than it had gotten slightly bigger which they had been told that it could do naturally. “Maybe he’s a little fussier when it gets bigger but it’s hard to tell because of his age,” the mother remarked.

The pertinent physical exam showed a smiling infant with growth parameters around the 10%. The lesion on his right flank was a uniform brown color with discrete edges measuring 18 mm x 15 mm which was slightly larger than the 14 mm x 12 mm measured by the dermatologist. The rest of his examination was normal. The diagnosis of a healthy male with a presumed solitary mastocytoma was made. The parents had an appointment for follow up with dermatology and were to call if they noticed anything different with the lesion especially any systemic problems.

Discussion
Mast cells (MCs) were first discovered by Paul Ehrlich in 1878. Previously in 1869, Nettleship and Tay described a toddler with chronic urticaria and a brown skin lesion which is believed to be the first reported case of mastocytosis. Urticaria pigmentosa was a term first used by Sangster in 1878, and in 1936 the term mastocytosis was used.

“Mast cells first evolved 500 million years ago in Ascidians (sea squirts), providing host innate immunity against bacteria and parasites….MCs gained additional functions regulating inflammation, wound healing, coagulation, adaptive immunity and acute allergic responses.” In the bone marrow they differentiate from common myeloid precursors and the immature MCs leave the bone marrow and begin residing in tissues contacting the external environment such as the skin, gastrointestinal and respiratory tracts. They also reside in spaces surround nerves. MCs mature in their terminal location. MC release a variety of inflammatory mediators when activated including storage granules containing histamine, tryptase and other substances, phospholipid membrane metabolism substances and by synthesizing additional substances such as cytokines and chemokines. Mature MCs have two major subpopulations with one type residing in a particular location but there is interconversion between the two depending on the microenvironment.

Learning Point
As the understanding of mast cells has evolved so has the terminology and classification, and this can be confusing as clinical presentations can have overlapping symptoms as well.

Primary MC disorders are categorized into those that arise because of clonal proliferation (due to a KIT mutation in the growth factor), and those that have exaggerated release of MC contents (possibly due to gene duplication in a trypase gene). In general, children have more cutaneous disease that often resolves. Adults more often have systemic disease and it may not resolve.

Presentations of MC disorders include:

  • Cutaneous
    • Treatment usually is with second or third generation antihistamines and supportive care
    • Common triggers are cutaneous rubbing and exposure to extreme temperatures (especially hot but also cold – which can make bathing difficult). Other triggers include drugs, insect venom, fever, and premenstrual timing in adults.
    • Evaluation can be extensive. Serum typtase may help classify the various types. Bone marrow biopsy may be necessary.
    • Mastocytoma
      • Usually solitary but can be up to 3 lesions
      • Brown to yellow color
      • Trunk and extremities but can affect any area
      • Often present at birth but can show up in first few months of life. Rare in adults
    • Diffuse cutaneous mastocytosis
      • Usually extensive (but not always) involvement with a thickening of the skin. Often referred to as “peau d’orange” or elephant or crocodile skin.
      • Children often have episodic generalized blistering and blistering has worse long-term prognosis
      • Presents at birth or soon after resolves by adolescence usually
      • Can be associated with systemic symptoms such as flushing, gastrointestinal symptoms and rarely hypotension
    • Maculopapular cutaneous mastocytosis/urticaria pigmentosa
      • There are two different subtypes as well
      • Multiple brown to red color lesions that are oval to round in shape. They can coalesce.
      • Can be seen in children with regression by adolescence but usually seen in adults
      • If does not regress, more systemic symptoms are seen in adults.
  • Systemic involvement
    • Treatment is second or third generation antihistamines, MC stabilizing drugs, immunomodulators
    • Mainly seen in adults
    • Problems can include flushing, abdominal pain, diarrhea, muscle aches, bone pain, hypotension, and psychiatry and neurological symptoms.
  • Primary Mast cell activation syndrome
    • Mainly seen in adults
    • Similar presentations for systemic involvement above
  • MC leukemia – can present with fever, hepatosplenomegaly, and weight loss. Prognosis is poor.
  • Other Associations
    • Associated with inflammatory disorders such as asthma, inflammatory bowel disease, chronic urticaria
    • Associated with vascular remodeling in disorders such as retinopathy of prematurity, hypoxic-ischemic encephalopathy and bronchopulmonary dysplasia. Possibly also in sudden infant death syndrome.

Questions for Further Discussion
1. What are common causes of anaphylaxis? A review can be found here
2. What are indications for a bone marrow biopsy?
3. What causes flushing? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Immune System Disorders and Skin Pigmentation Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Matito A, Azana JM, Torrelo A, Alvarez-Twose I. Cutaneous Mastocytosis in Adults and Children. Immunology and Allergy Clinics of North America. 2018;38(3):351-363. doi:10.1016/j.iac.2018.04.001

Bahri R, Custovic A, Korosec P, et al. Mast cell activation test in the diagnosis of allergic disease and anaphylaxis. J Allergy Clin Immunol. 2018;142(2):485-496.e16. doi:10.1016/j.jaci.2018.01.043

Wilcock A, Bahri R, Bulfone-Paus S, Arkwright PD. Mast cell disorders: From infancy to maturity. Allergy. 2019;74(1):53-63. doi:10.1111/all.13657

Author
Donna M. D’Alessandro, MD
Professor of P

When Can Menstrual Suppression Start in Patients with a Disability?

Patient Presentation
A 12-year-old female came to clinic with her mother for her health maintenance visit. She had a seizure disorder, intellectual disability and was non-verbal, but would communicate sometimes through a picture board. She also had limited mobility that primarily allowed her to be up for short time periods at school or home. Her mother said she was doing well at school and in her therapies. She had recently seen her developmental disabilities specialist and orthopaedic surgeon and her ankle-foot orthoses were being updated as she had grown. Her mother said that she had not noticed any pubertal changes but wanted to know what she could expect when she had menarche.

The pertinent physical exam showed an interactive but non-verbal child in her wheelchair. She had microcephaly and some mid-line facial anomalies. Heart, lungs and abdomen were normal. She had increased tone. Tanner stage was 1 for breast and pubic hair.

The diagnosis of a healthy child with developmental disabilities was made.
The pediatrician counseled the mother that she was still pre-pubertal and in the future the family could consider menstrual suppression if they wanted to after she had achieved menarche. “Puberty comes at different times for all girls. All girls should have at least 1 menses so we know that the genital and hormone systems are working correctly. Then there are options for stopping or making her periods more predictable if you want to do that. Usually we use some form of hormones such as birth control pills but there are other choices too. Not only are there the hygiene issues to think about, but for some girls who can’t communicate as well, there can be mood changes or irritability. For girls with seizures, menarche can also change the number of seizures. The hormones themselves could interfere with her seizure medicine so we would need to think about that too if we started her on some medicine for her periods,” the pediatrician offered. The mother was happy with the information and as her daughter had an appointment with her neurologist soon, said she was going to do some more research herself and also discuss the issue with the neurologist.

Discussion
Menstrual suppression using hormonal therapy is commonly used for a variety of reasons:

  • Patient preference
  • Contraception
  • Heavy or painful menses
  • Treatment of concomitant problems such as menstrual migraine, mood issues, nausea
  • Specific patient populations
    • Disabilities
    • Oncology
    • Transgender and gender nonbinary

Methods of suppression include:

  • Estrogen and progesterone
    • Combined oral contraceptives (COC) – very good menstrual suppression and generally used as first line treatment for many patients
      • Traditional dosing with active medication for 21-24 days and then 4-7 day placebo break.
      • Extended cycles – varies with continuous medication for an extended period of time and then planned placebo break, or until breakthrough bleeding occurs and then placebo break of ~4 days.
      • Amenorrhea rate: ~80% at 1 year
      • Potential problems: increased risk of venous thromboembolism in immobile patients, anti-epileptic medication interactions, breakthrough bleeding
    • Vaginal ring – can be placed for 3 weeks and then replaced. When breakthrough bleeding occurs, then ~4 day break is given.
    • Transdermal patch – placed weekly, when breakthrough bleeding occurs, then ~4 day break is given.
  • Progesterone only
    • DMPA (depo-medroxyprogesterone acetate) – given every 12-13 weeks, no specific break is given
      • Amenorrhea rate: ~46% at 1 year
      • Potential problems: weight gain, irregular breathrough bleedings, bone mineral density decreased but can improve after being off the medication.
    • Intrauterine device with levonorgestrel – menstrual suppression is achieved for many, for others they often have oligomenorrhea. Menstrual suppression better with 52 mg IUD that is approved for placement for 5 years.
      • Amenorrhea rate: ~50% at 1 year for the 52 mg IUD, 60% at 5 years of continuous use.
      • Potential problems: may require sedation for placement for some patients
    • Progestin oral contraceptive – can be used but is not as good as COC for menstrual suppression. Side effects may not be tolerable for some patients. Breakthrough bleeding can occur.
  • Estrogen only
    • Nexplenon – estrogen implant
      • Amenorrhea rate: 22%
      • Potential problems: irregular bleeding, may need sedation for placement or removal
  • GnRH-agonist – different formulations but given every 12 weeks. For short term use only.
    • Amenorrhea rate: 100%
    • Potential problems: short term use only as has menopausal symptoms, decreased bone density
  • Surgical
    • Endometrial ablation or hysterectomy have serious long-term risks and therefore are not generally considered for menstrual suppression in the pediatric population. However, for older women these may be appropriate options. Legal and ethical considerations must be addressed as well.

Discussions about specific options and menstrual suppression management may require assistance from appropriate specialists in addition to primary care providers.

Learning Point
Below are menstrual suppression considerations in special populations:

  • Disability patients
    • Common reasons
      • Hygiene
      • Mobility constraints
      • Mood/behavioral issues
      • Contraception
      • Menstrual predictability
      • Safety concerns
      • Seizure management
    • Population has a wide variety of physical and developmental problems and abilities and therefore best choice varies.
      For patients with intellectual and communication disabilities, managing hygiene and mood/behavioral issues are very common. Which option depends on the patient and family wishes. Considerations also include ability to take pills, place rings or patches frequently, or receive injection every few weeks.
      Risks of sedation for placement of some devices and anti-epileptic medication interactions are also important in this patient population.
    • Some families raise the issue of menstrual suppression before menarche. “Although counseling can be conducted, to ensure the absence of an obstructive congenital anomaly, demonstrate a functional hypothalamic-pituitary-gonadal axis and endogenous estrogen production, no method should be initiated before the onset of menses.” [bolding by author]
  • Oncology patients
    • Common reasons
      • Thrombocytopenia from treatment
      • Pretreatment therapy for bone marrow or stem cell transplant
    • Usually this is for short time periods
    • GnRH agonists are preferred method by many oncologists
    • Considerations also include that potential foreign bodies may increase infection or other risks in immunocompromised individuals
  • Transgender patients
    • Common reasons
      • Gender dysphoria
      • Contraception
      • Menstrual predictability
      • Safety issues
    • Usually estrogen containing options are avoided as they can increase feelings of gender dysphoria
    • Using testosterone is also an option in this population for menstrual suppression

Questions for Further Discussion
1. What evaluation can be considered for heavy menstrual bleeding? A review can be found here
2. What are causes of secondary amenorrhea? A review can be found here
3. What are the common sexually transmitted infections in your location and how are they treated?
4. What is the definition of gender dysphoria? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Menstruation and Birth Control.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Chuah I, McRae A, Matthews K, Maguire AM, Steinbeck K. Menstrual management in developmentally delayed adolescent females. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017;57(3):346-350. doi:10.1111/ajo.12595

Pradhan S, Gomez-Lobo V. Hormonal Contraceptives, Intrauterine Devices, Gonadotropin-releasing Hormone Analogues and Testosterone: Menstrual Suppression in Special Adolescent Populations. Journal of Pediatric and Adolescent Gynecology. 2019;32(5):S23-S29. doi:10.1016/j.jpag.2019.04.007

Humphrey KN, Horn PS, Olshavsky L, Reebals L, Standridge SM. Features of Menstruation and Menstruation Management in Individuals with Rett Syndrome. Journal of Pediatric and Adolescent Gynecology. 2021;34(2):144-153. doi:10.1016/j.jpag.2020.11.002

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What are Treatments for Hallux Valgus

Patient Presentation
A 14-year-old female came to clinic with a history of rolling her right ankle over on a player’s foot the evening before at a basketball game. She didn’t feel or hear a “popping” sensation and was able to walk afterwards. She iced the ankle during the evening and in the morning. She complained of pain around the lateral malleolus and also around the 5th metatarsal head of her right foot. She was concerned because state playoff games were to begin in about 10 days. She denied any other foot or extremity pain. The past medical history was positive for a soft tissue wrist injury 1 year previously that healed without problems.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. Her right ankle was mildly swollen without bruising. She was tender anterior to the lateral malleolus and at the 5th metatarsal head. She had no pain in the rest of the foot and ankle. She did have mild great toe pronation with first metatarsal head prominence. This was noted bilaterally.

The radiologic evaluation of foot and ankle radiographs were negative.

The diagnosis of of mild ankle sprain with incidental mild hallux valgus was made. The pediatrician counseled her about supportive care for the ankle with instruction on returning to play. When questioned about the hallux the patient denied any pain, problems with walking, shoe wear or fitting shoes. She said usually wore flatter, open shoes or athletic shoes. The pediatrician noted that hallux can become worse with time, but the family declined seeing a podiatrist or orthotist at that time, and said they would consider it after the state playoff games.

Discussion
Hallux valgus (HV) is commonly called a bunion. The word bunion comes from Greek meaning “turnip.” The great toe is seen to be pronated with a prominent first metatarsal head which can be swollen and painful, which can look like a turnip. They are also called metatarsus primus varus, or metatarsus primus adductus. Angulation can occur in other joints such as at the 5th metatarsal head and is sometimes called “bunionette” or tailor’s bunion. The cause “…for the pathological deformity is considered to be metatarsus primus varus… but there often are other anatomic abnormalities present.” These include distal metatarsal articular angulation, oblique metatarsal-cuneiform articulation, flexible pes planus, long first ray, ligamentous laxity, and metatarsus adductus. Shoe wear and pressure may not be the cause of the deformity but may be the cause of the symptoms such as pain with high heel wearing. Increased or decreased muscle tone may be the cause of the deformity in patients with neurological conditions. HV in children is relatively uncommon, but more common in the adolescent population. However “[i]t is estimated that 40% to 50% of adult bunions actually have their onset in childhood.” Females are more common (up to 80%).

On physical examination it is important to assess if the HV is rigid or flexible. As with many pediatric orthopaedic conditions, rigid deformities are causes for concern. Other abnormalities such as pes planus and metatarsus adductus should be noted. Radiographs of the feet in weight-bearing and non-weight-bearing views help determine the bony pathology, whether or not the growth plates are open or closed, and to evaluate the angles particularly the HV angle. Mild HV deformities are >10 degree angulation, moderate is 25-40 degree angulation and severe is > 40 degree angulation.

Learning Point
Congenital HV is rare and usually treated conservatively with padding and physical therapy.

Juvenile HV occurs in the skeletally immature patient. Usually it is progressive because of the flexibility of the tissues in the foot. Initial treatment is conservative with padding, bracing (e.g. orthotics, splinting, bracing) and physical therapy, but often this still progresses. Orthotists can also counsel on shoe selection. Main indication for surgery is pain and interference with walking or shoe wearing. Angle progression and severity also assist in determining surgical timing. There are numerous (> 100 different) operative treatments but no specific consensus on the optimal treatment. Operating on the skeletally immature foot has increased risk of affecting the growth plates, recurrence and need for surgical revision but the advantage of operating earlier is the process is less advanced. Operating on the skeletally mature foot has the advantages of not affecting the growth plate but the disadvantages of operating when the disease is likely more advanced. Outcomes are age dependent and there is an increased recurrence risk in skeletally immature patients. Recurrence overall is still relatively common. Factors associated with increased risk include hypermobility, hyperlaxity, rheumatoid arthritis, hypothyroidism, neuromuscular condition (e.g. Down Syndrome, Charcot-Marie-tooth, muscular dystrophies, etc.) or cerebrovascular accident, non-compliance with surgical instructions, and continued use of inappropriate footwear such as high heels.

Questions for Further Discussion
1. What are indications for referral to orthopaedics, sports medicine or podiatry?
2. What is club foot and how is it treated? A brief review can be found here
3. What are the Ottawa Ankle Rules? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Toe Injuries and Disorders and Foot Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Raikin SM, Miller AG, Daniel J. Recurrence of Hallux Valgus. Foot and Ankle Clinics. 2014;19(2):259-274. doi:10.1016/j.fcl.2014.02.008

Chell J, Dhar S. Pediatric Hallux Valgus. Foot and Ankle Clinics. 2014;19(2):235-243. doi:10.1016/j.fcl.2014.02.007

Rampal V, Giuliano F. Forefoot malformations, deformities and other congenital defects in children. Orthopaedics & Traumatology: Surgery & Research. 2020;106(1):S115-S123. doi:10.1016/j.otsr.2019.03.021

Bunions – OrthoInfo – AAOS. Accessed October 28, 2021. https://www.orthoinfo.org/en/diseases–conditions/bunions/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa