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Congenital talipes equinovarus (CTEV) is a condition of the lower limb in which there is fixed structural cavus, forefoot adductus, hindfoot varus and ankle equinus. In Caucasian populations the incidence is around 1.2 per 1,000 live births, with a male to female ratio of 2.25:1. The left and right feet are equally commonly affected, and 50% of cases are bilateral. It is important to differentiate CTEV from a non-structural or positional talipes which is fully correctable. This positional variant occurs about five times as commonly as CTEV. The latter condition does not require casting or surgical treatment. The majority of CTEV cases are picked up at the early baby check or on prenatal ultrasound, and referred to the paediatric orthopaedic service. However, some cases are mistaken early on as the positional variant, and may therefore present to the GP e.g. at the six week check. Urgent referral is warranted as the Ponseti treatment should be started early. The feet must be examined directly to see if the components of the deformity are fixed, defining CTEV. The hips (stability, length equivalence, range and symmetry of abduction) and spine (in particular looking for peripheral stigmata of spina bifida) must also be examined. Most cases of CTEV occur in isolation i.e. without other anomalies. However, a proportion are syndromic. In a recent study of patients with fixed CTEV, 27.7% had a syndromal cause. Over the past 25 years there has been a dramatic shift away from extensive surgical releases to manipulative methods/serial casting such as the Ponseti technique. The technique involves a series of manipulations and casts, usually on a weekly basis, in which the foot is brought round to a corrected position. The boots and bar splintage is a vital part of the Ponseti technique and relapse is strongly correlated with non-compliance.

The hip and proximate tissues are implicated in a variety of childhood conditions, and in the differential diagnosis of many more. To a large extent the possible diagnoses are limited by the child's age, an accurate history and thorough examination. Developmental dysplasia of the hip (DDH) is a spectrum disorder of joint development and/or instability. It is a major cause of morbidity in children and adults. It can be classified into three types: neuromuscular; teratological; and idiopathic (the most common type). Examination of the hips is carried out neonatally using Ortolani and Barlow manoeuvres to look for dislocation. These tests have high sensitivity but low specificity, and this is one reason why DDH is still picked up late. When a limping child presents it is important that the less common diagnoses, including infection, neoplasia and slipped femoral epiphysis are kept in mind and urgent referral made if necessary. In one study, where a diagnosis was made, the hip joint was the culprit in the majority of cases. Of these, 40% were diagnosed as irritable hip or transient synovitis. Other inflammatory arthritides/tendinoses accounted for 3.2%, Perthes' disease 2%, and infection 3.6%. Any age group is vulnerable to infection such as septic arthritis, osteomyelitis and pelvic pyomyositis. Early diagnosis and treatment, comprising antibiotics with or without surgery, is critical. In the limping child, fever with focal tenderness or restricted range of movement is indicative of infection unless investigations show otherwise.