Bone Disorders in Children — with Dr. Roshan Gunalan (SJMC)

In this episode of Medifly Podcast, consultant paediatric orthopaedic surgeon Dr. Roshan Gunalan explains the most common bone and joint conditions seen in children — including bow legs, knock knees, flat feet, club foot, and hip dysplasia — clarifying which presentations are normal physiological variants and which require treatment. He emphasises that the timing of any intervention is critical because children's bones are growing and dynamic, unlike those of adults. Dr. Roshan also debunks the popular myth that wearing nappies causes bow legs, and outlines the Ponseti method for treating club foot.

Host: Dr. Roshan Gunalan, consultant orthopaedic surgeon at Subang Jaya Medical Centre, specialising in paediatric orthopaedics, limb lengthening, and deformity surgery.

Welcome & Introduction

Host: Hi everyone, welcome back to Medifly Podcast. Today I'm still at Subang Jaya Medical Centre, but with a different doctor. I'm with Dr. Roshan Gunalan, a consultant orthopaedic surgeon here. Thank you very much, doctor, for agreeing to be on this podcast. Would it be okay if you introduced yourself?

Dr. Roshan Gunalan: No problem. I work at Subang Jaya Medical Centre as a consultant orthopaedic surgeon. My main specialty is dealing with paediatric orthopaedics — children with any bone or joint problems, as well as limb deformities, and general trauma, injuries, and fractures.

Host: You went to Dublin and then came back to Malaysia?

Dr. Roshan Gunalan: That's right. I did my undergraduate degree in Dublin, and after I completed that I moved back to work in Malaysia in my early days as a doctor.

Choosing Paediatric Orthopaedics as a Subspecialty

Host: What made you choose paediatrics, doctor?

Dr. Roshan Gunalan: In general, we do orthopaedics first and then subspecialise into different fields. Orthopaedics in Malaysia actually has nine different subspecialties — joint replacements, spine surgery, tumours, hand and micro surgery, and so on. The one I do is paediatrics as well as limb lengthening and deformity surgery.

I started working at University Malaya in 2011, and from there I was in the unit together with Professor Saw Aik, who is quite well known in Malaysia for paediatric orthopaedic conditions. Early on he guided me toward this field — and even took me overseas to introduce me to other specialists. It is not a very large or lucrative specialty; in Malaysia we probably have only about 25 to 30 paediatric orthopaedic surgeons who are fully qualified in that sense.

The Most Common Paediatric Orthopaedic Presentations

Host: After doing this for so long, what are the most common paediatric orthopaedic problems you see?

Dr. Roshan Gunalan: It varies quite a lot because you see a wide range of ages. The very young present differently; older children have different issues. But the majority present with limb problems — they walk a little oddly, the position of their limbs is not correct, or they come in with pain or infections. The most common presentations are generally related to gait, walking pattern, or an obvious deformity.

Bow Legs & Knock Knees

Host: What about bow legs and knock knees?

Dr. Roshan Gunalan: That is one of the most common things we see, and this is a very important point in paediatric orthopaedics. Bow legs and knock knees have a very large physiological component — meaning it is normal and changes over time.

When a child is born and during the first 2 to 2½ years, their legs are generally a little bowed. Around 3 to 4 years old they go in the opposite direction into what is called a valgus position — an X shape. They reach adult alignment only at around 8 to 10 years of age.

The key aim is to differentiate between the physiological variant and the pathological variant. The pathological variant occurs in only about 5% of children. In that 5%, the bowing does not follow the normal pattern — it actually gets worse as the child gets older, leading to knee pain and falling.

"95% of bow legs and knock knees are physiological — meaning normal. The aim is to assess each child and differentiate whether it's a physiological or a pathological type."

Host: Is it painful for the children?

Dr. Roshan Gunalan: Most of the time, no. Bow legs and knock knees are generally painless conditions. The way the child stands and walks looks a little abnormal, but the majority are fully functional — they can run, jump, and climb even with the leg position as it is.

Host: At what point do parents know it's physiological or not?

Dr. Roshan Gunalan: The timing of any intervention is very, very important. Some parents want it treated early, but that is not the right approach. Generally, the correct treatment age is usually two to three years. If you treat a bow leg too early, the child can end up going in the opposite direction. If you treat it too late, it becomes more difficult. Treatment is very time-specific, based on the age of the child and the type of condition.

Host: Does early walking play a role?

Dr. Roshan Gunalan: Yes, development plays a part. Children who tend to walk a little earlier actually tend to develop a little more bow leg initially, because they start putting weight on the immature bone earlier.

The Nappies (Pampers) Myth

Host: One myth that Indonesian or Asian parents often believe is that wearing nappies causes a child to walk bow-legged. Is that a myth?

Dr. Roshan Gunalan: Yes, it's probably a myth. Wearing nappies, carrying, swaddling — none of that actually plays a part in bow legs or knock knees. This is about the shape of the bone. If the bone itself is curved, whatever you put on top makes no difference. The foundation is the bone.

"Whatever you wrap around the child, whatever shoes you put on — if the shape of the bone is curved, the leg is going to be curved. The foundation is the bone."

Flat Feet

Dr. Roshan Gunalan: Flat feet is actually one of the most common conditions I see in the outpatient clinic. Like bow legs, it is divided into two categories: physiological (flexible) and pathological.

The arch of the foot does not technically develop fully until the age of 7 or 8. So a one-year-old presenting with flat foot is generally expected. Majority of cases are what is called a flexible flat foot — meaning the bones and joints inside are normal, but the supporting muscle is a little weak. When these children tiptoe, you can actually see the arch reconstitute itself.

• Flexible flat foot that is painless: Does not require much treatment. Strengthening exercises are sufficient, and the arch gradually develops.
• Flexible flat foot that is painful: Will need treatment. Any condition that causes pain requires treatment.
• Rigid (pathological) flat foot: Not flexible at all; generally requires some form of treatment.

Host: Where does the pain occur?

Dr. Roshan Gunalan: The foot is a very complex structure with many small joints and ligaments. When the alignment is off and the child is active, some joints tend to wear out faster. The pain can occur at the foot itself, at the top of the foot, or even further up the leg — sometimes children present with knee pain that is actually caused by an unstable or rigid flat foot base.

Hypermobility & Childhood Clumsiness

Host: When I was a child, I would fall over suddenly without any obstacle. Could that be related to flat foot?

Dr. Roshan Gunalan: Flat foot generally does not cause someone to fall. However, there is a condition called hypermobility or hyperlaxity that can contribute to children falling more often than they should. These children tend to be a little clumsy, tend to have some flat foot, and sometimes have very non-specific pains here and there — especially in the 6 to 10 years age group. So it is not necessarily due to flat foot.

Club Foot

Host: What about a foot that turns inward — is that club foot? Is it common?

Dr. Roshan Gunalan: Club foot is not common in the general population — approximately one in a thousand — but I see it regularly because I treat it. There is a genetic component to club foot, and it develops during the formation of the muscles, bones, and joints in the womb. Honestly, there are more theories than actual proven facts as to why it happens.

Like the other conditions, club foot exists on a spectrum:

• Positional (flexible) club foot: The foot looks turned inward at birth but is supple and flexible. It does not need active treatment — stretching exercises are sufficient and the foot returns to a normal position as the child grows.
• Rigid (pathological) club foot: Requires formal treatment.

The Ponseti Method

Host: I heard there is something called the Ponseti method?

Dr. Roshan Gunalan: Correct. The Ponseti method is currently the standard treatment for rigid club foot in Malaysia and in many countries worldwide. It works on the principle that if you stretch a muscle and maintain that stretch for a period of time, it will lengthen — the tendons lengthen.

The process is called serial casting:

1. A cast is applied to the child's foot.
2. Every week the cast is changed and the foot is gently manipulated into a better position.
3. This continues for approximately five to six weeks, gradually moving the foot back into correct alignment.
4. After casting, a small procedure may be performed to lengthen the tendon at the back of the ankle.
5. The child then goes into a foot abduction orthosis (a specialised brace/shoe) to maintain the correction achieved.

The orthosis is worn for 23 hours a day for the first three months — one hour is allowed for bathing and free time. After three months, it is worn only during sleep (naps and overnight) until the child is approximately four to five years old.

"This is not a 'come today, cure tomorrow' condition. They are with you for five to six weeks, every week changing the cast. It is not an easy process."

The success rate is very good if the child is treated early, but compliance is the biggest challenge. No child is comfortable wearing the orthosis, and when the child cries, parental compliance drops. If the orthosis is stopped early, the club foot recurs and the entire treatment process must begin again.

"Once you stop using the orthosis, the club foot recurs — it starts to bend inward again. You have to push through the initial phase and make sure they use it."

Hip Dysplasia

Host: What about hip dysplasia? Is that also something you see?

Dr. Roshan Gunalan: It is not super common in the general population, but it does occur. Hip dysplasia is a spectrum of disorders — ranging from a mild click in the hip at birth with nothing else wrong, all the way to a severely dislocated hip that cannot move.

The hip is a ball-and-socket joint. In hip dysplasia, the socket is flat rather than round, and the femoral head (the ball) can also be less rounded, so it slips off easily — an unstable hip.

Most cases are picked up early through neonatal screening performed by the paediatrician, although there can be some variation in accuracy since it is a clinical test.

Treatment varies with age, but all treatments share one single aim: to bring the ball and socket into contact. When the femoral head and the acetabulum are in contact, the child's growth drives remodelling and healing. No contact means no healing.

• 0 to 6 months: A Pavlik harness (a brace) or double-nappying to hold the leg in position.
• Older infants: A spica (cement) cast to hold the position.
• Older children: Surgery — dividing the bone, realigning it, and fixing with wires, plates, and screws.

"The aim is the same regardless of age — bring the ball and socket together. When you're younger it's just positioning; as the child grows, the joint forms back into a proper shape. Contact between the femoral head and the acetabulum is everything."

Hip dysplasia is generally painless in the early years, which is why it can be missed. In adulthood, an untreated dysplastic hip leads to significant complications — which is precisely why early detection and treatment matter so much.

The Role of Maternal Nutrition & Genetics

Host: How much does the mother's nutrition during pregnancy — such as calcium intake — affect the child's bone health?

Dr. Roshan Gunalan: Nutrition does play a part, and being malnourished or having certain deficiencies can contribute to bone issues in a child. However, the majority of bone diseases in children are either metabolic in cause or congenital. That means even a healthy, well-nourished mother can have a child with a genetic component causing conditions like brittle bones or hip dysplasia. You cannot attribute these conditions solely to maternal diet.

Key Advice for Parents

Host: If you had one piece of advice for parents about their children's bone health, what would it be?

Dr. Roshan Gunalan: A few important points:

• Children are not just small adults. The conditions we see, the responses to treatment, and even the way fractures heal are all different from adults.
• The child is growing — treatment is time-specific. For conditions like club foot and hip dysplasia, early detection means better prognosis and more predictable outcomes. For bow legs, knock knees, and flat feet, there is also a specific treatment window — you cannot simply treat everyone early and expect it to work.
• If you notice abnormal walking or limping, get it checked. The majority of the time it may well be a physiological variant requiring only reassurance and monitoring. But if the small percentage of pathological cases are missed, treatment becomes significantly more difficult as the child grows, and can lead to further complications in adulthood.
• Often it is not the parents but a relative — a grandmother or an aunt — who first notices something is not right. Take that observation seriously and seek an assessment.

"Children are not just small adults. The pathologies we see, the response to treatment, and even how they heal from fractures — all of it is different from adults."

Closing Remarks

Host: Thank you very much, Doctor. For everyone who wants to know more about Dr. Roshan's work, he is based at Subang Jaya Medical Centre. Leave any questions in the comments below. Thank you again, Dr. Roshan.

Dr. Roshan Gunalan: My pleasure. Thank you.

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