Common Foot Abnormalities - PowerPoint Presentation

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Common Foot Abnormalities

3rd annual art & practice of pediatric orthopedics for the pcpFriday, October 26, 2018Jeana Summers, DO

­­      Jeana Lyn Summers, DO Pediatric Orthopaedic Fellow  http://www.phoenixchildrens.org jsummers1@phoenixchildrens.com

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Objectives

Discuss normal pediatric foot anatomy/imagingIdentify commonly seen conditions of the pediatric foot and recognize abnormalities Discuss non-operative treatment options in the primary care settingIdentify when to refer to an orthopedist and what studies to obtain prior to referral

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outline

Foot anatomyXray analysisCommon termsCommon pediatric foot conditionsMetatarsus adductusCavus deformitiesPlanus deformitiesOsteochondrosesToe conditions

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Shock absorption at heel strike

Stability during weight bearingLevel arm for force generation

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xray

1 yr

2 yr3 yr4yr5yr6yr

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2y

4y

6y8y

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Equinus

VarusValgusPronation/supinationCavusCalcaneusAbductionAdduction Calcaneal valgusEquino varusEquino

cavo varusPlano valgusAbducto plano valgusEquino plano valgusCalcaneal cavusCavo varus

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Equinus:

latin – relating to horses

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Varus = Inversion

Valgus = Eversion

PronationSupination

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Cavus

= hollow arch

Abduction = away from midlineAdduction = Towards midline

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Common pediatric foot conditions

Metatarsus adductusCavus deformities:Charcot-Marie-Tooth (CMT) DiseaseClubfoot (congenital talipes equinovarus)Cavovarus Equinovarus Equinovalgus Planus deformities:Tarsal coalitionCongenital vertical talusFlexible pes planovalgus (flexible flatfoot)

Accessory navicularCalcaneovalgus footOsteochondrosesKohler’s diseaseIselin’s diseaseSever’s diseaseToe conditionsSyndactylyPolydactyly

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Metatarsus adductus

Adduction of forefoot (at TMT joint)/normal hindfoot alignmentPackaging disorder1 in 1,000 birthsNormally, the heel bisector line goes through the 2nd and 3rd webspaceMid – heel bisector line through 3rd toeModerate – heel bisector line through 3rd

& 4th webspaceSevere – heel bisector through 4th and 5th webspaceSpontaneously resolve in 90% of cases by age 45% more will resolve in early walking years (age 1-4)

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Cavus deformities

Charcot-Marie-Tooth (CMT) DiseaseClubfoot (congenital talipes equinovarus)Cavovarus Equinovarus Equinovalgus

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CMT

Hereditary motor sensory neuropathyAutosomal dominant Peripheral myelin protein 22 (PMP22)Duplication on chromosome 17Weakness inperoneus brevistibialis anteriorintrinsic muscles

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clubfoot

Congenital talipes equinovarusMost common musculoskeletal birth defect80% isolated deformityMuscle contracturesCavus (tight intrinsics, FHL, FDL)Adductus of forefoot (tight tibialis posterior)Varus (tight tendoachilles, tibialis posterior, tibialis anterior)Equinus (tight tendoachilles)Bony deformitiesTalar neck is medially and plantarly deviatedCalcaneus is in varus and rotated medially around talus

Navicular and cuboid are displaced medially

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Sometimes diagnosed in utero

Seen on ultrasoundGet established with orthopedist so parents can discuss treatment prior to birthAssociated anomalies very common when diagnosed in 1st trimesterTrue clubfeet normally diagnosed during 2nd trimester (anomalies are less common)False positive rate is higher due to higher probability of intrauterine crowding in 3rd

trimester

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Clubfoot treatment

Ponseti method >90% success rate to avoid comprehensive surgical releaseExpect to walk, run, and be fully active Goal is to correct in the following order:CavusAdductusVarusE

quinusFoot abduction orthosis critical for longterm successUse full time x3mos and then at night (=/- naps) for 2-4 years

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Silverskold test

Check dorsiflexion with both knee flexion and extensionIf tight only with knee extension, gastrocnemius is tightIf also tight with knee flexion, then soleus is also tight

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Cavovarus

Elevated longitudinal arch (cavus)Plantarflexion of 1st rayForefoot pronationHindfoot varusForefoot adductionWeak tib ant and peroneus brevis overpowered by strong peroneus longus and post tib

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Equinovarus

Commonly seen withCPDMDResidual clubfootSpina bifidaTibial deficiencyImbalance: invertors overpower evertorsRelative overpull of tib post and/or tib ant and gastrocsoleus

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Equinovalgus

Commonly seen withIdiopathic flatfoot CP (spastic diplegia and quadriplegia)Spina bifidaFibular hemimeliaTypically bilateralDeformities:Midfoot abductionHindfoot valgusEquinus

contractureMay have forefoot supination Develop instability during push off and external foot progression

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Confusion test

Used in patients with poor selective motor control (i.e. CP)These patients cannot dorsiflex foot when askedPatient performs active hip flexion while seatedResults in ankle dorsiflexion due to mass action pattern of legIf the foot supinates with dorsiflexion, the tib ant is likely contributing to the varus deformity

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Planus deformities

Tarsal coalitionCongenital vertical talusFlexible pes planovalgus (flexible flatfoot)Accessory navicularCalcaneovalgus foot

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Tarsal coalition

Calcaneonavicular tarsal coalitionUsually 8-12 years oldAnteater sign on XRTalocalcaneal Usually 12-15 years oldTalar beaking on lateral XRC-sign

Flattening of longitudinal archAbduction of forefootValgus hindfootPeroneal spasticityFailure of mesenchymal segmentation  coalition between 2 or 3 tarsal bonesPain theories:Microfracture at coalition bone interfaceSecondary chondral damage or degenerative changesOssification of previously fibrous or cartilaginous coalitionIncreased stress on other hindfoot jointsCT to rule out additional coalitions (5%) and determine size, location, and extent

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Congenital vertical

talusRocker bottom footCommonly associated withMyelodysplasiaArthrogryposisDiastematomyeliaChromosomal abnormalitiesTreatmentSurgical treatment is often necessary

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Flexible pes planovalgus

Decreased medial longitudinal arch25% are associated with gastrocnemius-soleus contracturesFoot is flat during standing and reconstitutes with toe walking, hallux dorsiflexion, or foot hangingRule out:Tarsal coalition (pain at sinus tarsi)Congenital vertical talus (rocker bottom foot)Accessory navicular (focal pain at navicular)Treatment:Observation, stretching, shoe wear modifications, orthoticsArch will redevelop with ageAchilles tendon or gastroc lengthening

Calcaneal lengthening osteotomy (possible cuneiform osteotomy)

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Coleman block test

Evaluates hindfoot flexibility and pronation of forefootPlace 1” block under lateral footAllow 1st, 2nd, and 3rd MT to hang freely into plantar flexion and pronationEliminates the contribution of the plantarflexed 1st ray and forefoot pronation to the hindfoot deformityFlexible hindfoot will correct to neutral or valgus when block is placed under lateral aspect of foot

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Accessory navicular

Normal variant in up to 12% of the populationMajority are asymptomaticPlantar medial enlargement of the navicular boneAssociated with flat feet and posterior tibial tendon insufficiency XR: AP/lateral/external oblique (best view)Treatment:Activity restriction, shoe modification, NSAIDsCast immobilizationexcisionMost children and adolescents who have symptoms will be asymptomatic when they reach skeletal maturity

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Calcaneovalgus foot

Packaging issueLooks similar to vertical talusXRAP/lateral tibia – evaluate for posteromedial bowingPlantar flexion lateral XR Treatment:Observation and passive stretching exercisesTypically resolves spontaneously by 3-6 months Cast

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Osteochondroses:

Kohler’s diseaseAVN of navicular bone4-7yo4x more common in boys than girlsCentral 1/3 of the navicular is a watershed zonePain in dorsomedial midfootXR:Sclerosis, fragmentation, and flattening of navicularTypically self-limiting

Intermittent symptoms 1-3 yrs after diagnosis –NSAIDsImmobilization with short walking cast

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Osteochondroses: Iselin’s disease

Traction apophysitis of the tuberosity of the 5th metatarsal8-13yoCommon in active kids who play sports with repetitive inversion stressPain with resisted eversion and extreme plantar flexionXR: enlarged apophysis with disordered ossification and widened chondro

-osseous junctionTreatment: stretching, rest, activity modification, icingCast immobilizationSurgical excision

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OSTEOCHONDROSES: Sever’s

diseaseOveruse injury of the calcaneal apophysisSeen in immature athletes who participate in running and jumping sportsTraction apophysitis secondary to repetitive microtrauma experienced during gait (similar to Osgood Schlatter’s

Disease)Typically self-limitingActivity modificationAchilles tendon stretches (can help decrease recurrence)Ice application before and after athleticsHeel cups/heel padsNSAIDsShort leg cast for immobilization, if pain persists

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Toe conditions: Syndactyly

1 in 2,000 birthsMost frequently between 2nd and 3rd toeDue to incomplete or absent apoptosis during gestationAutosomal dominantTypes:Simple – soft tissue onlyComplex – bony fusionUsually painless with cosmetic concerns onlyMay perform digital release for complex syndactyly or for aesthetic reasons in simple forms

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Too many little piggies

: PolydactylyExtra digits 1 in 500 birthsPostaxial (lateral side of foot) is most commonFailure of differentiation in apical ectodermal ridge during 1st trimester of pregnancyAutosomal dominantRemoval of extra digit performed at 9-12 months of ageSmall skin tags can be removed in newborn nursery

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Thank you!

Questions?