Pediatric Foot Deformities-2

Professor Freih Abu Hassan

1-Outtoe gait

2- Intoe gait

3- Tip toe gait

4- Flat feet

5- Coalition

6- Cavus foot

7- Equinovarus

8- Equinovalgus

9- Kohler’s disease

10- Sever’s disease

11- Freiberg’s disease

12- Ismelin’s disease

13- Juvenile hallux Valgus

14- Skew foot

Developmental

deformities

At birth Children have 70–90 degrees of passive &

active external rotation of the hip.

In adults 90% have 0-10 degrees of out-toeing

1- Outtoeing

Common under the age of 18 m.

1- Ligamentous laxity

2- Hip external rotators contracture.

3- Relative femoral retroversion

4- External tibial torsion 5- Flexible flat feet

Usually resolves without treatment.

When a child is first starting to

walk, the feet turned out for

stability; they should never be

turned in.

What are the causes of the

intoeing?

Due to the hip, knee, or foot

Or a combination

2- Intoeing.

L TFA R TFA

Clue is the age of the child

= Hip may continue to be internally

rotated till the age of 14

= Tibia int. rotate till the age of 6-7 y

What are the causes toe walking? = Idiopathic (habitual) –they prefer it

= Tight/Short Achilles tendon

= Neurological: CP

= Muscular disorder :DMD

3- Tip toe gait.

= Toe walking is a phase in normal

gait development.

= If the gait does not mature to a heel- toe

by the age of 3 y Physio- and casting

= If >4years lengthening of

Gastrosoleus complex

= If toe walking starts after walking age

check for DMD or spine

4-Flat Feet

No Longitudinal arch

of the foot

1-Pseudo flat Feet in infants

fat in the sole 2-Developmental in children

Excessive body weight

3- Ligamentous laxity

Physiological

P.F to Flexible flat feet

Physical exam = Foot is flat with standing and

reconstitutes with toe walking or

foot hanging.

= Deformity characterized by

Valgus heel

Forefoot abduction- toes sign

Normal subtalar motion

1-Congenital

Pathological

CVT

( Peroneal spasmodic flat feet.)

2- Painful

A-Tarsal coalition.

1-Idiopathic

2- O.O

3- JCA

4- Degenerative

B- Subtalar irritation

Called accessory navicular bone

= The only symptomatic tarsal accessory bone

= Causes painful and palpable prominence

at the inner border of the foot.

= Can cause shoe wear difficulties.

= Total coalition is called “os naviculare

cornutum” as it forms on radiograph a horn

C- Os Tibiale Externum

Surgical excision if non‐op fails

Kidner procedure Excise & advance PTT

= Tight T.A.

= Paralytic

(Polio, C.P, Spina B., Muscle dis. )

3-Neuromuscular

Historical treatment

Prospective

controlled

study

*14% of children never develops

an arch.

*Flat feet do not hinder athletic

activity.

*Many outstanding athletes

have flat feet.

Don’t forget

*Shoes will never correct

any type of flat feet.

*Effective R/ of Parents.

*Correct diagnosis

(flexible VS rigid)

Normal child needs normal shoes

Special shoes or inserts only for

abnormal children

e.g Neuromuscular diseases

5-Tarsal Coalution

• Disorder of mesenchymal segmentation

• 50% bilateral

• 90% CN or TC

• May be bony, cartilaginous or fibrous

• Multiple coalitions may exist in same foot

• Leading cause of peroneal spastic flatfoot

• Hindfoot pain aggravated by activity

• Repeated Ankle sprains

Physical exam = Limited subtalar motion

= Heel cord contractures

• Become symptomatic when

coalition ossifies

–Talonavicular 3-5y

–Calcaneonavicular 8-12y

–Talocalcaneal 12-16y

• X-Rays:

–CN • Oblique View calcaneonavicular

• Lateral – “anteater” sign

–TC • Narrowed posterior subtalar joint

• Ring or C sign of Lefleur • Harris axial view - irregular middle facet

C‐sign of Lefleur Harris axial view

CT scan = identify coaliton and cross-sectional

area of a coalition

MRI Helpful to visualize a fibrous or

cartilagenous coalition

• Asymptomatic - observation

• Symptomatic:

– Non-operative

• activity modification

• orthotics

• short leg walking cast for 6 weeks

– Operative

• Resection

• Fusion

• Calcaneonavicular

– Excision & EDB interposition or fat graft

• Talocalcaneal

• Resection

• Calc lengthening osteotomy in unresectable

bar & excessive valgus deformity

• Subtalar arthrodesis in (subtalar OA)

• Triple arthrodesis in (midfoot OA)

6-Cavovarus Foot

Elevated longitudinal arch caused by fixed

plantar flexion of the forefoot

80% neurogenic in etiology = Charcot-Marie-Tooth

= Freidreich's ataxia

= Cerebral palsy

= Polio

= Spinal cord lesions

(Syringomylia, tumor, Spina Bifida)

• Non neurological causes include:

– Idiopathic

– CTEV, AMC

– Traumatic

• Compartment syndrome

Muscles Imbalance

Cavus (How it happens)

Always look for spinal dysraphism

Charcot-Marie-Tooth

Flexible hindfoot

will correct to neutral when block

placed under lateral aspect of foot

Rigid hindfoot

will not correct into neutral

Coleman block test To evaluate flexibility of hindfoot

Pt. Stands with 1st ray hanging

over the edge

Soft tissue procedures = Transfer posterior tibialis to dorsum of

foot to improve foot drop (augment weak

tibialis anterior)

= Dorsiflexion 1st metatarsal osteotomy

and transfer of EHL to neck of 1st MT

when hallux clawing combined with cavus foot

Flexible hindfoot cavus deformities

(normal Coleman block test)

Non-operative: well moulded orthosis

Rigid hindfoot cavus deformities

(abnormal Coleman block test)

= Calcaneal valgus osteotomy combine with soft tissue procedure

= Dorsal cuneiform ostetomy

= Arthrodesis/Ilizarov

7-Equinovarus Foot

Common foot deformity seen with

= CP (usually spastic hemiplegia)

= Duchenne muscular dystrophy

= Residual clubfoot deformity

= Tibial deficiency (hemimelia)

Muscle imbalance includes

spasticity of

= Tibialis posterior

and/or tibialis anterior

= Gastoc-soleus complex

Confusion test

To distinguish AT vs PT as the

primarily involved muscle.

Patient performs active hip

flexion against resistance

while seated

if the foot supinates with

dorsiflexion, tibialis anterior is

most likely contributing to the

equinovarus deformity

Operative TAL with tibialis posterior split transfer

to peroneus brevis, in

= Spastic hemiplegia ages 4 to 7

= Flexible equinovarus hindfoot

Rancho procedure Overactive anterior tibialis flexible equinovarus deformity

Split anterior tibialis transfer to

cuboid with TAL

Calcaneal osteotomy

in a rigid hindfoot varus deformity

lateral closing wedge osteotomy

8-Equinovalgus Foot

Deformity consists of Midfoot abduction

Heel valgus

Equinus contracture

Typically bilateral

Muscle imbalance includes -Spasticity of

Peroneals

Gastoc-soleus complex

-Weakness of

Posterior tibialis

Anterior tibialis

Operative Calcaneal osteotomy with soft tissue

procedure for rigid deformities

Soft tissue procedures

TAL, Peroneus brevis lengthening

Bony procedures

Calcaneal osteotomy

medial slide ostetomy or calcaneal

lengthening osteotomy

lateral column lengthening through calcaneus or cuboid

Grice procedure Extraarticular subtalar arthrodesis

to block valgus

Subtalar arthroeresis stabalizes subtalar joint in correct

alignment without fusion

implant or spacer is placed laterally in the

subtalar joint to prop open

9-Kohler’s Disease

• AVN of navicular due to repetitive

compressive forces

• Males (5:1) / around 5 years of age

• X-Ray - flattening, sclerosis,

irregularity of navicular

• Treatment

= Short leg walking cast

• self limiting

• symptoms typically resolve in 7 to 15

months

• Prognosis excellent

10-Sever’s Disease

Traction apophysitis

• Heel pain & tenderness, aggravated by activity & relieved by rest

• Decreased ankle dorsiflexion

• Normal X-Rays

- Sclerosis and fragmentation of calcaneal

apophysis normal variant

• Treatment:

Activity modification, rest, heel cushion,

stretches, NSAIDS, cast.

Resorption, fragmentation,

and increased

sclerosis leading

to eventual union .

Fragmentation of the

apophysis is not diagnostic

because multiple centers of

ossification may exist in the

normal apophysis

11-Frieberg’s Infarction

• AVN usually of 2nd MT head due to vascular insufficiency 2ry to chronic stress

• Adolescents (>13y); 80% female

• X-Ray: MT head flattening and irregularity

• Treatment:

–Non-operative •metatarsal pad

–Operative •Curettage & bone graft

•Extension osteotomy

• Traction apophysitis of the tuberosity of 5th metatarsal

• Seen in physically active child 8 - 13 y of age.

Treatment

rest, activity modification, ice

12-Iselin disease

Metatarsus primus varus

13-Juvenile hallux valgus

Non-operative treatment

= Wide shoes or sneakers

= Avoid narrow shoes and high heels.

Surgical treatment Restricted until the end of growth.

= Concern for damage to the growth plate

= The condition tends to recur.

14-Skewfoot

= Rare complex foot deformity of mal-

alignment of the tarsals & metatarsals

= Clinically (forefoot adduction and

hindfoot valgus)

=Synonyms include S-shaped foot ,

serpentine foot, and Z-foot deformity

= Never been recorded at birth

= Often discovered after cast treatment

for metatarsus adductus or clubfoot

= Shoewear and abnormal gait

= Forefoot adducted and increased heel

valgus( +/- Achilles tendon contracture)

= Can develop painful callosities and bursa

Clinical Features

Treatment

= Manipulations & serial casting if

discovered in infancy

= Symptomatic : modifications in shoewear

= Surgical treatment

In older patients who have failed

conservative treatment

need to correct all components of deformity

Surgical Options

= Tarsometatarsal capsulotomies with

Grice subtalar arthrodesis

= Medial cuneiform opening-wedge

osteotomy with plantar fasciotomy

= Calcaneal lengthening osteotomy,

Medial cuneiform opening wedge

osteotomy, and ETA