evaluation of pediatric foot pain - lieberman's...
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John Flibotte, MS IIIGillian Lieberman, MD
Evaluation of Pediatric Foot Pain
John Flibotte, Harvard Medical School Year IIIGillian Lieberman, MD
May 2006
John Flibotte, MS III Gillian Lieberman, MD
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Our Patient…
AP is a 10 year old boy with chronic R foot pain
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Anatomy of the Foot
Manusov EG, et al. (1996), Part II
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DDX of Pediatric Foot PainForefoot/ Midfoot
•Overlapping/ Curly Toes
•Accessory Navicular
•Osteomyelitis •Onychocryptosis (Ingrown Nail)
•Hallux Valgus
•Turf Toe
•Sesamoiditis
•Sesamoid Stress Fx
•Frieberg’s Disease (AVN of second metatarsal epiphysis)
•Stress Fracture
•Fracture
•Kohler’s Disease (Ischemic Necrosis of Navicular)
•Bone Cysts
•Ewing’s Sarcoma
•Osteoid Osteoma
•Synovial Sarcoma
Structural Abnormality
Infectious Repetitive/ Acute Trauma
Tumor/ Growth
Foot Pain
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DDX of Pediatric Foot Pain
Structural Abnormality
Infectious Repetitive/ Acute Trauma
Tumor/ Growth
Foot Pain
•Pes Planus (Flatfoot)
•Flexible
•Rigid Tarsal Coalition
•Os Trigonum Syndrome
•Osteomyelitis •Plantar Fasciitis
•Calcaneal Apophysitis (Sever’s Disease)
•Calcaneal Stress Fx
•Retrocalcaneal Bursitis (Haghund’s Disease)
•Lisfranc Joint Sprain
•Ankle Sprain
•Osteochondritis dessicans
•Fracture
•Bone Cysts
•Ewing’s Sarcoma
•Osteoid Osteoma
•Synovial Sarcoma
Hindfoot Pain
Manusov EG, et al. (1996), Parts I & II
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Anatomy of the Calcaneus
http://education.yahoo.com/reference/gray/subjects/subject?id=63
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Anatomy of the Talus-1Lateral View Medial View
http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1
Navicular Facet
Tibial FacetFibular Facet
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Anatomy of the Talus-2
Navicular Facet
Middle Articular Facet (for sustentaculum tali)
Posterior Articular Facet
Inferior Aspect
http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1
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Standard Views of the Foot
• Lateral
• Oblique
• Anteroposterior-----------------------------------------------------------One Special View: Harris Beath View
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Obtaining a Lateral View
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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Normal Lateral Radiograph of Foot
http://www.rad.washington.edu/RadAnat/FootLateral.html
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Normal Lateral Radiograph of Foot
http://www.rad.washington.edu/RadAnat/FootLateralLabelled.html
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Oblique Radiograph of Foot
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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Normal Oblique Radiograph of Foot
http://www.rad.washington.edu/RadAnat/FootOblique.html http://www.rad.washington.edu/RadAnat/FootOblique Labelled.html
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AP View of the Foot
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
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Normal AP Radiograph of the Foot
http://www.rad.washington.edu/RadAnat/FootAPLabelled.htmlhttp://www.rad.washington.edu/RadAnat/FootAP.html
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Obtaining the Harris Beath View
http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html
John Flibotte, MS IIIGillian Lieberman, MD
Our Patient’s Initial Radiographs
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Our Patient’s Lateral Views
Children’s Hospital Boston
Loss of Foot ArchNarrowed Joint Space
Narrowed Joint Space
Loss of Middle Facet Space
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Our Patient’s Oblique Views
Children’s Hospital Boston
Normal Appearance
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Patient’s Harris Beath Views
LR
Children’s Hospital Boston
Loss of Talocalcaneal Joint Space Loss of Talocalcaneal Joint
Space
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Patient’s Coronal CT
Children’s Hospital BostonBilateral Bony Fusion
John Flibotte, MS IIIGillian Lieberman, MD
Diagnosis:
Talocalcaneal coalition
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Discussion of Coalition• Results from abnormal differentiation and
segmentation of primitive mesenchyme with resultant lack of joint formation
• Postulated autosomal dominant inheritance with variable penetrance
• 50%-60% are Bilateral• Prevalence 1-2%• Can occur between any tarsal bone;
talocalcaneal and calcaneonavicular coalitions are most common
Newman & Newberg (2000)
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Types of Coalition
• Osseous
• Fibrous
• Cartilaginous
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Pathogenesis of CoalitionLimitation of Normal Subtalar & Midfoot
Motion
Inflammation of Involved Joints
Irritation of Peroneal Tendon Crossing Subtalar Joint
Peroneal Tendon Spasm
“Peroneal Spastic” Rigid Flatfoot
Manusov EG, et al. (1996), Part II
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Talocalcaneal Coalition-1• Coalition between the talus calcaneus
– Most commonly between middle facet of talus and sustentaculum tali of calcaneus
• Represents 48% of all Tarsal Coalitions• Typically become symptomatic in 8-12 y.o. children• Imaging Modalities:
– Difficult to see on standard views– May be suggested by loss of foot arch – Harris Beath View to demonstrate subtalar joint– May need fine-cut CT– May also be seen on MRI– If a bone scan is done, will show as area of increased uptake
Newman & Newberg (2000)
John Flibotte, MS III Gillian Lieberman, MD
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Talocalcaneal Coalition-2• Secondary Plain Film Signs:
– Talar beak– Narrowing of the subtalar joint– Rounding of the lateral talar process– Lack of depiction of middle facets on lateral– C-sign
• Secondary Signs on CT:– Talar beak– Joint Narrowing– Broadening and down-sloping of sustentaculum tali
Newman & Newberg (2000)
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Middle Facet on Lateral
• Short solid arrow: middle facet
• Long solid arrow: posterior facet
• Open arrow: lateral process of talus (anterior extent of posterior facet)
• Normal= Open space
Liu PT, et al. (2003)
Companion Normal Case
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Absence of Middle Facet
• Curved arrow: talar beak
• Long arrow: loss of middle facet space
• Short arrows: C-sign present
• Loss of posterior facet space Liu PT, et al. (2003)
Companion Coalition Patient Case
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Talar Beak• Secondary to
impaired subtalar joint motion
• Represents navicular overriding the talus
• Periosteal elevation occurs at site of talonavicular ligament
• Osseous repair results in talar beak
Newman & Newberg (2000)
Companion Coalition Patient Case
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C-Sign
• Results from bone bridging between talar dome and sustentaculum tali
• Seen in osseous and non-osseous coalition
• Varies based on sustentaculum size and orientation
Newman & Newberg (2000)
Companion Coalition Patient Case
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Another Patient with Coalition
9 year old girl with Chronic R foot pain
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Our Patient 2 Bone Scan
Children’s Hospital Boston
Focal Areas of Increased Tracer Uptake
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Patient 2 Sagittal CT
R L
Children’s Hospital Boston
Bony Fusion Preserved Joint Space
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Calcaneonavicular Coalition• Coalition between calcaneus navicular• Represents 43% of all Tarsal Coalitions• Typically become symptomatic in 12-16 yo children• Best Imaging Modality:
– Plain Film, 45 degree internal oblique– May also be seen on CT, MRI, bone scan
• Ragiographic Signs:– Bony Bar (seen with osseous coalition)– Bones in close proximity, irregular surfaces, anteromedial
calcaneus is widened/ flattened (seen with fibrous or cartilaginous coalition)
– Hypoplasia of the talus– Anteater sign
Newman & Newberg (2000)
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“Anteater” Sign
www.peeperandfriends.com
www.porpoiserecords.com
Newman & Newberg (2000)
Companion Coalition Patient Case
John Flibotte, MS IIIGillian Lieberman, MD
How did they come up with that anteater sign?
John Flibotte, MS III Gillian Lieberman, MD
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“Anteater” Sign
www.peeperandfriends.com
www.porpoiserecords.com
Newman & Newberg (2000)
Companion Coalition Patient Case
John Flibotte, MS III Gillian Lieberman, MD
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“Anteater” Sign
www.peeperandfriends.com
www.porpoiserecords.com
Newman & Newberg (2000)
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Performance of Secondary Signs
• The next slide shows the individual performance of secondary signs evaluated in a retrospective blinded study
• Table shows that individual stand alone signs have a low sensitivity, but high specificity
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Performance of Secondary Signs
Crim & Kjeldsberg (2004)
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Combination of all Secondary Signs
• Evaluated both retrospectively and prospectively by attending and resident radiologists
• Results:– Calcaneonavicular Coalition
• Attending (100% sens, 97% spec)• Resident (80% sens, 98% spec)
– Talocalcaneal Coalition• Sensitivity 100%• Specificity 88%
Crim & Kjeldsberg (2004)
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Treatment
• Initially managed conservatively with steroid injections, orthotics
• Surgery may be undertaken to separate fused tarsal bones
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Conclusions
• Coalition is a frequent cause of pediatric foot pain that may present in late childhood or early adulthood
• There are many secondary signs of coalition that can be seen on plain film radiographs
• The combination of multiple secondary signs is a sensitive and specific way to screen for coalition
• CT & MRI may be needed to confirm existence of coalition
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References1. Newman JS, Newberg AH. “Congenital tarsal coalition: multimodality evaluation with emphasis
on CT and MR imaging.” Radiographics. 2000 Mar-Apr;20(2):321-32. 2. Liu PT, Roberts CC, Chivers FS, Kile TA, Claridge RJ, DeMartini JR, Kenrich RE, Freed LH.
"Absent middle facet": a sign on unenhanced radiography of subtalar joint coalition. AJR Am J Roentgenol. 2003 Dec;181(6):1565-72.
3. Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot.” Am Fam Physician. 1996 Aug;54(2):592-606.
4. Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle.” Am Fam Physician. 1996 Sep 1;54(3):1012-26, 1031.
5. Crim JR, Kjeldsberg KM. “Radiographic diagnosis of tarsal coalition.” AJR Am J Roentgenol. 2004 Feb;182(2):323-8.
6. Websites:http://education.yahoo.com/reference/gray/subjects/subject?id=63http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.htmlhttp://www.rad.washington.edu/RadAnat/FootLateral.htmwww.porpoiserecords.comwww.peeperandfriends.com
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Acknowledgements
With thanks to:
• Muneeb Ahmed, MD• Larry Barbaras our Webmaster• Gillian Lieberman, MD• Pamela Lepkowski