69: Metatarsus Adductus - Feilmeier Flashcards
what do you see with metatarsus adductus?
Medial deviation of the forefoot on the rearfoot
- Concave medial border
- Convex lateral border
- Prominent styloid process
what is metatarsus adductus associated with?
hip dyplasia
torticollis
what is the level of deformity metatarsus adductus?
lisfranc’s tarso-metatarsal jt
other causes of pigen/in-toeing besides metatarsus adductus
- Tibial/Malleolar torsion
- Femoral anteversion (inward twisting of the femur-medial torsion)
- Total ROM ~100 degrees. If >70 degress internal rotation may be present
- “Psuedo”- femur is normal, but soft tissue are allowing tighter internally, not allowing external
- also check for ortolani and barlow hip dysplasia
v-finger test
- Infant’s heel in the examiners hand second webspace
- Medical foot rests against index finger
- Lateral foot rests against middle finger
- Foot observed from plantar aspect
- Observe for medial deviation of forefoot
- Forefoot deviates away from middle finger
clinical “ARM” evaluation
- Attitude
- Position that is visible
- Relationship
- Forefoot to rearfoot
- All three planes
- Movement
- Flexible, Semi Flexible, Rigid
heel bisector
should go through the second met area
metatarsus adductus vs. adductovarus vs. skewfoot
- (A) Metatarsus Adductus
- Transverse plane adduction
- Most Common
- (B) Metatarsus adductovarus
- Transverse plane adduction
- Frontal plane inversion of forefoot(supinatus)
- (C) Skewfoot
- Transverse plane adduction
- Frontal plane inversion of forefoot (supinatus)
- Rearfoot eversion
berg classification
bleck’s severity of deformity
based on bisection fo the heel relative
metatarsus adductus angles
mild
moderate
severe
Metatarsus adductus angle =Relationship between the longitudinal axis of the lesser tarsus and the line bisecting the second metatarsal
- 15-20 degrees-mild
- 21-25 degrees-moderate
- > 25 degrees-severe
soft tissue abnormalities assoc with met add
- Anterior Tibial Tendon: More plantar insertion on cuneiform
- Posterior Tibial Tendon contracture
- Abductor Hallucis-hyperactivity/abnormal insertion
- Peroneal tendons
- Ligaments
- Joint capsules
bone abnormalities assoc with met add
- Arrest of normal ontologic rotation
- Medial cuneiform
- Growth pattern disturbance
- Trapezoidal shape
- Absence-metatarsal varus?
does severity correlate with outcomes?
nope
non-op treatment
- Observation (mild)
- Stretching (mild)
- Splints
- Corrective shoes (reverse shoes)
- Serial casting (all)
tx newborn to 2 years
serial casting
- Casting treatment past 8 months is controversial. Not all agree that casting after 1 year is effective
- Have to remember aggressive or excessive casting can damage immature osseous structures
- Classification DOES NOT correlate well with expected outcome
casting technique
- Short Leg typically works but may need long leg
- Fast Drying Plaster (more accurate modeling) vs. fiberglass (faster)
- Minimal cast padding
- Ankle at 90°
- STJ Neutral
- Cup foot at 5th met base with thenar eminence with thumb on bottom and index finger on the top- parallel to each other.
- Or, thumb at 5th met cuboid and index finger around posterior heel holding STJ neutral
- Thumb of other hand gently pushes 1st MPJ laterally (transverse plane) -abducting the forefoot
stretching/casting position (picture)
surgical tx 2-4 yo
- Soft tissue releases
- Abductor Hallucis release
- Release soft tissue 1st Met – Cuneiform jt
- Release soft tissue naviculo-cuneiform jt
- Release cuneiform insertion of Anterior Tibialis
- Combination of the above
tx 4 yo +
- Where is the deformity and how can you make the foot rectus?
- Soft Tissue Procedure
- Tarsometatarsal capsulotomy (Heyman-Herndon-Strong Procedure)
- Osseous Procedures
- Multiple Metatarsal Osteotomies (Berman and Gartland, Lepird)
- Medial opening wedge osteotomies
- Lateral closing wedge osteotomies
- TMTJ Arthrodesis
who can get soft tissue release?
2-6 yo
criticism soft tissue release
stiff foot
technique soft tissue release
- Transverse or longitudinal incision
- May need to osteotomize the 2nd met to allow mobility of the other metatarsals (keystone)
- Pin 6-8 weeks
- Cast 3-4 months
- Splinting after
when do we do osteotomy?
greater than 6 yo
name these osteotomies
(A) Peabody and Muro
(B) McCormick and Blount
(C) Steytler and Van DerWalt
(D) Berman and Gartland procedures
fowler procedure
- Opening-wedge osteotomy of the first cuneiform.
- The defect is replaced by a triangle shaped bone graft.
lepird procedure
•Oblique wedge osteotomy of the first and fifth metatarsals are performed with through and through rotational osteotomy of second, third and fourth metatarsals.
