Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

#5 Surg > 70 - Metatarsus Adductus > Flashcards

70 - Metatarsus Adductus Flashcards

1
Q

Definition of metatarsus adductus

A

Medial deviation of the forefoot on the rearfoot
o Concave medial border
o Convex lateral border
o Prominent styloid process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Incidence of metatarsus adductus

A
  • 1/1000 live births? (1964) – 10x more frequent than clubfoot
  • ~50% bilateral
  • M=F
  • Associated with: Hip Dysplasia, torticollis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Etiology of metatarsus adductus

A
  • Generally unknown
  • “Packing vs. manufacturing”?
  • Family history
  • Late or first pregnancy
  • Position in womb: Breech, twins, lack of amniotic fluid (oligohydramnios)
  • Sleeping position
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Level of deformity

A
  • The dominant location of the deformity is at Lisfranc’s tarso-metatarsal joint
  • Secondary or compensatory positional deformity can exist at other joints in the hindfoot and forefoot
  • * PRONATION IS THE PRIMARY COMPENSATION FOR METATARSUS ADDUCTUS*
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

History for evaluation of child with metatarsus adductus

A
  • Perinatal history
  • Neuromuscular developmental landmarks
  • Family history of deformity
  • Sleeping and sitting positions
  • Growing pains
  • Shoe wear
  • Level of activity
  • Participation in sports
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Clinical evaluation

A
  • Foot position in all three planes
  • Ankle
  • Leg position/ROM
  • Knee
  • Hip (Ortolani, Barlow, Gait)
  • Radiographs?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Leg position/ROM

A

Tibial/Malleolar torsion – Gives “pigeon-toed” appearance

Femoral anteversion (inward twisting of the femur-medial torsion)
o	Gives “pigeon-toed” appearance
o	Total ROM ~100 degrees. If >70 degrees internal rotation may be present
o	“Pseudo”- femur is normal, but soft tissue are allowing tighter internally, not allowing external rotation.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Ortolani

A

The Ortolani method is an examination method that identifies a dislocated hip that can be reduced into the socket (acetabulum). Ortolani described the feeling of reduction as a “Hip Click” but the translation from Italian was interpreted a sound instead of a sensation of the hip moving over the edge of the socket when it re-located. After the age of six weeks, this sensation is rarely detectable and should not be confused with snapping that is common and can occur in stable hips when ligaments in and around the hip create clicking noises. When the Ortolani test is positive because the hip is dislocated, treatment is recommended to keep the hip in the socket until stability has been established.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Barlow

A

The Barlow method is an examinaiton method that identifies a loose hip that can be pushed out of the socket with gentle pressure. Approximately 80% of “Barlow Positive” hips will resolve spontaneously in the first few weeks of life. Early treatment may be recommended when the hip is “dislocatable” but minor degrees of instability can be treated with multiple diapers followed by an Ultrasound Study at approximately six weeks of age.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

V-finger test

A

Infant’s heel in the examiners hand second webspace
o Medical foot rests against index finger
o Lateral foot rests against middle finger
o Foot observed from plantar aspect
o Observe for medial deviation of forefoot
o Forefoot deviates away from middle finger

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Clinical evaluation - “ARM”

A

Clinical evaluation “ARM”

A = Attitude
o Position that is visible

R = Relationship
o Forefoot to rearfoot
o All three planes

M = Movement
o Flexible
o Semi Flexible
o Rigid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Metatarsus adductus variations – KNOW THIS***

A
  • A = Metatarsus adductus
  • B = Metatarsus adductovarus
  • C = Skewfoot
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Metatarsus adductus

A

o Transverse plane adduction (ONLY)

o Most Common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Metatarsus adductovarus

A

o Transverse plane adduction
o Frontal plane inversion of forefoot(supinatus)
o TWO PLANES

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Skewfoot

A

o Transverse plane adduction
o Frontal plane inversion of forefoot (supinatus)
o Rearfoot eversion
o KNOW THIS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Berg classification

A
  • Just know Berg’s is just describing simple metatarsus adductus – Describes the different deformities we talked about it
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Bleck’s severity of deformity

A
  • Based on bisection of the heel relative-Where does the line exit the forefoot?
  • Really simple – just the bisector – NOT useful besides dictation and describing the deformity
  • Does not have any bearing on outcome, so it is NOT clinically relevant
18
Q

Bleck’s clinical classification

A
  • Bisect Heel – extend to forefoot
  • Normal = Line passes between 2nd and 3rd toes
  • Mild = Line passes through 3rd toe
  • Moderate = Line passes between 3rd and 4th toes
  • Severe = Line passes between 4th and 5th toes
19
Q

Metatarsus adductus angle

A
  • Relationship between the longitudinal axis of the lesser tarsus and the line bisecting the second metatarsal
  • The most significant angular relationship in the diagnosis of metatarsus adductus.
20
Q

Mild moderate and severe metatarsus adductus angle

A

Generally considered that metatarsus adductus angles of:
o 15-20 degrees-mild
o 21-25 degrees-moderate
o > 25 degrees-severe

21
Q

Soft tissue abnormalities

A
  • Anterior Tibial Tendon: More plantar insertion on cuneiform
  • Posterior Tibial Tendon contracture
  • Abductor Hallucis-hyperactivity/abnormal insertion
  • Peroneal tendons
  • Ligaments
  • Joint capsules
22
Q

Bone abnormalities

A

Arrest of normal ontologic rotation

Medial cuneiform
o Growth pattern disturbance
o Trapezoidal shape
o Absence-metatarsal varus?

23
Q

Non-operative treatment

A
  • Observation (mild only)
  • Stretching
  • Splints
  • Corrective shoes
  • Serial casting***
24
Q

Surgical treatment

A
  • Soft tissue

- Bone

25
Q

Treatment for newborn to 2 years

A
  • Newborn to 2 years
    o Serial Casting
    o Stretching/Manipulation
    o Orthopedic Appliances
  • 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
26
Q

Casting

A
  • Short Leg typically works but may need long leg
  • Fast Drying Plaster (more accurate modeling) vs. fiberglass
  • 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-abducting the forefoot
27
Q

Metatarsus adductus surgical treatment (salvage) - WHEN?

A

o Over 2-4 y/o with failure of conservative treatment

o Procedures vary with the age of the patient

28
Q

Metatarsus adductus surgical treatment (salvage) - WHY?

A

Radiographic findings

  • Severe Deformity
  • Secondary Joint compensation

Functional abnormality
- In toeing, Instability, Pain, Severe compensation

29
Q

Metatarsus adductus treatment (2-4 years)

A
  • 2 to 4 years: soft tissue releases
  • Abductor hallucis release
  • Release soft tissue 1st met – cuneiform joint
  • Release soft tissue naviculocuneiform joint
  • Release cuneiform insertion of Anterior Tibialis
  • Combination of the above
30
Q

Metatarsus adductus treatment (4 years and older)

A
  • Where is the deformity and how can you make the foot rectus?
  • Soft Tissue Procedure
  • Osseous Procedures
31
Q

Metatarsus adductus treatment (4 years and older) - SOFT TISSUE

A

Soft Tissue Procedure

o Tarsometatarsal capsulotomy (Heyman-Herndon-Strong Procedure)

32
Q

Metatarsus adductus treatment (4 years and older) - OSSEOUS

A 
Osseous Procedures
o	Multiple Metatarsal Osteotomies (Berman and Gartland, Lepird)
o	Medial opening wedge osteotomies
o	Lateral closing wedge osteotomies
o	TMTJ Arthrodesis
33
Q

Soft tissue release

A
  • 2 – 6 years old (remember ages are a continuum)
  • Has been criticized for causing a STIFF FOOT***
  • Must be accurate anatomically
  • Transverse or longitudinal incision
  • May need to osteotomize the 2nd met to allow mobility of the other metatarsals
  • Pin 6-8 weeks
  • Cast 3-4 months
  • Splinting after
  • REMEMBER: CORA IS AT THE TARSAL METATARSAL JOINT ***
34
Q

Osteotomy (6 years and older)

A
  • Drill and break
  • Crescentic
  • Wedge
  • Lepird
  • Cuboid
  • Cuneiform (opening wedge medially or closing wedge laterally)
  • Beyond the age of 6, can no longer just think about soft tissue, we will need to do an osteotomy
35
Q

Fowler procedure

A
  • Opening-wedge osteotomy of the first cuneiform.

- The defect is replaced by a triangle shaped bone graft.

36
Q

Lepird procedure

A
  • Oblique wedge osteotomy of the first and fifth metatarsals are performed with through and through rotational osteotomy of second, third and fourth metatarsals.
  • Leprid – people use this term all the time – He’s from Iowa – Small town
37
Q

TMTJ arthrodesis

A
  • Skeletally mature
  • Older patients?
  • Correction at the level of deformity
  • Allows most complete correction/anatomic correction
  • Probably even easier and reproducible than metatarsal osteotomies – Can use plates
38
Q

Example of radiograph evaluation

A
  • I am looking at a AP radiograph of a skeletally mature individual, weight bearing
  • Adequate for visualization for bone and soft tissue
  • Increased soft tissue density surrounding 1st and 5th MPJ
  • Bone density is overall normal with increased bone density on the second metatarsal due to increased WB
  • I see slight increase in abduction of the hallux
  • 1st MPJ appears to be slightly narrowed and I see slight increase in IM angle
  • Tibial sesamoid position is a 4
  • No DJD or osteophytes in IMJ
  • Joints 2-4 are rectus at MPJ and IPJs
  • 5th digit is in a slight adducted position and re
  • Slight increase in 4-5 IM angle (splay foot)
  • Hard to see any changes at TMTJ
  • 2-4 appears to be increase in metatarsus adductus
39
Q

Example of how casting can cause bony changes

A
  • Immature osseous structures can be
  • Damaged with improper surgery or
  • Overly aggressive
  • Conservative management
  • Born with club foot, had club foot, casting, surgery as a child, now has flatfoot
40
Q

Considerations

A
  • Bleck – Severity does not correlate with outcomes
  • Williams – No treatment in the flexible foot until at least 8 months?
  • Bebax orthosis
  • Mild to Moderate does not usually cause pain or gait disturbances long term
  • Resolve over time or foot compensates?
  • Primary compensation = STJ pronation
  • Higher recurrence of HAV with MA
  • When correcting HAV with MA the IM angle is more important – measured value seem low, but actual value much higher

#5 Surg (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions