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#5 Surg > 71 - Pediatric Flatfoot > Flashcards

71 - Pediatric Flatfoot Flashcards

1
Q

Etiologies of pediatric flatfoot

A
  • Isolated pathology (we all start with a flatfoot – it just stays in some)
  • Ligamentous laxity (kids are a little more flexible)
  • Neurologic and muscular abnormality
  • Genetic conditions and syndromes (if parents had flatfoot, it is more likely)
  • Collagen disorders
  • Obesity (200-300 pounds at 9-10 years old is a concern – too much weight on a child’s foot)
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2
Q

Clinical history of pediatric flatfoot

A
  • Age of onset
  • Pain +/- (Pain in foot, knee, and/or leg)
  • Activity level - Generalized foot/leg fatigue – Can’t keep up with friends, might not necessarily be localized pain, but just general fatigue
  • Trauma
  • Previous treatment
  • Family history
  • Pain usually is worse with weightbearing - If it is not worse with weightbearing, thing of other differentials
  • Pain nonweightbearing think other causes
    o Infection (A common differential is hematogenous osteomyelitis)
    o Arthridity
    o Tumor
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3
Q

Exam findings in pediatric flatfoot - Appearance

A

o WB vs NWB (BIGGEST thing to look at to determine flexible vs rigid)
o Medial talar head prominence (if the foot is really collapsing, the talar gets pushed off to the side)

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4
Q

Exam findings in pediatric flatfoot - Range of motion

A

o STJ, ankle, knee, hip – FULL biomechanical exam
o NOTE: usually I don’t get into the knee and hip with my biomechanical exam except for in kids, since it is more common for knee/hip issues to be causing foot pathology
o In kids, you will see tibial torsion, femoral torsion, and different developmental problems that could be causing pathology

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5
Q

Areas of tenderness

A
  • Navicular tuerosity
  • Metatarsals
  • Ankle
  • Sinus tarsi (excessive pronation can make this area tender)
  • Plantar fascia (not so much plantar fasciitis, but growth issues/spurts can cause pain)
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6
Q

Describe navicular tuberosity pain

A

o Navicular tuberosity **NUMBER 1 PLACE FOR TENDERNESS **

  • This is where posterior tibial tendon inserts
  • Recall that the PTT is the main tendon for arch support, and if the arch is collapsed, it is getting overworked
  • Accessory navicular can be present which can also be problematic
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7
Q

Describe metatarsal pain

A

More common in equinus because the midfoot will compensate and there will be more pressure on metatarsals

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8
Q

Types of pediatric flatfoot

A
  • Rigid
  • Flexible
  • Skewfoot
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9
Q

Rigid flatfoot

A

o Arch flat with WB and NWB
o Arch not re-creatable with Hubscher maneuver (test for rigid vs flexible deformity)
o Hubscher maneuver: in WB, dorsiflex 1st metatarsal, look for arch to re-create itself

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10
Q

Flexible flatfoot

A

o Arch will be higher NWB than WB

o Arch is re-creatable with Hubscher maneuver

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11
Q

Skewfoot

A

o Pronated rearfoot with adductovarus forefoot

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12
Q

Gait exam

A
  • Hip and knee position
  • Angle and base (in toed or out toed)
  • Toe walking (may or may not be pathologic)
  • Early heel off
  • Valgus heel (does it stay pronated or supinate late?)
  • Poor propulsion (due to either muscle weakness or excessive pronation w/o locking)
  • NOTE: focus on the hip and knee position (torsional deformities) and all other deformities listed
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13
Q

Flexible flatfoot overview

A
  • Normal arch during non-WB
  • Flattening of arch during stance
  • May be symptomatic or asymptomatic
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14
Q

Heel rise test

A
  • Valgus while standing

- Inverted on heel rise in a flexible deformity

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15
Q

Asymptomatic flexible pediatric flatfoot

A

Can be Physiologic or Nonphysiologic
- Counseling will come into play here – we may just leave it alone, especially if the parents had a flatfoot as well that hasn’t bothered them

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16
Q

Physiologic asymptomatic flexible pediatric flatfoot

A

o Non progressive
o Will likely get better with time
o No treatment needed

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17
Q

Non-physiologic asymptomatic flexible pediatric flatfoot

A

o Progressive (they’ve always had flat feet and it is continuing to get worse)
o More severe
o May need stretching program for equinus to prevent or slow progression

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18
Q

Flexible flatfoot

A

Average Values for ROM of STJ

  • Children have a pronated attitude of their foot during development. This is normal until 7-8 yrs of age
  • A young child with a cavus foot is MORE alarming Indicates a neuromuscular abnormality which needs further investigation
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19
Q

Average values for ROM of STJ in flexible flatfoot - CHILD

A

MORE FLEXIBLE
o Total STJ ROM 50-60 degrees
o 15-20 degrees of eversion
o 35-40 degrees of inversion

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20
Q

Average values for ROM of STJ in flexible flatfoot - ADULT

A

LESS FLEXIBLE
o Total STJ ROM 25-35 degrees
o 10 degrees of eversion,
o 20 degrees of inversion

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21
Q

Volpe’s treatment classification system

A

Mild

  • Collapsed, but medial arch is visible
  • RCSP 2-5 degrees valgus
  • Toes 4 and 5 seen on too many toes sign

Moderate

  • Medial arch not visible
  • RCSP 6-10 degrees valgus
  • Toes 3-5 seen on too many toes sign

Severe

  • Medial arch not visible, convexity noted from talar head
  • RCSP >10 degrees of valgus
  • Toes 2-5 seen on too many toes sign
22
Q

Notes on Volpe’s treatment classification system

A
  • This is a nice chart to see where your patient is in terms of mild, moderate and severe deformity
  • This is mainly meant for kids who are over 7 years of age
  • **If your patient is younger than 7, use 8-(age of child) = maximum RCSP normal for age **
  • If you have a 2 year old with 6 degrees of valgus in RCSP, it is not going to be pathological, however when you see that same 6 degrees of valgus in RCSP of a 10 year old, it would equate to a moderate deformity
  • Also takes into consideration the “too many toes sign”
23
Q

Biomechanical cause of flexible flatfoot

A

1 = Excessive internal rotation of the hip
o Tight hip muscles
o Femoral torsion
o Ryder’s test: Place greater trochanter in frontal plane, femoral condyles should be in line

2 = Excessive internal knee rotation
o	Pseudotorsion (soft tissue problem)

3 = Internal rotation of tibia (bony problem)
o Lack of external malleolar position

4 = Any type of excessive internal rotation causes closed kinetic chain pronation

24
Q

Adducted Gait

A
  • Internal tibial torsion (bony)
  • Femoral anteversion (bony)
  • Tight medial hamstrings (muscles are pulling everything in)
  • Pigeon-toed deformity
25
Q

Abducted Gait

A
  • Met abductus
  • Forefoot abductus
  • External malleolar torsion
  • External tibial torsion
  • External femoral torsion
  • Tight lateral hamstrings
26
Q

Forefoot varus

A
  • Inverted position of the transverse plane of the metatarsal heads
    to the long bisection of the calcaneus with STJ neutral and MTJ locked
  • FFV compensation – STJ must pronate leading to calcaneal eversion, allowing FF to reach ground
  • When you do this, it unlocks the midtarsal joint (MTJ) leading to hypermobility of the FF
  • If the calcaneus everts beyond 4-6°, STJ will maximally pronate and therefore can’t re-supinate
  • In forefoot varus, the child will have an arch in non-WB
  • In RCSP, the flexible flatfoot will show the deformity
27
Q

Flexible forefoot valgus (RARE FOR FLATFOOT ETIOLOGY***)

A
  • Everted position of the metatarsal heads in the transverse plane compared to the long bisection of the calcaneus with STJ in neutral and MTJ locked
  • Compensation: MTJ supinates, unstable leading to 1st ray hypermobility (lateral column instability) and STJ pronates
  • Hypermobility at the MTJ secondary to both forms of compensation leads to collapsing pes plano valgus foot type
28
Q

Equinus (COMMON***)

A
  • Inadequate dorsiflexion of the foot at the ankle with the knee extended
  • Need at least 20-30 degrees of dorsiflexion in a young child
  • 10-12 year old should have 15 degrees
  • Inadequate dorsiflexion of the ankle will lead to STJ and OAMTJ pronation
  • Make sure put STJ in neutral and lock midtarsal joint when checking for equinus or you will be getting good ankle ROM, but you’re only see the compensation measures (forefoot is dorsiflexing, not the actual ankle which you are checking)
29
Q

Compensation for equinus

A
  • STJ and MTJ pronation (most common – unlocking the MTJ for pronation)
  • Medial column sag (midfoot compensation)
  • Tarsometatarsal breech (midfoot compensation)
  • Early heel-off
30
Q

Muscle imbalance

A
  • Weak posterior tibial tendon results in diminished supination of the STJ
  • Abnormal insertion of the PTT into an accessory or gorilloid navicular renders the pull of the PTT ineffective
  • PTT may come around the medial malleolus too far anteriorly
31
Q

Obesity

A
  • Wide base of gait
  • Medial force when weightbearing, causing arch to collapse
  • STJ pronates to end ROM
32
Q

Flexible flatfoot radiographic findings - Lateral view

A

o Flattening of talar dome
o Anterior break cyma line (S line)
o Decreased calcaneal inclination angle
o Increased talar declination angle

33
Q

Flexible flatfoot radiographic findings - AP view

A

o Increased talocalcaneal angle (Kite’s angle)

o Talonavicular articulation less than 50%

34
Q

Symptomatic flexible flatfoot conservative treatment

A 
o	Activity modification
o	Orthoses
o	Stretching (specifically for equinus) 
o	NSAIDS
o	Manage primary etiology – Manage obesity, ligamentous laxity, hypotonia, proximal limb problems
35
Q

Functional devices for symptomatic flexible flatfoot

A

o Do not use orthotics until 3 years of age Normal gait pattern not developed until then, and large fat pad makes it difficult to get accurate contour of foot
o Whitman-Roberts Plate - High medial and lateral flange, cups heel in vertical attitude
o Heel Stabilizers - Type A, B, C, D
o Gait Plates - For angle of gait, changes break of shoe, at toe off abduct or adducts foot
o Root Functional Orthosis - Maintains MTJ and STJ stability by addressing leg, RF and FF deformities
o UCBL (common in kids) - From WB impression, high medial and lateral flange and deep heel cup, Ability to resist abnormal motion, Downside = bulky to fit in shoes
o Blake Inverted Orthotic (wedge) - Initially for runners, 25 degrees of inversion is standard

36
Q

Congenital Talipes calcaneovalgus – FLEXIBLE DEFORMITY

A
  • Congenital deformity
  • Opposite of clubfoot
  • Limited plantarflexion of ankle joint and inversion
  • Everted position of the foot
  • Foot is dorsiflexed, everted and abducted against the leg
37
Q

Clinical presentation of congenital talipes calcaneovalgus

A
  • Skin wrinkling on dorsal-lateral aspect of the foot
  • Foot may contact anterior aspect of the tibia
  • Achilles tendon is not tight, even with maximum dorsiflexion
  • In comparison to congenital vertical talus, it is flexible, vertical talus is rigid
  • It is reducible
38
Q

Treatment of congenital talipes calcaneovalgus

A
  • VERY easy to treat this deformity with very good outcomes
  • Can be passively corrected by serial stretching and casting
  • Conservative treatment should start immediately and correction should be achieved prior to child bearing weight
  • Golden age 3-12 months (prior to child walking)
  • Splinting well tolerated
39
Q

Ganley splint for congenital talipes calcaneovalgus

A
  • Rearfoot is maintained in inversion and forefoot in eversion (adjustable RF FF relationship)
  • Night and naptime wear when child begins to ambulate in order to maintain the correction
40
Q

Conservative treatment of congenital talipes calcaneovalgus

A
  • Combine nighttime use of the Ganley splint with day time use of an orthotic device
  • Orthotic should be in slight supination
  • Shoe should limit abduction and dorsiflexion of the FF at the MTJ
  • Taping
  • Triplane Wedge
  • Shoe Therapy
  • Shoe Therapy brands = Inflare Last Shoe, Bebax Shoe
41
Q

Taping for congenital talipes calcaneovalgus

A

o Change daily
o Adjunct to passive stretching
o Parents can administer
o Helps determine the amount of control

42
Q

Triplane wedge for congenital talipes calcaneovalgus

A 
o	For children under 3 yo
o	Inner shoe wedge
o	Keeps heel inverted
o	Decreases abnormal pronation
o	Made of ¼” cork or felt (you can make this in office) 
o	Affects all three body planes
43
Q

Shoe therapy for congenital talipes calcaneovalgus

A

o Children should wear shoes when they begin weightbearing
o Shoes should be flexible, not stiff sole
o Shoes should be ½” longer than the foot

44
Q

Rigid flatfoot deformities

A
  • Congenital vertical talus (will be evident right away)
  • Tarsal coalition (takes a couple years to develop)
  • Peroneal spastic flatfoot
  • Post - Traumatic
45
Q

Congenital Vertical Talus

A
  • Severe equinus, rigid deformity
  • Rocker bottom deformity
  • Dorsal dislocation of TN joint (NOT reducible with stress plantarflexion)
46
Q

Treatment of congenital vertical talus

A
  • Doesn’t respond well to conservative treatment

- Usually requires surgical reduction

47
Q

Tarsal coalition

A
  • Usually noted as child’s foot matures – sudden weight gain or increased activities
  • Talocalcaneal and calcaneonavicular most common
  • Patient presents with pain along coalition site, ankle, sinus tarsal and/or peroneal
48
Q

Peroneal spastic flatfoot

A
  • Severe peroneal spasm that tries to stabilize the foot

- Will have very little eversion or inversion

49
Q

Causes of peroneal spastic flatfoot

A
  • Tarsal coalition
  • Juvenile arthritis
  • Osteochondral fracture of rearfoot
  • Tumors
50
Q

Treatment of peroneal spastic flatfoot

A
  • Determine cause
  • Immobilize
  • Peroneal nerve block
  • Activity modification
  • Orthotics
51
Q

Skewfoot

A
  • Hindfoot valgus with forefoot adductus should be suspected if treating infant for metatarsus adductus and it is not responding
  • May or may not be symptomatic
  • Difficulty with shoe wear
52
Q

Treatment of skewfoot

A
  • Only if symptomatic
  • Stretching
  • Casting
  • Orthotics
  • Surgery

#5 Surg (12 decks)

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