71: Pediatric Flatfoot - Frush

Question 1

flat foot pain is usually …

Answer 1

WB

if NWB think other causes (infection, arthridity, tumor)

Question 2

areas of tenderness flat foot

Answer 2

navicular tuberosity

metatarsals

ankle

sinus tarsi

plantar fascia

Question 3

rigid vs flexible vs skewfoot

Answer 3

• Rigid
  
  • Arch flat with WB and NWB
  • Arch not recreatable with Hubscher maneuver
• Flexible
  
  • Arch will be higher NWB than WB
  • Arch is recreatable with Hubscher maneuver
• Skewfoot
  
  • Pronated rearfoot with adductovarus forefoot

Question 4

a pronated foot is normal until …

Answer 4

7-8 yrs

a child with cavus foot is MORE alarmin (neuromuscular abnormality)

Question 5

avg ROM STJ adult vs child

Answer 5

• Child
  
  • Total STJ ROM 50-60 degrees
  • 15-20 degrees of eversion
  • 35-40 degrees of inversion
• Adult
  
  • Total STJ ROM 25-35 degrees
  • 10 degrees of eversion
  • 20 degrees of inversion

Question 6

classification mild vs. moderate vs sever

Answer 6

Question 7

ryder’s test

Answer 7

Place greater trochanter in frontal plane, femoral condyles should be in line

Question 8

biomechanical causes of flexible flatfoot

Answer 8

• Excessive internal rotation of the hip
  
  • Tight hip muscles
  • Femoral torsion
  • Ryder’s test
    
    • Place greater trochanter in frontal plane, femoral condyles should be in line
• Excessive internal knee rotation
  
  • Pseudotorsion
• Internal rotation of tibia
  
  • Lack of external malleolar position

Question 9

any type of excessive internal rotation causes …

Answer 9

ckc pronation

Question 10

describe adducted gait

Answer 10

1. Internal tibial torsion
2. Femoral anteversion
3. Tight medial hamstrings

” Pigeon-toed deformity “

Question 11

describe abducted gait

Answer 11

1. Met abductus
2. Forefoot abductus
3. External malleolar torsion
4. External tibial torsion
5. External femoral torsion
6. Tight lateral hamstrings

Question 12

describe mechanics of FF varus

Answer 12

• Inverted position of the transverse plane of the metatarsal heads to the long bisection of the calcaneus with STJ neutral and MTJ locked
• Compensation for FFV: STJ must pronate leading to calcaneal eversion, allowing FF to reach the ground
• MTJ consequently is unlocked leading to hypermobility of the FF
• If the calcaneus everts beyond 4-6 degrees, the STJ will maximally pronate and therefore can’t resupinate
• Non-WB child has an arch
• In RCSP, the flexible flatfoot will show

Question 13

describe mechanics of flexible FF valgus

Answer 13

• 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
• Hypermobility at the MTJ secondary to both forms of compensation leads to collapsing pes plano valgus foot type
• Compensation:
  
  • 1.MTJ supinates, unstable leading to 1st ray hypermobility (lateral column instability)
  • 2.STJ pronates

Question 14

equinus in a child

Answer 14

• 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 yo 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

Question 15

compensation for equinus

Answer 15

• STJ and MTJ pronation
• Medial column sag
• Tarsometatarsal breech
• Early heel-off

Question 16

what muscle imbalances might be contributing to pediatric flat foot?

Answer 16

• 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

Question 17

flat foot findings with obesity

Answer 17

• Wide base of gait
• Medial force when weightbearing
• STJ pronates to end ROM

Question 18

lateral and AP view findings flexible flat foot

Answer 18

• LATERAL VIEW
• Flattening of talar dome
• Anterior break cyma line
• Decreased calcaneal inclination angle
• Increased talar declination angle
• AP VIEW
• Increased talocalcaneal angle
• Talonavicular articulation less than 50%

Question 19

conservative tx symptomatic flexible flatfoot

Answer 19

• Activity modification
• Orthoses
• Stretching
• NSAIDS
• Manage primary etiology
  
  • Manage obesity, ligamentous laxity, hypotonia, proximal limb problems

Question 20

at what age could you use orthotics?

Answer 20

do not use orthotics until 3 yrs of age

• Normal gait pattern not developed until then
• Large fat pad makes it difficult to get accurate contour of foot

Question 21

congenital talipes calcaneovalgus

Answer 21

• 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
• In comparison to congenital vertical talus, it is flexible, vertical talus is rigid
• It is reducible
• Can be passively corrected by serial stretching and casting
• Conservative treatment should start immediately and correction should be achieved prior to child bearing weight

Clinically:

• 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

Question 22

tx congenital talipes calcanealvalgus

Answer 22

• Golden age 3-12 months
• Prior to child walking
• Splinting well tolerated
  
  • Ganley splint
  • RF maintained in inversiona nd FF in eversion. night and naptime wear when child begins to ambulate
  • 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

Question 23

what is a triplane wedge?

Answer 23

• For children under 3 yo
• Inner shoe wedge
• Keeps heel inverted
• Decreases abnormal pronation
• Made of ¼” cork or felt
• Affects all three body planes

Question 24

what type of shoes should children be wearing?

Answer 24

Children should wear shoes when they begin weightbearing

Shoes should be flexible, not stiff sole

Shoes should be ½” longer than the foot

Question 25

what are the rigid flatfoot deformities?

Answer 25

• Congenital vertical talus
  
  • Severe equinus
  • Rocker bottom deformity
  • Dorsal dislocation of TN joint
  • Not reducible with stress plantarflexion
  • Usualy needs surgical reduction
• Tarsal coalition
  
  • 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 peroneals
• Peroneal spastic flatfoot
  
  • Severe peroneal spasm that tries to stabilize the foot
  • Will have very little eversion or inversion
  • Causes: Tarsal coalition, juvenile arthritis, Osteochondral fracture of rearfoot, tumors
  • Treatment: Determine cause, Immobilize, Peroneal nerve block, Activity modification, orthotics
• Post - Traumatic

Question 26

hindfoot valgus with forefoot adductus =

Answer 26

skewfoot

• Should be suspected if treating infant for metatarsus adductus and it is not responding
• May or may not be symptomatic
• Difficulty with shoe wear
• Tx only symptomatic with stetching, casting, orthtocis or surgery