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congenital pes planus Flashcards

vertical talus calcaneovalgus flexible flatfoot accessory navicular tarsal coalition

1
Q

What are the causes of congenital pes planus?

A
  • Calcaneovalgus foot
  • Accessory navicular
  • Tarsal coalition
  • Vertical talus
  • Flexible flatfoot

CAN TV F

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2
Q

What is calcaneovalgus ?

A
  • A soft tissue deformity characterised by
  • Excessive dorsiflexion HINDFOOT
  • HINDFOOT VALGUS
  • NO DISLOCATION/ bony deformity
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3
Q

What is the aetiology of calcaneovalgus foot?

A
  • Uterine packaging
  • More common in females, first born
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4
Q

What is calcaneovalgus foot associated with?

A
  • Vertical talus
  • Posteriomedial tibial Bowing
  • Paralytic foot deformity
    • L5 spina bifida
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5
Q

What do you clinically see in a child with calcaneovalgus foot ?

A
  • Excessive Dorsiflexion of hindfoot
  • PASSIVELY CORRECTABLE
  • dorsal surface of foot rests on ant tibia
  • looks similar to vertical talus but nb this is rigid hindfoot, midfoot
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6
Q

What is the pathoanatomy of calcaneovalgus foot?

A
  • Spasticity of
    • foot dorsiflexors/evertors L4/5
  • Weakness of
    • plantar flexors/invertors S1/2
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7
Q

What do you see on X-rays?

A
  • 1st metatarsal lines up with talus cf vertical talus when axis of talus is plantar to 1st metatarsal
  • postmedial tibial bowing
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8
Q

What is the treatment of calcaneovalgus foot?

A

Non operative

  • observation and passive stretching exercises
  • Resolves spontaneously
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9
Q

What is the complication of calcaneovalgus foot?

A
  • Limb length discrepancy due to posteriomedial bowing
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10
Q

Is an accessory navicular common?

What is the pathoanatomy of accessory navicular ?

A
  • 12% of population normal variant
  • occurs as a plantar medial enlargment of navicular bone
  • navicular ossify in girls 3, boys 5 the accessory navisular does not ossify prior to 8 years
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11
Q

What are the symptoms of an accessory navicular?

A
  • Majority asymptomatic
  • MEDIAL ARCH PAIN= worse with OVERUSE
  • TENDER- medial and plantar navicular
  • FLEXIBLE FLAT FOOT
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12
Q

What is the best X-ray to see the accessory navicular?

A
  • External oblique
  • ap / lateral
  • MRI can delineate insertion of tibialis post tendon
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13
Q

What is the tx of accessory navicular?

A

non operative

  • Restrict activity, shoe modification, analgesia
    • Majority asymptomatic by time of skeletal maturity
  • Cast immobilisation - ongoing pain, short time

Surgery

  • SURGICAL EXCISION OF ACCESSORY NAVICULAR.
    • ​resect bone flush to medial cuneiform.
    • May have to slpit tibalis post as navicular may be within it
  • TRANSFER POST TIBIALIS TENDON TO UNDERSURFACE OF NAVICULAR improve symptoms but not pes planus
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14
Q

What is the classification of pes planus ?

A

Type1-3 1= sesmoid within post tibialis tendon 2• separate a Crawley bone attached to native navicular 3= complete boney enlargement

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15
Q

What is this?

A
  • Vertical talus
  • aka congential covex pes valgus
  • A rare disorder consisting of a irreducible dorsal dislocation of the navicular on the talus -> a rigid flat foot deformity
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16
Q

What is the pathoanatomy of vertical talus?

A
  • Rockerbottom deformity consists of
    • fixed hindfoot equinovalgus
      • due to contracture of Achilles tendon and peroneal tendons
    • Rigid midfoot dorsiflexion
      • 2ary to dislocated navicular
    • ​Forefoot abducted and dorsiflexed
      • ​contracture of EHL, EDL, Tib anterior
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17
Q

What is the genetics of vertcial talus?

18
Q

What are the associated conditions of vertcial talus?

A
  • Myelodysplasia- common
  • arthrogryposis
  • Diastematomyelia
  • chromosomal abnromalities
19
Q

What is the prognosis of vertical talus?

A
  • Poor in untreated cases
  • significant disability
20
Q

What are the signs of vertical talus?

A

Signs

  • Rigid foot deformity
    • fixed hindfoot equinovalgus
    • fixed midfoot dorsiflexion
    • forefoot abducted & dorsiflexed
  • talar head prominence on medial plantar arch
21
Q

What is seen lateral xray with vertical talus?

A

Lateral xray

  • vertical position of talus
  • dorsal dislocation of navicular
  • Mery’s angle >20 degrees
  • forced plantar-flexion view= shows persistent dorsal dislocation of navicular
22
Q

What does the ap xray ahow?

A
  • valgus of the midffoot
  • Talocalcaneal angle >40<strong>o</strong> , normal 20-40 degrees
23
Q

What is the tx for vertical talus?

A

Non operative

  • Preoperative serial manipulation & casting for 3 months
    • stretches soft tissue doesn’t eliminate need for surgery
    • foot is placed in plantarflexion and inversion
24
Q

Describe the surgical tx of verticlal talus?

A
  • Surgical release and talonavicular reduction and pinning
    • most cases
    • preformed at 6-12 months
    • involves talus release w lengthening of contracted dorsolat tendons- TA, peroneals
    • Talonavicular joint is reduced & pinned while reconstruction of calcaneonavicular ligament- spring
  • ​Minimal invasive correction
    • ​Serial casting to stretch dorsal structures & gradually reduce talonavicular joint
    • when reduced closed/open pin of TN joint
  • Talectomy
    • resistant cases
25
How do you tell the difference betwen vertical and oblique talus?
* talonavicular angle - see pic * in oblique talus- the talonavicular joint will reduce on plantarflexed xray
26
What is tarsal coalition?
* Congential abnormality that leads to * **fusion of tarsal bones** * **rigid flatfoot** * result in a syndrome**= peroneal spastic flatfoot**
27
Where are the common tarsal coalitions?
* **Calcaneonavicular** * **​​**most common * **Talocalcaneal**
28
What is the epidemiology of tarsal coalition?
* incidence 1-6% * most found incidentally and are asymptomatic * age of onset * calcaneonavicular 8-12yrs * talocalcaneal 12-15 yrs
29
What is the pathoanatomy of tarsal coalition?
* Mesenchymal segmentation -\> coalition of tarsal bones * Coalition maybe * **fibrous** * **cartilaginous** * **osseous** * ​when subtalar joint is restricted by coalition-\>distal joints compensate * **​flattening of arch** * **valgus hindfoot** * **peroneal spasticity** *
30
What is tarsal coalition associated with?
* **Fibular hemimelia** * **Apert syndrome**
31
What are ths symptoms and signs of tarsal coalition?
Symptoms * Pain worse on activity * calf pain- peroneal spasticity * **recurrent ankle sprains** **​signs** * **hindfoot valgus** * forefoot abduction * **Limited subtalar motion** * **Arch of foot doesn't reconsititute on tip toeing**
32
What imaging is good to view tarsal coalition?
Xrays * **45 degree oblique view** * **'anteater sign'**- see pic * gd for calcaneonavicular coalition * **lateral** * **talar beaking** * sign of talocalcaneal coalition * result of limited subtalar joint motion * **Harris** * irregular middle facet joint * **CT** * rule out additional coalition * **MRI** * identify fibrous/cartilagneous coalition
33
What is the tx of tarsal coalition?
Non operative * **Observation** * asymptomatic * **immobilisation in cast/orthotics** * symptomatic pts Surgery * **Surgical resection of coalition and interpositional fat graft or extensor digitorium brevis** * resistance cases of consx tx * _if coalition \<50%_ * 80% pain relief * **Subtalar athrodesis** * _​if coalition is \>50%_ * **​Triple arthrodesis** * **​**fusion of subtalar, calcaneocuboid, talonavicular joints * advanced coalition that fails just resection
34
ddescribe the surgical technique for excision of tarsal coalition?
* Approach * calcaneonavicular * oblique incision just distal to subtalar joint * Talocalcaneal * curved incision medial side of foot * develop interval between Flexor Digitorium Longus and NV bundle * **Excise bar and leave defect 1cm in size** * interpose EDB ( calcaneonavicular) * Interpose fat (talocalcaneal) * Calcaneal osteotomy can be added for valgus * BK cast NWB 3 /52
35
What is the flexible flat foot?
* Physiological variant consiting of a * decrease in the medial longitudinal arch and valgus hindfoot and forefoot adbuction when weightbearing
36
What is the pathoanatomy of flexible flatfoot?
* generalised ligamentous laxity * 25% assoc with gastronemius-soleus contractures
37
What is the prognosis of flexible flatfoot?
* Most of time resolves spontaneously
38
What is the classification of flexible flatfoot?
* **Hypermobile flexible pes planovalgus** * **familial** * most common * _generalised ligamentous laxity_ * usually bilateral * associated with **accessory navicular** * **Flexible pes planovalgus with tight heel cord** * **Rigid planovalgus with tarsal coalition**
39
Describe the signs and symptoms of flexible flatfoot?
* usually asymptomatic * **foot is flat only when standing**, reconsitutes with toe walking , hallux dorsiflexion, or foot hanging * normal and painless subtalar movement * hindfoot corrects into valgus on tiptoes
40
What is seen on radiographs in flexible flatfoot?
* Ap and lateral * to rule out tarsal coalition * congential vertical talus * accessory navicular * lateral shows * meary's angle- apex plantar
41
What is the tx of flexible flatfoot?
Non operative * **Observation, stretching,shoewear modifications, orthotics** * asymptomatic * counsel parents that arch will develop * atheletic support with soft arches or stiff soles may improve * orthotics don't change natural history of disease Surgery * **Achilles tendon & gastronemius tendon lengthening** * painful flexible flatfoot with refractory symptoms with stretching * **Calcaneal lengthening osteotomy** * if symptoms continue * evans osteotomy

Foot and Ankle FRCS (31 decks)

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