congenital pes planus Flashcards
vertical talus calcaneovalgus flexible flatfoot accessory navicular tarsal coalition
What are the causes of congenital pes planus?
- Calcaneovalgus foot
- Accessory navicular
- Tarsal coalition
- Vertical talus
- Flexible flatfoot
CAN TV F
What is calcaneovalgus ?
- A soft tissue deformity characterised by
- Excessive dorsiflexion HINDFOOT
- HINDFOOT VALGUS
- NO DISLOCATION/ bony deformity
What is the aetiology of calcaneovalgus foot?
- Uterine packaging
- More common in females, first born
What is calcaneovalgus foot associated with?
- Vertical talus
- Posteriomedial tibial Bowing
- Paralytic foot deformity
- L5 spina bifida
What do you clinically see in a child with calcaneovalgus foot ?
- 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
What is the pathoanatomy of calcaneovalgus foot?
- Spasticity of
- foot dorsiflexors/evertors L4/5
- Weakness of
- plantar flexors/invertors S1/2
What do you see on X-rays?
- 1st metatarsal lines up with talus cf vertical talus when axis of talus is plantar to 1st metatarsal
- postmedial tibial bowing
What is the treatment of calcaneovalgus foot?
Non operative
- observation and passive stretching exercises
- Resolves spontaneously
What is the complication of calcaneovalgus foot?
- Limb length discrepancy due to posteriomedial bowing
Is an accessory navicular common?
What is the pathoanatomy of accessory navicular ?
- 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
What are the symptoms of an accessory navicular?
- Majority asymptomatic
- MEDIAL ARCH PAIN= worse with OVERUSE
- TENDER- medial and plantar navicular
- FLEXIBLE FLAT FOOT
What is the best X-ray to see the accessory navicular?
- External oblique
- ap / lateral
- MRI can delineate insertion of tibialis post tendon
What is the tx of accessory navicular?
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
What is the classification of pes planus ?
Type1-3 1= sesmoid within post tibialis tendon 2• separate a Crawley bone attached to native navicular 3= complete boney enlargement
What is this?
- 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
What is the pathoanatomy of vertical talus?
-
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
-
fixed hindfoot equinovalgus
What is the genetics of vertcial talus?
- 20% FHX
What are the associated conditions of vertcial talus?
- Myelodysplasia- common
- arthrogryposis
- Diastematomyelia
- chromosomal abnromalities
What is the prognosis of vertical talus?
- Poor in untreated cases
- significant disability
What are the signs of vertical talus?
Signs
-
Rigid foot deformity
- fixed hindfoot equinovalgus
- fixed midfoot dorsiflexion
- forefoot abducted & dorsiflexed
-
talar head prominence on medial plantar arch
- produced a convex plantar surface
-
http://www.orthobullets.com/video/view?id=99
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What is seen lateral xray with vertical talus?
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
What does the ap xray ahow?
- valgus of the midffoot
- Talocalcaneal angle >40<strong>o</strong> , normal 20-40 degrees
What is the tx for vertical talus?
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
Describe the surgical tx of verticlal talus?
-
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
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
What is tarsal coalition?
- Congential abnormality that leads to
- fusion of tarsal bones
- rigid flatfoot
- result in a syndrome= peroneal spastic flatfoot
Where are the common tarsal coalitions?
-
Calcaneonavicular
- most common
- Talocalcaneal
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
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
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What is tarsal coalition associated with?
- Fibular hemimelia
- Apert syndrome
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
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
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
-
fusion of subtalar, calcaneocuboid, talonavicular joints
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
- calcaneonavicular
-
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
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
What is the pathoanatomy of flexible flatfoot?
- generalised ligamentous laxity
- 25% assoc with gastronemius-soleus contractures
What is the prognosis of flexible flatfoot?
- Most of time resolves spontaneously
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
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
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
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
- if symptoms continue
