Neonatal Orthopaedics Flashcards
What is congenital talipes equino varus (CTEV)? What is it also referred to?
Equinous of the foot, heel is turned in or up (varus), midfoot is deviated towards the midline (adductus), first metatarsal points downwards (plantarflexion and cavus).
Club foot
What diseases are associated with congenital talipes equino varus?
- Spina bifida
- Arthrogryposis
- Cerebral palsy
When does congenital talipes equino varus occur in development? How can it be diagnosed?
Between 12 to 20 weeks. Can be diagnosed on ultrasound.
What does the bone pathology of congenital talipes equino varus involve?
- Normal ankle mortise
- Talus is small, malformed, rotated medially and tilted into equinus
- Calcaneus is in varus and equinus
- Navicular is medially displaced
- First ray is plantarflexed (cavus)
- Internal rotation of tibia noted with growth
What soft tissue pathology is involved in congenital talipes equino varus?
- Shortened thickened muscles
- Atrophy of the lower leg muscles
- Smaller, higher calf muscle
- Joint capsules, ligaments and fascia contracted
- Empty heel pad
How is congenital talipes equino varus assessed? What does it involve?
It is assessed Pirani scoring, which involves six clinical signs.
What two categories are included in Pirani scoring?
- Hindfoot score
- Posterior crease
- Empty heel
- Rigid equinous - Midfoot score
- Curvature of lateral border
- Medial crease
- Talar head coverage
What does the management of congenital talipes equino varus involve?
Ponsetti Method
- Gentle manipulation to correct deformity
- Plasters to maintain correction
- Percutaneous tendoachilles tenotomy (at ~8 weeks of age)
- Boots and bar to maintain correction
What doe a percutaneous tenotomy involve?
- Tendon palpated approximately 1cm above calcaneum
- Tendon divided completely
- 10-15 degrees dorsiflexion gained
- Long leg cast applied with knee flexed at 30 degrees, for 3 weeks
What does the bracing with boots and bar involve?
- Fitted after removal of last cast
- Open toed, high, straight shoes connected to a bar
- 60-70 degrees ER
What are the two most common types of surgery completed for ongenital talipes equino varus relapses?
- Tibialis anterior tendon transfer (TATT)
2. Split tibialis anterior tendon transfer (SPLATT)
Positional
Caused by inter-uterine ‘packaging effects’
- Positional TEV
- Metatarsus adductus
- Talipes calcaneovalgus
Greatest risk factor of neonatal foot deformities?
First born
General assessment for…?
- Subjective
- Hips: DDH screen, tone, ROM
- Spine
- Head shape and neck ROM
- Age appropriate development: rotational profile (hip IR/ER, foot progression angle, thigh foot angle)
What does positional (postural) talipes equinovarus?
- Foot is in plantarflexion and inversion, with full passive range of motion.
- No structural abnormality of the foot or calf.
What does treatment of positional (postural) talipes equinovarus involve?
- Stretches: dorsiflexion and eversion
- Stimulation of evertors by touch
What does metatarsus adductus involve?
- Curved or adducted forefoot, with normal hindfoot.
- Prominent base of fifth metatarsal
- +/- searching big toe, internal tibial torsion, soft tissue contracture of medial structures, medial crease
What is involved in the assessment of metatarsus adductus?
- Pirani scoring for forefoot
- Heel bisector line
- Passive forefoot abduction
- Full PROM expected
- Active ROM by stimulating forefoot abduction by stroking lateral border
What does Bleck’s classification involve?
Classifies metatarsus adductus
Treatment of metatarsus adductus
- Active stimulation and stretches into abduction
- Straight last shoes or reverse shoes (walking age)
- Deformity can appear worse when infants learn to stand - dynamic balance component
- Serial casting if limited passive abduction
What does talipes calcaneovalgus involve?
- Ankle in dorsiflexion and forefoot in abduction (dorsum of foot to tibia)
- Heel in valgus
- Prominent navicular
What does the treatment of talipes calcaneovalgus involve?
If full PROM: encourage plantarflexion and inversion by stimulating the plantar reflex and stroking medial border of the foot.
If limited PROM: cast into inversion and plantarflexion until full ROM, with thermoplastic splint to prevent recurrence
Treatment of CVT
- Surgical techniques
- Reverse Ponsetti method
Treatment of CVT
- Surgical techniques
- Reverse Ponsetti method
What does the reverse Ponsetti technique involve?
- Reduce the talonavicular…
What does developmental dysplasia of the hip involve?
Femoral head and acetabulum are in improper alignment or grow abnormally or both.
What is the incidence of developmental dysplasia?
1-30 per 1000 births
What is a dysplastic hip involve?
- The hips have inadequate acetabulum formation
- Often not clinical apparent
Subluxation
The femoral head can be partially displaced outside of the acetabulum
- Incomplete contact between the articular surfaces of the femoral head and acetabulum
Dislocatable
The femoral head is located within the acetabulum, but can be displaced by stress manoeuvres.
Clinical assessment of DDH
- Observation of skin folds
- Limb length (Galeazzi sign)
- Hip ROM: flexion and abduction especially
- Ortolani and Barlow manoeuvres
- Screen feet (talipes)
- Screen head (torticollis)
Clinical assessment of DDH
- Observation of skin folds
- Limb length (Galeazzi sign)
- Hip ROM: flexion and abduction especially
- Ortolani and Barlow manoeuvres
- Screen feet (talipes)
- Screen head (torticollis)
Radiological examination
- Usually done <6 months of age
Alpha angle
Smaller alpha angle, indicative of DDH. The normal value is >60 degrees.
Treatment for DDH
- Maintain reduction of the hip in the physiological position of hip flexion and abduction
- Bony stimulation of femoral head and acetabulum
- …
Pavlik harness
- Anterior straps control flexion
- Posterior straps control abduction
- Ideal position is symmetrical hips at 90 degrees of flexion and 50 abduction
Precautions of Pavlik harness
- Extreme hip abduction = avascular necrosis of the femoral head
- Extreme flexion = posterior hip dislocation and femoral nerve damage
Precautions of Pavlik harness
- Extreme hip abduction = avascular necrosis of the femoral head
- Extreme flexion = posterior hip dislocation and femoral nerve damage
