Paeds Non-Hip Flashcards
What are risk factors for the development of clubfoot?
[CORR (2009) 467:1146–1153]
- Family history
- Boys
- Race (highest in Hawaiians and Maoris)
- Early amniocentesis (<13 weeks)
- Oligohydramnios
- Exposure to cigarette smoke inutero
What is the Pirani scoring system of clubfoot and what can it predict?
- Six signs are scored from 0 (no abnormality), 0.5 (moderate abnormality), 1 (severe abnormality)
- 3 signs related to the hindfoot
- Severity of the posterior crease
- Emptiness of the heel
- Rigidity of the equinus
- 3 signs related to the midfoot
- Curvature of the lateral border of the foot
- Severity of the medial crease
- Position of the lateral part of the head of the talus
- Predicts need for tenotomy
* 85% of feet with a score above 5 required tenotomy
What is the main radiographic feature in clubfoot?
[Orthobullets]
Hindfoot parallelism
- Talus and calcaneus are parallel/less divergent on AP and lateral
What are the 4 components of the clubfoot deformity?
[CORR (2009) 467:1146–1153]
CAVE
- Midfoot cavus
- Forefoot adductus
- Hindfoot varus
- Hindfoot equinus
Describe the pathoanatomy resulting in the deformity in clubfoot
[J Am Acad Orthop Surg 2003;11:392-402]
- Navicular displaces medially (articulates with the medial head of talus)
- Cuboid is adducted infront of the calcaneus
- Metatarsals are adducted on the midfoot
- Calcaneus is adducted and inverted around the talus medially
- Forefoot is pronated relative to the hindfoot (causing cavus)
- Tight muscles (gastroc/soleus, tib post, FHL, FDL)
- Tight posteromedial capsule and ligaments
Describe the Ponsetti method for clubfoot correction.
[J Am Acad Orthop Surg 2003;11:392-402] [J Am Acad Orthop Surg 2010;18:486-493]
- Serial foot manipulation followed by casting to maintain the correction with foot abduction orthosis as the final stage
- Manipulations are held for 1-3 minutes followed by above knee plaster cast with knee at 90° flexion
- Weekly cast change and manipulation
- ~6 cast changes required to correct most clubfeet
- Ponsetti method started ideally within the first month of life
- The order of foot deformity correction is cavus, adductus, varus, equinus (CAVE)
- Cavus correction
- Usually achieved with the first cast
- Technique – pressure under first metatarsal head to elevate it in line with other metatarsals
- Forefoot adduction and hindfoot varus corrected simultaneously
- With foot in slight supination and equinus the forefoot is abducted while stabilizing counterpressure is applied to the lateral head of the talus
- This will simultaneous correct adduction and hindfoot varus as the calcaneus abducts freely under the talus (important to avoid max dorsiflexion)
- Equinus correction
- Perform when hindfoot is neutral or slight valgus and forefoot is abducted 70° relative to the leg
- Technique – progressive dorsiflexion applied with broad pressure over sole of foot
- Heel cord tenotomy
- Required in ~75% of cases
- Performed after 4-6 weeks of casting
- Percutaneous tenotomy performed in clinic or OR followed by cast immobilization for 3-4 weeks
- Foot abduction orthoses (‘boots and bars’, Denis-Browne bar)
- Required to prevent relapse
- 15° dorsiflexion needed for proper fit
- Clubfoot placed in 70° abduction, unaffected foot in 40° abduction with feet shoulder width apart
- Worn full time (23 hours/day) for 3 months followed by bed and naptime use until age 4 (range 2-5)
- Patient should be followed every 3 months after bracing starts until 2 years of age
What is the most common factor related to clubfoot relapse?
[J Am Acad Orthop Surg 2010;18:486-493]
Failure to comply with foot abduction orthoses
By what age is clubfoot relapse most likely to occur?
[Am Acad Orthop Surg 2017;25:195-203]
Most frequently by age 5
- Rare after age 5 and extremely rare after 7
What are the signs of clubfoot relapse?
[Am Acad Orthop Surg 2017;25:195-203]
- Loss of dorsiflexion is the earliest sign
- Older infants – mild forefoot adductus, cavus, heel varus and limited abduction
- Walking child – increased lateral contact during stance phase, heel varus, inward deviation of toes, and dynamic supination during swing phase
How do you manage clubfoot relapse?
[Am Acad Orthop Surg 2017;25:195-203]
- Mild dorsiflexion loss
* If early, home exercise program and increased foot abduction orthosis use - If <10° dorsiflexion
* Repeat manipulation and casting as per Ponsetti (2-3 casts usually required changed weekly)
* Repeat tenotomy if 15° dorsiflexion not achieved
* Resume foot abduction orthosis - If >2.5 years of age:
* Consider anterior tibial tendon transfer to 3rd cuneiform (now sufficiently ossified)
* First requires obtaining original correction with manipulation and casting (2-3 casts) and heel cord tenotomy if <10° dorsiflexion
* Anterior tendon should never be split (split weakens eversion power)
* Technique for anterior tibial tendon transfer:- 3-4cm incision starting just distal to the navicular and extending proximal inline with tibialis anterior tendon is made
- The tibialis anterior tendon is released from the base of the 1st MT and a whip stitch is placed in the tendon
- A 2nd incision is made over the lateral cuneiform and localized with fluoro guidance, once confirmed a drill hole is made dorsal to plantar
- The tendon is tunneled subcutaneously from the medial to lateral incision
- Keith needles are threaded on to the sutures and passed through the drill hole and out through the plantar aspect of the foot
- The ankle is dorsiflexed and everted and the sutures are tied over a button
- The patient is casted for 6 weeks
- If age 4-9 with well-formed medial cuneiform ossific nucleus:
* Consider closing wedge osteotomy through the cuboid and medial opening wedge osteotomy through the cuneiforms (flip-flop technique) - Patients whose parents are unwilling to allow repeated cast and brace treatment and patients with feet that are otherwise refractory to the Ponseti method:
* Consider posteromedial release (required in less than 5%)- Highly associated with development of pain, stiffness and weakness in late adolescence and early adulthood
* Technique for posteromedial release [Lovell and Winter]: - Cincinnati incision
- Extends medially from navicular, posteriorly just below medial malleolus and 1cm proximal to the posterior heel crease, laterally just below lateral malleolus ending at the sinus tarsi
- Releases include:
- Heel cord lengthening
- Posterior release of ankle and subtalar joint
- Plantar fascia
- Abductor hallucis
- +/- Tib post tendon lengthening
- +/- Talonavicular joint capsule release
- +/- FHL and FDL release
- Highly associated with development of pain, stiffness and weakness in late adolescence and early adulthood
What are the associated conditions with congenital knee dislocation?
[JAAOS 2009;17:112-122]
- Ipsilateral DDH (70-100% of cases)
- Clubfoot
- Arthrogryposis
- Myelodysplasia
- Larsen syndrome
What is the classification of congenital knee dislocation?
[JAAOS 2009;17:112-122]
- Grade 1 = recurvatum
- Grade 2 = subluxation
- Grade 3 = complete dislocation
What is the clinical presentation of congenital knee dislocation?
[JAAOS 2009;17:112-122]
- Knee hyperextension
- Inability to flex knee in complete dislocation
What is the management of congenital knee dislocation?
[JAAOS 2009;17:112-122]
- Nonoperative
- Closed reduction and serial casting
- Closed reduction achieved by traction followed by knee flexion
- Serial casting in progressive knee flexion
- Operative
- Failure of nonoperative
- <30° of flexion after 3 months of casting
- Performed at ~6 months of age
- Involves open reduction and quadriceps lengthening
- Percutaneous quadriceps release
- Open V-Y quadriceps advancement
- Possible femoral shortening osteotomy (relative lengthening of extensor mechanism) [POSNA]
What is the management of ipsilateral congenital knee dislocation and DDH?
[JAAOS 2009;17:112-122]
- Treat congenital knee dislocation first
- Once adequate knee flexion achieved patient can be placed in Pavlik harness
* Pavlik harness helps to hold knee in flexion and maintain hip reduced
What is the definition of congenital dislocation of the patella?
Congenital, irreducible lateral patellar dislocation present at birth
What are the findings in patients with congenital dislocation of the patella?
- Anatomical
- Tight lateral structures (capsule, ITB, etc)
- Quadriceps contracture
- Lateralized patellar tendon insertion on tibia
- Hypoplastic patella
- Shallow trochlear groove
- Clinical
- Knee flexion contracture
- Genu valgum
- External tibial torsion
- Prominent femoral condyles
What is the management of congenital patellar dislocation of the patella?
Operative
- Principles:
- Extensive lateral release
- ITB, capsule, biceps femoris
- VY lengthening of quadriceps
- Medial capsule imbrication OR MPFL reconstruction
- Lateral patellar tendon insertion addressed via:
- Roux-Goldthwait procedure:
- Lateral half of patellar tendon detached from tibial tubercle, passed deep to remaining patellar tendon and attached medial to the medial half of the patellar tendon
- Patellar tendon periosteal sleeve medialization (complete medialization of patellar tendon)
- Roux-Goldthwait procedure:
- Extensive lateral release
What is developmental coxa vara?
[Lovell and Winter]
Decreased femoral neck shaft angle believed to be a result of a primary defect in endochondral ossification of the medial part of the femoral neck
What is the presentation of developmental coxa vara?
[Lovell and Winter]
Painless limp (unilateral) or waddling gait (bilateral)
- Due to abductor weakness and minor LLD in unilateral cases
What are the radiographic features of developmental coxa vara?
[Lovell and Winter]
- Decreased femoral neck-shaft angle (<120o)
- Vertical position of physeal plate
- Triangular metaphyseal fragment in inferior femoral neck with associated inverted Y appearance
- Shortened femoral neck
- Decrease in normal anteversion

How is the amount of varus deformity in developmental coxa vara quantified on plain films?
[Lovell and Winter]
Hilgenreiner epiphyseal angle (H-E)
- Angle between the physeal plate and Hilgenreiner line
- Normal = <25° (average 16°)
- Coxa vara = 40-70°

What is the management of developmental coxa vara?
[Lovell and Winter]
- Nonoperative
- H-E angle <45
- H-E angle 45-59 and asymptomatic
2.Operative
- H-E angle >60
- H-E angle 45-59 and symptomatic
- Symptomatic limp, Trendelenburg gait, or progressive deformity
- Neck shaft angle <100
- Technique:
- Valgus-producing proximal femoral osteotomy
What is the goal of correction in developmental coxa vara?
- <38° H-E angle [Orthobullets]
- 16° H-E angle [Lovell and Winter]






















