Pediatric Feet Flashcards
Normal foot
plantar grade
“neutral” hindfoot
plum line should intersect with the posterior border
medial and lateral borders of the foot are straight
Tripod
Foot acts as a tripod - lateral, medial, and posterior rays- with weight bearing spread across the calcaneous
Hx of foot deformity
CC
Hx of CC - pain, deformity?
what is the issue of deformity?
Think: is it a problem with abnormal walk?
was it something gradual (onset) or acute?
Gradual onset
DDx: spinal dysraphism
neuromuscular disease
congenital
Acute onset
DDx: trauma fx abuse strain sprain infection
PE of the foot
watch them walk !!!!
What are you looking for in a PE
-muscle atrophy- asymmetry
-swelling – affected or distant area
-deformity, rotational position – what normals are for rotation ?
-angular position
-hindfoot position
Active range of motion – need to know normal
Passive range of motion
Muscle testing- muscle strength
Neurologic exam
-Patellar &Achilles deep tendon reflexes
-Babinski test (UMN)
Infant benign foot deformities
Congenital
- simple polydactyly
- simple syndactyly
- metatarsus varus (adductus)
- calcaneovalgus
- congenital curled toe
Infant pathologic foot deformities
Congenital
- complex polydactyly
- complete and/or complex syndactyly
- club foot
- vertical talus
- cleft foot
- macrodactyly
Polydactyly
congenital foot deformity
often an isolated trait
small nubbin on lateral border of the foot (post axial)
extra bones
Preaxial polydactyly
either thumbs for upper extremities or big toes for lower extremities have nubbin
Postaxial polydactyly
little finger or toe has nubbin
What is a nubbin?
collection of tissue with artery and vein
Tie off the nubbin => will turn dry gangrene and fall off few days to wks
may have nail => indicate little bone
Goal of tx of polydactyly
be able to wear shoes comfortably
-> need to surgically remove
surgically remove to insure comfortable shoe wear
Syndactyly
failure of programmed cell death- sporadic cases are 80%
mesenchymal limb bud -> AER -> signaling of cell death defective -> webbing of the fingers (skins only)
Usually occurs between 3rd/4th toes
occurs bilaterally/symmetrical
Variations of syndactyly
Complete
Incomplete
Simple
Complex
Complex syndactyly
webbing the entire length of the digit
Incomplete syndactyly
webbing partial length of digit
Simple syndactyly
soft tissue union
Complex syndactyly
bony union
Surgery indications for syndactyly
FOR THE FEET, ONLY DO SURGERY if SHOE WEAR IS DIFFICULT
THETHERING DEFORMITY ON THE FINGERS DUE TO SYNDACTYLY – NEED SURGERY
Etiology of the Packaging defects
First pregnancy
Multiple gestation
large baby
Packaging defect
plegiocephaly - head misshapen
frontal bone is more prominent than another side
eyes and ears are asymmetric
metatarsus varus
calcaneovalgus
clubfoot
Metatarsus varus (adductus)***
result of packing defect
Mild>moderate = medial border of the foot curves inward severe = medial border of foot curves inward and it's stiff
Mild/moderate vs severe metatarus varus
Mild/moderate = flexible severe = stiff
PE metatarus varus
ALWAYS CHECK THE HIPS
gentle manipulation of foot with diaper changes
Tx metatarus varus
start putting them on shoes
corrective shoes - straight last , reverse last, be back shoes
rarely require surgery
When will a reverse shoe not be tolerated
severe metatarsus varus because they are not flexible
will have skin problems if given reverse shoe
Calcaneovalgus
packing defect
benign non position foot
flexible foot position corrects with gentle manipulation
foot is dorsiflexed to the tibias anterior
DDx : vertical talus or fibular hemimelia
PE: always check the hips
Serial casting
can be used to tx metatarsi varus -refer to orthopedic surgeon
rarely needed for calcaneovalgus
Doesn’t work for vertical talus
Calcaneovalgus present with hip dysplasia
unilateral CV
foot splay?
Congenital curled toe**
-result from contracture
-presentation: standing on the lateral aspect of the little toe
-shoe wear is a problem
do surgery but it is of high risk
Clubfoot *
- Idiopathic : unknown
- a packaging defect
- arthrogryposis - resistant = foot doesn’t respond well
- myelodysplasia - marrow dysplasia
- hereditary
ABNORMAL MESENCHYMAL TISSUE IN THE MEDIAL BORDER
Associated problem with clubfoot
spinal dysphargism = particularly if the foot is bent unilaterally
Tx of clubfoot
nonoperative - need two different shoe sizes
infants - stretch, cast to correct the talocalcaneal joint => ensure that aspiration is resolved
wait until children is 5-6 mon to a year to do a surgery
talus and subtalus and talus/navicular joints need to be open
Dx of clubfoot
check hips for dysplasia or instability
check spine for sacral clefts, dimples, hairy patches
Presentation of clubfoot
pt stands on dorsolateral of the foot
development of the leg affected is thinner
limb on the affected side is always smaller
Sx of clubfoot
posterior crease medial crease empty heel pad adducts of forefoot varus of hind foot supination mid/forefoot
Differentiate b/n clubfoot and metatarsus !!!
Posterior crease is deep
medial crease - only soft tissue = calcareous is not at the anatomical position
hind foot is varus (point inward)
mid foot and forefoot are supinated
Vertical talus **
Rockerbottom foot - > rigid foot = can’t plantar flex = AKA RIGID HINDFOOT VALGUS
This is a pathologic condition
DX vertical talus
palpate the head of the talus through the skin
Presentation of vertical talus
weight bearing on the head of the talus
Tx of vertical talus
-cant reduce mid foot and talus
refer to orthopedic surgeon to restore tripod
Macrodactyly
pathologic = overgrowth syndrome
gigantism of bones, muscles, nerves (4x size), vasculature
population: seen in AMISH people
Tx of macrodactyly
refer to ortho surgeon
goal is to wear comfortable shoes
Cleft foot***
central failure of formation
can happen in hand and feet
Acquired foot deformity
- Pes planus - flat feet
- flexible
- rigid: tarsal coalition - Cavus - serious pathological condition - need to know Ddx
* **cavovarus
Presentation of a child with flat foot
the medial side is not well balanced
bottom of the foot is blanched
longitudinal foot in a toodler
NORMAL
less than 2 y/o
A 2 y/o has a longitudinal arch
DDx : spinal dysphyragism
congenital spinal and neuromuscular diseases
Pes Planus
BENIGN
rarely symptomatic
subluxation of the talonavicular joint***
- *flattened longitudinal arch
- mild
- moderate
- severe
- *hindfoot valgus
- *Flexible
- *Rigid
presentation of per planus
walking on the talus
acquired vertical talus
flexible - assoc. with ligamentous laxity
Flexible pes planus***
DDx
ligamentous laxity
tight tendoachilles
overcorrected clubfoot
fibular longitudinal deficiency - absence of the fibula (no lateral strut of the fibula)
=> this can clue in on leg length deficiency and it is a congenital problem!
Test for flexible flat feet
how can you tell flexibility? stand on toes
arched support may be needed but RARE
Hind foot valgus - Pes planus
subtalar instability
ankle instability
Notes on hind foot valgus - per plans
LOW GRADE SPINAL BIFIDA
FIBULA IS ATROPHIC – INDICATION OF PARTIAL PARALYSIS
GROWTH PLATE
FIBULA DID NOT GROW AS WELL
DISTAL TIBIA SHOULD BE PARALLEL WITH THE TALUS BUT ITS NOT
TWO SCREWS ARE PUT IN – THEN , MEDIAL ASPECT OPENS UP
TETHER THE SIDE THAT IS GROWING !
Rigid pes planus
Tarsal coalitions - fibrous, cartilagenous, boney
nonpainful
painful - refer to ortho
Tarsal coalitions
an abnormal connection that develops between two bones in the back of the foot (the tarsal bones)
50% -60 % of coalitions are bilateral
Peroneal spasm!!!!!
Synostosis tarsal coalition
boney coalition
synchondrosis tarsal coalition
cartilagious coalition
syndesmosis tarsal coalition
fibrous coalition
Sites of tarsal coalitions
**Calcaneonavicular - begins to ossify @ 8-14 yrs.
**Talocalcaneal - begins to ossify 12 yrs to adult
**Calcanealcuboid
Talonavicular
Navicularcuboid
Navicularcunieform
Accessory navicular
Pes planus
TIBILARIS POSTERIOR INSERTS at the point in navicular
CAN TEST THIS BY HAVING PATIETNT ABDUCT FOOT AND TRY TO ADDUCT IT AGAINST RESISTANCE
Cavus/cavovarus***
Genetic
Increased height of longitudinal arch
Hindfoot varus-ALL WEIGHT BEARING ON THE LATERAL SIDE
Claw Toes
Deformities may be flexible or fixed
MUSCLE IMBALANCE FROM SENSORY/MOTOR NEUROPATHY
MIDDLE CREASE
Tx goal for cavus
RESTORE PLANTAR GRADE
BEST THEM TO GO TO A NEUROLOGIST
PCP WILL DO THAT
underlying causes of cavus (conditions are PROGRESSIVE AND DEGENERATIVE)
Charcot-Maire Tooth Disease Spinocerebellar Degenerations Myelodysplasia Polio Spastic Monoplegia or Dyplegia Polyneuritis Myopathy Trauma Spinal Cord Tumor Occult Spinal Dysraphism Arthrogryposis Congenital Lymphedema Congenital Syphilis Residual Clubfoot Deformity
Workup for Cavus
Detailed history Prenatal Perinatal Developmental history Family Medical History Onset of deformity (congenital, gradual,rapid)- SORT OUT DDX Functional Status***ESP FOR OLDER PTS
PE of Cavus
WATCH THEM WALK Examine Gait Muscle Strength Testing Reflexes Upper and Lower Extremities Muscle Tone & testing for strength Clonus-INVOLUNTARY MUSCLE CONTRACTION Babinski Sign Superficial Abdominal Reflex SUBTLE WEAKNESS OF TIB ANTERIOR COMPENSATING Meticulous Examination of the Spine Skin Posterior & Sagital views Palpate for defects- SPINA BIFIDA CAN BE A DDX
Referral of Cavus
Neurology EMG & Nerve Conduction Studies MRI (head &/or spine) Muscle &/or Nerve Biopsy Genetics DNA Testing
Lab tests for Cavus
CBC with Diff
Urinalysis
CPK prn
XR measurement of Cavus
** LINES SHOW CAVUS
1ST LINE – FIRST RAY (TOP PIC)
Kelikian’s “Push-up” Test
Test for Cavus
TOES CLAWED NO MATTER WHAT HAPPENS TO METATARSAL HEADS
Non surgical Tx of Cavus
Stretching contracted plantar fascia
Insoles for painful flexed metatarsal heads
Shoes , Braces & Orthotics DO NOT correct or prevent deformity- NOT USEFUL – COSTLY
Orthotics in flexible deformity
AFO with dorsiflex assist
Goal tx of caves
MAINTAIN AND PROMOTE FUNCTION WITHOUT SHOE WEAR PROBLEMS
Goal tx of caves
MAINTAIN AND PROMOTE FUNCTION WITHOUT SHOE WEAR PROBLEMS
