Pediatrics Flashcards
1
Q
APGAR
A
Scoring system for perinatal asphyxia, indicator of immediate needs, score is 1-5 Evaluates appearance (blue, pink body/blue extremities, pink), pulse, grimace, activity, respiratory effort
2
Q
Developmental landmarks
A
3 months: lifts head up when prone 6 months: rolls over 9 months: sits up 12 months: stands/cruises 14 months: walks 15-18 months: uses words 18-21 months: combines words 21-24 months: three word sentences 36 months: propulsive gait
3
Q
Splints and braces
A
Used for 3 months to 3 years, worn at night, naps, as tolerated during the day
Best for positional abnormalities (soft tissue) such as internal/external femoral rotation
Not as effective for osseous deformity (tibial torsion)
Splints and braces are to be worn as much as possible at night and during naps, throughout the day as tolerated
4
Q
Bar braces
A
With braces that have a rigid bar connecting the feet, a 15 or 20 degree varus bend should be placed in the bar to prevent subluxation of STJ or MTJ
5
Q
How long to use splint
A
If you use a splint following serial plaster casting, use the splint TWICE AS LONG as the total casting time
6
Q
Ganley splint
A
First splint designed to treat combined leg and foot disorders
Same indications as denis browne bar (metatarsus adductus, convex pes planovalgus and positional abnormalities of the leg) but also allows FF to RF control
If treating an internal rotation problem, torque bar is placed between the rearfoot plates
If treating an external rotation problem, torque bar is placed between the forefoot plates
Remember that the bar is used on the shorter distance
Adjustments are made simply by bending the bars
7
Q
Denis-browne bar
A
Has been used to treat metatarsus adductus, convex pes planovalgus and positional abnormalities of the leg
Originally designed to treat clubfoot
The bar is screwed or riveted on the child’s shoes
8
Q
Fillauer bar
A
Same as denis brown bar except it clamps to soles of patient’s shoes
Requires rigid soled shoes for clamp to stay on
9
Q
Unibar
A
Same as denis browne bar except it has a ball and socket joint beneath each foot which can be tightened into a varus position to prevent STJ and MTJ subluxation, eliminating the need to bend the bar
10
Q
Counter rotation system (Langer)
A
Designed to correct torsional abnormalities of the leg
Functionally the same as the denis brown bar but several hinges allow for greater freedom of motion
Best tolerated splint, allows crawling
11
Q
Bebax shoe
A
Used to treat FF to RF abnormalities (metatarsus adductus)
Recommended for use after serial casting of MA but not as the primary correction
Also available is the clubax - a device designed for rearfoot or leg deformities, specifically clubfoot
12
Q
Standard AFO
A
Ankle set at 90 degrees
Used in various neuromuscular disorders which may cause equinus (CP, muscular dystrophy)
ALso used to treat drop foot
13
Q
Osteochondrosis
A
Epiphyseal ischemic necrosis
A disease of the growth or ossification centers in children which begins as a degeneration or necrosis and is followed by regeneration or recalcification
14
Q
Blount’s disease
A
Osteochondrosis of the medial proximal tibial epiphysis
Causes bowing of the legs
15
Q
Freiberg’s infarction
A
Osteochondrosis of the metatarsal head
2nd is most common followed by 3rd, 4th and 5th
More common in girls
ROM pain, swelling, thickening of MPJ
16
Q
Kohler disease
A
Osteochondrosis of the navicular
More common in boys
Ages 3-6
Often asymptomatic, pain/swelling possible
Navicular becomes sclerotic and flattened (coin on edge or silver dollar sign)
Self limiting, recovery usually takes from 2-4 years
Navicular ultimately resumes normal shape and density
17
Q
Kohlz’s disease
A
Osteochondrosis of the primary ossification center of the patella
18
Q
Leg-Calve-Perthes disease
A
Osteochondrosis of the femoral head
Occurs between ages 3-12
10% are bilateral
Most common form of osteochondrosis
The younger the child the better the prognosis, due to trauma in 30%
Male:female 5:1
Insidious onset of limping, generalize groin pain, referred pain to the knee
19
Q
Osgood-Schlatter disease
A
OSteochondrosis of the tibial tuberosity
More common in boys
Age 10-15
Caused by excessive traction of patellar from the patellar ligament
Symptoms include pain, swelling
Self limiting, treatment is symptomatic
20
Q
Sever’s disease
A
Osteochondrosis of the calcaneus (apophysis)
Caused by excessive traction of the achilles tendon
Ages 6-12
More common in patients with equinus
Radiographic diagnosis is difficult, the normal eiphysis can have 2 or more centers (appearing fragmented), irregular borders and is often sclerotic
Treatment: RICE, NSAIDs, rest, eliminate sports, heel lifts, Achilles stretching
21
Q
Iselin’s disease
A
Osteochondrosis of the 5th metatarsal base
22
Q
Buschke’s disease
A
Osteochondrosis of the cuneiforms
23
Q
Diaz or Mouchet’s disease
A
Osteochondrosis of the talar body (usually associated with trauma)
24
Q
Thiemann’s disease
A
Osteochondrosis of the phalanges
25
Lewin’s disease
Osteochondrosis of the distal tibia
26
Ritter’s disease
Osteochondrosis of the fibular head proximally
27
Treve’s disease
Osteochondrosis of the fibular sesamoid ***
28
Renandier’s disease
Osteochondrosis of the tibial sesamoid ***
29
Congenital dislocated hip
More common in females, breech, first born
Associated with oligohydramnios, torticollis, metatarsus adductus, calcaneal valgus
In older children, limited abduction, asymmetric thigh folds, relative femoral shortening, limp, positive Trendelenberg, externally rotated foot, waddling gait
Best position to prevent dislocation is flexed and abducted (think about Peterson telling the mom to put her baby in a baby holder)
When a dislocation occurs, the femoral head is usually posterior and superior to the acetabulum
Most dislocaitons occur during the first two weeks of birth
30
Etiology of congenital dislocated hip
Ligamentous laxity
Acetabular dysplasia
Malpositioning (breech, caring babies with hips adducted and extended)
31
Ortolani’s sign
Baby supine, knees flexed, lift and abduct the thigh 1 at a time
Positive when a palpable click is felt as the foam oral head is entering the acetabulum
O equals already out, positive is popping back in
32
Barlow’s sign
Baby supine, hips and knees flexed, pressed down and out on knee
Positive when the dislocatable hip becomes displaced with a palpable clunk as the head slips over the posterior aspect of the acetabulum
B equals back, able to dislocate hip backwards
33
Anchor sign
Asymmetry of thigh and gluteal folds
| More folds on dislocated hip side
34
Galezzi’s sign
While the hips and knees are flexed, a dislocated hip result in all lower knee
35
Abduction test
Baby supine, hips and knees flexed to 90, abduct the knees to resistance
A dislocated hip will have a limitation of abduction on the affected side
36
Clubfoot
Talipes equinovarus
37
Triplane deformity of talipes equinovarus
Ankle equinus
Hindfoot varus
Forefoot adduction
38
Incidence of clubfoot
```
1 in 1000 live births
Male to female ratio 2:1
50% are bilateral
Right foot more common than left
Lowest incidence in Asian, highest incidence in Polynesians
```
39
Types of clubfoot
Idiopathic: Intrauterine position
| Non-idiopathic: Spina bifida, CP, MD, meningitis, post-polio, traumatic, Streeter’s disease
40
Radiographic evaluation of clubfoot
Kite’s angle: Normal 20-40 degrees, clubfoot 0-15 degrees
Calcaneal inclination angle: Normal 20-25 degrees, clubfoot 17°
Talar head/neck relative to body
Adduction: Normal 10-20 degrees, clubfoot 80-90 degrees
Plantar flexion: Normal 25-30 degrees, clubfoot 45-65 degrees
41
Serial casting for clubfoot
Begin is soon as possible
Stretching and manipulation prior to cast application
Applied tincture of benzoin to child skin to help under cast Dick
Cast applied with 2 in plaster, long leg cast to prevent it from slipping off, flex knee 75-90 degrees
Mold cast with the foot in the reduced position
Can bivalve the last cast to use as a night splint
42
Order of reduction of clubfoot deformity in casting
Adduction
Varus
Equinus
Remember AVEnue
43
When to consider surgical intervention for clubfoot
No improvement with serial casting after 12 weeks
44
Complications of serial casting for treatment of clubfoot
Metatarsus adductus
Heel varus
Pes planovalgus over-correction
Rocker bottom deformity from too much equinus correction
AVN of the talus or flattening of the talar head
Navicular subluxation dorsally over talus
45
Timing of soft tissue release for clubfoot
Children 3 months to 12 months in age
46
Posterior release for clubfoot
Reflect the origin abductor hallucis and plantar fascia
Z plasty of Achilles tendon
Release posterior medial and lateral ankle joint
Release posterior medial and lateral subtalar joint - this releases posterior talofibular and calcaneofibular ligaments
47
Medial release for clubfoot
Z-plasty posterior tibial tendon
Release tail of the navicular joint - spring ligament and knot Henry are severed
Release entire medial subtalar joint including superficial deltoid ligament
48
Lateral release for clubfoot
Release interosseous talocalcaneal ligament
Release bifurcate ligament
Release lateral subtalar joint
49
Timing osseous procedures for clubfoot
1-4 years
| Once the child reaches 1-year-old, bony correction of deformity may also be performed along with soft tissue release
50
Calcaneal osteotomies for clubfoot
All aimed to abduct the forefoot on the rearfoot ( opposite of flatfoot reconstruction)
Lichtblau: Lateral closing based osteotomy to the anterior calcaneus
Evans: Lateral closing based cuboid calcaneal osteotomy
Ganley’s lateral closing based osteotomy of cuboid
51
Congenital vertical talus
Also and congenital pes planovalgus, reversed clubfoot, Persian slipper, rocker bottom flat foot
52
Description of congenital vertical talus
Primary dislocation of the navicular dorsally on the neck of the talus which locks the talus in a vertical position
Forefoot is abducted and dorsiflexed at the mid tarsal joint consistent with flatfoot
Calcaneus is in valgus and equinus
RIGIDITY is the hallmark of the deformity
Contracted gastrocsoleus and elongated spring ligament
53
Incidence of congenital vertical talus
Majority are bilateral
Right more common than left
Often occurs with other congenital deformities, most notably arthrogryphosis
Foot may touch the front of the tibia and birth
Walking is not delayed because it is not painful
Awkward/clumsy gait and difficult shoe gear
Taylor head is prominent on medial plantar aspect of foot and may have a callus over it from bearing most of the body weight
54
Abnormal subtalar joint facets in congenital vertical talus
Anterior facet is absent
Middle facet is hypoplastic
Posterior facet is malformed and misshapen
55
Radiographic evaluation of congenital vertical talus
Definitive diagnosis is lateral x-ray and comparing it to a 2nd lateral x-ray with the foot maximally plantar flexed demonstrating that talonavicular joint does not change, fixed deformity
Navicular is not evident radiographically and told the age of 3 so it is difficult to establish it subluxation
56
Radiographic measurements in congenital vertical talus
Line bisecting talus on lateral x-ray is parallel to tibia
Talocalcaneal angle on AP x-ray is increased usually greater than 40°
Talar neck is hypoplastic, may have hour glass shape, may have flat surface
Navicular articulates with dorsal neck of the talus
Negative Hubscher maneuver
57
Hubscher maneuver
The Hubscher maneuver (or Jack's test) is a method of evaluating the flexibility of a pes planus or flat foot type. The test is performed with the patient weight bearing, with the foot flat on the ground, while the clinician dorsiflexes the hallux and watches for an increasing concavity of the Arches of the foot.
58
Treatment of congenital vertical talus
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Closed reduction
Open reduction (type of open reduction varies based on age)
```
59
Closed reduction for treatment of congenital vertical talus
Rarely successful
| Manipulation and casting is recommended as a means of stretching the soft tissues for future surgery
60
Open reduction for treatment of congenital vertical talus
3 months to 3 years: If close reduction fails, open reduction should be performed at 3 months of age, many procedures described, all involved posterior release and reduction of TN joint
3-6 years: In addition, extra-articular arthrodesis or arthroereisis to maintain reduction and stabilize subtalar joint
6 years in up: Postpone surgery until skeletal maturity and perform triple arthrodesis, may require removal of head/neck of talus to obtain reduction
61
Flexible pes planus (pediatric flat foot)
Positive Hubscher maneuver
Heel re-supinates with heel raise
Nonpainful
Longitudinal arch present during weight-bearing
Different than rigid pes planus which is caused by coalition or vertical talus in pediatrics
62
Description of flexible pes planus
Higher incidence in African American
Most are asymptomatic
Foot appears externally rotated in relation to the leg
Weight-bearing axis of the lower extremity is medial to axis of the heel
Most infants are flat footed and developing arch during the 1st decade of life
63
Symptoms of flexible pes planus
Often asymptomatic
Muscle cramps, especially calf and anterior leg
Arch pain
Heel pain
64
Radiographic evaluation of flexible pes planus
Meary’s angle (lateral)
Calcaneal inclination angle (lateral)
Talocalcaneal angle (AP)
Talonavicular articulation (AP)
65
Meary’s angle
Lateral x-ray
Angle between the long axis of the talus and first metatarsal bone
Normal is 0°
Pes planus: 1-15° mild, over 15° severe
66
Calcaneal inclination angle
Lateral x-ray
Normal is 20-25 degrees
Pes planus: Less than 15°
67
Talocalcaneal angle
As seen on AP
This is the angle formed by the intersection of a line bisecting the head and neck of the talus and a line running parallel with the lateral surface of the calcaneus
Normal: Less than 25°
Pes planus: Over 25° (splay foot)
68
Talonavicular articulation
Also talar head uncoverage
Less than 50% is normal
Pes planus: 60-70%
69
Cause of flexible flatfoot
```
Compensated forefoot varus
Compensated forefoot valgus
Rearfoot equinus
Adducted foot
Abducted foot
Neuro trophic feet
Muscle imbalance
Posterior tibial tendon rupture
Ligamentous laxity (Ehlers-Danlos, Marfan sites, Downs, osteogenesis imperfecta)
Calcaneovalgus
Enlarged accessory navicular
```
70
Treatment of flexible flatfoot
Young children: Manipulation, strapping, casting may be beneficial
Older children: Orthotics are beneficial
Do not use orthotics with short Achilles tendon as it will prevent recreation of arch, instead use heel cup to 25 mm to keep heel in vertical position
Can add medial flare of ⅛ inch on rearfoot post to help eliminate excess pronation
Surgical treatment is based on Planal dominance
71
Transverse plane correction of flatfoot
Evans
| Kidner
72
Evans
Lateral based opening wedge osteotomy of the calcaneus 1.5 cm proximal to the calcaneocuboid joint
Insertion of bone graft or implant into osteotomy
73
Kidner
Removal of prominent navicular tuberosity or accessory navicular and transplantation of posterior tibial tendon into the underside of the navicular
74
Sagittal plane correction of flatfoot
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Lowman
Cotton
Hoke
Miller
Young
```
75
Lowman
Talonavicular wedge osteotomy to plantar flex the forefoot
TAL
Tibialis anterior is rerouted under the navicular and sutured in to spring ligament
Tenodesis of medial arch with slip of Achilles tendon which is left attached to the calcaneus and folded forward along the medial arch as an accessory ligament
Desmoplasty (splitting) of the talonavicular ligament
76
Cotton
Opening dorsal based wedge osteotomy of the medial cuneiform
77
Hoke
Plantar based wedge with removal and fusion of the navicular and 2 medial cuneiforms to plantar flex the forefoot
This is performed with a TAL
78
Miller
Naviculo-1st cuneiform-1st metatarsal base fusion with wedge shaped joint resection to plantar flex the forefoot
79
Young (Keyhole technique)
Re route the anterior tibial tendon through a keyhole in the navicular without detaching it from its insertion
Anterior tibial tendon comes anterior to ankle joint, plantar through navicular, than attach is to the plantar medial cuneiform and plantar medial base of the 1st metatarsal
Posterior tibial tendon advanced under the navicular
80
Frontal plane correction of flatfoot
Chambers
Baker
Selakovich
Arthroereisis
81
Chambers
Raises the posterior facet of the subtalar joint by using a bone graft under the sinus tarsi
82
Baker
Osteotomy inferior to the STJ posterior facet with bone graft
83
Selakovich
Opening wedge osteotomy of the sustentacular and talar I with bone graft which restricts abnormal subtalar joint motion
84
Calcaneal osteotomies for correction of flat foot
Gleich
Silver
Koutsogiannis
85
Gleich
Oblique calcaneal osteotomy of posterior tuber displaced anteriorly
Helps increased calcaneal inclination angle
86
Silver
Lateral opening wedge osteotomy of posterior tuber of calcaneus with graft
87
Koutsogiannis
Oblique crescentic osteotomy of the posterior tuber of calcaneus
88
Triple arthrodesis for flat foot
Reserved for 2nd stage salvage procedure
89
Grice and Green extraarticular subtalar arthrodesis
Bone graft is inserted laterally into the sinus tarsi between the talus and calcaneus
This procedure is acceptable for children because it provides excellent stability without interfering with the growth of the tarsal bones
90
Skewfoot
Z foot, serpentine foot, compensated met adductus
Adducted forefoot, normal midfoot, valgus hindfoot
Usually acquired from gradual compensation metatarsus varus that occurs with weight-bearing or improper manipulation and casting
Fixed hindfoot valgus and severe rigid MTA
Increased calcaneocuboid ankle, normal 0-5 degrees ( line along the lateral aspect of the calcaneus and lateral aspect of the cuboid)
91
Cavus foot description
```
High arched foot
Elevated longitudinal arch
Primarily a sagittal plane deformity
Painful calluses under metatarsal heads
Chronic inversion ankle sprains
Heel, knee or hip pain may develop secondary to lack of shock absorption from abnormal architecture of foot
```
92
Radiographic evaluation of cavus
Can take weight-bearing and nonweightbearing films to determine if deformity is reducible
Bullet hole sinus tarsi
Calcaneal inclination angle above 30° ( normal 20-25 degrees)
Angle of Mary over 6° ( normal 0 degrees)
Angle of hips over 150° ( normal 135-140 degrees)
93
Classification cavus foot based on location apex of deformity
Metatarsal cavus: Apex at Lisfranc joint
Lesser tarsus cavus: Apex at lesser tarsal bones
Forefoot cavus: Apex at show parts joint
Combination cavus: Apex generalized over lesser tarsals
94
Causes of cavus foot
Often times the 1st manifestation of many neuro muscular disorders
Spina bifida, Charcot-Marie-Tooth, Friedreich's ataxia, poliomyelitis, spinal cord tumors, myelomeningocele, CP, infection, syphilis, trauma, spinal cord lesion
95
Surgical treatment of cavus
Soft tissue for flexible deformities
| Osseous procedures for rigid deformities
96
Soft tissue procedures for cavus
Plantar fascial release - Steindler stripping
Jones Tenosuspension
Heyman procedure
Hibbs procedure
Split tibialis anterior tendon transfer (STATT)
Peroneus longus tendon transfer
Tibialis posterior tendon transfer
Peroneal anastomosis
Peroneal longus and tibialis posterior tendon transfer to the calcaneus
97
Steindler stripping
Plantar fascia and long plantar ligament is released
| Abductor hallucis, FDB and abductor digiti quinti are stripped from the periosteum of the calcaneus
98
Jones tenosuspension
Jones tendon transfer or Jones tenosuspension is a tendon transfer performed to remove the deforming force for hallux malleus deformity. It is most often performed with interphalangeal joint (IPJ) fusion of the hallux.
Transfer of the EHL from its insertion, through the neck of the first metatarsal and tied on itself. Jones combined this tendon transfer with an incision of the plantar fascia.
99
Heyman procedure
Transfer of all lesser extensor tendons to their respective metatarsal heads
100
Hibbs procedure
Hibbs tenosuspension is an underutilized procedure when it comes to dealing with lesser toe pathology in conditions such as Charcot-Marie-Tooth disease.
Procedure to transfer the extensor digitorum longus tendons into the peroneus tertius tendon to eliminate a deforming force and create a stabilizing force.
101
Peroneal anastomosis
At the lateral ankle the peroneus longus is anastomosed to the peroneus brevis. This decreases plantar flexion of 1st metatarsal and increases eversion forces to the foot
102
Peroneus longus and tibialis posterior tendon transfer to the calcaneus
Peroneus longus is cut in the area of the cuboid and attached to the lateral border of the Achilles tendon
Tibialis posterior is cut and attached to the medial border of the Achilles tendon
103
Osseous procedures for rigid cavus foot
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Cole
Japas
DuVries
Dwyer
McElvenny-Caldwell procedure
DFWO
Jahss
```
104
Cole
Dorsiflexor a wedge osteotomy through the navicular cuneiform joint and cuboid bone
105
Japas
A mid tarsal the osteotomy ( apex of the V is proximal and at the highest point of the cavus deformity, usually the navicular)
The lateral limb the the extensor the cuboid and the medial limb of the the extends through the cuneiform
No bone is excised, the distal part of the osteotomy is shifted dorsal
106
DuVries
Dorsal based closing wedge osteotomy with fusion through the mid tarsal joint ( talonavicular joint and calcaneocuboid joint)
Functions to dorsiflex
107
Dwyer
Lateral based closing wedge osteotomy of the calcaneus or medial based opening wedge osteotomy the calcaneus
108
McElvenny-Caldwell procedure
Dorsal based closing wedge osteotomy and fusion of 1st tarsal metatarsal joint
If the deformity is severe, also fuse naviculocuneiform joint in this fashion
Functions to dorsiflex the 1st ray
109
DFWO
Dorsiflexory wedge osteotomy of the 1st or all metatarsals
110
Jahss
Dorsal based closing wedge osteotomy across the tarsometatarsal articulations
111
Tarsal coalitions
Bridge between 2 or more tarsal bones that restricts motion
Most common cause of peroneal spastic, spasm occurs is response to the body to immobilize the subtalar joint
Male more common than female
Onset of pain is insidious or may follow athletics, minor trauma
Occasionally anterior and posterior muscles are in spasm causing a varus deformity
Incidence is around 1%
Approximately 50% or bilateral
Talocalcaneal and calcaneonavicular coalitions are roughly equal in distribution and account for over 90% tarsal coalitions
Common peroneal blocks may be used to relax spastic peroneals to fully evaluate range of motion
112
Symptoms of tarsal coalitions
Deep, aching pain aggravated by activity, relieved by rest
Decreased range of motion
Muscle spasm, peroneal is a are often fatigued from overuse
Halo sign
Talonavicular beaking
Anteater nose sign
113
Cause of tarsal coalition
Congenital, failure of segmentation of primitive mesenchyme
| Acquired (infection, arthritis, trauma, iatrogenic)
114
Fusion tissue types in tarsal coalition
Syndesmosis-fibrous
Synchondrosis-cartilaginous
Synostosis - osseous
115
Talocalcaneal
Approximately 45% tarsal coalitions
Almost always involve the middle facet
Symptoms begin at 12-18 years
Pain in sinus tarsi or over middle facet (just anterior to medial malleoli)
Decreased ROM at STJ and MTJ
CT is gold standard for analysis
Harris beath: middle and posterior facets are not parallel, mid facet not well defined
Lateral: talar beaking, broadened lateral process of talus, narrow posterior STJ facet, unable to visualize mid facet, ball-and-socket AJ, concave undersurface of the talar neck, halo sign or sunburst around sinus tarsi (sclerotic ring)
Ischerwood: consists of 3 views to see all 3 facets (especially anterior)
116
Treatment of talocalcaneal coalition
⅓ patient’s response to conservative cares shoe modification, orthotics, rest, sinus tarsi steroid injection
Surgical: Resect far, interposed adipose, range of motion improves immediately
Triple arthrodesis if DJD present or previous surgery failed
117
Calcaneonavicular
Approximately 45% of tarsal coalitions
An extra-articular coalition
Symptoms begin at 8-12 years of age
Pain typically localized over coalition
Moderate decrease in range-of-motion at STJ and MTJ
Medial oblique at 45°: Incomplete fusion of bony ends which are irregular and lack cortical definition, close proximity of calcaneus and navicular, flattening of navicular as it approaches the calcaneus, hypoplastic talar head
Lateral: Prolongation of the anterior process of the calcaneus, calcaneus can be seeing “reaching up” towards the navicular
118
Treatment of calcaneal navicular coalition
Conservative: Decrease motion through orthotics, rest, NSAIDs
Surgical: Cowell procedure - reflect or June of extensor digitorum brevis, resect bar, interpose muscle belly into defect, suture to plantar medial surface of the foot with Keith needles, button fixation
Triple arthrodesis if DJD present or previous surgery failed
119
Talonavicular coalition
Less than 2% of tarsal coalitions
Most her asymptomatic, however if painful occurs at 3-5 years of age
Chief complaint is usually bomp pain from shoe gear over medial prominent talonavicular joint
Lateral radiograph will demonstrate absence of dorsal portion of sign aligned
Conservative treatment to pad metatarsal prominence
Surgical treatment to resect medial prominence
120
Calcaneal cuboid coalition
Less than 2% of tarsal coalitions
Asymptomatic
On lateral radiograph, will see absence of plantar portion of cyma line
121
Metatarsus adductus description
Adduction of the FF at tarsometatarsal joints
Rearfoot is normal
1 in 1000 live births
55% bilateral
Males = females
Prominent styloid process
Intoed gait with frequent tripping
Severity of adduction progressively decreases from medial to lateral
Usually idiopathic, rarely associated with neuromuscular disease
10% are associated with dislocated hip
86% resolve satisfactorily without treatment, spontaneous improvement should be almost complete at three months if it is to occur
122
Cause of metatarsus adductus
Intrauterine position
Tight abductuor hallucis muscle
Absent or hypoplastic medial cuneiform
Abnormal insertion of anterior tibial tendon
123
Classificaitons of metatarsus adductus
Dynamic: baby born with straight feet for 7-8 months, then develops c shaped foot due to tightening or contracture of abductor hallucis
Flexible: straightens out or over corrects when force is applied to the medial aspect of hte foot, treatment is with straight last shoe
Rigid: Little change in FF to RF position with medial pressure, biggest problem is shoe fit (prominent styloid process) - treatment is serial casting or surgical
124
Crawford and Gabriel Classification of metatarsus adductus
Stroking the lateral border of the foot with cause peroneal muscle contractions which will demonstrate the degree of active forefoot mobility
Type I: flexible, forefoot will correct past neutral into slightly overcorrected position
Type II: partially flexible, does not correct to neutral actively but does passively
Type III: rigid, does not correct to neutral actively or passively
125
Bleck classification of metatarsus adductus
Normal = line from heel extends between 2nd and 3rd toes
Mild = line from heel extends through 3rd toe
Moderate = line from heel extends between 3rd and 4th toes
Severe = line from heel extends between 4th and 5th toes
126
Classic method of measuring metatarsus adductus angle
Marked out medial proximal aspect of 1st metatarsal base, medial distal aspect of talonavicular joint
Mark out lateral proximal aspect of 4th metatarsal base, lateral distal aspect of calcaneocuboid joint
Drawn line between the medial and lateral landmarks
Compare line perpendicular to this to the line bisecting 2nd metatarsal longitudinally
Metatarsus adductus angle above 20° is considered adducted
Metatarsus adductus ankle at birth is 25-30 degrees, and approximately 20° a 1 year
By 4 years and into adulthood, normal is approximately 15°
127
Lepow technique for measuring metatarsus adductus angle
Take the perpendicular of aligned passing through the lateral base of the 5th and medial base of the 1st metatarsals and compare with the 2nd metatarsal
Values are comparable to values obtained by the traditional methods
128
Engle’s angle for measuring metatarsus adductus
Bisect the intermediate cuneiform and compare with the 2nd metatarsal, a normal value using this method is 24°, the ankle increases with an adducted foot
129
Soft tissue procedures for metatarsus adductus
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Indicated for children 2-8 years
Heyman, Herndon and strong
Thompson procedure
Lange
Lichtblau
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130
Heyman, Herndon and Strong
Release all soft tissue structures at Lisfranc’s joint except lateral and plantar lateral ligaments
Initially described using 1 transfer skin incision, revised to 2 or 3 longitudinal incisions
131
Thompson procedure
Resection of the abductor hallucis muscle
| Release medial head flexor hallucis brevis if necessary
132
Lange
Capsulotomy of the 1st metatarsal 1st cuneiform joint
| Division of the abductor hallucis
133
Lichtblau
Sectioning of the hyperactive abductor hallucis
134
Osseous procedures for metatarsus adductus
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Indicated for children 8 years and older
Berman and Gartland
Lepird
Johnson osteochondrotomy
Fowler
Peabody-Muro
Steytler and Van Der Walt
McCormick and Blount
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135
Berman and Gartland
Laterally based crescentic osteotomies of metatarsal bases 1 through 5
136
Lepird
Lateral closing based wedge osteotomy of 1st through 5th metatarsal bases
Oblique rotational osteotomies of the 3 central metatarsals
137
Johnson osteochondrotomy
Lateral based closing abductory wedge osteotomy of the 1st metatarsal
Resection of osteocartilaginous 2.5 mm lateral based wedge from lesser metatarsals
138
Fowler
Opening wedge osteotomy of the medial cuneiform with insertion of bone
139
Peabody-Muro
Excision of the base of the central 3 metatarsals
Osteotomy of the 5th metatarsal
Mobilization of the 1st metatarsal cuneiform joint
140
Steytler and Van Der Walt
Oblique osteotomy of all metatarsals
141
McCormick and Blount
Arthrodesis of 1st metatarsal cuneiform joint
Osteotomy of metatarsals 2, 3, 4
Possible lateral based wedge resection of cuboid
142
Polydactyly
Supernumerary digits
More common in African american and female
Associated with Down’s, Lawrence-Moon-Biedl syndrome, Trisomy 13 and 18
30% have a family history
143
Classification of polydactyly
Preaxial - involves hallux (15%)
Central - involves digits 2, 3 or 4 (6%)
Postaxial - involves 5th digit (79%)
144
Treatment of polydactyly
Remove the most peripheral digit
| Wait until after 1 year of age
145
Syndactyly
Webbing between toes
M>F
Traumatic as the result of burns
146
Brachymetatarsia
Shortened metatarsal
Although deformity is isolated to metatarsals, the patient usually perceives the problem to be with the toe which appears short
Most commonly 4th or 1st
Most commonly bilateral and symmetrical
Females to males 25:1
Becomes evident at 4-15 years
Plantar callus may develop
Clinical signs include floating toe, short toe, plantar fissure
Associated with Downs, parathyroid dysfunction, polio, trauma, idiopathic, albright, turner syndrome
