Pediatric Disorders of the Foot Dr. Donald Kucharzyk Pediatric Orthopedic Surgeon The Orthopaedic,...

“Pediatric Disorders of the Foot”

Dr. Donald Kucharzyk Pediatric Orthopedic Surgeon The Orthopaedic, Pediatric & Spine Institute


The Ossific Development of the Foot Begins in utero At birth talus, calcaneus, cuboid,

metatarsals and phalanges are ossified

The navicular and cunieforms are cartilaginous

The cuneiform ossifies between 4 and 20 months


The lateral cuneiform ossifies between 4 and 20 months

The medial cuneiform ossifies at 24 months

The intermedial cuneiform ossifies at 36 months

The navicular ossifies between the second and fifth years of life


Standard Radiography Radiographs should be obtained

weightbearing or those that can’t simulated weightbearing

Initial radiographs include AP and Lateral

Forced Dorsiflexion Lateral for talo-calcaneo alignment: divergent/convergent


Normal Alignment Usual angles measured include the

AP and Lateral talocalcaneal angles AP angle is 42 degrees (range 27-

56) in a newborn and decreases to 34 degrees by 4 years of age

Lateral angle decrease from a mean 45 degrees at birth to an average of 33 degrees at 4 years of age


Normal Variations Many variations of “normal” are

seen especially in the newborn Especially when dealing with

accessory bones of the foot More than 20% of children have

one or more accessory bones


“Os Trigonum” Formed from the lateral projection

of the groove in the posterior talus The flexor hallucis longus pases

through this groove Between 8 and 11 years of age it is

two centers that fuse with the talus in a year


Injury is seen in with forced plantar flexion

Sports that require extreme plantar flexion can predispose patients to injury

Dancers especially Ballet are prone to injury to this area

Treatment includes rest, cast immobilization and surgical excision of the ossicle


“Accessory Navicular” ‘Bauhin’ in 1605 described this

condition Prevalence is between 14 and 26

percent Three types exist: Type I is a small

ossicle, Type II is a 8-12mm ossicle that extends from the navicular, Type III is a cornuate navicular remaining after fusion


Pain over an enlarged area at the medial aspect of the navicular

Area may be reddened or callused Pain aggravated by tight fitting

shoes Treatment involves soft pads over

the navicular ‘navicular cookie’, UCBL inserts of associated with pes planovalgus, and surgical excision…simple excision to Kidner procedure


“Osteochondroses” Kohler’s Disease Osteochodrosis of the tarsal

navicular Pain about the midfoot with

tenderness and swelling with radiographic changes of sclerosis, flattening and irregular lucency of the tarsal navicular


Age distribution is between 2 an 7 years

Treatment involves walking cast immobilization

Kohler’s is a self limiting disorder that in all cases resolves over time


Freiberg’s Infarction Destructive changes of the second

metatarsal head Etiology is thought to be AVN of the

metatarsal head Age commonly seen after 13 years of

age Pain under the second metatarsal head

with limping and decreased activity seen


Radiographs reveal a lucency and collapse with flattening and loss of the normal shape of the condyles; bone scan will show increased uptake

Treatment includes a hard-soled shoe or short leg walking cast and then a metatarsal pad

Surgical excision, curettage and bone grafting, dorsiflexion osteotomy and MTP joint debridement have been used


“Metatarsus Adductus” Forefoot deviation inward relative

to the hindfoot Spontaneous active medial

deviation of the foot Concave medial border Bean shaped appearance of the

sole of the foot Separation of the first and second

toes


Etiology is intrauterine compression Associated with torticollis and DDH Incidence Wynne-Davies was 1 in

1000 births Clinical types: Type I: passive and

active correction fully, Type II: passive correct limited active correction, Type III: passive and active correction limited


Treatment involves simple observation in those that are Type I

Type II requires stretching exercises by the parents and perhaps a brace at night

Type III requires either serial casting or a brace full-time and if refractory, release of the abductor hallucis and capsulotomy and over the age of 3, metatarsal osteotomy


“Talipes Calcaneovalgus” Postural deformity due to

intrauterine compression Foot appears hyper-dorsiflexed

against the tibia External rotation attitude of the tibia Associated with metatarsus adductus

on the opposite side, DDH, and posteromedial bowing of the tibia


Incidence as high as 30 to 50 percent

Treatment involves gentle stretching exercises by the parents with normalization within 3 to 6 months, resistant feet require serial casting and AFO braces

Residual pes planovalgus can be seen in the older child


“Flexible Pes Planovalgus” No specific incidence of flatfoot

exists but it is the most common deformity seen by pediatric orthopaedists

No clinical or radiographic definition of a flatfoot

Reflection of generalized ligamentous laxity in the foot


Radiographic evaluation of the lateral talo-first metatarsal angle ‘Meary’s’ will be angled apex plantarward: “Plantar Sag Sign”

Differential Diagnosis: tarsal coalition, congenital vertical talus, talipes calcaneovalgus, accessory navicular, and inflammatory conditions


Clinically the foot will have an arch with the foot suspended and collapsed with weightbearing and hindfoot valgus

Inversion of the heel will reconstitute the arch seen during tip-toe standing

Arch difficult to see during the early years due to the presence of subcutaneous fat


Treatment is supportive when the foot is asymptomatic

Symptomatic patients may require the use of arch supports or if tight Tendo Achilles seen then stretching exercises needed

Recalcitant cases may require the use of UCBL inserts and Achilles Tendon Lengthening


Surgery is reserved for severe painful flat feet and importantly joint-sparing

Arthroereisis of the subtalar joint via Stay-Peg or Staple

Lateral Column lengthening of the calcaneus with bone grafting BEST

Medial Column shortening with calcaneal sliding osteotomy and medial soft tissue imbrication


“Congenital Talipes Equinovarus” Clubfoot is most common congenital

deformity seen; 1.24 times per 1000 births; boys two times greater than girls; bilateral in 50% of cases

Represents a congenital dysplasia of all musculoskeletal tissues distal to the knee with the extremity never being “normal”


Etiology has been proposed from arrest in embryonic development to a reactive fibrotic response to a primary germ plasm defect in the cartilaginous talus producing a dysmorphic neck and navicular subluxation MOST ACCEPTED

Etiology is therefore multifactoral and modulated by developmental aberrations early in limb bud development


‘Pathoanatomy’ Scarpa reported the medial and

plantar displacement of the navicular, cuboid and calcaneus around the talus

Contracture of the soft tissue maintains this pathologic malalignment of the joints

Midtarsal subluxation: navicular and cuboid displaced medially with plantar and medial rotation of the calcaneus


Deformity of the talus observed with medial and plantar deviation of the anterior end, short talar neck, and dysmorphic small talar body

Delayed appearance of the ossification center of the talus

Underdevelopment of the sustentaculum talus

Talar neck rotated internally relative to the ankle mortise 45 degrees


Calcaneus internally rotated 22 degrees

Body of talus externally rotated within the mortise

Navicular displaced medially and plantarward on the talar head

Cuboid displaced medially on the anterior end of the calcaneus producing midfoot varus and adductus

Contracture of the periarticular soft tissue


“Associated pathologic conditions” Downs or Larsen’s Syndrome Arthrogryposis Diastrophic Dysplasia Spina bifida and dysraphism Fetal Alcohol Syndrome Streeter’s Dysplasia


“Classification” Type I: benign Frequency 20% Type II: moderate Frequency 33% Type III: severe Frequency 35% Type IV: very severe Frequency 12%


“Treatment” Initial treatment is manipulation and

serial casting Kite et al: the earlier treatment begun

the greater the chance for success Sequential correction of each

deformity: forefoot adduction first then hindfoot varus next and finally correction of the equinus…… Kite et al 1964


Ponsetti et al confirmed the need to correct all aspects of the deformity but not individually but simultaneously

Ponsetti’s correction included a percutaneous achilles tendon release…78% success

Crawford, Kucharzyk et al……85% success

Dimeglio et al reported results with a clubfoot CPM…….success rates of 72%


Surgical correction for those resistant to corrective casting and Achilles tenotomy

Performed as early as 3 months and as late as 12 months

Surgical release must address all of the pathoanatomic structures including the hindfoot and midfoot


Turco described the first one-stage posteromedial release with two incisions

Carroll emphasized the plantar fascial release and capsulotomy of the calcaneocuboid joint with two incisions

McKay and Simmons most extensive release performed and features a “cable cast” through single incision

Cincinnatti Incision most commonly used approach now


“Postoperative Complications” Loss of Correction Dorsal Subluxation of the Navicular Valgus Overcorrection Dorsal Bunion


“Revision and Secondary Procedures” Prevalance of repeat surgery…….10% Not all feet with residual deformity or

muscle imbalance undergo additional surgery

Additional stiffness and muscle weakness can occur as a result of repeat surgery and immobilization

Surgery should address a specific problem and address a functional problem and pain


“Functional Problems” Poor foot position: supination/inversion Excessive internal foot progression

angle: painful lateral ray weightbearing Muscle imbalance/weakness: triceps

incompetence calcaneus gait and calf pain


“Surgical Procedures” Anterior Tibial Tendon Transfer Transfer for Insufficent Triceps Lateral Column Shortening Calcaneal Osteotomy Supramalleolar Osteotomy Tibial Osteotomy


“Congenital Vertical Talus” Condition producing ‘rocker-bottom’

deformity with fixed equinus of the calcaneus and dorsal dislocation of the navicular on the talus

Seen in association with myelomeningocele, arthrogryposis, spinal muscular atrophy, neurofibromatosis, DDH, trisomy 13-15-18


Clinical appearance reveals a foot with a convex plantar surface apex at the talar head, calcaneus is fixed in equinus, Achilles tendon contracted, peroneal and anterior tibialis tendons are taught, navicular palpable on the talar neck, and no passive correction of the deformity


Etiology is unknown Pathoanatomy reveals the navicular

to articulate with the dorsal aspect of the nec of the talus, head of talus is flattened, calcaneus is displaced posterolaterally and in equinus, subtalar joint is abnormal, elongation of the medial column and shortening of the lateral column, contractures of the ligaments


Radiographic reveals talus in vertical position parallel to the talus, calcaneus is in equinus, navicular dislocated dorsally on the talus,

Differential Diagnosis include: infantile calcaneovalgus, oblique talus, and flatfoot with heel cord contracture

Treatment begins with serial casting to stretch out the soft tissue


Surgical correction is the mainstay of treatment

Single stage release performed at one year of age recommended

Four components of release: reduction of navicular, lengthening of toe extensors and peroneals for forefoot reduction, release equinus contracture, transfer anterior tibialis tendon to talus to stabilize the correction


“Tarsal Coalition” Peroneal spastic flatfoot Abnormal connection between two or

more of the bones of the foot producing pain and limitation of motion of the foot

Etiology is unknown with the most likely cause being failure of segmentation of the fetal tarsal bones


Clinically present between 12 and 16 years

Pain is the usual presenting complaint

Abduction of the forefoot Stiffness of the hindfoot with

restricted subtalar joint Hindfoot valgus deformity Tightness of the peroneal tendons


Radiographics include AP, lateral, oblique, and Harris view

Standing Oblique…….calcaneonavicular

Harris view…….talocalaneal Anteater Sign……elongation of the

calcaneus and seen with calcaneonavicular

CT Scan of the hindfoot best for assessing tarsal caolitions if xray’s questionable


Frequency of the various types of the tarsal caolitions

Calcaneonavicular: most common Medial Talocalcaneal: second most

common Calcaneocuboid: Third most common Significant incidence of a second

coalition in a foot in which one coalition has been identified has ben seen


Treatment: Intially conservative with the use of a firm orthosis flattened on the bottom to reduce inversion and eversion stresses on the foot…….UCBL

Refractory to conservative care require surgical excision of the coalition with interposition of muscle

Long Term results reveal that these patients will require subtalar fusions or triple arthrodesis


“Pes Cavus Foot” Abnormal elevation of the

longitudinal arch of the foot Complex deformity consisting of

forefoot equinus and varus or calcaneus of the hindfoot

Etiology is Neuropathic


Associated conditions: cerebral palsy, poliomyelitis, Friedreich’s ataxia, myelomeningocele, tethered cord, lipomeningocele, diastematomyelia, Charcot-Marie-Tooth disease, Peripheral Sensory Motor Neuropathies, tumor


Common pathologic finding: Muscle Imbalance

Posterior tibialis and peroneus longus remain strong and invert the hindfoot with depression of the first metatarsus

Tibialis anterior and peroneus brevis are weak and cannot dorsiflex the ankle or evert foot

This combination produces hindfoot varus, forefoot equinus, and pronation deformity


Clawing of the toes seen Atrophy of the calf musculatures Coleman ‘Block Test’ allows one to

evaluate the varus component of the deformity to determine flexibilty and if any fixed bony deformity exists

Radiographic studies include AP and Lateral xrays; Meary’s angle increased


MRI of the Brain and spinal cord to evaluate for cerebral palsy or spinal cord abnormalities

EMG’s reveal a neuropathic pattern NCV reveal velocities to be slowed

as seen in CMT syndrome DNA studies to look for mutations

associated with peripheral neuropathies and Friedreich’s Ataxia


“Treatment” Conservative care has little role Surgical correction the staple of care Decision making determined by: apex of

the deformity, type of pes cavus, position of hindfoot, presence of claw toe deformity, presence of skin changes on sole of foot, abnormal shoe wear, rigidity of the deformity, strength of the muscles, stability of the neurologic disease, and age of the patient


Surgical Procedures divided into soft tissue, osteotomies, and triple arthrodesis

Soft Tissue: plantar releases, peroneal longus to brevis transfer, anterior transfer of the posterior tibialis tendon, transfer of the toe extensors to the metatarsal heads


Bony surgery: Metatarsal osteotomies, calcaneal osteotomies (Dwyer), midfoot osteotomies (Cole dorsal closing wedge), triple arthrodesis (Lambrinudi or Hoke)

Recommendation: calcaneal osteotomy for hindfoot varus correctable with plantar release, midfoot osteotomy when rigid cavus but hindfoot not severe, inflexible hindfoot varus and stiff cavus deformity triple arthrodesis


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Pediatric Disorders of the Foot Dr. Donald Kucharzyk Pediatric Orthopedic Surgeon The Orthopaedic,...

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