Dr. S.R. Bala, Senior paediatric orthopaedic surgeon. ROLE OF X-Ray in CTEV Dr. S.R. Bala, Senior paediatric orthopaedic surgeon.

Guidelines for taking Xray If xrays are taken, weight bearing xrays should be preferred 2 views are preferred , AP view in plantar flexion and lateral view in dorsiflexion.

 Lateral view shows a decreased lateral talocalcaneal angle of 11 degrees - the talus and calcaneus are nearly parallel. Equinus heel is also present with the hindfoot plantarflexed in relation to the tibia.

 A, Frontal view of the right foot shows hindfoot varus with a decreased AP talocalcaneal angle of 17 degrees. There is also forefoot varus - the line through the long axis of the talus lies lateral to the first metatarsal and actually bisects the third metatarsal shaft

Radiographic characteristics include: hindfoot varus - decreased AP talocalcaneal angle, < 20 degrees equinus heel - decreased lateral talocalcaneal angle, < 35 degrees (the talus and calcaneus are nearly parallel); increased lateral tibiocalcaneal angle, > 90 degrees metatarsus adductus - medial displacement of the first metatarsal relative to the long axis of the talus talonavicular subluxation - medial subluxation of the navicular with respect to the talus

NORMAL RANGE OF ANGLES TALO CALCANEAL : AP - 300 – 550 DLAT - 250 – 500 TIBIO CALCANEAL : STRESS LAT - 100 – 400 TALUS FIRST METATARSAL: AP 50 -150 TC INDEX : Sum of TALO-CAL in AP & LAT >400

In Club Foot Talocalcaneal angle < 20 degrees – HEEL VARUS. Talo 1st Metatarsal angle becomes negative – Fore foot ADDUCTION. Tibiotalar angle becomes negative – EQUINUS

Talo-cal Talo-!st Meta Talo-Cal Tibio-Cal

Technique Antero-posterior (AP) and lateral radiographs of both normal and affected feet are taken in position of maximum correction. AP talocalcaneal (TC), AP talo-first metatarsal (T-MT) and lateral TC angles are measured .

The AP T-MT angle is more on the positive side in clubfoot and the lateral T-C angle is decreased in clubfoot .

The 3 main components of the deformity are evident on radiographs and can be reproducibly quantified. With proper positioning and exposure, quantification of alignment abnormalities on plain radiographs is reliable.

No confirmatory imaging is routinely used No confirmatory imaging is routinely used. Oblique positioning of the heel on the DP view can simulate hindfoot varus. If the lateral view is one of the foot rather than the ankle, the flat talar dome has a spurious appearance.[4]

Hindfoot equinus is plantar flexion of the anterior calcaneus (similar to a horse's hoof) such that the angle between the long axis of the tibia and the long axis of the calcaneus (tibiocalcaneal angle) is greater than 90° (see the image below).

Summary Diagnosis is mostly clinical, and Xray has limited role. 1)difficulty in positioning. 2) Delayed ossification of cuboid. 3)Ossific nuclei doesnot represent actual shape of tarsals/ 4)Poor correlation between clinical