1. Common Pediatric Foot Deformities

2. CLUBFOOT Congenital talipes equino varus (CTEV)

3. Anatomy/Terminology 1.Hindfoot – talus, calcaneus 2.Midfoot – navicular, cuboid,cuneiforms 3.Forefoot –metatarsals and phalanges

4. CLUB FOOT Congenital Talipes Equino-Varus Definitions Talipes: Talus = ankle Pes = foot Equinus: (Latin = horse) Foot that is in a position of planter flexion at the ankle, looks like that of the horse. Calcaneus: Full dorsiflexion at the ankle

5. Anatomy/Terminology Varus Valgus In the hindfoot, coronalrotation produces heel varus (medial) or valgus (lateral) In the hindfoot, coronalrotation produces heel varus (medial) or valgus (lateral)

6. Plane of deformity Sagital plane rotation of the the hindfoot produced equinus (plantarflexion) or calcaneus (dorsiflexion)

7. Plane of deformity Coronal rotation of the midfoot and forefoot is discribed as adduction or abduction as it relates to medial or laterl deviation of the foot

8. Plane of deformity Pronation and supination are axial rotations through the midfoot and the midfoot-forefoot articulation

9. Congenital Talipes Equino-Varus CTEV Incidence 0,4-1:1000 live births Male : Female 2:1 50% Bilateral In affected families, clubfeet are about 30 times more frequent in offspring

10. CLUB FOOT Etiology a. Congenital (CTEV) 1. Idiopathic—(Commonest) 2. Myogenic—Arthrogryposis 3. Neurogenic—Spina bifida, Myelocele, Meningocele, Cerebral palsy 4. Osteogenic— Absent tibia b. Acquired (ATEV) 1. Paralytic—Poliomyelitis, Myopathy, *Peroneal muscle dystrophy 2. Inflammatory— Postinfective contracture of muscle 3. Traumatic—Injury in leg, ankle or foot, VIC

11. Congenital Talipes Equino-Varus CTEV Basic Pathology defect in development of talus leads to soft tissue changes in joints, or vice versa Abnormal Tarsal Relation Congenital Dislocation / Subluxation Talo Calcaneo Navicular Joint Soft Tissue Contracture Congenital Atresia EGG & CHICKEN

13. Congenital Talipes Equino-Varus CTEV Diagnosis Characteristic Deformity : Hind foot Equinus (Ankle joint) Varus (Subtalar joint) Fore foot Adduction (Med tarsal joint) Supination fore foot Cavus

14. Congenital Talipes Equino-Varus CTEV Diagnosis “ Hind foot “ “ Fore foot “ “ Hind foot “ “ Fore foot “ Equinus, Varus Adduction, Supination, Cavus Equinus, Varus Adduction, Supination, Cavus

15. Congenital Talipes Equino-Varus CTEV Diagnosis Short Achilles tendon High and small heel No creases behind Heel Abnormal crease in middle of the foot Foot is smaller in unilateral affection Callosities at abnormal pressure areas Internal torsion of the leg Calf muscles wasting Deformities don’t prevent walking

16. Congenital Talipes Equino-Varus CTEV Diagnosis AP/Lat standing or AP/stress dorsiflex lat films X-Ray needed to assess progress of treatment

18. CLINICAL TEST 1.Dorsiflexion test: In a newborn child, the dorsum of foot can be brought in contact with the tibia anteriorly by passive dorsiflexion but not in CTEV. 2. Plumb line test: A plumb line drawn from the center of the patella to the tibial tubercle, should cut the foot at first or second intermetatarsal space normally while in CTEV, it deviates laterally due to internal torsion of tibia. Evaluate hips for dysplasia because intrauterine “packing” problems are commonly associated

20. Congenital Talipes Equino-Varus CTEV Treatment Non surgical treatment should begin shortly after birth 1.Gentle manipulation 2.Immobilization - Strapping ???? - POP or synthetic cast

21. Congenital Talipes Equino-Varus CTEV Treatment Non surgical treatment should begin shortly after birth 3.Splints to maintain correction - Ankle-foot orthosis ???? - Dennis Brown splint

22. Congenital Talipes Equino-Varus CTEV Treatment Manipulation and serial casts Validity, up to 6 months ! Technique “Ponseti” Maintaining the correction Follow up to watch and avoid recurrence

23. Sequence: C.A.V.E Once appropriate cavus, adductus, and varus are achieved, it is often necessary to perform percutaneous Achilles tenotomy to correct hindfoot equinus, after which point the final cast can be applied for 3 weeks.

25. Congenital Talipes Equino-Varus CTEV Surgical Treatment Indications Late presentation, after 6 months of age ! Complementary to conservative treatment Failure of conservative treatment Residual deformities after conservative treatment Recurrence after conservative treatment

26. Congenital Talipes Equino-Varus CTEV Surgical Treatment Soft tissue operations 1.Release of contractures 2.Tenotomy 3.Tendon elongation 4.Tendon transfer 5.Restoration of normal bony relationship

27. Congenital Talipes Equino-Varus CTEV Surgical Treatment

28. Congenital Talipes Equino-Varus CTEV Surgical Treatment Bony operations Indications Usually accompanied with soft tissue operation Types: - Osteotomy, to correct foot deformity or int. tibial torsion - Wedge excision - Arthrodesis (usually after bone maturity) one or several joints - Salvage operation to restore shape

30. Metatarsus adductus MA is medial deviation of the forefoot at the level of the midtarsal joints Etiology : abnormal mechanical intrauterine forces

31. Metatarsus adductus treatment Spontaneus resolution-only observation Home stretching program Serial casts Surgery

32. CONGENITAL FLATFOOT (Planovalgus) Deformity consisting: – Hindfoot valgus – Midfoot supination and abduction – Deviation of plantar arch Treatment- surgery

33. Pes Planus (flatfoot) A.General - refers to loss of normal medial long. arch - usually caused by subtalar joint assuming an everted position while weight bearing - generally common in neonates/toddlers B. Evaluation - painful? - flexible? (hindfoot should invert/dorsiflex approx 10 degrees above neutral - arch develop with non-weight bearing pos?

34. Pes Planus (flatfoot) C. Treatment (i) Flexible/Asymptomatic - no further work up/treatment is necessary! (ii) rigid/painful - must r/o tarsal coalition - usually assoc with peroneal muscle spasm - need AP/lat weight bearing films of foot

36. Calcaneovalgus foot The foot is in extreme dorsiflexion Treatment: – Home stretching program – Serial casts – Surgery

37. Calcaneovalgus foot ankle joint dorsiflexed, subtalar joint everted classic positional deformity more common in 1 st born, LGA, twins treatment requires stretching: plantarflex and invert foot excellent prognosis