1. “Pediatric Disorders of the Foot”
Dr. Donald Kucharzyk
Pediatric Orthopedic Surgeon
The Orthopaedic, Pediatric &
Spine Institute

2. “Pediatric Disorders of the Foot”
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

3. “Pediatric Disorders of the Foot”
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

4. “Pediatric Disorders of the Foot”
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

5. “Pediatric Disorders of the Foot”
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

6. “Pediatric Disorders of the Foot”
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

7. “Pediatric Disorders of the Foot”
“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

8. “Pediatric Disorders of the Foot”
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

9. “Pediatric Disorders of the Foot”
“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

10. “Pediatric Disorders of the Foot”
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

11. “Pediatric Disorders of the Foot”
“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

12. “Pediatric Disorders of the Foot”
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

13. “Pediatric Disorders of the Foot”
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

14. “Pediatric Disorders of the Foot”
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

15. “Pediatric Disorders of the Foot”
“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

16. “Pediatric Disorders of the Foot”
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

17. “Pediatric Disorders of the Foot”
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

18. “Pediatric Disorders of the Foot”
“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

19. “Pediatric Disorders of the Foot”
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

20. “Pediatric Disorders of the Foot”
“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

21. “Pediatric Disorders of 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

22. “Pediatric Disorders of the Foot”
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

23. “Pediatric Disorders of the Foot”
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

24. “Pediatric Disorders of the Foot”
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

25. “Pediatric Disorders of the Foot”
“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”

26. “Pediatric Disorders of the Foot”
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

27. “Pediatric Disorders of the Foot”
‘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

28. “Pediatric Disorders of the Foot”
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

29. “Pediatric Disorders of the Foot”
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

30. “Pediatric Disorders of the Foot”
“Associated pathologic conditions”
Downs or Larsen’s Syndrome
Arthrogryposis
Diastrophic Dysplasia
Spina bifida and dysraphism
Fetal Alcohol Syndrome
Streeter’s Dysplasia

31. “Pediatric Disorders of the Foot”
“Classification”
Type I: benign Frequency 20%
Type II: moderate Frequency 33%
Type III: severe Frequency 35%
Type IV: very severe Frequency 12%

32. “Pediatric Disorders of the Foot”
“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

33. “Pediatric Disorders of the Foot”
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%

34. “Pediatric Disorders of the Foot”
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

35. “Pediatric Disorders of the Foot”
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

36. “Pediatric Disorders of the Foot”
“Postoperative Complications”
Loss of Correction
Dorsal Subluxation of the Navicular
Valgus Overcorrection
Dorsal Bunion

37. “Pediatric Disorders of the Foot”
“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

38. “Pediatric Disorders of the Foot”
“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

39. “Pediatric Disorders of the Foot”
“Surgical Procedures”
Anterior Tibial Tendon Transfer
Transfer for Insufficent Triceps
Lateral Column Shortening
Calcaneal Osteotomy
Supramalleolar Osteotomy
Tibial Osteotomy

40. “Pediatric Disorders of the Foot”
“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

41. “Pediatric Disorders of the Foot”
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

42. “Pediatric Disorders of the Foot”
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

43. “Pediatric Disorders of the Foot”
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

44. “Pediatric Disorders of the Foot”
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

45. “Pediatric Disorders of the Foot”
“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

46. “Pediatric Disorders of the Foot”
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

47. “Pediatric Disorders of the Foot”
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

48. “Pediatric Disorders of the Foot”
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

49. “Pediatric Disorders of the Foot”
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

50. “Pediatric Disorders of the Foot”
“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

51. “Pediatric Disorders of the Foot”
Associated conditions: cerebral palsy, poliomyelitis, Friedreich’s ataxia, myelomeningocele, tethered cord, lipomeningocele, diastematomyelia, Charcot-Marie-Tooth disease, Peripheral Sensory Motor Neuropathies, tumor

52. “Pediatric Disorders of the Foot”
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

53. “Pediatric Disorders of the Foot”
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

54. “Pediatric Disorders of the Foot”
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

55. “Pediatric Disorders of the Foot”
“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

56. “Pediatric Disorders of the Foot”
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

57. “Pediatric Disorders of the Foot”
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

58. “Pediatric Disorders of the Foot”
Thank You