Watkin's CH 29: Pediatrics

Cerebral Palsy: Treatment

PT, OT, splinting, bracing

Metatarsus Adductus: Treatment, Conservative

*(children less than 3 years old)* →Manipulation and serial casting are the standard treatment. →Shoes, orthotics →Splints (Ganley), braces

What is the gold standard for diagnosing tarsal coalitions?

*CT scan* is the gold standard for diagnosis, but *radiographs are very useful.*

Metatarsus Adductus: Treatment, Surgical (osseous)

*Children 8 years and older*—osseous procedures

Metatarsus Adductus: Treatment, Surgical (soft tissue)

*Children between 2 and 6 or 8 years of age,* soft tissue procedures are recommended.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *McElvenny-Caldwell Procedure*

*Dorsiflexory fusion of the 1st metatarsal-medial cuneiform joint*. If the deformity is severe, then a naviculocuneiform joint fusion is added.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *Cole*

*Dorsiflexory wedge osteotomy through the naviculocuneiform* joint and *cuboid* bone

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *JAHSS*

*Dorsiflexory wedge* osteotomy across the *tarsometatarsal joints.*

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *Dwyer*

*Lateral closing* wedge or an *opening medial* wedge.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Calcaneal Osteotomies *Gleich*

*Oblique osteotomy displaced anteriorly.* →Helps increase the calcaneal inclination angle.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Transverse Plane *Evans*

*Opening osteotomy of the calcaneus 1.5 cm* proximal to the calcaneocuboid joint with insertion of a bone graft.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (soft tissue) *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 boarder of the Achilles tendon*, and the *tibialis posterior is cut and attached to the medial boarder of the Achilles tendon*.

Ponseti technique Serial casting should be done...

*weekly.* ∙Percutaneous tendoachilles tenotomy for, hindfoot stall. ∙Once corrected abduction *foot orthotics worn full time for 12 weeks, then at night and during naps until age 4 years.* →*If there are no signs of improvement after 12 weeks, consider surgical intervention.*

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *Japas*

*∙V-osteotomy through the entire midfoot.* ∙The apex of the "V" is proximal and at the highest point of the cavus, usually in the *navicular.* ∙The lateral limbs of the "V" extend through the cuboid, and the medial limb of the "V" extends through the cuneiform. ∙No bone is excised; the distal part of the osteotomy is shifted dorsally.

Congenital Dislocated Hip: Increased incident in...

1. Females (five to eight times greater) 2. Children with older sibling with a dislocated hip (10 times more likely) 3. Breech presentation 4. Joint laxity 5. First born

Clubfoot (Talipes Equinovarus): Treatment, Surgical Soft Tissue Release (Children 3 to 12 Months) *Two most popular incisions?*

1. Medial hockey stick, with a secondary lateral if necessary. 2. Cincinnati incision.

Reduction of the clubfoot deformity should be performed in the following order:

ADDUCTION VARUS EQUINUS

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *DuVries*

Dorsiflexory *fusion through the MTJ.*

Cavus Foot Type (Pes Cavus): Treatment, Surgical (osseous) *DFWO*

Dorsiflexory wedge osteotomy of the 1st metatarsal or all metatarsals.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (soft tissue) *Peroneal Anastomosis*

In the area of the lateral ankle, the tendon of the *peroneus longus is anastomosed to the tendon of the peroneus brevis*. →*Decreases plantarflexion of the 1st metatarsal* and increases eversion forces of the foot.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Calcaneal Osteotomies *Silver*

Lateral opening wedge with graft.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Calcaneal Osteotomies *Koutsogiannis*

Medial slide calcaneal osteotomy.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Sagittal Plane *Miller*

Naviculo-1st cuneiform-1st metatarsal fusion. →Posterior tibial tendon and spring ligament advancement using an osteoperiosteal flap.

Metatarsus Adductus: Treatment, Surgical (osseous) *Steytler and Van Der Walt*

Oblique osteotomy of all metatarsals.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Sagittal Plane *Cotton*

Opening dorsal wedge on the 1st cuneiform.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Frontal Plane *Selakovich*

Opening wedge osteotomy of the *sustentaculum tali with bone graft*, which restricts abnormal STJ motion.

Iselin disease:

Osteochondrosis involving the *5th metatarsal base.*

Lance disease:

Osteochondrosis involving the *cuboid.*

Buschke disease:

Osteochondrosis involving the *cuneiforms.*

Lewin disease:

Osteochondrosis involving the *distal tibia.*

Thiemann disease

Osteochondrosis involving the *epiphyseal ossification centers in the phalanges.*

Ritter disease:

Osteochondrosis involving the *fibular head proximally.*

Treve disease:

Osteochondrosis involving the *fibular sesamoid.*

Assmann disease:

Osteochondrosis involving the *head of the 1st metatarsal.*

Diaz or Mouchet disease:

Osteochondrosis involving the *talar body* (usually associated with trauma).

Renandier disease:

Osteochondrosis involving the *tibia sesamoid.*

Flexible Pes Planus (Flatfeet) Surgical Treatment: Frontal Plane *Baker*

Osteotomy *inferior to the STJ posterior facet* with bone graft

Flexible Pes Planus (Flatfeet) Surgical Treatment: Sagittal Plane *HOKE*

Plantarly based wedge arthrodesis of the *navicular and the medial and intermediate cuneiforms.* →Performed with a TAL.

Metatarsus Adductus: Treatment, Surgical (soft tissue) *Heyman, Herndon, and Strong*

Release of all soft tissue structures at Lisfranc joint except lateral and plantar lateral ligaments →Initially described using one transverse skin incision, revised to two or three longitudinal incisions

Flexible Pes Planus (Flatfeet) Surgical Treatment: Triple Arthrodesis

Reserved for second stage salvage procedure.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (soft tissue)

Soft tissue procedures may be adequate for flexible deformities.

What are some complications of cast treatment?

a. Metatarsus adductus b. Heel varus c. Pes planovalgus—overcorrection d. Rocker bottom foot, from overzealous correction of the equinus e. AVN or talar head flattening. →Infant connective tissue is stronger than infant bone and cartilage. During casting, tremendous forces are exerted on the navicular and talar head. f. Navicular subluxation—usually dorsally over talus

Flexible Pes Planus (Flatfeet) Surgical Treatment is based on....?

plane dominance.

Developmental Landmarks:

→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 Child develops a propulsive gait

Cerebral Palsy: Signs and Symptoms

∙"Scissors gait" due to adductor spasticity ∙Speech defects, retardation, seizures, visual defects ∙Ankle equinus

Metatarsus Adductus: Engel Angle

∙*Bisect the intermediate cuneiform and compare with the 2nd metatarsal. A normal value using this method is 24°.* ∙The angle increases with an adducted foot.

Radiographic signs of a TC coalition on lateral radiograph:

∙*C sign or halo sign*: A C-shaped line formed by the medial outline of the talar dome and the inferior outline of the sustentaculum tali. →*C sign or halo sign has been shown to be the most sensitive and specific radiographic sign of a STJ coalition.* ∙Absence of the STJ facets: The *middle facet may be nonvisualized.* →There is often joint space narrowing with diminished clarity of the posterior facet even if only the middle facet contains the coalition. ∙*Talar beak sign*: Flaring of the superior margin of the talar head ∙Rounding of the lateral talar process: →The lateral process of the talus becomes blunted or flattened. ∙Shortening of talar neck: ∙Dysmorphic sustentaculum tali: →The sustentaculum tali may be ovoid shaped as opposed to its normal brick shape. ∙*Ball-in-socket*: Configuration of talus in the ankle mortise takes on a *more rounded shape versus its normal squared off* shape. →This finding is best viewed on *ankle A/P images.*

Muscular Dystrophies: Symptoms

∙*Characterized by progressive weakness, atrophy, loss of DTRs, secondary contractures, and deformity*. ∙*Proximal muscle weakness* involvement is more pronounced than distal. ∙Pseudohypertrophy is an apparent hypertrophy of certain muscles specifically the calves. ∙The apparent muscle bulk is actually fat deposits. ∙Although these muscles may look overdeveloped, they are actually weaker than normal.

Congenital Dislocated Hip Radiographic Diagnostic Studies:

∙*Hilgenreiner line (Y line)*: line *connecting the most inferior portion of the acetabulum on both sides.* ∙*Ombrédanne line* (Perkins vertical line): →Draw a line perpendicular to Hilgenreiner line at the *outer most aspect of the acetabulum.*

Köhler Disease: Symptoms

∙*Often asymptomatic* but may present with pain and swelling →Navicular becomes *sclerotic and flattened (coin on edge, or silver dollar sign).* ∙*Self-limiting, and recovery usually takes from 2 to 4 years.* ∙Navicular ultimately resumes normal shape and density.

Freiberg Infraction:

∙*Osteochondrosis* of the *metatarsal head.* →*2nd metatarsal head is most frequently involved* followed by the 3rd, 4th, and then 5th. ∙*More common in girls* and usually occurs between ages 10 and 18 years. ∙Can occur in adults. ∙Radiographic evaluation reveals *sclerosis and fragmentation of the metatarsal head* with *flattening* of the articular surface.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (soft tissue) *Steindler Stripping*

∙*Plantar fascia along with the long plantar ligament, abductor hallucis, FDB, and abductor digiti quinti are all stripped from the periosteum* of the calcaneus. ∙Tendon transfers are also effective treatment for flexible deformities: →Jones tenosuspension →Heyman procedure: Transfer of all four extensor tendons to their respective metatarsal heads. →Hibbs procedure →Split tibialis anterior tendon transfer (STATT) →Peroneus longus tendon transfer →Tibialis posterior tendon transfer

Flexible Pes Planus (Flatfeet) Surgical Treatment: Sagittal Plane *Lowman*

∙*Plantarflexory talonavicular wedge* arthrodesis performed with a TAL. ∙The *tibialis anterior tendon is rerouted under the navicular and sutured into the spring ligament* to further support the arch. →Next, a slip of the Achilles tendon, which is left attached to the calcaneus, is folded forward along the medial arch as an accessory ligament.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Frontal Plane *Chambers*

∙*Raise the posterior facet of the STJ* using a bone graft under the sinus tarsi.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Transverse Plane *Kidner*

∙*Removal of prominent navicular tuberosity* or accessory navicular and *transplantation of the tibialis posterior tendon into the underside* of the navicular bone.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Sagittal Plane *Young (Keyhole Technique)*

∙*Reroute the anterior tibial tendon through a keyhole in the navicular* without detaching it from its insertion. ∙Posterior tibial advanced under the navicular.

Cavus Foot Type (Pes Cavus): Treatment, Conservative

∙*Shoe modification and orthotics* can alleviate symptoms by increasing the weight-bearing surface of the foot and relieving painful callus under the ball of the foot. ∙*Extra depth shoes combined with a metatarsal bar* may help alleviate pressure under the ball of the foot. →In *young patients, passive stretching, manipulation, and casting* may be beneficial.

Clubfoot (Talipes Equinovarus): Treatment, Conservative Serial Casting (Begin As Soon As Possible)

∙*Stretching and manipulation should be performed prior to cast* application. ∙Apply tincture of benzoin to child's skin to help the undercast stick to the skin. ∙A cast is applied with 2-inch cast material. (Short or long leg cast may be used; generally in infants, use a long leg to prevent cast from slipping off. Flex knee at 75° to 90°.)

Syndactyly: Classification

∙*Type I* (Most Common) →Zyngodactyly: Partial or complete webbing of the 2nd and 3rd toes ∙*Type II* →Synpolydactyly: One soft tissue mass covering the 4th, 5th, and 6th toe ∙*Type III*: Associated with metatarsal fusion

Congenital Vertical Talus: Treatment Open Reduction

∙3 months to 3 years: If closed reduction fails, open reduction should be performed at 3 months of age. ∙Many procedures have been described; they all involve a *posterior release and reduction of the talonavicular joint.* ∙3 to 6 years: In addition to open reduction, an extra-articular arthrodesis (Green-Grice type) or arthroereisis may be attempted to maintain reduction and stabilize the STJ. ∙6 years and up: At this point, it is *best to postpone surgery until skeletal maturity (10 to 14 years of age)*, at which time a triple arthrodesis is performed, which may require removal of the head and neck of the talus to obtain reduction.

Flexible Pes Planus (Flatfeet) Surgical Treatment: Grice and Green Extra-Articular Subtalar Arthrodesis

∙A *bone graft is inserted laterally in 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.*

Osteochondrosis (Epiphyseal Ischemic Necrosis:

∙A *disease of the growth or ossification center* in children, which *begins as a degeneration* or necrosis and is followed by regeneration or recalcification.

Cerebral Palsy: Description

∙A broad term used to describe several *static nonprogressive neuromuscular disorders* resulting from brain damage before, during, or immediately after birth. ∙Types of CP include the following: →Spastic CP (most common, 70%) →Athetoid CP (20%) →Ataxic CP (10%) →Rigidity CP →Tremor CP →Atonic CP

Friedman Counter Splint or Flexosplint:

∙A dynamic splint consisting of a belt around the posterior heels, *allowing motion in all planes except internal rotation* ∙Indicated for *internal tibial torsion.*

Metatarsus Adductus: Measuring the Metatarsus Adductus Angle Classic Method

∙A line is drawn between the medial-proximal aspect of 1st metatarsal base and the medial-distal aspect of the talonavicular articulation. ∙A second line is drawn between the lateral-proximal aspect of the 4th metatarsal base and the lateral-distal aspect of the calcaneocuboid joint. ∙A third line is drawn between the bisection of these two lines. ∙Next, the angle is measured between a line drawn perpendicular to this third line and a line drawn down the longitudinal shaft of the 2nd metatarsal. ∙*Metatarsus adductus angle above 20° is considered adducted.* ∙MTA angle at birth is 25° to 30°; at 1 year (begin walking), it is around 20°; and by 4 years, it is at the adult normal of around 15°.

Clubfoot (Talipes Equinovarus): Introduction

∙A triplanar deformity involving: →Ankle equinus →Hindfoot varus →Forefoot adduction ∙1:1,000 live births ∙Male to female (2:1) ∙Fifty percent of cases are bilateral. ∙Occurs in the right foot more than the left ∙Lowest incident in Asians; →Highest in Polynesians

APGAR:

∙APGAR is an acronym for a scoring system to *evaluate perinatal asphyxia*. It is not an indicator of long-term outcome, but rather an indicator of *immediate needs.* ∙The score is the sum of points gained on assessment of the following five signs. →0-2 Serious asphyxia →3-4 Moderate asphyxia →5-7 Mild asphyxia →8-10 Normal

Tarsal Coalitions: Talonavicular (TN) Coalitions

∙Account for about 2% of tarsal coalitions. →Mostly asymptomatic; when painful, pain begins around 3 to 5 years of age. ∙Chief complaint is usually *bump pain from shoe gear rubbing on the medial prominence.* ∙Lateral radiographs show *absence of the dorsal portion of the Cyma line.* →Surgical correction involves resecting the medial prominence.

Congenital Dislocated Hip Radiographic Diagnostic Studies: Quadrant System

∙After drawing the Hilgenreiner and Ombrédanne lines, the normal position of the developing femoral *head should be in the lower medial quadrant.* →A *dislocated hip will show at least part of the femoral head in the outer upper quadrant.*

Clubfoot (Talipes Equinovarus): Osseous Procedures (1 to 4 Years)

∙After the child reaches the *age of at least 1 year*, bony correction involving a *lateral closing wedge may be required to shorten the lateral column* and prevent long term stiffness of the hindfoot.

Congenital Dislocated Hip: Treatment

∙Aimed at aligning the femoral head in the acetabulum and holding it there, *by keeping the hips in a flexed and abducted position.* →With early detection, this may be accomplished by specific pillow arrangement in the crib, double or triple diapering, a Pavlik harness, or a Spica cast. →As the child grows, traction plus closed reduction is required. →If undiagnosed by age 6 or 7, open reduction and eventually a hip implant may be required due to permanent arthritic changes.

Congenital Dislocated Hip Clinical Diagnostic Studies: Galeazzi Sign

∙Also known as Allis sign. ∙While the *hips and knees are flexed*, a *dislocated hip results in a lower knee position on the affected side*. →May be false-positive in B/L cases.

Congenital Vertical Talus:

∙Also known as congenital convex pes planovalgus, reverse clubfoot, Persian slipper, rocker-bottom flatfoot

Tarsal Coalitions: Description

∙An *abnormal bridge between two or more tarsal bones* that restrict motion. ∙Incidence: is about 1%, and 50% of cases are bilateral. ∙Tarsal coalitions are the *most common cause of peroneal spastic flatfoot.* →Spasm occurs in response to the immobilization of the STJ. ∙Common peroneal block may be required to relax the spastic peroneal muscles and fully evaluate STJ ROM. ∙Coalitions occur *more in males* than in females. ∙Symptoms, if any, are usually insidious in onset or may follow athletics or minor trauma. ∙Occasionally, anterior and posterior muscles are in spasm, causing a varus deformity. ∙*TC and CN coalitions are roughly equal in distribution and account for over 90% of tarsal coalitions*. Conservative treatment for coalitions includes decreasing the motion of the involved joints with shoe modifications or braces, casting, or splints. RICE and NSAIDs.

Congenital Dislocated Hip Radiographic Diagnostic Studies: Von Rosen Sign (Frog Leg View)

∙An A/P radiograph is taken with the *hips extended and the thighs abducted 45° and medially rotated.* ∙A line is drawn through the long axis of the femur. ∙In a normal hip, this line should extend through the lateral corner of the acetabulum. →In a dislocated hip, the line will bisect the ASIS.

Standard AFO:

∙Ankle set at 90° ∙Used in various neuromuscular *disorders that may cause equinus (CP, muscular dystrophy [MD])* ∙Also used to treat *drop foot.*

IPOS Shoe:

∙Anti-adductus orthosis type 2 ∙Indicated for *metatarsus adductus.* ∙Functions by the use of *varied correctional elastic tension bands* (formerly springs were used).

Flexible Pes Planus (Flatfeet): Symptoms (Quite Varied)

∙Are quite varied and are often asymptomatic. →When symptoms are present, they may include *muscle cramps*, especially calf and *anterior leg, arch pain, and heel pain.*

Metatarsus Adductus: Treatment, Surgical (osseous) *Mccormick and Blount*

∙Arthrodesis of 1st-metatarsal-cuneiform joint ∙Osteotomy of metatarsals 2, 3, and 4 →Possible wedge resection of cuboid

Congenital Dislocated Hip Radiographic Diagnostic Studies: Wiberg CE Angle

∙Based on the assumption that if the femoral head is inadequately covered by the acetabulum, it will develop DJD. This test shows how much is covered. →Draw a line connecting the center of the femoral head (C) with the lateral most aspect of the acetabulum (E). ∙Measure the angle created by this line and Ombrédanne line. →If this angle is less than 20° in a child over 5 years, there is an increased likelihood of developing DJD.

Twister Cables:

∙Belt (around waist) cables (inside pant leg course down to shoe) ∙*Controls the degree of abduction at heel contact.* ∙Used to treat *scissors gait of CP patients.*

Metatarsus Adductus: *Bleck Classification*

∙Bisect the heel and extend the line distally to see where it falls on the toes.

Tarsal Coalitions: Calcaneocuboid (CC) Coalitions

∙Calcaneocuboid coalitions account for about 2% of tarsal coalitions. ∙Radiographically, there is an absence of the CC joint. →Asymptomatic.

Tarsal Coalitions: Calcaneonavicular (CN) Coalitions

∙Calcaneonavicular coalitions account for about 45% of tarsal coalitions. ∙CN coalitions are *considered extra-articular*, and when pain is present, usually begins around 8 to 10 years of age. ∙*Pain is often localized to the area over the coalition.* ∙There may be a moderate decrease in ROM at the STJ and MTJ. ∙Medial oblique radiographs may show where the calcaneus and navicular are in close proximity or connected (calcaneonavicular bar). →With incomplete fusion, the bone ends are irregular and lack cortical definition. ∙*Lateral head of the talus may be hypoplastic.* ∙Lateral views show the classic elongated anterior process of the calcaneus, *anteater sign.* ∙Surgical treatment involves resection of coalition and placing the EDB muscle belly in void (Cowell procedure).

Metatarsus Adductus: Treatment, Surgical (soft tissue) *Lange*

∙Capsulotomy of the 1st metatarsal-1st cuneiform joint ∙Division of the abductor hallucis

Cavus Foot Type (Pes Cavus): Causes

∙Cavus foot is often the first manifestation of many neuromuscular disorders, including: →spina bifida →Charcot-Marie-Tooth disease →Friedreich ataxia →poliomyelitis →spinal cord tumors →myelomeningocele →CP →infection →syphilis →trauma →spinal cord lesion.

Congenital Dislocated Hip: Classical signs

∙Classical signs in older children include limited *abduction, asymmetric thigh folds, relative femoral shortening, a limp, positive Trendelenburg test, externally rotated foot, waddling gait.* ∙*Best position for the hips to prevent dislocation is flexed and abducted.* ∙When a dislocation occurs, the *femoral head is usually posterior and superior to the acetabulum.* →Most dislocations occur during the first 2 weeks after birth. →Commonly associated with oligohydramnios, torticollis, metatarsus adductus, and calcaneal valgus.

Metatarsus Adductus Treatment, Surgical (osseous) *Johnson Osteochondrotomy*

∙Closing abductory base wedge osteotomy of the 1st metatarsal ∙Resection of osteocartilaginous 2.5 mm wedge from the lesser metatarsals

Metatarsus Adductus: Treatment, Surgical (osseous) *Lepird*

∙Closing wedge osteotomy of 1 and 5 metatarsal bases. ∙Oblique rotational osteotomies of the three central metatarsals.

Flexible Pes Planus (Flatfeet): Causes

∙Compensated FF varus ∙Compensated FF valgus ∙RF equinus ∙Adducted foot ∙Abducted foot ∙Neurotrophic feet ∙Muscle imbalance ∙Posterior tibial tendon rupture ∙Ligamentous laxity (Ehlers-Danlos, Marfan's, Down's, osteogenesis imperfecta) ∙Calcaneovalgus ∙Enlarged or accessory navicular

Congenital Vertical Talus: Description

∙Condition in which the *talus is plantarflexed* so severely the *navicular primarily dislocates dorsally onto the neck of the talus, locking the talus in a vertical position*. ∙Forefoot is *abducted and dorsiflexed* at the midtarsal joint, and the calcaneus is in valgus and equinus. ∙The foot may actually touch the front of the tibia at birth. ∙Talar head is prominent on medial plantar aspect of foot and may have a callus over it from bearing most of the body weight. ∙*Rigidity is the hallmark of this deformity*. ∙The *gastroc-soleus is contracted*, and the spring ligament becomes elongated. ∙The majority of cases are bilateral, and the right foot is more commonly affected than the left. ∙*Walking is not delayed* because the condition is not painful in childhood; however, gait is awkward, clumsy, and almost peg-like, and shoes may be difficult to wear. ∙Often occurs with other congenital deformities, most notably arthrogryposis. ∙STJ facets are abnormal. →Anterior—absent →Middle—hypoplastic →Posterior—malformed (misshapen)

Macrodactyly: Treatment

∙Condition is not painful, and *treatment is performed for cosmetic and shoe fitting purposes.* ∙*Epiphysiodesis*—the soft cartilage of the physis is surgically resected with a scalpel or by multiple drilling; this will stop the bone from lengthening, *but the bone will still increase in girth.* ∙Amputation or partial amputation ∙Plastic reduction/debulking procedure

Freiberg Infraction: Treatment

∙Conservative care involves *metatarsal pads, short leg casts, and stiff post-op shoe.* ∙Surgical treatment is aimed at *removing any bony lipping from the perimeter of the metatarsal head*; when DJD is severe, an implant may be indicated.

Flexible Pes Planus (Flatfeet): Treatment

∙Conservative treatment in young children involves manipulation and strapping, whereas in older patients orthotics are beneficial. ∙Flexible flatfoot with short tendon Achilles is not an indication for orthotics or arch supports because the short tendon Achilles will prevent re-creation of the arch and instead cause increased pressure under the talar head. ∙*With these, children use a heel cup whose margins have been increased to 25mm.* →This keeps the heel in a more vertical position. →*Adding a medial flare of about 1/8″ on the rearfoot post* will help eliminate some of the excess pronation.

Congenital Vertical Talus: Radiographic Evaluation

∙Definitive diagnosis is determined by taking a lateral x-ray and comparing it with a second lateral x-ray with the foot maximally plantarflexed, demonstrating that the talonavicualar relationship does not change. →Navicular is not evident radiographically until age 3, and so it is difficult to establish its subluxation. ∙Line bisecting talus on lateral radiograph is parallel to tibia. ∙*Talocalcaneal angle on A/P is increased, usually >40°.* ∙*Talar neck is hypoplastic and so may have an hourglass* shape and may have a flat surface. ∙Navicular articulates with the dorsal neck of the talus. ∙Negative Hubscher maneuver.

Calcaneovalgus Foot:

∙Deformity in infants, which *causes the foot to appear pushed up against the front of the leg.* →It is a flexible deformity caused by an *abnormal positioning in the uterus*. ∙Characterized by *excessive dorsiflexion of the ankle* and *eversion of the foot.* →Dorsal surface of the foot may be in contact with the anterior surface of the leg. →The condition usually resolves spontaneously with growth but may require serial casting.

Counter Rotation System (Langer):

∙Designed to correct *torsional abnormalities of the leg.* ∙Functionally the same as the Denis-Browne bar, but *several hinges allow greater freedom of motion* ∙*Best tolerated splint*; allows unencumbered crawling.

Congenital Dislocated Hip Radiographic Diagnostic Studies: Acetabular Index

∙Draw a line extending through the most medial and lateral aspect of the acetabulum. ∙The angle created between this line and Hilgenreiner line is the acetabular index. →*Value should be between 27° and 30°* at birth and decrease to 20° by age two. →An angle *greater than 30° indicates a dislocated hip.*

Congenital Dislocated Hip Radiographic Diagnostic Studies: Shenton Curved Line (Menard Curved Line)

∙Draw a line up the *medial side of the femoral neck to continue up into the obturator foramen.* ∙This should be a *continuous arc;* with a hip dislocation, the obturator foramen is too low.

Congenital Dislocated Hip Radiographic Diagnostic Studies: Von Rosen Method

∙Draw the Hilgenreiner line and then draw a parallel line passing through the upper margin of the pubic symphysis. →In a dislocated hip, the femur will extend up between these lines.

Metatarsus Adductus: Treatment, Surgical (osseous) *Peabody-Muro*

∙Excision of the base of the central three metatarsals ∙Osteotomy of 5th metatarsal →Mobilization of the 1st-metatarsal-cuneiform joint.

Ganley Splint:

∙First splint to treat combination foot and leg disorders. ∙Same indications as Denis-Browne bar but also *allows FF to RF control.* →If treating *internal rotational problems, torque bar is placed* between the rearfoot plates, and if treating an *external rotational problem, the torque bar is placed between the two forefoot plates.* ∙Adjustments are made by simply bending the aluminum bars.

Flexible Pes Planus (Flatfeet): Description

∙Flexible pes planus deformity is *usually asymptomatic.* ∙Most infants are flatfooted and develop an arch during the first decade of life. ∙There is a higher incidence in blacks. ∙The foot appears externally rotated in relation to the leg. ∙Weight-bearing axis of the LE is *medial to the mid-axis of the foot.*

Cavus Foot Type (Pes Cavus): Description

∙Foot type with an *elevated longitudinal arch.* →Primarily a *sagittal plane deformity.* ∙Foot has less surface area touching the ground, and painful callus may develop under the metatarsal heads. ∙More prone to *chronic inversion ankle sprains.* ∙Heel, knee, or hip pain may develop secondary to lack of shock absorption from the abnormal architecture of the foot.

Skewfoot (Z-foot, Serpentine foot, Compensated Metatarsus adductus)

∙Foot type with an adducted forefoot, normal midfoot, and a valgus hindfoot. ∙Usually acquired from gradual compensation of a metatarsus varus that develops with weight-bearing or improper manipulation and casting. ∙Other signs include a fixed hindfoot valgus and severe rigid metatarsus adductus. ∙Also an increased calcaneocuboid angle. ∙*Calcaneocuboid angle* is the angle created by a line drawn along the lateral aspect of the calcaneus and a line drawn along the lateral aspect of the cuboid on an A/P radiograph; *normal is 0° to 5°.*

Denis-Browne Bar:

∙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.

Clubfoot (Talipes Equinovarus): Types

∙Idiopathic: Intrauterine position ∙Nonidiopathic: →Spina bifida →CP →MD →Meningitis →Postpolio →Traumatic →Streeter dz

Syndactyly: Treatment

∙If cosmesis is not a concern, no treatment ∙Desyndactyly procedure (see Chapter 8 )

Syndactyly: Davis and German Classification System

∙Incomplete—webbing does not extend to distal toes. ∙Complete—extends to distal toes ∙Simple—phalanges not involved ∙Complicated—phalanges involved

Legg-Calvé-Perthes Disease: Symptoms

∙Insidious in onset ∙Limping ∙Generalized groin pain ∙Referred pain to the knee is common.

Metatarsus Adductus: Cause

∙Intrauterine position ∙Tight abductor hallucis muscle ∙Absent or hypoplastic medial cuneiform ∙Abnormal insertion of anterior tibial tendon.

Muscular Dystrophies: Diagnosis

∙Involves clinical evaluation, EMG, muscle biopsy, and an elevated CPK.

Metatarsus Adductus: Treatment, Surgical (osseous) *Berman and Gartland*

∙Laterally based crescentic osteotomies of metatarsal base 1 to 5.

Congenital Dislocated Hip: Etiology

∙Ligamentous laxity ∙Acetabular dysplasia ∙Malpositioning a. In utero (i.e., breech) b. Postnatal (carrying babies with hips adducted and extended)

Macrodactyly:

∙Local gigantism of one or more toes ∙Usually unilateral →M > F ∙Heredity does not play a role in the deformity. ∙Usually involves toes 1st, 2nd, or 3rd ∙May be associated with neurofibromatosis ∙Blood vessels and tendons are not affected. ∙*Poor circulation because blood vessels have not enlarged with the digit* ∙Can often affect the metatarsal head as well as the phalanges ∙Involvement of 2 or 3 adjacent digits is more common than single digit involvement.

Cavus Foot Type (Pes Cavus): Classification (Based on Apex of Deformity)

∙Metatarsal cavus: Lisfranc joint ∙Lesser tarsus cavus: Lesser tarsal bones ∙Forefoot cavus: Chopart's joint ∙Combination: Apex generalized over lesser tarsals

Metatarsus Adductus: Description

∙Metatarsus adductus is an *adduction of the FF at the tarsometatarsal joints*; the rearfoot is normal. ∙Affects 1 in 1,000 live births, *male to female ratio is equal, and 55% of cases are bilateral*. ∙Ten percent of cases are associated with dislocated hip, and *86% of cases resolve satisfactorily without treatment.* ∙Spontaneous improvement should be almost complete at about 3 months. ∙Clinical symptoms include an *intoed gait with frequent tripping and a prominent styloid process*. ∙The *severity* of the adduction progressively *decreases from medial to lateral.* →Metatarsus adductus is usually idiopathic and rarely associated with neuromuscular disease.

Tarsal Coalitions: Cause

∙Most often congenital due to *failure of segmentation of primitive mesenchyme*. →Condition can be acquired through infection, arthritis, trauma, or iatrogenic.

Muscular Dystrophies: Description

∙Muscular dystrophy is a group of *inherited chronic progressive disorders characterized by progressive weakness and degeneration of the skeletal muscles.* ∙Some MD's are seen in infancy or childhood, whereas others may appear in middle age or later.

Congenital Dislocated Hip:

∙Occurrence is 0.1%. ∙Sixty percent are on left side, 20% to 30% B/L.

Blount Disease: Infantile Type

∙Occurs *before age 6 years* →Caused by *early walking and obesity.*

Blount Disease: Adolescent Type

∙Occurs at *8 to 15 years* →Caused by *trauma and infection.*

Metatarsus Adductus: Treatment, Surgical (osseous) *Fowler*

∙Opening wedge osteotomy of the *medial cuneiform with insertion of bone graft.*

Sever Disease:

∙Osteochondrosis of the *calcaneus (apophysis)* caused by excessive traction of the Achilles tendon. ∙Occurs between ages *6 and 12 years and is more common in patients with equinus*. ∙*Radiographic diagnosis is difficult because the normal epiphysis can have multiple ossification centers* and irregular borders and is often sclerotic.

Legg-Calvé-Perthes Disease:

∙Osteochondrosis of the *femoral head* occurring primarily in males (5:1) between ages 3 and 12 years. ∙Ten percent of cases are bilateral, and a history of trauma precedes 30% of cases. →*Most common form of osteochondrosis*; the younger the child; the better the prognosis.

Blount Disease:

∙Osteochondrosis of the *medial portion of the proximal epiphyseal ossification center in the tibia* causing *bowing of the leg or legs.* →Symptoms include: *limping* and *lateral bowing* of the leg. →Radiographic evaluation reveals *sclerotic medial cortex with spurring.*

Köhler Disease:

∙Osteochondrosis of the *navicular* (tarsal scaphoid). ∙The condition is more common in *boys and occurs between ages 3 and 6 years.*

Osgood-Schlatter Disease:

∙Osteochondrosis of the *tibial tuberosity.* →More common in boys and occurs between ages 10 and 15 years. ∙Caused by *excessive traction on the patellar ligament*. ∙Symptoms include: →Local pain and swelling with tenderness on palpation. →The condition is *self-limiting, and treatment is symptomatic.*

Freiberg Infraction: Symptoms

∙Pain on ROM of the affected MPJ. ∙Local tenderness and swelling. ∙Generalized thickening at the MPJ.

Brachymetatarsia: Treatment

∙Palliative treatment includes orthotics and accommodative devices. ∙*Surgical treatment consists of reestablishing a normal metatarsal parabola.* →This can be accomplished by *lengthening the short metatarsal via bone graft or callus distraction or shortening* long adjacent metatarsals. ∙Surgery correction should be delayed until after skeletal maturity. ∙Surgical procedure (using a bone graft) →V-Y skin plasty →Z-Plasty EDL lengthening; FDL lengthening is not necessary. →Sectioning of the short extensor and interossei →Insert bone graft, up to 1.5 cm, and fixate with K-wire. ∙Monitor digital circulation for the first 24 hours. ∙Non-weight-bearing cast for 2.5 to 3 months after surgery.

Congenital Dislocated Hip Clinical Diagnostic Studies: Nelaton Line

∙Particularly useful in children with *B/L dislocations.* ∙An imaginary line is drawn *connecting the anterior iliac spine and the tuberosity of the ischium.* →If the tip of the *greater trochanter is palpable distal to this line*, the hip is dislocated.

Cavus Foot Type (Pes Cavus): Treatment, Surgical (soft tissue) *Plantar Fascial Release*

∙Plantar fasciotomy may relax some of the plantar structures.

Polydactyly: Classification

∙Preaxial: Involves the hallux (15%) ∙Central: Involving digits 2, 3, or 4 (6%) ∙Postaxial: Involving the 5th digit (79%), six subtypes ∙Postaxial polydactyly can also be divided into: →Type A: Well-formed articulated digit →Type B: Rudimentary often without skeletal component.

Sever Disease: Treatment

∙RICE ∙NSAIDs ∙Elimination of sports ∙Heel lifts ∙Achilles stretching exercises

Congenital Vertical Talus: Treatment Closed Reduction

∙Rarely successful. ∙Manipulation and casting is recommended as a means of *stretching the soft tissues for future definitive surgical* treatment in an attempt to avoid skin sloughing.

Clubfoot (Talipes Equinovarus): Treatment, Surgical Soft Tissue Release (Children 3 to 12 Months) *Posterior Release*

∙Reflection of the origin of abductor hallucis and plantar fascia ∙Z-Plasty of Achilles tendon ∙Release of the posterior, medial, and lateral ankle joint ∙Release of the posterior, medial, and lateral STJ. ∙In doing so, the *posterior talofibular and calcaneofibular ligaments are severed.*

Clubfoot (Talipes Equinovarus): Treatment, Surgical Soft Tissue Release (Children 3 to 12 Months) *Lateral Release (Performed Through the STJ in the Single Medial Incision Approach)*

∙Release of the interosseous talocalcaneal ligament. ∙Release of the bifurcate ligament. ∙Release of the lateral STJ.

Metatarsus Adductus: Treatment, Surgical (soft tissue) *Thompson Procedure*

∙Resection of the abductor hallucis muscle ∙Release medial head of FHB, if necessary

Fillauer Bar:

∙Same as Denis-Browne bar except it *clamps to soles of patient's shoes.* ∙Requires *rigid soled shoes for attachment.*

Unibar:

∙Same as the Denis-Browne bar except it has a *ball and socket joint beneath each foot*, which can be *tightened into a varus position (preventing STJ and MTJ subluxation)* eliminating the need to bend the bar.

Metatarsus Adductus: Treatment, Surgical (soft tissue) *Lichtblau*

∙Sectioning of the hyperactive abductor hallucis

Brachymetatarsia:

∙Shortened metatarsal ∙Although the *deformity is isolated to the metatarsals*, the patient usually perceives the problem to be in the toe itself because the toe is what appears short clinically. ∙*Affected toes are dorsally displaced*, often causing problems with shoe gear. ∙Most commonly affects the 1st or 4th metatarsal ∙Most commonly B/L and symmetrical ∙*Females* to males (25:1) ∙Becomes evident between 4 and 15 years ∙Plantar callus may develop on adjacent metatarsal heads. ∙*Clinical signs include a floating toe*/short toe and a plantar fissure of sulcus where the metatarsal head should be. ∙Toe is functionless due to lack of mechanical advantage. ∙Associated conditions: →Down syndrome →Pseudohypoparathyroidism →Pseudo-pseudohypoparathyroidism →Poliomyelitis →Trauma →Idiopathic →Albright →Turner syndrome

Splints and braces:

∙Splints and braces are used between *3 months and 3 years*. →When sizing with a bar, *measure from one ASIS to the other plus 1 inch*. ∙Splints used to abduct the foot are best used with *triplanar varus wedge to prevent subluxation of the MTJ* ∙Braces that have a rigid bar connecting the feet should have a *15° to 20° varus bend to prevent subluxation of STJ or MTJ*. ∙Are *best used on positional abnormalities*, which are soft tissue problems (i.e., internal and external femoral rotation), as opposed to bony abnormalities or torsional problems (i.e., tibial torsion). ∙*Should be worn as much as possible at night*, during naps, and as much as tolerated during the day. →If splints follow serial plaster immobilization, *wear splint for twice as long as total casting time.*

Macrodactyly: Classification

∙Static deformity—growth rate is proportional to other digits (most common). ∙Progressive deformity—disproportionately fast growth rate until puberty

Polydactyly:

∙Supernumerary digits →*More common in blacks and females* ∙Associated with: →Down syndrome →Lawrence-Moon-Biedl syndrome →Chondroectodermal dysplasia trisomies 13 and 18 →Thirty percent have a positive family history.

Polydactyly: Treatment

∙Supernumerary digits are removed for cosmetic reasons and for comfort in shoes. ∙With all other factors equal, remove the most peripheral digit. ∙*Surgery should be avoided until at least 1 year of age* when the full pattern of skeletal involvement becomes clear and when the child can better tolerate anesthesia.

Tarsal Coalitions: Coalition Tissue Types

∙Syn*desmo*sis—*f*ibrous ∙Syn*chondro*sis—*c*artilaginous ∙Syn*osto*sis—*oss*eous

Metatarsus Adductus: Measuring the Metatarsus Adductus Angle *Lepow Technique*

∙Take the perpendicular of a line 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 method. ∙MTA angle at birth is 25° to 30°; at 1 year (begin walking), it is around 20°; and by 4 years, it is at the adult normal of around 15°.

Tarsal Coalitions: Talocalcaneal (TC) Coalitions

∙Talocalcaneal coalitions account for about 45% of tarsal coalitions, *almost all involve the middle facet.* ∙Symptoms usually begin around age 12 to 14 years. →*Pain* is usually located in the *sinus tarsi or over the middle facet.* ∙Associated decreased ROM at the STJ and MTJ. ∙*Lateral, Harris-Beath, and Isherwood views* are the best radiographic views for visualization. ∙Surgical treatment involves *resection of the coalition and interposing soft tissue between bones.* →Triple arthrodesis may be warranted if previous surgery has failed or joint destruction is severe.

Clubfoot (Talipes Equinovarus) Evaluation: Beatson and Pearson Assessment Method

∙The talus and calcaneus are longitudinally bisected on a lateral and A/P x-ray. ∙The calcaneus is bisected on the lateral film by using the CIA. ∙The talocalcaneal angle of the A/P view is added to the talocalcaneal angle of the lateral view. →*If the sum is less than 40°, the foot is clubbed.*

Clubfoot (Talipes Equinovarus) Evaluation: Simon's Assessment Method (Simon's Rule of 15)

∙The talus, calcaneus, and first metatarsal are longitudinally bisected on an A/P x-ray, with the foot positioned in the maximally corrected position. ∙In a clubfoot, *the talo-first metatarsal angle was greater than 15*° and the *talocalcaneal angle (Kite's ankle) was less than 15°.*

Muscular Dystrophies: Treatment

∙There is no cure; treatment is aimed at *maintaining ambulation for as long as possible* ∙(PT, braces, weight control, surgery to control contractures). ∙*Keeping patients active is important*; inactivity often leads to worsening of the underlying muscle disease.

Wheaton Brace System:

∙This additional AK piece is designed to *lock into the BK component.* ∙The *knee is fixed at 90°*, *preventing twisting of the femur or hip* and allowing isolated unilateral *treatment of tibial torsion.*

Brachymetatarsia: Classification

∙Type I: Shortening of the 1st metatarsal only. ∙Type II: Shortening of 1 or 2 of the lesser metatarsals (usually 4th and/or 3rd). ∙Type III: Shortening of the 1st and one or more (but not all) of the lesser metatarsals. ∙Type IV: Shortening of all the metatarsals.

Wheaton Brace:

∙Used for *metatarsus adductus.* ∙Designed as an *alternative to serial casting* for metatarsus adductus ∙Similar in appearance to an AFO, with a *medial flare to abduct the forefoot.*

Bebax Shoe:

∙Used to treat *forefoot to rearfoot abnormalities* such as *metatarsus adductus* ∙Recommended for *use after serial casting* of metatarsus adductus, but not for primary correction ∙Also available is the Clubax, a device designed for rearfoot or leg deformities specifically clubfoot.

Cavus Foot Type (Pes Cavus): Radiological Evaluation

∙WB and NWB radiographs should be taken to determine whether the deformity is reducible. ∙A *"bullet hole" sinus tarsi seen on lateral radiograph is indicative of a cavus foot.*

Syndactyly:

∙Webbing between toes ∙M > F ∙Traumatic syndactyly may occur most notably as a result of burns. ∙Acrosyndactyly—partial joining of digits with proximal opening, usually due to IU environmental factors

Clubfoot (Talipes Equinovarus) Evaluation: Horizontal Breech

∙While the talar head and neck are medially deviated, the *talar body and trochlear talar surface may be slightly externally rotated* within the mortise. →Leading to an *external torsional deformity of the tibia and fibula.* ∙*Lateral malleolus becomes displaced posteriorly off its articular talar facet*, *leading to a decrease in the bimalleolar axis.* ∙The bimalleolar axis is the angle between the *longitudinal bisection of the hindfoot and the malleolar plane*. →Normal bimalleolar axis values are 75° to 90°; in a clubbed foot, this angle *decreases to less than 75°.*

Congenital Dislocated Hip Clinical Diagnostic Studies: Anchor Sign

∙With the baby prone, legs are adducted and extended. →*Look for asymmetry of thigh and gluteal folds.* →Will be more folds on the dislocated side.

Congenital Dislocated Hip Clinical Diagnostic Studies: Abduction Test

∙With the baby supine, hips and knees are flexed to 90°. →*Abduct the knees to resistance.* →Dislocated hip will have *limitation of abduction on the affected side.*

Congenital Dislocated Hip Clinical Diagnostic Studies: Ortolani Sign

∙With the baby supine, hips and knees are flexed to 90°. →Hips are examined one at a time by grasping the baby's thigh with the middle finger over the greater trochanter and *lifting and abducting the thigh* while stabilizing the pelvis and opposite leg with the other hand. →*Test is positive when a palpable click* is felt as the femoral head is made to enter the acetabulum.

Congenital Dislocated Hip Clinical Diagnostic Studies: Barlow Sign

∙With the baby supine, the *hips and knees are flexed*. ∙With the thumb on the lesser trochanter in the groin and the middle finger of the same hand on the greater trochanter laterally, *gently apply pressure down on the knee while simultaneously applying lateral pressure with the thumb*. →Dislocatable hip then becomes displaced with a *palpable clunk as the head slips over the posterior aspect of the acetabulum*. →Provocative test, which actively dislocates an unstable hip.

Clubfoot (Talipes Equinovarus): Treatment, Surgical Soft Tissue Release (Children 3 to 12 Months) *Medial Release (Talonavicular and Medial STJ Release)*

∙Z-Plasty of the *posterior tibial tendon.* ∙Release of the *talonavicular joint.* →In doing so, the *spring ligament and Henry's knot are severed.* ∙Release of the *entire medial STJ, which will include the superficial deltoid ligament.*