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Pediatric Disorders of the Foot

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

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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

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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

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Pediatric Disorders of the Foot

• Standard Radiography
• Radiographs should be obtained weightbearing or
  those that cant simulated weightbearing
• Initial radiographs include AP and Lateral
• Forced Dorsiflexion Lateral for talo-calcaneo
  alignment divergent/convergent

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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

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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

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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

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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

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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

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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
  excisionsimple excision to Kidner procedure

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Pediatric Disorders of the Foot

• Osteochondroses
• Kohlers 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

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Pediatric Disorders of the Foot

• Age distribution is between 2 an 7 years
• Treatment involves walking cast immobilization
• Kohlers is a self limiting disorder that in all
  cases resolves over time

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Pediatric Disorders of the Foot

• Freibergs 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

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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

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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

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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

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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

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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

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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

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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

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Pediatric Disorders of the Foot

• Radiographic evaluation of the lateral talo-first
  metatarsal angle Mearys will be angled apex
  plantarward Plantar Sag Sign
• Differential Diagnosis tarsal coalition,
  congenital vertical talus, talipes
  calcaneovalgus, accessory navicular, and
  inflammatory conditions

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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

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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

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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

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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

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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

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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

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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

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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

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Pediatric Disorders of the Foot

• Associated pathologic conditions
• Downs or Larsens Syndrome
• Arthrogryposis
• Diastrophic Dysplasia
• Spina bifida and dysraphism
• Fetal Alcohol Syndrome
• Streeters Dysplasia

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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

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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

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Pediatric Disorders of the Foot

• Ponsetti et al confirmed the need to correct all
  aspects of the deformity but not individually but
  simultaneously
• Ponsettis correction included a percutaneous
  achilles tendon release78 success
• Crawford, Kucharzyk et al85 success
• Dimeglio et al reported results with a clubfoot
  CPM.success rates of 72

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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

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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

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Pediatric Disorders of the Foot

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

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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

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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

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Pediatric Disorders of the Foot

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

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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 13-15-18

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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

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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

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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

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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

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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

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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

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Pediatric Disorders of the Foot

• Radiographics include AP, lateral, oblique, and
  Harris view
• Standing Oblique.calcaneonavicular
• Harris view.talocalaneal
• Anteater Signelongation of the calcaneus and
  seen with calcaneonavicular
• CT Scan of the hindfoot best for assessing tarsal
  caolitions if xrays questionable

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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

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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

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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

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Pediatric Disorders of the Foot

• Associated conditions cerebral palsy,
  poliomyelitis, Friedreichs ataxia,
  myelomeningocele, tethered cord, lipomeningocele,
  diastematomyelia, Charcot-Marie-Tooth disease,
  Peripheral Sensory Motor Neuropathies, tumor

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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

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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 Mearys angle increased

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Pediatric Disorders of the Foot

• MRI of the Brain and spinal cord to evaluate for
  cerebral palsy or spinal cord abnormalities
• EMGs 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 Friedreichs Ataxia

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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

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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

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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

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Pediatric Disorders of the Foot

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