15.11.3 Paediatric Foor Deformaties

Question 1

Clubfoot
Def
Epidemiology

Answer 1

Def
- Hindfoot
➡️Equinus
➡️Varus
- Midfoot
➡️Cavus (high arch in middle of foot)
- Forefoot
➡️Adductus

CAVE (how deformity corrects) -> Cavus, Adductus, Varus, Epuinis

Epidemiology
- Most common congenital deformity 1/1000 (Maori 6.8 per 1000)
- Males > females 2x
- 50% bilateral
- 80% isolated deformity (IDIOPATHIC)
- Associated conditions (SYNDROMIC/ NEUROMUSCULAR)
Distal Arthrogryposis
Spinal bifida
Amniotic band syndrome
Tibial hemimelia
Congenital myotonic dystrophy
- 7% another anomaly; 7.6% neurodevelopmental condition

Question 2

Clubfoot pathophysiology

Answer 2

Begin as limb buds form
Abnormally dense collagen fibres in medial and posterior structures (Achilles, tib post tendons; tibionavicular and calcaneonavicular ligaments)
Diagnosed on U/S from 12 weeks gestation Genetic component (25%)- family history
Polygenic cause influenced by external factors (maternal smoking), Maternal diabetes
Alcohol consumption
Seasonal variation – maternal temperature during embryonic development In utero positioning
Syndromic more severe and resistant to treatment

Went through this very quick

Question 3

Idiopathic clubfoot

Answer 3

• not a packing disorder
• Can be associated with
  ➡️Hip dysplasia (25x more likely)
  ➡️Torticollis
• On exam
  ➡️Small foot and calf
  ➡️Shortened tibia
  ➡️Medial and posterior skin creases
• X ray not needed

Question 4

Pirani score

Answer 4

Slide 6

Implications
- Higher score at beginning of treatment correlates with increase in number of casts and increase requirement for Achilles tenotomy
- Helps with counselling parents Monitors progressive correction

Question 5

Ponseti

Answer 5

• Weekly, serial casting
• Fulcrum is head of the talus, SUPINATION around the talus
• Gradual correction
• Pirani score weekly should decrease
• Average 6-8 casts
• After casts: Achilles tenotomy (percutaneous) and POP for 3 weeks
• Then: Abduction foot orthosis (Dennis Brown boots/ Mitchell boots)
• Abduction up to 60 degrees relative to tibia
• Then dorsiflexion, need 20-30 degrees, if not, Achilles tenotomy (805 of cases)
• Hidfoot varus will correct
• Avoid fingers on calcaneus
• Avoid pronation

Question 6

Abduction foot orthoses

Answer 6

• Dennis Brown
• Mitchell
• Full time wear (23/24 hours) for 3 months
• Then nap times and night time for 4 YEARS Affected foot 70 degrees
• Normal foot 40 degrees
• Shoulder width

Question 7

Bracing

Answer 7

• Compliance is crucial
• Recurrence up to 80% if poor compliance (6% if compliant)
• Family education is crucial
• 4-5 year commitment

Question 8

Dynamic supination

Answer 8

• After walking, usually 2-3 years (over 30 months)
• Foot well corrected, but dynamic supination still present
• Surgery: Tibialis anterior transfer
• Internal splint to decrease supination 20% of cases

Question 9

Relapse

Answer 9

• Common
• Non-compliance
• Overactivity of tib ant tendon
• Progressive neuromuscular disease
• EVAC – Equinus FIRST
• What to do?
• Re-Ponseti!
• Can do repeat Achilles tenotomy
• If recurrent and stiff – may need surgery (bony and soft tissue surgery)

Question 10

Complications

Answer 10

• Recurrence
• Residual cavus
• Pes planus
• Undercorrection
  Intoeing gait
• Osteonecrois of talus
• Flat top talus
• Dorsal bunion

Question 11

CVT

Answer 11

• congenital vertical talus
• rigid flat foot in baby
• mostly syndromic
• Persian slipper

Question 12

Pes planus (flat foot)

Answer 12

• rigid or mobile/ flexible flat feet
• no medical arche
• hindfoot in valgus
• toes peeking out in lateral side
• assess wheter rigid or mobile by letting pt stand on toes (if it corrects from … -> …)

Flexible
- 25% adults
- Ligaments laxity often the cause
- Could be tight achilles
- Often asym and pain free
- Treatment is often conservative

Rigid
- Most common from a tarsal coalition (fusion)
- Between talus and calcaneus
- Or navicular and calcaneus
- Can complain of pain or asymptomatic
- Treatment is surgery to remove the fusion

Question 13

Polydactyly

Answer 13

Extra finger
- Very common
- Pre-axial and post axial
- Need x rays to check if bones in foot also
- Duplicated
- Surgery is recommended to make shoewear easier
- Check hand for extra finger too

Question 14

Local gigantism

Answer 14

• Non-hereditary condition
• Can be associated with syndromes
• Can be due to overgrowth from:
  ➡️Fat
  ➡️Vascular
  ➡️Cosmetic problems
• Treatment is difficult, often better to amputate the affect digit

Question 15

Cavo varus feet

Answer 15

High arch feet
- High arched feet
- Most associated with neurological
- Cause
➡️Like Charcot-Marie-Tooth
➡️c/o ankle sprains
- Treatment can be conservative and then
- Surgical
- Conservative: insoles, splints