69: Metatarsus Adductus - Feilmeier Flashcards Preview

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Flashcards in 69: Metatarsus Adductus - Feilmeier Deck (27)

what do you see with metatarsus adductus?

Medial deviation of the forefoot on the rearfoot

  • Concave medial border
  • Convex lateral border
  • Prominent styloid process


what is metatarsus adductus associated with?

hip dyplasia



what is the level of deformity metatarsus adductus?

lisfranc's tarso-metatarsal jt


other causes of pigen/in-toeing besides metatarsus adductus

  • Tibial/Malleolar torsion
  • Femoral anteversion (inward twisting of the femur-medial torsion)
  • Total ROM ~100 degrees. If >70 degress internal rotation may be present
  • “Psuedo”- femur is normal, but soft tissue are allowing tighter internally, not allowing external
  • also check for ortolani and barlow hip dysplasia


v-finger test

  • Infant’s heel in the examiners hand second webspace
  • Medical foot rests against index finger
  • Lateral foot rests against middle finger
  • Foot observed from plantar aspect
  • Observe for medial deviation of forefoot
  • Forefoot deviates away from middle finger


clinical "ARM" evaluation

  • Attitude
    • Position that is visible
  • Relationship
    • Forefoot to rearfoot
    • All three planes
  • Movement
    • Flexible, Semi Flexible, Rigid


heel bisector

should go through the second met area


metatarsus adductus vs. adductovarus vs. skewfoot

  • (A) Metatarsus Adductus
    • Transverse plane adduction
    • Most Common
  • (B) Metatarsus adductovarus
    • Transverse plane adduction
    • Frontal plane inversion of forefoot(supinatus)
  • (C) Skewfoot
    • Transverse plane adduction
    • Frontal plane inversion of forefoot (supinatus)
    • Rearfoot eversion


berg classification


bleck's severity of deformity

based on bisection fo the heel relative


metatarsus adductus angles




Metatarsus adductus angle =Relationship between the longitudinal axis of the lesser tarsus and the line bisecting the second metatarsal

  • 15-20 degrees-mild
  • 21-25 degrees-moderate
  • > 25 degrees-severe


soft tissue abnormalities assoc with met add

  • Anterior Tibial Tendon: More plantar insertion on cuneiform
  • Posterior Tibial Tendon contracture
  • Abductor Hallucis-hyperactivity/abnormal insertion
  • Peroneal tendons
  • Ligaments
  • Joint capsules


bone abnormalities assoc with met add

  • Arrest of normal ontologic rotation
  • Medial cuneiform
    • Growth pattern disturbance
    • Trapezoidal shape 
    • Absence-metatarsal varus?


does severity correlate with outcomes?



non-op treatment

  • Observation (mild)
  • Stretching (mild)
  • Splints
  • Corrective shoes (reverse shoes)
  • Serial casting (all)


tx newborn to 2 years

serial casting

  • Casting treatment past 8 months is controversial. Not all agree that casting after 1 year is effective
  • Have to remember aggressive or excessive casting can damage immature osseous structures
  • Classification DOES NOT correlate well with expected outcome


casting technique

  • Short Leg typically works but may need long leg
  • Fast Drying Plaster (more accurate modeling) vs. fiberglass (faster)
  • Minimal cast padding
  • Ankle at 90°
  • STJ Neutral
  • Cup foot at 5th met base with thenar eminence with thumb on bottom and index finger on the top- parallel to each other.
    • Or, thumb at 5th met cuboid and index finger around posterior heel holding STJ neutral
  • Thumb of other hand gently pushes 1st MPJ laterally (transverse plane) -abducting the forefoot


stretching/casting position (picture)


surgical tx 2-4 yo

  • Soft tissue releases
    • Abductor Hallucis release
    • Release soft tissue 1st Met – Cuneiform jt
    • Release soft tissue naviculo-cuneiform jt
    • Release cuneiform insertion of Anterior Tibialis
    • Combination of the above


tx 4 yo +

  • Where is the deformity and how can you make the foot rectus?
  • Soft Tissue Procedure
    • Tarsometatarsal capsulotomy (Heyman-Herndon-Strong Procedure)
  • Osseous Procedures
    • Multiple Metatarsal Osteotomies (Berman and Gartland, Lepird)
    • Medial opening wedge osteotomies
    • Lateral closing wedge osteotomies
    • TMTJ Arthrodesis


who can get soft tissue release?

2-6 yo


criticism soft tissue release

stiff foot


technique soft tissue release

  • Transverse or longitudinal incision
  • May need to osteotomize the 2nd  met to allow mobility of the other metatarsals (keystone)
  • Pin 6-8 weeks
  • Cast 3-4 months
  • Splinting after


when do we do osteotomy?

greater than 6 yo


name these osteotomies

(A) Peabody and Muro

(B) McCormick and Blount

(C) Steytler and Van DerWalt

(D) Berman and Gartland procedures


fowler procedure

•Opening-wedge osteotomy of the first cuneiform.

•The defect is replaced by a triangle shaped bone graft.


lepird procedure

•Oblique wedge osteotomy of the first and fifth metatarsals are performed with through and through rotational osteotomy of second, third and fourth metatarsals.

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