guidelines for evaluation of 5 common peds problems

7/25/2019 Guidelines for Evaluation of 5 Common Peds Problems

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206 Journal of the American Podiatric Medical Association

This article provides readers with a user-friendly,

comprehensive overview of five of the most com-

monly seen orthopedic foot and leg conditions. It is

intended primarily as a practical guide for those con-

cerned with the diagnosis and treatment of disorders

of the childs foot and leg. It is also intended to serve

as an introduction to management of these disorders

for those who are new to the field of podopediatrics.

The authors, all of whom are faculty members in

the Department of Pediatrics at the New York College

of Podiatric Medicine and clinicians at the Foot Clinics

of New York, have attempted to define, outline both

clinical and radiographic diagnostic criteria for, and

design a logical treatment plan for the following pedi-

atric orthopedic conditions: calcaneovalgus, metatar-

sus adductus, internal tibial torsion, talipes equinovarus

(clubfoot), and flexible pes valgo planus (acquired

flexible flatfoot).

The articles succinct, schematic style is designed

to facilitate its use as a practical guide and a handy

reference, directing the reader quickly to the essen-

tial information needed to diagnose and manage

these conditions appropriately.

CALCANEOVALGUS

Definition

Calcaneovalgus is defined as a congenital flexible

flatfoot deformity usually present at birth. It affects

females more frequently than males, can be unilater-

al or bilateral, and is present in 1 in 10 live births.

The deformity consists mainly of extreme dorsiflex-

ion of the foot and calcaneal valgus. It is one of the

most common foot deformities. Fortunately, it is gen-

erally flexible and has an excellent prognosis if treat-

ed early and appropriately.

Guidelines for Evaluation andManagement of Five CommonPodopediatric Conditions

JOHN F. CONNORS, DPM*

ELISSA WERNICK, DPM*

LAURENCE J. LOWY, DPM

JEFFREY FALCONE, DPM

RUSSELL G. VOLPE, DPM

Practice guidelines for five of the most common podopediatric deformi-

ties are presented. In establishing these diagnosis and management

guidelines, the authors have reviewed an extensive body of literature

and considered their experience as clinicians in one of the busiest set-

tings for the evaluation and treatment of disorders of childrens feet. No

attempt has been made to be encyclopedic; rather, the authors empha-

size practical visual descriptors and the rationale for treatment to

demonstrate the value of early intervention in moderate-to-severe or-

thopedic pathology of the foot and leg. (J Am Podiatr Med Assoc 88(5):

206-222, 1998)

*Diplomate, American Board of Podiatric Orthopedicsand Primary Podiatric Medicine; Fellow, American College

of Foot and Ankle Orthopedics and Medicine; Associate Clin-

ical Professor, Department of Pediatrics, New York College

of Podiatric Medicine, 53 E 124th St, New York, NY 10035.

Diplomate, American Board of Podiatric Orthopedics

and Primary Podiatric Medicine; Assistant Clinical Professor,

Department of Pediatrics, New York College of Podiatric

Medicine, New York.

Diplomate, American Board of Podiatric Orthopedics

and Primary Podiatric Medicine; Professor and Chairman,

Department of Pediatrics, New York College of Podiatric

Medicine, New York.


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Volume 88 Number 5 May 1998 207

Visual Descriptors

1. Up and out appearance of the foot.

2. The forefoot is near or touches the anterior aspect

of the ankle and lower leg.

Rationale for Treatment

1. If left untreated, it may lead to symptomatic flat-

foot during childhood and beyond.1-16

2. Severe cases have been associated with congenital

dislocation of the peroneal tendons, which is a

major concern with respect to the developing foot.9

3. Abnormal joint relationships will develop if it is

left untreated during the first year of life.12

4. Ambulation may be delayed because of poor bal-

ance. A wider gait angle is needed. Patients have

an outward rotation of the legs and an outward

position of the toes.12

5. If left untreated, it will result in permanent muscleimbalance (tight dorsiflexors versus lax medial

structures), which may lead to progressive defor-

mity of the bones and joints.1, 10

Diagnosis

Diagnosis is made by both clinical and radiographic

observation. The following criteria should be evaluat-

ed, and at least four clinical or two radiographic cri-

teria should be present.

Once a clinician has satisfied the diagnostic crite-

ria, the pathologys severity must be evaluated as per

Grading of Severity.

Clinical Criteria

1. There is excessive dorsiflexion at the ankle and

eversion of the hindfoot, with limited plantarflex-

ion and inversion.

2. The heel has a valgus orientation that can range

from slight to marked eversion.

3. The talar head is palpable both medially and later-

ally.

4. The foot distal to the midtarsal joint is abducted

and everted.

5. The range of motion of the subtalar joint is normal.

6. The Achilles tendon is not taut, even during com-

plete dorsiflexion.

7. The skin lines around the ankle joint produce

deep creases and furrows anterolaterally and the

skin is extremely taut medially.

8. When plantarflexion is attempted, a deep depres-

sion is noted at the sinus tarsi.

Associated Findings

1. The talocalcaneal ligaments are relaxed or absent.12

2. External tibial torsion exists in many cases.5, 12, 13

Radiographic Criteria

Lateral View

1. Talar Bisection Line. In a normal foot, the

talar bisection line either bisects the cuboid or pass-

es through the dorsal surface of the bone. In a calca-

neovalgus foot, this line falls plantar to the cuboid.

The talus may be markedly plantarflexed.

2. Talocalcaneal Relationship. In a normal foot,

there is no overlap between the talus and the calca-

neus. In a calcaneovalgus foot, the talus overlaps the

anterosuperior portion of the calcaneus.

3. Cyma Line. In a normal foot, there is no break in

continuity in the cyma line. In a calcaneovalgus foot,

the line is usually significantly altered by an anterior

break. This indicates a breach in the midtarsal joint.

Dorsoplantar View

The relationship between the talus, navicular, and

first metatarsal is significant. Owing to the cartilagi-

nous structure of the navicular at birth, it cannot be

visualized in a young infant, and the first metatarsal

should be used as a guide.

1. Talar Bisection Line. In a normal foot, the

talar bisection line bisects the first metatarsal shaft.

In a calcaneovalgus foot, the talar bisection line falls

medially outside the foot and does not approximatethe first metatarsal.

2. Talocalcaneal Angle. The normal value for

the dorsoplantar talocalcaneal angle in a newborn is

30 to 40. In a calcaneovalgus foot, the angle is mark-

edly increased.

Grading of Severity

The degree of available plantarflexion at the ankle

and the lateral talar bisection line helps distinguish

the various grades of severity (Table 1).

Treatment

Treatment should begin as early as possible.10-12, 14, 15

Although some authors believe that treatment is un-

warranted because the deformity is flexible and

reduces spontaneously during weightbearing,6-8 much

of the literature supports instituting treatment during

the first year of life.1-5, 10-12, 14 Treatment is determined

by the severity of the deformity and whether the

child has begun weightbearing (Table 2).


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increased bulk of the young foot obliterates bony

prominences, giving a straight appearance.22

Diagnosis

Diagnosis may be made by means of at least two of the

following three screening methods. Two are clinical

assessments, and one is a radiographic assessment.

Clinical Assessment

1. V-Finger Test. The V-finger test may be used

as the initial screening tool. In this test, the heel is

placed between the index and middle fingers and the

lateral aspect of the foot is observed for deviation

from the middle finger. Gapping from the finger at

the styloid process of the lateral border of the foot

indicates metatarsus adductus. This test may be used

in cases in which the heel is sufficiently small to be

accommodated in the second interspace of the hand.With metatarsus adductus, the line extending distally

from the heel falls lateral to the second interspace.

2. Heel-Bisector Angle (Blecks Method).

Another screening tool that may be used is the heel-

bisector angle. A longitudinal heel bisector is extend-

ed distally and its relationship to subsequent toes

and interspaces is noted. Ideally, this line should ex-

tend through the second digit and second interspace.

Radiographic Assessment

1. Metatarsus Adductus Angle. The metatarsusadductus angle is the angle formed by the intersec-

tion of the bisector of the second metatarsal and the

transection of the lesser tarsus.

Although the deformity may be diagnosed clinical-

ly, in instances when screening tools are question-

able, insufficient, or equivocal (eg, when there is dif-

ficulty distinguishing metatarsus adductus from tal-

ipes equinovarus), radiographs may be obtained and

the metatarsus adductus angle measured. Slight dis-

crepancies in normal values exist,4, 17, 22-24 but signifi-

cant increases in the angle indicate metatarsus ad-

ductus deformity. Normal ranges are as follows:Birth to 4 months of age: 20 to 30

1 to 3 years: 15 to 20

4 to 6 years: 10 to 15

2. Talocalcaneal Angle (Kites Angle). The ta-

localcaneal angle may be used adjunctively to help

distinguish metatarsus adductus from talipes equino-

varus. An angle of less than 15 strongly suggests tal-

ipes equinovarus.

Grading of Severity

Severity may be assessed clinically or radiographical-

ly. As metatarsus adductus is rarely a contested diag-

nosis, only one criterion is necessary to grade the

severity.

Clinical Assessment

1. Most authors agree that severity should be assessed

clinically as follows:18-21, 25-27

Mild: Flexible; passively correctable

Moderate: Semiflexible/reducible

Severe: Rigid2. Blecks method (modified):

Normal: Heel bisector extends through the

second digit and the second interspace.

Mild: Heel bisector extends through

the third digit.

Moderate: Heel bisector extends through

the third interspace and the fourth toe.

Severe: Heel bisector is lateral to the

fourth digit.

Radiographic Assessment

The metatarsus adductus angle should be measured

and assessed according to Table 3. Ontogeny brings a

progressive reduction of the angle; thus values for

children of ages that fall outside the age groups cited

in the table may be interpreted by the practitioner by

extrapolation.

Treatment

Treatment is based on the severity of the condition

and the age of the child (Table 4). While many authors

contend that the deformity spontaneously reduces,most investigators advocate treatment as soon as

possible, especially in patients with moderate-to-

severe cases.5, 8, 17-28


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transverse-plane deformity caused by a fixed struc-

tural abnormality occurring in the tibia.2, 29, 30 This

results in an abnormal angle between the knee and

ankle axes for a given patient age. Essentially, there

is a medial rotation of the distal tibia on the proxi-

mal tibia.8, 29, 34, 37

The causes of in-toeing from the leg include intra-

uterine position, angular deformities, compensatory

mechanisms, and iatrogenic complications.29, 31, 38 In-

toeing may be caused by a variety of abnormalities ofcongenital or acquired origin. It may stem from a

fixed bony deformity, soft-tissue contractures, muscle

paralysis and imbalance, or a change in the planes of

articulation. Internal tibial torsion may have a heredi-

tary basis.

Visual Descriptors

1. Tripping and falling due to internal or adducted

attitude of the feet and legs.

INTERNAL TIBIAL TORSION

Definition

Lower-leg torsion is one of the most common leg

abnormalities seen in infants.5, 29-34 The following ter-

minology is used with respect to this deformity:

Version describes normal variations in limb rota-

tion. Tibial version is the angular difference between

the axis of the knee and the transmalleolar axis.8, 29

Torsion describes version beyond two standard

deviations from the mean and is considered abnor-

mal and described as a deformity.8, 29A torsional de-

formity is a twisting about the longitudinal axis.34

Internal tibial torsion is the most common cause

of in-toeing.8, 29, 31 The condition is most often bilater-

al. Unilateral internal tibial torsion is most common

on the left side.8, 29, 31

Internal tibial torsion is an abnormal increase in

tibial version in an internal direction.29, 35, 36 It is a

Table 3. Grading of Severity of Metatarsus Adductus Angle (all values in degrees)

Birth4 Months 13 Years 46 Years

Mild 3140 2125 1620

Moderate 4145 2630 2125

Severe > 45 > 30 > 25

Table 4. Treatment for Metatarsus Adductus

Birth3 Months 36 Months 612 Months 12 Years

Mild Observation Manipulation Manipulation Straight-last shoes

Control of sleeping Padded straight-last shoesa Bracingb

position

Moderate Manipulation Serial castingc Serial castingc If flexible and reducible,

Padded straight-last shoesa Bracingb serial castingc

Bracingb Possible Ipos Anti-Adductus Bracingb

Ipos Anti-Adductus Orthosis3 Orthosis Possible Ipos Anti-Adductus

Orthosis

Severe Serial castingc Serial castingc Serial castingc Serial castingc; if no

Manipulation Bracingb Bracingb improvement at ap-

Bracingb Possible Ipos Anti-Adductus Ipos Anti-Adductus Orthosis proximately 2 months,

Orthosis possible surgery

Note: Internal tibial torsion frequently accompanies metatarsus adductus, and its presence may influence the choice of

treatment.a Padding should consist of 1/4-inch felt applied to the medial aspect of the first metatarsal head and along the lateral

aspect of the calcaneocuboid joint.b Bracing may include use of the Ganley splint or Wheaton Bracing System4.cAll serial casting to be followed by bracing and padding.

3 Ipos Orthopedics Industry, Niagara Falls, NY.4 Wheaton Brace Co, Carol Stream, IL.


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2. Internal or adducted attitude of the feet and legs

at rest.

3. Internal or adducted attitude of the feet and legs

during ambulation; usually increased from atti-

tude at rest.2

4. Perceived genu varum beyond what is considered

physiologically normal for a particular age.


1. Treatment can avoid injuries secondary to trip-

ping and falling.

2. The family history may suggest that the condition

will not be outgrown.29, 39 (If the tibias of the par-

ents and adolescent siblings show normal align-

ment, the probability of spontaneous correction

by the age of 7 or 8 years is greater. However, if

there is a family history of persistent abnormal

internal tibial torsion, the prognosis for sponta-

neous correction is guarded, and aggressive thera-

peutic measures should be considered.)38

3. Treatment can avoid compensatory, pronatory

changes as the child matures, such as increased

abducted gait with breakdown at the midtarsal

joint.4, 29

4. Treatment can reduce muscle fatigue and pain

associated with dynamic muscle imbalance.

5. Treatment can reduce inappropriate joint motion

at the knees.40

6. If left untreated, there may be residual in-toe gait

as the patient matures.

7. Patellar tendinitis and osteoarthritis may develop

owing to compensation.

8. There may be progressive worsening of the condi-

tion.40

9. Treatment may result in avoidance of surgery.

Diagnosis

Internal tibial torsion may be diagnosed by means of

one of the following clinical or radiographic criteria.

Diagnosing internal tibial torsion by means of clinical

measures is more common than by means of radio-

graphic measures. Malleolar position provides the

best clinical measure.

Clinical Criteria

Internal tibial torsion is diagnosed clinically by means

of one of the following four criteria. The child should be

observed walking and running during gait evaluations.

1. Foot-Progression Angle. The foot-progres-

sion angle is the angular difference between the axis

of the foot and the line of progression. The child is

evaluated during gait.8, 39, 41

2. Gait Analysis. The principal presenting sign is

an adducted attitude of the foot. There is contact-

phase adduction of the foot and leg, with adduction

continuous throughout the gait cycle. The leg is inter-

nally rotated during swing and the foot plants adduct-

ed to the line of progression. This is essentially a non-

quantified estimate of the foot-progression angle.8, 39

3. Thigh-Foot Angle. The child is placed in theprone position with the foot and knee flexed at right

angles.8, 38, 41, 42 The bisection of the thigh and the axis

of the foot (through the second metatarsal) are mea-

sured and the difference is noted.

4. Malleolar Position. The child is seated on the

edge of a table with his or her knee flexed 90; the

infant is placed in the prone position and his or her

knee is flexed to a right angle. Through proper posi-

tioning of the limb, the tibial transcondylar line (axis

of the knee joint) is made parallel either to the edge

of the table (when sitting) or to the top of the table

(when lying prone). The transmalleolar line (axis ofthe ankle) is determined by placing the thumb on the

distal tip of the medial malleolus and the index finger

on the distal tip of the lateral malleolus. The degree

of tibial torsion is determined by the angle formed

between the transcondylar tibial axis and the axis of

the ankle joint (bimalleolar axis).2, 29, 30, 32, 41, 43


True tibial torsion can be most accurately measured

and diagnosed with radiographs, ultrasound, or com-

puted tomography (CT). However, not all of these

methods are indicated in children, and internal tibial

torsion is most often diagnosed by means of clinical

measures.

With accurate radiography, the actual torsion is

apparent; thus the superiority of this method is obvi-

ous. Yet the risk of exposure to radiation often rules

out this diagnostic method for the pediatric population.

The advent of CT and ultrasound has greatly facili-

tated the measurement of tibial torsion. The use of

CT scans enables the practitioner to measure tibial tor-

sion more precisely than with normal radiographs.44

However, CT scans are expensive and difficult to per-

form on children. Ultrasound is often preferred over

CT and offers the advantage of a lack of radiation.38

The authors discourage the use of radiographic

interpretation for determination of internal tibial tor-

sion. Clinical interpretation is strongly recommended.

Grading of Severity

The severity of internal tibial torsion may be graded

according to Table 5. Each section of Table 5 repre-


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sents a grading scale based on one of the clinical cri-

teria. Normal clinical values for malleolar position

are given below to serve as guidelines.

Normal Values (Malleolar Position)5, 29, 30, 43

Birth: 0 to 5 external. Most of the increase in tib-

ial torsion occurs during the first year of life.

Age 1: 5 to 10 external. The tibia externally ro-

tates approximately 2 each year from ages

1 to 6.

Age 6: 13 to 18 external. By age 6, adult values

should be reached.

Treatment

The method of treatment depends on the patients

age, the severity of the deformity, whether excessive

torsional deformities are medial, and the presence or

absence of familial incidence.8, 38

Any significant transverse-plane deviation from

normal values may have an abnormal pronatory ef-

fect on the developing childs foot and may either per-

petuate an existing pronation abnormality or create

one.45

The aim of treatment is to prevent internal tor-

sional forces from being applied to the lower extrem-

ity and reduce any compensatory mechanisms that

may result from the deformity. The ultimate goal of

treatment is rapid, complete functional reduction of

the problem (Table 6).

There are three different categories of treatment:

1. Definitivea. Serial casting (above the knee). The physician

must cast one joint above the level of pathology.

b. Bracing (CRS5 [Counter Rotation System],

Denis-Browne, Wheaton Bracing System).

2. Cosmetic

a. Twister cables.

b. Gait plates (should be used only if the child has

a propulsive gait).

c. Outer sole wedges.

3. Salvage

a. Tibial rotational osteotomy (indicated only inthe older child [over 8 to 10 years old] who has

significant cosmetic and functional deformity).

Table 5. Grading of Severity of Internal Tibial Torsion (all values in degrees)

Nonambulatory 2 Years 4 Years 6 Years

According to Foot-Progression Anglea

Mild Unable to determine 810 47 03

Moderate Unable to determine 15 1315 1012

Severe Unable to determine > 20 1720 1517

Asymmetrical Unable to determine b b b

According to Thigh-Foot Angle

Mild 03 46 79 1013

Moderate (2)0 04 57 810

Severe (5)(2) (2)0 05 68Asymmetrical b b b b

According to Malleolar Position

Mild (2)5 57 810 1113

Moderate 02 25 69 10

Severe < 0 < 2 < 6 < 10

Asymmetrical b b b b

Note: Numbers in parentheses indicate negative values.a Values represent internal attitude from line of progression.b Treatment strongly recommended.

5 Langer Biomechanics Group, Deer Park, NY.


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TALIPES EQUINOVARUS(CLUBFOOT)

Definition

Talipes equinovarus is a congenital foot deformity

that usually consists of four elements:

1. Inversion and adduction of the forefoot.

2. Inversion (varus) of the heel and hindfoot.

3. Equinus throughout both the ankle and the subta-

lar joint.

4. Internal tibial torsion.

Visual Descriptors

1. Down and in attitude of the foot.

2. May resemble metatarsus adductus.

3. Small foot with soft heel and contracted heel

cord.5, 8, 13

4. Heel varus with forefoot adductus.


Few practitioners would contest the need for treat-

ment of this deformity. Most institute treatmentimmediately upon diagnosis, often in the hospital

neonatal unit. Left untreated, the following may

occur:

1. Osteoarthritic conditions may develop in later life

owing to compensatory mechanisms.

2. There may be difficulty in fitting shoes, especially

as the foot becomes less flexible.

3. The patient may suffer ridicule by his or her peers

because of the abnormal appearance of the foot.

Table 6. Treatment for Internal Tibial Torsion

Nonambulatory 12 Years > 2 Years > 6 Years

Mild Observation Observation Observation Observation

Exercise Exercise Exercise Exercise

Orthoses Orthoses

Moderate Serial casting Nonambulatory: Gait platesa Gait platesa

Exercise Serial casting Exercise Orthoses

Bracing Bracing Exercise

Ambulatory:

Bracing

Outer sole wedge

Exercise

Severe Serial casting Nonambulatory: Outer sole wedge Orthoses

Bracing Serial casting Gait platesa Exercise

Bracing Exercise

Exercise If conservative

treatment fails,

Ambulatory: tibial osteotomy

Bracing

Walking castOuter sole wedge

Asymmetrical Serial casting Nonambulatory: Outer sole wedge Orthoses

Bracing Serial casting Gait platesa Exercise

Bracing

Exercise If conservative

treatment fails,

Ambulatory: tibial osteotomy

Bracing

Walking cast

Outer sole wedge

a Gait-plate therapy should be used only if the child has a propulsive gait pattern (heel-to-toe gait).


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4. There will be a tendency toward lateral ankle

sprains.

5. Pain may develop on the lateral border of the foot

owing to the shape of the foot and heel-strike

implications.

6. There may be progressive worsening of the condi-

tion, especially of the tendo Achillis equinus.

Diagnosis

The diagnosis of clubfoot is not difficult, and the con-

dition is seldom confused with other foot deformi-

ties. Sometimes severe metatarsus adducto varus is

confused with clubfoot. However, the equinus com-

ponent of clubfoot makes the differentiation clear.

Diagnosis may be made by a thorough physical and

clinical examination as well as radiographically.

Clinically, the overall appearance and range of

motion of the affected joints are extremely important.

The following findings indicate talipes equinovarus:

Clinical Criteria

1. Equinus and varus of the hindfoot with adducto

varus of the forefoot and medial rotation.5, 8, 13, 46

2. Small calf compared with the contralateral side.

3. Prominent anterior aspect of the talus on the lat-

eral aspect of the dorsum of the foot.

4. The skin is thinned and stretched on the dorsolat-

eral aspect, with skin creases deeply furrowed on

the medial aspect of the foot.8, 13

5. The lateral malleolus is posterior to and moreprominent than the medial malleolus.

6. During passive dorsiflexion and eversion of the

foot, the tight posterior tibial tendon and triceps

surae can be palpated.

7. Upon palpation, hypertrophied, shortened liga-

ments and a tight joint capsule will be noted on

the medial aspect of the foot and the posterior

aspects of the ankle and subtalar joints.

8. There is a frequent association with internal tibial

torsion.

Many authors divide talipes equinovarus into one of

the following subtypes.5, 8, 13, 46, 47 Diagnosis based onthese subtypes becomes important for grading of

severity (Table 7).

1. Nonrigid. Known also as postural clubfoot, this

type is a severe positional or soft-tissue deformity;

it is diagnosed when the following features are

present:

a. Manually reducible to 75% to 100% correction

on the transverse, sagittal, and frontal planes.

b. Mild and flexible.2

c. The peroneal muscles function when stimulat-

ed. Stroking the lateral border causes eversion

and withdrawal from the stimulus.2

d. Normal-sized heel with mild equinovarus atti-

tude of the foot.

e. The lateral border of the foot is convex, with a

normal relationship of the cuboid to the calca-

neus. The medial border is concave, with nor-mal skin creases. The forefoot is in slight varus

but not equinus.

f. Mild calf and leg atrophy.

2. Rigid (Moderate)

a. Manually reducible to 50% to 75% correction on

the transverse, sagittal, and frontal planes.

b. The posterior and medial creases of the foot

are more visible than in the nonrigid category.

The lateral border of the foot is more convex,

with the cuboid bone displaced medially, and

the medial border is more concave, with fur-

rowed skin.

c. Peroneal-muscle function is very difficult or im-

possible to demonstrate.2

d. Smaller-than-normal heel.

e. Calf size and feel are almost normal.

f. Equinus is more dominant than varus, with in-

creased forefoot adduction.

3. Rigid (Severe)

a. Manually reducible to 25% to 50% correction on

the transverse, frontal, and sagittal planes.

b. The foot is extremely stiff and resistant to man-

ipulation.c. The heel is much smaller than normal.

d. Moderate-to-severe heel varus.

e. The medial border of the foot is very concave,

with deeply furrowed skin. The lateral border

of the foot is very convex, with the cuboid

bone displaced medially over the anterolateral

end of the calcaneus.

f. The calf is tapered and cylindrical with a firm

feel.

g. The attitude of the foot is varus adduction of

the forefoot, equinus, and cavus.

4. Teratologic. This subtype is associated with under-

lying neuromuscular disorders such as myelodys-

plasia, arthrogryposis multiplex congenita, spina

bifida, and other congenital deformities.

a. Manually reducible to


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e. The calf feels markedly firm, with an almost

cylindrical, peglike appearance.

f. The skin is atrophied, with a congenital groove

usually present on the inferomedial aspect of

the foot.

g. Thick hyperkeratosis may be present after

weightbearing and during ambulation, especial-

ly on the lateral aspect of the foot.

h. The overall attitude of the foot is extreme

varus with equinus. The foot tends to turn in-

ward at a right angle to the leg, with marked

cavus deformity.


Radiographs are extremely useful in grading severity

and measuring the success of treatment. However, a

standard policy for required x-rays in the treatment

of clubfoot has not been established.13 One of the

problems encountered with radiographs of infants is

that some bones are primarily cartilaginous and,

therefore, angular measurements may be inaccurate.

Another problem is that films are often not taken in a

standardized, reproducible manner (the child cries,the foot twists, the physicians hands slip). There-

fore, x-rays for clubfoot are often used to define pat-

terns rather than clarify details.13

Two of the most common radiographic views

taken are the anteroposterior view and the forced-

dorsiflexion lateral view. These views can clarify the

relationship between the talus and the calcaneus,

confirming the diagnosis of clubfoot.6, 8, 13, 46 If an

infant is 6 months of age or older, initial radiographs

are useful to supplement the physical examination.2

Anteroposterior View

1. Talocalcaneal Angle

Normal: 20 to 50 48, 49

Pathologic: Decreased, especially


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Table 8. Treatment for Talipes Equinovarus (Clubfoot)

Birth1 Year

(Nonambulatory)12 Years > 2 Years

Nonrigid Stretching exercises Stretching exercises Physical therapy

Serial immobilization casting Consider serial casting Prescription shoe

Follow up with Denis-Browne Denis-Browne bar or CRS with Surgical consultation

bar, CRS, Wheaton Bracing high-top straight- last shoe Custom-fabr icated orthoses

System with high-top as night splint

straight-last shoe Physical therapy/muscle

stretching

Prescription shoe, straight or

reverse lastSurgical consultation

Rigid (Moderate) Serial immobilization casting Consider serial casting Prescription shoe, reverse last

Prescription shoe, reverse last Prescription shoe, reverse last Surgical consultation

(as a follow-up to casting) Night splint Custom-fabricated orthoses

Splint: Denis-Browne bar, Denis-Browne bar, CRS, ankle-foot

CRS, ankle-foot orthosis orthosis

Surgical consultation Surgical consultation

Rigid (Severe) Surgical consultation Surgical consultation Surgical consultation

Follow up surgery with serial Follow up surgery with serial casting Prescription shoe, reverse last,

casting Prescription shoe, reverse last, as a follow-up to surgery

as a follow-up to surgery Ankle-foot orthosis, Denis-Ankle-foot orthosis, Denis-Browne Browne bar, CRS as a follow-

bar, CRS as a follow-up to surgery up to surgery

Custom-fabricated orthoses

Teratologic If rigid or nonrigid

(must be assigned a category),

follow previous plan

Underlying etiology must be

addressed by appropriate

medical consultation,

eg, arthrogryposis, muscle

disease, spina bifida, etc.

Treatment

The treatment of clubfoot may require both conser-

vative and surgical care depending on the classifica-

tion and degree of deformity.2 Treatment should be

instituted as early as possible and is based on the

severity of the deformity and the age of the child

(Table 8).


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FLEXIBLE PES VALGO PLANUS(ACQUIRED FLEXIBLE FLATFOOT)

Definition

Flexible pes valgo planus is a multifaceted foot de-

formity described by different authors and practi-

tioners in various ways. The following is a distillationof the most basic components of the condition as de-

scribed in the literature. It should be noted that

radiographic evidence of deviations at various joints

can and should be taken into account when defining

the entity.

Flexible pes valgo planus is a flexible foot defor-

mity consisting of an everted or valgus heel with a

decreased medial longitudinal arch during weight-

bearing. The arch may be normal, low, or absent dur-

ing nonweightbearing. With weightbearing, there is

abduction of the forefoot on the rearfoot, a decrease

or collapse of the medial column, and eversion of thecalcaneus after heel lift. During gait, the foot or feet

are maximally pronated with little or no resupina-

tion. Accentuation of the aforementioned postures

may be evident.

The deformitys reducibility may be based on flex-

ibility. It is frequently associated with generalized lig-

amentous laxity.

Visual Descriptors

1. Flatfoot

2. Fat foot3. Floppy foot

4. The medial malleolus may be abnormally prominent

5. The medial talar bulge may be evident

6. The forefoot is abducted on the rearfoot with an

everted heel

7. Too-many-toes sign

8. Out-toe gait


1. With resultant tendo Achillis contractures, flat-

foot leads to disability later in life.50

2. Treatment can avoid surgery necessitated by

hypermobile flatfoot and tight tendo Achillis.

Both hypermobile flatfoot and equinus may lead

to arthritis and pain as the child matures. Both

may be severe and debilitating.8, 50

3. The condition may lead to tarsal tunnel syn-

drome, with its sequelae and possible need for

surgery.51

4. Treatment can avoid deformation of shoes as

well as premature wear.5, 52

5. The condition may lead to hallux abducto valgus

later in life.50, 52, 53

6. The condition may lead to joint damage.54-57

7. Flatfoot may lead to foot strain, pain, fatigue, and

leg discomfort in the obese or older child.5

8. Structural changes may occur in the tarsal bones

during adulthood. The deformity may become

rigid.5

9. Adaptive changes in the older child (due to lack

of treatment early on) may preclude the sponta-

neous correction that some authors believe oc-

curs. The changes often necessitate surgery.58

10. Pediatric patients may experience no symptoms

initially (only a small percentage do), but fatigue,

pain, discomfort, and aching may present later

during adulthood. Symptoms tend to become

more severe with age.11, 50, 59, 60

11. Flatfoot has socioeconomic implications, and

cosmesis should be taken into account.52

12. Flatfoot may cause shoe fitting to become a prob-lem.52, 61

13. Bone and soft-tissue abnormalities have been

exhibited in the untreated flatfoot, including osteo-

arthritic changes, osteoporosis and osteopenia,

medial soft-tissue swelling, joint damage, and

structural changes of the tarsal bones.56, 57

Rationale for the Use of OrthopedicDevices in Treatment

1. They extend the wear of shoes, particularly the

heel counter.52

More even shoe wear is achieved.62

2. Heel varus wedges have greatly improved foot-

ground patterns, reducing pathologic pressure

beneath the medial longitudinal arch and helping

to correct pronatory forces.54, 63

3. When feet are radiographed within shoes with

orthoses, normal articular relationships are seen,

particularly at the naviculocuneiform and talo-

navicular joints. Also, calcaneal pitch is restored

or improved.2, 5

4. Orthotic devices have reduced symptoms in ath-

letes, as well as decreased rearfoot pronation and

eversion with respect to speed and amplitude.64, 65

5. Inadequate support of the talus is the basic cause

of flatfoot.50

6. Heel cups and University of California Biomechan-

ics Laboratory orthotic devices have resulted in

improved foot function.66, 67

7. They can decrease symptoms such as anterior tib-

ial muscle pain (shin splints) and diffuse pain as

well as improve gait patterns.62

8. There is decreased stability with a valgus heel.

With the heel realigned (inverted), increased sta-


13/17


14/17


equals relaxed calcaneal stance position.

3. Longitudinal arch height5: Longitudinal arch de-

pressed but visible with weightbearing.

4. Too-many-toes sign: toes 4 and 5 visible (from

posterior).

5. Gait: Gait analysis is essential in the evaluation of

pes valgo planus.

Mild (Radiographic Criteria)

Radiographic criteria for a grading of mild are pre-

sented in Table 9.Note: Increases in the talometatar-

sal angle and the cuboid abduction angle should be

considered pathologic regardless of age. The degree

of increase is considered in the grading of severity.

Moderate (Clinical Criteria)

1. Symptomatology: In a child younger than 4 years,

fatigue or a desire to be carried after moderateactivity. In a child older than 4 years, pain with

moderate-to-excessive activity (eg, prolonged

walking, athletic pursuits).

2. Relaxed calcaneal stance position70: 6 to 10

everted.Note: The Schoenhaus-Jay/Valmassy for-

mula may be applied.

3. Longitudinal arch height5: Longitudinal arch not

visible with weightbearing.

4. Too-many-toes sign: toes 3 through 5 visible.

5. Gait: Gait analysis is essential.

Moderate (Radiographic Criteria)

Radiographic criteria for a grading of moderate are

presented in Table 10.

Severe (Clinical Criteria)

1. Symptomatology: Pain with weightbearing or mild

activity (any age). In a child younger than 4 years,

fatigue or a desire to be carried during activities.

In a child older than 4 years, reluctance to partici-

pate in sports or weightbearing activities.2. Relaxed calcaneal stance position70: >10 evert-

ed.76Note: The Schoenhaus-Jay/Valmassy formula

may be applied.

Table 9. Grading of Severity of Flexible Pes Valgo Planus (Radiographically): Mild (all units in degrees)

Birth1 Year 14 Years > 4 Years Birth2 Years > 2 Years

Talar declination angle66, 75 3540 3035 2530

Dorsal talocalcaneal angle 4050 3540 3035

Lateral talocalcaneal angle 5055 4045 3540

Calcaneal inclination angle 510 1015

Talometatarsal angle67, 72 315 315

Cuboid abduction angle 58 58

Table 10. Grading of Severity of Pes Valgo Planus (Radiographically): Moderate (all units in degrees)


Talar declination angle66, 75 4045 3540 3035

Dorsal talocalcaneal angle 5055 4550 3540

Lateral talocalcaneal angle 5560 4550 4045

Calcaneal inclination angle 5, 75 05 510

Talometatarsal angle67, 77 1530 1530

Cuboid abduction angle 811 811


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3. Longitudinal arch height5: Longitudinal arch not

visible, medial border of foot convex with head of

the talus visible.

4. Too-many-toes sign: toes 2 through 5 visible.

5. Gait: Gait analysis is essential.

Severe (Radiographic Criteria)

Radiographic criteria for a grading of severe are

presented in Table 11.

Treatment

Treatment of flexible flatfoot is one of the most con-

troversial subjects in the orthopedic literature, and

the individual practitioner must use discretion. How-

ever, the suspected long-term effects of lack of treat-

ment for the deformity warrant a bias toward man-

agement. The question of whether the symptom-free

child is bound to become the symptomatic adult has

not yet been answered,74 but it appears that many

asymptomatic pediatric flatfeet do progress to painful

deformities during adolescence and adulthood. Thefew long-term studies discounting treatment are flawed

at best, usually focusing only on form, not function.

Treatment should be tailored to each individual

situation.78 The age of the patient and the severity of

the flatfoot should be taken into account. Table 12

shows general guidelines culled from several investi-

gators.11, 50, 52, 54, 66, 67, 70, 76, 79-82

Table 11. Grading of Severity of Pes Valgo Planus (Radiographically): Severe (all units in degrees)


Talar declination angle66, 75 > 45 > 40 > 35

Dorsal talocalcaneal angle > 55 > 50 > 40

Lateral talocalcaneal angle > 60 > 50 > 45

Calcaneal inclination angle 5, 75 0 05

Talometatarsal angle67, 72 > 30 > 30

Cuboid abduction angle > 11 > 11

Table 12. Treatment for Pes Valgo Planus

Nonambulatory 13 Years > 3 Years

Mild Observation Oxford shoe or good sneaker Tarso Supinator shoe with padding

Leather shoe with long counter,

Thomas heel

Moderate Observation Tarso Supinator shoe Leather shoe with long counter,

Possible shoe padding with padding Thomas heel

Leather shoe with long counter, Padding

Thomas heel Heel cupHeel cup or stabilizer UCBL orthosis

UCBL orthosis

Severe Probable calcaneovalgus: Heel cup UCBL orthosis

After casting, monitor UCBL orthosis Depending on age, extent of deformity,

for long-term prognosis and response to conservative treat-

ment, possible surgical evaluation

Note: Padding may consist of appropriate materials applied to the longitudinal arch. The literature supports the efficacy

of heel varus wedges. Physical therapy or exercise should be instituted when the flatfoot is accompanied by soft-tissue con-

tractures.

Abbreviation: UCBL, University of California Biomechanics Laboratory.


16/17


Conclusion

Practice guidelines for five of the most common

pediatric orthopedic deformities have been present-

ed. The definition, etiology, visual description, ratio-

nale for treatment, diagnosis, grading of severity, and

guidelines for treatment for each deformity have

been included.This review has been designed to provide the

reader with a better understanding of these common

pediatric conditions and an improved ability to evalu-

ate and treat them. Early recognition increases the

likelihood of successful management of these defor-

mities. Many of the treatments that are most effective

in producing a normal, functional foot are best insti-

tuted before the child begins to walk. Thus it is un-

fortunate if referrals and consultations are not re-

quested until after children have begun to walk or after

several years with no improvement in the deformity.

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guidelines for evaluation of 5 common peds problems

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