Download - Pes plenovalgus dr zahid h malik
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Dr. Zahid H Malik
PG Y-5
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WARNING….
THERE ARE QUESTIONS AT THE
END OF THIS PRESENTATION
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OBJECTIVES
Anatomy
Definition
Imaging
Types
Presentation
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Tarsal Coalition & Peroneal Spastic Flatfoot
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Vid anat.
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Maintenance of the longitudinal arches
The longitudinal arches are supported and stabilisedby:
The muscles whose tendons run into the apex of the arches and tend to increase their height (e.g. tibialisanterior)
The muscles whose tendons run into the sole of the foot (e.g. peroneus longus tibialis post. and smallintrinsic muscles which also run longitudinally
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shape of the bones which allows them to interlock
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A variety of longitudinally arranged ligaments which prevent the extremities separating, for example the long and short plantar ligaments and by the plantar calcaneonavicular ("spring") ligament.
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The plantar aponeurosis links the extremities of the arches, and acts as the equivalent of a tie beam in an architectural arch.
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PES PLANUS AND PES VALGUS(‘FLAT-FOOT’)
The term ‘flatfoot’ applies when the apex of the arch has collapsed
and the medial border of the foot is in contact (or nearly in contact) with the ground;
the heel becomes valgus
and the foot pronates at the subtalar-midtarsal
complex.
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3 components that are involved in producing the alignment abnormalities of symptomatic adult flatfoot:
collapse of the longitudinal arch
hindfoot valgus
forefoot abduction
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Assesment of these components
Each of these components can be assessed on either the lateral or AP view of the foot.
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COLLAPSE OF LONGITUDINAL ARCHLateral: 1st metatarsal talar angle < 4Lateral: Calcaneal pitch 18 to 20°
FOREFOOT ABDUCTIONAP: Talonavicular coverage angleAP: 1st metatarsal talar angle
HINDFOOT VALGUSLateral: Talo-calcaneal angleAP: Talo-calcaneal angle
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Assesment of these components
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OTHER SIGNS
AP & Lateral: CYMA line
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Calcaneal pitch
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Lateral talar - 1st metatarsal angle
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MILD :greater than 4° convex downward is considered pes planus
with an angle of 15° - 30° considered moderate , and
greater than 30° severe
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conve
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Imaging
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AP Talar - 1st metatarsal angle
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Lateral Talocalcaneal Angle
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AP Talocalcaneal angle (Kite's angle)
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CYMA line
A cyma line is an architectural term designating the union of two curve lines.
A normal midtarsal joint should create a smooth cyma between the talonavicular joint and calcaneocuboidjoint on both the AP and lateral views (Figures a).
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Flexible Pes Planovalgus (Flexible Flatfoot)
Physiologic variant consisting of a decrease in the medial longitudinal arch and a valgus hindfoot and forefoot abduction with weightbearing
Epidemiologyincidence
unknown in pediatric population
20% to 25% in adults
Pathoanatomygeneralized ligamentous laxity is common
25% are associated with gastrocnemius-soleus contracture
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NATURAL HISTORY
The arch is usually obscured in an infant's foot because of subcutaneous fat.
Both footprint[26,39] and radiographic[42] studies of the child's foot demonstrate that the longitudinal arch develops during the first decade of life
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This observation also leads to the overwhelming conclusion that prophylactic treatment of a typical flatfoot is unnecessary, with profound implications for the corrective shoe and insert–orthosis .
Development of the arch is independent of the use of such external orthoses or the wearing of corrective shoes.
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PresentationSymptoms
usually asmptomatic in children
may have arch pain or pretibial pain
Physical exam
inspection
foot is only flat with standing and reconstitutes with toe walking, halluxdorsiflexion, or foot hanging
valgus hindfoot deformity
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recommended viewsrequired
weightbearing AP foot
evaluate for talar head coverage and talocalcaneal angle
weightbearing lateral foot
evaluate Meary's angle
weightbearing oblique foot
rule out tarsal coalition
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The arch can often be restored
by simply dorsiflexing the great toe
(Jack’s test), and
during this manoeuvre the tibia
rotates externally
(Rose et al., 1985).
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DifferentialTarsal coalition
Congenital vertical talus
Accessory navicular
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Treatment:Nonoperative
observation, stretching, shoewear modification, orthotics
indications
asymptomatic patients, as it almost always resolves spontaneously
counsel parents that arch will redevelop with age
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Techniques
athletic heels with soft arch support or stiff soles may be helpful for symptoms
UCBL heel cups may be indicated for symptomatic relief of advanced cases
rigid material can lead to poor tolerance
stretching for symptomatic patients with a tight heel cord
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Operativecontinued refractory pain despite use of extensive conservative managemen.
Achilles tendon or gastrocnemius fascia lengthening
If flexible flatfoot with a tight heelcord with painful symptoms
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calcaneal lengthening osteotomy
calcaneal lengthening osteotomy (Evans)
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sliding calcaneal osteotomy
corrects the hindfoot valgus
plantar base closing wedge osteotomy of the first cuneiform
corrects the supination deformity
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Tarsal Coalition & Peroneal Spastic Flatfoot
Congenital anomaly that leads to fusion of tarsal bonesand a rigid flatfoot results in syndrome peronealspastic flatfoot
most common coalitions are
calcaneonavicular Slide 13
most common
talocalcaneal
talonavicular
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Other formscalcaneocuboid,
naviculocuboid,
naviculocuneiform,
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The true incidence of tarsal coalition is greater than the
1% usually quoted.
Tarsal coalition appears to be inherited, probably as a unifactorial disorder of autosomal dominant .
The specific type of coalition probably represents a genetic mutation that is responsible for failure of the primitive mesenchyme to segment
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age of onsetcalcaneonavicular
8-12 years old
talocalcaneal12-15 years old
Pathophysiologymesenchymal segmentation leading to coalition of tarsal bones
coalition may befibrous
cartilagenous
osseous
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Associated conditions
multiple coalitions are associated with
fibular deficiency
Apert syndrome
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PresentationSymptoms
pain worsened by activity
onset of symptoms correlates with age of ossification of coalition
calf pain
secondary to peroneal spasticity
recurrent ankle sprains
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Physical examinspection & palpationpes planus
collapse of the medial longitudinal arch
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The medial border of the foot from just
behind the first metatarsal head to a point about 2 cm distal to the calcaneal tuberosity
should be elevated from the floor when the subject is standing.
The apex of this arch is usually about 1 cm.
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system for gradingJack described a general system for grading the morphology of the medial longitudinal arch.
grade I arch is subjectively slightly depressed
on weightbearing.
grade II arch, the entire medial
border of the foot touches the floor but its edge is
straight.
grade III arch, the entire medial border of
the foot not only touches the floor but also bulges toward
the examiner in a convex manner
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Physical exam
inspection
hindfoot valgus
forefoot abduction
range of motion
limited subtalar motion
heel cord contractures
arch of foot does not reconstitute upon toe-standing
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Peroneal spastic pes planus.Tarsal coalition, rigid pes planus, and peroneal muscle
spasm together as essential components of
Peroneal spasm actually is an acquired or adaptive shortening of the muscle-tendon units
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Stretch reflex of a shortened muscle-tendon unit
Inversion stress by the examiner, producing an unsustained three-four-beat clonus of the peronealmuscles,.
That peroneal muscle tight-ness is the frequent resultof tarsal coalition and not the cause
must be emphasized
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Peroneal muscle tightness is seen in
rheumatoid arthritis, osteochondral fracture,
and infection in the subtalar joint (tuberculous, mycotic, or pyogenic), or neo-plasm (osteoid osteoma, osteochondroma,
fibrosarcoma) adjacent to the subtalar joint in the talus or
calcaneus.
The relaxed position of the subtalar joint is valgus,
which places the least strain on the talocalcanealinterosseous
ligament according to Lapidus.
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ImagingRadiographs recommended views
Required
anteroposterior view
standing lateral foot view
45-degree oblique view
most useful for calcaneonavicular coalition
Slide 30
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calcaneonavicular coalition
"anteater" sign
elongated anterior process of calcaneus
talocalcaneal coalition
talar beaking on lateral radiograph
occurs as a result of limited motion of the subtalar joint
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Congenital talonavicular
tarsal coalition (anteroposterior,
lateral,
and oblique views).
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Calcaneonavicularincomplete tarsal coalition.
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CT scan
necessary to
rule-out additional coalitions
determine size and extent of coalition
MRI
may be helpful to visualize a fibrous or cartilagenouscoalition
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TreatmentNonoperative
observationasymptomatic cases
immobilization with casting or orthoticsinitial treatment for symptomatic cases
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Operative
surgical resection of coalition with interposition of fat graft or extensor digitorum brevis
resistant cases when nonoperative management fails to relieve symptoms
subtalar arthrodesis
triple arthrodesis (subtalar, calcaneocuboid, and talonavicular)
advanced coalitions that fail resection
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Resection of calcaneonavicular
tarsal coalition.
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Resection of middle facet tarsal coalition
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Self-locking wedge. B,Axis-altering
device. C,Impact-blocking device.
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Questions
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?
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What s this shows??
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Zahid H Malik
ve a nice day Thanks for your participation
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