Foot Disorders

Paediatric Foot Disorders

M G UGLOW M G UGLOW FRCS(Tr & Orth)FRCS(Tr & Orth)

Foot Disorders

METATARSUS

ADDUCTUS

Foot Disorders

METATARSUS

ADDUCTUS

1:1000 incidence1:1000 incidence

50% bilateral50% bilateral

Results from intrauterine positionResults from intrauterine position

Forefoot adducted at TMT joint, Forefoot adducted at TMT joint,

sole is kidney shaped, heel is NOT sole is kidney shaped, heel is NOT

equinusequinus

Foot Disorders

METATARSUS

ADDUCTUS

86% resolve spontaneously by age 86% resolve spontaneously by age

6, 95% by age 16.6, 95% by age 16.

1010--15% also have DDH15% also have DDH

Medial skin crease suggestive of Medial skin crease suggestive of

resistant caseresistant case

Foot Disorders

Metatarsus Adductus

Grading System Grade IGrade I

–– OvercorrectsOvercorrects

Grade IIGrade II

–– Corrects to neutralCorrects to neutral

Grade IIIGrade III

–– Does not correct to neutralDoes not correct to neutral

Foot Disorders

Metatarsus Adductus

Treatment

CorrectableCorrectable

–– No treatmentNo treatment

Not correctableNot correctable

–– Serial castingSerial casting

–– ?straight last shoes?straight last shoes

Not correctable and symptomaticNot correctable and symptomatic

–– ? Surgery? Surgery

Foot Disorders

Metatarsus Adductus

Long term results of patients with Long term results of patients with

mildmild--moderate residual deformity moderate residual deformity

after treatment are good.after treatment are good.

SURGERY indicated in children SURGERY indicated in children

>5yo with severe symptomatic >5yo with severe symptomatic

residual metatarsus adductus. residual metatarsus adductus.

Foot Disorders

Surgical treatment

Metatarsus Adductus

Medial opening cuneiform and Medial opening cuneiform and

lateral closing cuboid osteotomieslateral closing cuboid osteotomies

oror

Medial capsular release + Evans Medial capsular release + Evans

closing wedge calcaneal osteotomyclosing wedge calcaneal osteotomy

and/orand/or

Multiple metatarsal osteotomiesMultiple metatarsal osteotomies

Foot Disorders

Skewfoot

Combination of forefoot deformity Combination of forefoot deformity

of metatarsus adductus and of metatarsus adductus and

hindfoot deformity of flatfoothindfoot deformity of flatfoot

Tarsometatarsal adduction, Tarsometatarsal adduction,

talonavicular lateral subluxation, talonavicular lateral subluxation,

hindfoot valgushindfoot valgus

Foot Disorders

Skewfoot

RareRare

Aetiology unknown Aetiology unknown

–– ? iatrogenic? iatrogenic

–– ? muscle imbalance? muscle imbalance

–– often syndromaloften syndromal

Natural history unknown ? Natural history unknown ?

–– Little evidence of disabilityLittle evidence of disability

Foot Disorders

Skewfoot

XX--Rays:Rays:

–– Adduction & Plantarflexion at TMT Adduction & Plantarflexion at TMT

–– Navicular laterally placed and Navicular laterally placed and

abducted and dorsiflexedabducted and dorsiflexed

–– Increased AP talocalcaneal angleIncreased AP talocalcaneal angle

Foot Disorders

Skewfoot

Symptoms: Pain over talar head, Symptoms: Pain over talar head,

1st MT head, 5th MT base1st MT head, 5th MT base

Treatment in young children:Treatment in young children:

Serial casts as for metatarsus Serial casts as for metatarsus

adductus with varus stress on heeladductus with varus stress on heel

Aim to convert foot to flatfootAim to convert foot to flatfoot

–– Danger of increasing hindfoot valgusDanger of increasing hindfoot valgus

Foot Disorders

Skewfoot

Treatment in older children: Treatment in older children:

–– Difficult to treat Difficult to treat -- recurrence commonrecurrence common

NonNon--operative treatment not successfuloperative treatment not successful

–– Surgery demanding and may include:Surgery demanding and may include:

-- calcaneal wedge or sliding osteotomycalcaneal wedge or sliding osteotomy

-- cuboid opening and medial cuneiformcuboid opening and medial cuneiform

closing wedge osteotomiesclosing wedge osteotomies

-- metatarsal osteotomiesmetatarsal osteotomies

-- lengthening tendolengthening tendo--achillesachilles

Foot Disorders

PES CAVUS

Elevated longitudinal arch due to Elevated longitudinal arch due to

plantar flexion of the forefoot &/or plantar flexion of the forefoot &/or

dorsiflexion of the calcaneus.dorsiflexion of the calcaneus.

Secondary contracture of plantar Secondary contracture of plantar

fascia.fascia.

Claw toes Claw toes -- often the first deformity often the first deformity

seen.seen.

Foot Disorders

Cavus Foot - Aetiology

> 50% > 50% NeuromuscularNeuromuscular

Hereditary Motor Sensory Neuropathy (CMT)Hereditary Motor Sensory Neuropathy (CMT)

PoliomyelitisPoliomyelitis

Friedreich’s ataxiaFriedreich’s ataxia

Cerebral PalsyCerebral Palsy

Spina bifidaSpina bifida

Spinal cord tumourSpinal cord tumour

SyringomyeliaSyringomyelia

Foot Disorders

Cavus Foot - Aetiology

Non neurological causes include:Non neurological causes include:

–– IdiopathicIdiopathic

–– CTEV, ArthrogryposisCTEV, Arthrogryposis

–– TraumaticTraumatic

Compartment SyndromeCompartment Syndrome

Foot Disorders

Types of Pes Cavus

Simple Simple –– hindfoot neutral, forefoot balancedhindfoot neutral, forefoot balanced

CavovarusCavovarus–– hindfoot varus, forefoot plantar flexedhindfoot varus, forefoot plantar flexed

CalcaneusCalcaneus–– hindfoot calcaneus, forefoot fixed equinushindfoot calcaneus, forefoot fixed equinus

EquinocavusEquinocavus–– hindfoot equinus, forefoot equinus hindfoot equinus, forefoot equinus

Foot Disorders

Cavovarus

Plantarflexion of first rayPlantarflexion of first ray

Pronation of forefootPronation of forefoot

Adduction of forefootAdduction of forefoot

Hindfoot varusHindfoot varus

Toes clawedToes clawed

Foot Disorders

With a fixed plantarflexed first metatarsal for

the foot to be plantigrade when weight bearing

the heel must go into varus

Foot Disorders

Coleman Lateral Block Test

Assesses hindfoot flexibility of the Assesses hindfoot flexibility of the

cavovarus footcavovarus foot

Foot considered a tripod Foot considered a tripod

Lift placed under lateral aspect of Lift placed under lateral aspect of

foot and look for hindfoot correction foot and look for hindfoot correction

Foot Disorders

Calcaneocavus

Dorsiflexion of calcaneusDorsiflexion of calcaneus

Plantarflexion of forefootPlantarflexion of forefoot

Neurological causeNeurological cause: Polio, CP, : Polio, CP,

spina bifida, spinocerebellar spina bifida, spinocerebellar

degeneration etcdegeneration etc

Iatrogenic:Iatrogenic: overlengthening of overlengthening of

Achilles tendonAchilles tendon

Foot Disorders

Calcaneocavus

Foot Disorders

Simple Cavus

RareRare

If flexible If flexible -- midfoot releasemidfoot release

If rigid If rigid -- metatarsal or midfoot metatarsal or midfoot

osteotomy at apex of cavusosteotomy at apex of cavus

Foot Disorders

Cavus foot symptoms

ClawtoesClawtoes

MetatarsalgiaMetatarsalgia

High archHigh arch

Anterior ankle painAnterior ankle pain

Recurrent ankle sprainsRecurrent ankle sprains

Foot Disorders

Cavus Foot X-Rays

Cavovarus:Cavovarus:

–– First metatarsal plantarflexed relative First metatarsal plantarflexed relative

to axis of talus on standing lateral Xto axis of talus on standing lateral X--

RayRay

Calcaneocavus:Calcaneocavus:

–– Dorsiflexed calcaneusDorsiflexed calcaneus

Foot Disorders

Cavus Treatment

Full neurologic workFull neurologic work--up especially if up especially if

unilateralunilateral

–– Spinal XSpinal X--Rays Rays

–– MRIMRI

–– NCSNCS

Referral to neurologistReferral to neurologist

Foot Disorders

Cavovarus foot - treatment

NonNon--operative well moulded operative well moulded

orthosisorthosis

Surgery : Plantar release, dorsal Surgery : Plantar release, dorsal

cuneiform ostetomycuneiform ostetomy

–– Tendon tranfersTendon tranfers

–– Calcaneal osteotomyCalcaneal osteotomy

–– Ilizarov for multiply operated caseIlizarov for multiply operated case

Foot Disorders

Calcaneocavus foot - treatment

<5 years <5 years

–– tenodesis of tendoachilles to fibulatenodesis of tendoachilles to fibula

55--12 years12 years

–– Extraarticular subtalar arthrodesisExtraarticular subtalar arthrodesis

–– Plantar release +/Plantar release +/-- calcaneal osteotomycalcaneal osteotomy

+/+/-- tendon transfers (into calcaneus)tendon transfers (into calcaneus)

>12 years>12 years

–– Triple arthrodesisTriple arthrodesis

–– IlizarovIlizarov

Foot Disorders

Foot Disorders

Congenital Vertical Talus

Irreducible dorsal dislocation of Irreducible dorsal dislocation of

navicular on talus with a fixed navicular on talus with a fixed

talocalcaneal complex. Dislocation talocalcaneal complex. Dislocation

can be limited to talonavicular joint can be limited to talonavicular joint

or can also involve calcaneocuboid or can also involve calcaneocuboid

joint.joint.

Common cause of rigid flatfootCommon cause of rigid flatfoot

50% bilateral50% bilateral

Foot Disorders

Congenital Vertical Talus

Teratologic Teratologic -- most CVTmost CVT

–– Chromosomal abnormalitiesChromosomal abnormalities

–– ArthrogryposisArthrogryposis

–– MyelomeningocoeleMyelomeningocoele

NeurogenicNeurogenic

Iatrogenic Iatrogenic -- overcorrection CTEVovercorrection CTEV

Idiopathic Idiopathic -- rarerare

Foot Disorders

Congenital Vertical Talus

PATHOLOGY:PATHOLOGY:

Navicular dorsally dislocated, wedge shaped Navicular dorsally dislocated, wedge shaped

with hypoplastic plantar componentwith hypoplastic plantar component

Talar head flattened dorsally, only posterior 1/3 Talar head flattened dorsally, only posterior 1/3

of talar dome articulates with tibiaof talar dome articulates with tibia

Calcaneus plantar flexed and everted Calcaneus plantar flexed and everted

Hypoplastic sustentaculum taliHypoplastic sustentaculum tali

Peronei and tib post sublux anteriorly Peronei and tib post sublux anteriorly

becoming dorsiflexors becoming dorsiflexors

Foot Disorders

CVT

Differential diagnosis

Oblique talusOblique talus

Tarsal coalitionTarsal coalition

Calcaneovalgus footCalcaneovalgus foot

Posteromedial bowing of tibiaPosteromedial bowing of tibia

Idiopathic pes planusIdiopathic pes planus

Paralytic pes valgusParalytic pes valgus

Foot Disorders

CONGENITAL VERTICAL

TALUS

Foot Disorders

CVT - RADIOLOGY

AP XAP X--Rays show increased talocalcaneal Rays show increased talocalcaneal

angle & forefoot abductionangle & forefoot abduction

Plantarflexed lateral XPlantarflexed lateral X--Ray:Ray:

Fixed forefoot dorsal dislocationFixed forefoot dorsal dislocation

Dorsiflexed lateral XDorsiflexed lateral X--Ray:Ray:

Fixed equinus of hindfootFixed equinus of hindfoot

Foot Disorders

NORMAL OBLIQUE TALUS VERTICAL TALUS

Foot Disorders

CVT TREATMENT

NonNon--operative initially operative initially -- stretchingstretching

-- serial castingserial casting

plantarflexion/inversionplantarflexion/inversion

stretch soft tissues in stretch soft tissues in

preparation preparation

for surgeryfor surgery

Foot Disorders

CVT - SURGERY

Surgery is aimed at correcting Surgery is aimed at correcting

hindfoot equinus and forefoot hindfoot equinus and forefoot

dorsiflexion and abductiondorsiflexion and abduction

Correction of hindfoot is the Correction of hindfoot is the

primary step in correction of the primary step in correction of the

footfoot

Foot Disorders

CVT : Surgery

LengthenLengthen–– AchillesAchilles

–– PeronealPeroneal

–– Tibialis AnteriorTibialis Anterior

–– Toe ExtensorsToe Extensors

ReleaseRelease–– Posterior anklePosterior ankle

–– Posterior subtalarPosterior subtalar

–– CalcaneocuboidCalcaneocuboid

–– TalonavicularTalonavicular

PlicatePlicate–– Tibialis PosteriorTibialis Posterior

–– Talonavicular capsuleTalonavicular capsule

Reduce & pin jointsReduce & pin joints

–– SSubtalarubtalar

–– Talonavicular Talonavicular

–– +/+/-- CalcaneocuboidCalcaneocuboid

Foot Disorders

CVT TREATMENT

Recurrent deformity corrected through Recurrent deformity corrected through

revision STR between 2revision STR between 2--6yo.6yo.

Late treatment:Late treatment:

STR + navicular excisionSTR + navicular excision

Subtalar arthrodesis 2Subtalar arthrodesis 211//22--6yr6yr

Triple arthrodesis >6yrTriple arthrodesis >6yr

Foot Disorders

OBLIQUE TALUS

Talonavicular subluxation that reduces Talonavicular subluxation that reduces

with plantar flexion of the foot.with plantar flexion of the foot.

Treatment Treatment -- observationobservation

-- UCBL insertUCBL insert

-- pinning reduced pinning reduced

talonaviculartalonavicular

joint & tendoachilles joint & tendoachilles

lengtheninglengthening

Foot Disorders

TARSAL COALITION

Disorder of mesenchymal Disorder of mesenchymal

segmentation leading to fusion of 2 segmentation leading to fusion of 2

or more tarsal bonesor more tarsal bones

Autosomal dominant with variable Autosomal dominant with variable

penetrancepenetrance

3% of population3% of population

50% bilateral50% bilateral

90% calcaneonavicular or 90% calcaneonavicular or

talocalcanealtalocalcaneal

Foot Disorders

TARSAL COALITION

May be bony, cartilaginous or fibrousMay be bony, cartilaginous or fibrous

Multiple coalitions may exist in same Multiple coalitions may exist in same

footfoot

Leading cause of peroneal spastic Leading cause of peroneal spastic

flatfootflatfoot

Foot Disorders

TARSAL COALITION

Become symptomatic when coalition Become symptomatic when coalition

ossifies:ossifies:

Hindfoot pain aggravated by activity. Hindfoot pain aggravated by activity.

Ankle sprainsAnkle sprains

Stiff subtalar jointStiff subtalar joint

Medial or lateral tendernessMedial or lateral tenderness

Peroneal spastic flatfoot Peroneal spastic flatfoot

TALONAVICULAR 3-5yo

CALCANEONAVICULAR 8-12yo

TALONAVICULAR 12-16yo

Foot Disorders

TARSAL COALITION

XX--Rays: Oblique Rays: Oblique -- calcaneonavicularcalcaneonavicular

Lateral Lateral -- “Anteater” sign“Anteater” sign

(elongated ant (elongated ant

process calc) process calc)

-- Talar beakingTalar beaking

-- Narrowed posterior Narrowed posterior

subtalar jtsubtalar jt

Harris axial view Harris axial view -- irreg middle irreg middle

facetfacet

CT Scan CT Scan -- talocalcaneal coalitiontalocalcaneal coalition

Foot Disorders

CALCANEO-

NAVICULAR

BAR

ANTEATER’S

NOSE

Foot Disorders

TALONAVICULAR

COALITION

Foot Disorders

TARSAL COALITION

Asymptomatic Asymptomatic -- observationobservation

Symptomatic:Symptomatic:

NONNON--OPERATIVE OPERATIVE -- activity modificationactivity modification

-- orthoticsorthotics

-- short leg walking castshort leg walking cast

OPERATIVEOPERATIVE

Calcaneonavicular Calcaneonavicular -- excision & EDB excision & EDB

interpositioninterposition

Talocalcaneal Talocalcaneal -- adolescent with <50% of adolescent with <50% of

facet involvedfacet involved

resectionresection

-- subtalar OA subtalar subtalar OA subtalar

Foot Disorders

CALCANEOVALGUS

FOOT 1:1000 live births1:1000 live births

Intrauterine PositioningIntrauterine Positioning

Associated with lateral tibial torsionAssociated with lateral tibial torsion

Common in first bornCommon in first born

Dorsiflexion/eversion/abductionDorsiflexion/eversion/abduction

Passively correctablePassively correctable

Resolves spontaneously Resolves spontaneously -- passive passive

stretches & splints may be usedstretches & splints may be used

Foot Disorders

CALCANEOVALGUS

FOOT DDx

Neurologic dysfunction eg Neurologic dysfunction eg

myelomeningocoele)myelomeningocoele)

Congenital Vertical TalusCongenital Vertical Talus

-- stiff & equinusstiff & equinus

-- lat stress Xlat stress X--RaysRays

Posteromedial bowing of tibiaPosteromedial bowing of tibia

Foot Disorders

JUVENILE BUNION

Bilateral, familial, more common in femalesBilateral, familial, more common in females

Aetiology: Imbalance of forcesAetiology: Imbalance of forces

Predisposing factors:Predisposing factors:

Metatarsus primus varusMetatarsus primus varus

Oblique 1st MTOblique 1st MT--medial cuneiform jtmedial cuneiform jt

Long 1st MTLong 1st MT

Ligamentous laxityLigamentous laxity

Hypermobile first rayHypermobile first ray

Forefoot pronationForefoot pronation

Heel cord contractureHeel cord contracture

Neurologic disordersNeurologic disorders

Shoewear with narrow toeShoewear with narrow toe--boxbox

Foot Disorders

JUVENILE BUNION

XX--Rays (AP & Lat Rays (AP & Lat

Standing):Standing):

Intermetatarsal angle (N Intermetatarsal angle (N

<=9<=900))

Hallux valgus angle Hallux valgus angle

(N<=16(N<=1600))

Distal metatarsal articular Distal metatarsal articular

angle (N<=15angle (N<=1500))

Proximal phalangeal Proximal phalangeal

articular angle (N<=5articular angle (N<=500))

First TMT jt alignmentFirst TMT jt alignment

Length of 1st MTLength of 1st MT

Foot Disorders

JUVENILE BUNION Most asymptomatic & require no Most asymptomatic & require no

treatmenttreatment

NonNon--operative treatment: wide shoes operative treatment: wide shoes

and arch supportand arch support

Surgical treatment Surgical treatment -- progression of progression of

deformity or failed nondeformity or failed non--op txop tx

SOFT TISSUE CORRECTION

OSTEOTOMY - metatarsal

- phalangeal

- cuneiform

ARTHRODESIS

Foot Disorders

JUVENILE BUNION

ComplicationsComplications

* OVERCORRECTION/HALLUX VARUS

* RECURRENCE 20% (soft tissue only >50%)

- inversely related to age

REOPERATE AFTER SKELETAL MAT

* PHYSEAL INJURY - rare

* AVN - rare

* STIFFNESS

* DEFUNCTIONING 1ST RAY

Foot Disorders

BUNIONETT

E Lateral prominence Lateral prominence

of 5th MT headof 5th MT head

Usually unilateralUsually unilateral

Irritated by shoewearIrritated by shoewear

Treatment:Treatment:

NonNon--operative operative --

shoewearshoewear

modificationmodification

Operative Operative --

exostectomyexostectomy

Foot Disorders

Flexible Flatfoot

Flattening of the Flattening of the

medial longitudinal medial longitudinal

arch on standingarch on standing

Heel valgus, forefoot Heel valgus, forefoot

pronation and pronation and

abduction.abduction.

Prominent talar head Prominent talar head

medially.medially.

7%7%--22% prevalence22% prevalence

Bilateral and familialBilateral and familial

Associated with Associated with

ligamentous laxity ligamentous laxity

and limb alignment and limb alignment

problemsproblems

Foot Disorders

Flexible Flatfoot

XX--RaysRays::

–– AP/lat/oblique standing + plantar flexed lateral:AP/lat/oblique standing + plantar flexed lateral:

Increased talar plantarflexion Increased talar plantarflexion

(talar(talar--1st MT angle >01st MT angle >000))

Foot Disorders

Flexible Flatfoot

Increased talocalcanealIncreased talocalcaneal

angle (20angle (20--404000 norm) norm)

Abduction of forefootAbduction of forefoot

with navicular subluxationwith navicular subluxation

Foot Disorders

Flexible Flatfoot

Symptoms: midfoot ache, pretibial pain, Symptoms: midfoot ache, pretibial pain,

excessive shoe wear. Pain and callosity excessive shoe wear. Pain and callosity

over talar head.over talar head.

Longitudinal arch develops spontaneously Longitudinal arch develops spontaneously

during first decade and most flatfooted during first decade and most flatfooted

adults are asymptomatic.adults are asymptomatic.

Foot Disorders

Flexible Flatfoot

No treatment if asymptomaticNo treatment if asymptomatic

If symptomatic If symptomatic

–– Arch orthosis/UCBL insertsArch orthosis/UCBL inserts

–– Achilles tendon stretches if tightAchilles tendon stretches if tight

If refractory If refractory

–– wedge or sliding calcaneal osteotomy wedge or sliding calcaneal osteotomy

–– +/+/-- Achilles tendon lengtheningAchilles tendon lengthening

Foot Disorders

KOHLER’S DISEASE

AVN of navicular due to repetitive AVN of navicular due to repetitive

compressive forcescompressive forces

Males (5:1) Males (5:1)

4 4 -- 5 yo5 yo

Bilateral in 1/3Bilateral in 1/3

Self limitingSelf limiting

XX--Ray Ray -- flattening, sclerosis, irregularity of flattening, sclerosis, irregularity of

navicularnavicular

Foot Disorders

KOHLER’S DISEASE

May be asymptomaticMay be asymptomatic

Present with pain over navicular, Present with pain over navicular,

antalgic gait, weight bearing on lateral antalgic gait, weight bearing on lateral

aspect of footaspect of foot

Treat with decreased activity, soft arch Treat with decreased activity, soft arch

support, inner heel wedge, Thomas heel support, inner heel wedge, Thomas heel

+/+/-- immobilisationimmobilisation

Prognosis excellentPrognosis excellent

Foot Disorders

FREIBERG’S INFRACTION

AVN usually of 2nd MT head (other MTs AVN usually of 2nd MT head (other MTs

may be affected) due to vascular may be affected) due to vascular

insufficiency 2insufficiency 200 to chronic stress to chronic stress

Adolescents; female 75%Adolescents; female 75%

Occasionally bilateralOccasionally bilateral

XX--Ray: MT head flattening Ray: MT head flattening

and irregularityand irregularity

Foot Disorders

FREIBERG’S INFRACTION

Metatarsalgia, mild swelling and Metatarsalgia, mild swelling and

stiffnessstiffness

Treatment: nonTreatment: non--operative operative -- walking walking

castcast

--

metatarsal padmetatarsal pad

operative operative -- curettage & curettage &

bone graftbone graft

-- shortening MTshortening MT

Foot Disorders

SEVER’S DISEASE

Traction apophysitis at insertion of Traction apophysitis at insertion of

Achilles tendonAchilles tendon

Heel pain & tenderness, aggravated by Heel pain & tenderness, aggravated by

activity & relieved by restactivity & relieved by rest

Decreased ankle dorsiflexionDecreased ankle dorsiflexion

Normal XNormal X--Rays Rays -- sclerosis and sclerosis and

fragmentation of calcaneal apophysis fragmentation of calcaneal apophysis

normal variantnormal variant

Treatment: Activity modification, rest, Treatment: Activity modification, rest,

Foot Disorders

ACCESSORY NAVICULAR

Normal variant seen in 4Normal variant seen in 4--21%21%

Often incidental discovery Often incidental discovery

Associated with flatfeetAssociated with flatfeet

Medial arch pain with overuse Medial arch pain with overuse

centred over navicular.centred over navicular.

External oblique XExternal oblique X--Ray view Ray view

demonstratesdemonstrates

Foot Disorders

ACCESSORY NAVICULAR

TYPE I TYPE I -- os tibiale externumos tibiale externum (sesamoid (sesamoid

inin

tib post). Asymptomatic.tib post). Asymptomatic.

TYPE II TYPE II -- synchondosissynchondosis. (70% of acc . (70% of acc

navic)navic)

Triangular up to 12mm Triangular up to 12mm

diameter,diameter,

tib post inserts into it. May tib post inserts into it. May

be be

symptomatic.symptomatic.

Foot Disorders

Foot Disorders

ACCESSORY NAVICULAR

Treated with restriction of activities Treated with restriction of activities

+/+/-- immobilisation in short leg cast, immobilisation in short leg cast,

then shoe modification/padding then shoe modification/padding

Excision relieves pain but does not Excision relieves pain but does not

correct flatfootcorrect flatfoot

Foot Disorders

CURLY TOE

“Underlapping toe”. “Underlapping toe”.

Flexion deformity of Flexion deformity of

PIP jt with external PIP jt with external

rotation and varus of rotation and varus of

the toe.the toe.

Usually occurs in Usually occurs in

lateral 3 toeslateral 3 toes

Familial, bilateral, Familial, bilateral,

symmetrical, rarely symmetrical, rarely

symptomaticsymptomatic

Congenitally short FDB Congenitally short FDB

& FDL without joint & FDL without joint

contracture initiallycontracture initially

Foot Disorders

CURLY TOE

25% resolve spontaneously. Remainder 25% resolve spontaneously. Remainder

don’t worsen with growth but may don’t worsen with growth but may

develop symptoms and become stiff.develop symptoms and become stiff.

Treatment if symptomatic or if severe Treatment if symptomatic or if severe --

flexor tenotomyflexor tenotomy (FDL +/(FDL +/-- FDB) at 3yoFDB) at 3yo

-- immediate improvement in alignmentimmediate improvement in alignment

-- further correction with growthfurther correction with growth

-- flexor function invariably returnsflexor function invariably returns

Late treatment Late treatment -- resection or arthrodesis resection or arthrodesis

of PIP joint may be necessary for of PIP joint may be necessary for

correctioncorrection

Foot Disorders

OVERLAPPING

FIFTH TOE

Familial, bilateral & asymptomatic Familial, bilateral & asymptomatic

Fifth toe adducted, extended & externally Fifth toe adducted, extended & externally

rotated at MTP jt & overlaps fourth toerotated at MTP jt & overlaps fourth toe

May cause footwear problemsMay cause footwear problems

Contracture of dorsal medial MTP capsule & Contracture of dorsal medial MTP capsule &

extensor tendon extensor tendon

NonNon--operative tx: stretching & buddy tapingoperative tx: stretching & buddy taping

Operative Operative -- tenotomy, dorsal capsulotomy & tenotomy, dorsal capsulotomy &

VV--Y advancementY advancement

Foot Disorders

CONGENITAL HALLUX

VARUS

“Atavistic Great Toe”“Atavistic Great Toe”

Great toe adduction deformity often Great toe adduction deformity often

associated with supernumerary associated with supernumerary

toestoes

Deformity at MTP joint with thick Deformity at MTP joint with thick

short first MT and firm band short first MT and firm band

(abductor hallucis)(abductor hallucis)

Surgical release Surgical release

Foot Disorders

OLIGODACTYLY

Congenital absence of toe(s)Congenital absence of toe(s)

Requires no treatmentRequires no treatment

Associated with fibular hemimelia Associated with fibular hemimelia

and tarsal coalitionand tarsal coalition

Foot Disorders

TOE POLYDACTYLY

Extra digits Extra digits -- preaxial, central or preaxial, central or

postaxialpostaxial

Incidence 2:1000Incidence 2:1000

Usually involves lateral ray (80%)Usually involves lateral ray (80%)

May be inherited (30%) (AD)May be inherited (30%) (AD)

25% bilateral25% bilateral

Associated with finger polydactyly & Associated with finger polydactyly &

metatarsal anomaliesmetatarsal anomalies

Preaxial deformities assoc with Preaxial deformities assoc with

longitudinal epiphyseal bracket of 1st longitudinal epiphyseal bracket of 1st

Foot Disorders

TOE POLYDACTYLY

Rudimentary digits treated by ligation in Rudimentary digits treated by ligation in

nursery and allowing “autoamputation”nursery and allowing “autoamputation”

Surgical excision of digit at 9Surgical excision of digit at 9--12 12

months:months:

-- save digit with best axial alignmentsave digit with best axial alignment

-- repair capsule & balance soft tissuesrepair capsule & balance soft tissues

-- shave MT prominencesshave MT prominences

-- central physolysis for longitudinal central physolysis for longitudinal

bracketbracket

Foot Disorders

TOE SYNDACTYLY

Fusion of adjacent toes (2ndFusion of adjacent toes (2nd--3rd)3rd)

Familial & asymptomaticFamilial & asymptomatic

Simple or ComplexSimple or Complex

Complete or partialComplete or partial

Simple does not require treatmentSimple does not require treatment

Complex treated as for fingers at Complex treated as for fingers at

18mths 18mths -- 5yrs.5yrs.

Foot Disorders

POLYSYNDACTYLY

Duplication of fifth toe with syndactyly Duplication of fifth toe with syndactyly

between the duplicated toes. These between the duplicated toes. These

may in turn be syndactylised to 4th toe.may in turn be syndactylised to 4th toe.

Treated usually by excision of lateral 5th Treated usually by excision of lateral 5th

toe toe

Excision of medial 5th toe if there is Excision of medial 5th toe if there is

syndactyly to fourth, or better contour is syndactyly to fourth, or better contour is

achieved.achieved.

Foot Disorders

MACRODACTYLY Increase in the size of the Increase in the size of the

constituent elements of a digit constituent elements of a digit --

bone, tendons, nerves, vessels, bone, tendons, nerves, vessels,

fat, skin enlarged.fat, skin enlarged.

Aetiology usually unknown but Aetiology usually unknown but

may be assoc with may be assoc with

neurofibromatosis, neurofibromatosis,

haemangioma, lymphangiomahaemangioma, lymphangioma

Treatment Treatment -- resection of soft resection of soft

tissuestissues

Foot Disorders

HAMMER

CLAW

MALLET

Foot Disorders

HAMMER TOE

Flexion deformity at PIP jt with Flexion deformity at PIP jt with

hyperextension at DIP jt +/hyperextension at DIP jt +/-- secondary secondary

hyperextension at MTP jt.hyperextension at MTP jt.

Flexor tightnessFlexor tightness

Bilateral, symmetrical, commonly 2nd toe.Bilateral, symmetrical, commonly 2nd toe.

Asymptomatic early Asymptomatic early -- later painful corn, later painful corn,

stiffnessstiffness

Treatment flexor tenotomy in early childhood Treatment flexor tenotomy in early childhood

Fixed deformity Fixed deformity -- release of MTP + extensor release of MTP + extensor

tenotomy +/tenotomy +/-- Girdlestone & resection Girdlestone & resection

Foot Disorders

CLAW TOE

Flexion deformity at PIP and DIP jts with Flexion deformity at PIP and DIP jts with

hyperextension at MTP jthyperextension at MTP jt

Usually all 4 lesser toes involvedUsually all 4 lesser toes involved

Usually assoc with pes cavus but can Usually assoc with pes cavus but can

be idiopathicbe idiopathic

Result of imbalance between intrinsics Result of imbalance between intrinsics

and extrinsicsand extrinsics

Often asymptomatic.Often asymptomatic.

Symptoms Symptoms -- metatarsalgia, painful metatarsalgia, painful

corns over PIP jtscorns over PIP jts

Foot Disorders

CLAW TOE

Treatment:Treatment:

NonNon--operative operative -- shoewear modification shoewear modification

(deep toe box, soft shoes), metatarsal (deep toe box, soft shoes), metatarsal

barbar

Operative Operative -- MTP dorsal capsulotomy + MTP dorsal capsulotomy +

extensor tenotomy + Girdlestone flexor extensor tenotomy + Girdlestone flexor

to extensor transferto extensor transfer

If deformity fixed If deformity fixed -- excision arthroplasty excision arthroplasty

or arthrodesis PIP jtor arthrodesis PIP jt

In CMT In CMT -- transfer EDL to MT necks + transfer EDL to MT necks +

fuse PIPsfuse PIPs

Foot Disorders

MALLET TOE

Flexion deformity at DIP jtFlexion deformity at DIP jt

Aetiology: FDL shorteningAetiology: FDL shortening

Commonly 2nd toeCommonly 2nd toe

Assoc with long 2nd MTAssoc with long 2nd MT

Symptoms from dorsal corn or toenail Symptoms from dorsal corn or toenail

irritationirritation

Treatment: young child Treatment: young child -- FDL tenotomy FDL tenotomy

fixed deformity fixed deformity -- excision excision

arthroplasty orarthroplasty or

Foot Disorders

SUBUNGUAL

EXOSTOSIS Benign bone tumour occurring on distal Benign bone tumour occurring on distal

phalanx of a digit beneath or adjacent to the phalanx of a digit beneath or adjacent to the

nail.nail.

Commonest in great toe. Usually on medial Commonest in great toe. Usually on medial

side of dorsum of phalanx. side of dorsum of phalanx.

Histologically similar to osteochondroma but Histologically similar to osteochondroma but

not adjacent to physis not adjacent to physis

May be painful & cause nail deformityMay be painful & cause nail deformity

Unknown aetiology ? traumaUnknown aetiology ? trauma

Treatment excision & nail bed repair.Treatment excision & nail bed repair.

10% recurrence 10% recurrence