Flatfoot in children

Flat foot in children

Introduction

Flatfoot is a term cosmetically applicable to all the feet which have a decreased or absent arch on weightbearing. Foot arch is present because of normal bony alignment with proper soft tissue tension.  We must remember that dynamic flexibility of foot is more important than static posture of foot. Presence of flatfoot should not be taken as abnormal in most cases. It can be considered a variant of foot just like straight hairs and curly hairs. It does not mean all newborns must have an arch at birth. A normal arch is expected to develop spontaneously by age of 5-7 yrs, hence a flatfoot in toddlers can be normal. It is due to ligamentous laxity and fatpad in sole, as they mature and walk, arch develops slowly in most cases. Many of these children who have flatfoot also have similarly affected parents. In fact most of the parents with flatfoot are leading a comfortable and healthy life without any intervention. It suggests to us the benign nature of Flexible flatfoot.

 How do we then know when its not normal and when to initiate treatment? Lets have a closer look.

Types

A flatfoot can be rigid or a flexible one depending upon mobility or on the presence of fixed deformity. Two simple tests which can be performed are : Jack's test and Heel rise test.

In Flexible flatfoot  arch disappears when foot is on ground but reappears when foot is off the ground. Arch also can be noted on extension of great toe (Jack test). In the rigid types it remains unchanged and symptomatic in most cases. When asked to stand on toes we can notice appearance of arch and heel inversion in flexible flatfoot. Rigid flatfoot which remain unaltered in any position are seen in tarsal coalitions, neglected vertical talus and syndromic cases like arthrogryposis.
Single leg rise test helps identify Tibialis posterior insufficiency. In this we ask the child to stand on affected leg and try to rise the heel.
Heel cord shortening can be assessed by asking the child to squat or heel walk.
Any excessive joint laxity, obesity, pain, swelling, angular or torsional deformities in lower limb is be noted.
Sensory and motor examination helps rule out neurogenic cause.

Pic: 1a, Flexible flatfoot: note the normal arch appears on non-weight bearing

Pic: 1b, Flexible flatfoot: Jack's test- Arch seen better on extension of great toe

Pic: 1c, Flexible flatfoot: Arch depressed on weight bearing

Check for joint laxity by trying to touch thumb to forearm

Xrays shows evidence of Acessory Navicular

Intraoperative pic showing Tip post rendon rupture with mucinous changes along its track

Intraop pic showing torn Tip post with fibrillation changes

Pic: 2a Flexible planovalgus : Symptomatic on Right side

Pic: 2b On standing: More toes seen on the outerside of right leg , note the heel lateral angulation. She had a painful right foot with progression of deformity.

Pic:2c On Heel rise: note the number of toes seen outside are less and heel line deviates medially

Pathology

As the arch decreases the normal tripod gait alters. There is attenuation of medial side structures like Talonavicular joint capsule, spring ligament and tibialis posterior. Posteriorly the Achillis tendon gets shortened, laterally peroneous brevis becomes more spastic and contracted. The heel cord instead of pulling in axis of ankle joint pulls laterally, so ankle dorsiflexion happens at subtalar joint instead of ankle. This leads to stress trasfer at midfoot joints, hence pain. Laterally impingement occurs and talus tilts medially and plantarflexes. As the heel goes in valgus forefoot is supinated, with time they become rigid and progressive. Altered mechanics leads to pain and progression with cyclical loading. In congenital vertical talus the medial border is convex and talus head can be palpated facing directly down. In Tarsal coalitions(Pic:3) these deformity are fixed and rigid, but they become symptomatic around 8-12years as compensatory foot flexibility reduces. The common tarsal coalitions are between talus and calcaneum followed by calcaneonavicular (Pic:3a, 3b) one.

In tibialis posterior insufficiency it starts as a simple tenosynovitis of Tip post tendon followed by tendinosis, tears and progression of deformity.

Xrays of a weight bearing foot are necessary. CT and MRI also help to localize the extent of lesion and aid in preoperative planning.

Xrays foot showing calcaneonavicular coliation

Lateral Xray showing Talocalcaneal colaition with beaking of anterior talus

Pic: 3a MRI:Calcaneonavicular coliation Axial cut

MRI: showing tenosynovistis of Tip post tendon

Pic: 3b MRI: Saggital cut Calcaneonavicular bar

Management

All flatfoot do not necessarily need treatment. These points listed below are RED FLAGS and need further referral to a specialist. Remember flatfoot don't need surgery for cosmetic reasons.

• Pain
• Progressive deformity
• Unilateral
• Frequent abnormal shoe wearoff

These symptoms should prompt for further Investigations and consultation with a specialist. Asymptomatic flexible flatfoot do not need any treatment. Symptomatic Flexible flatfoot can be managed initially by calf stretching, strengthening, arch supports and customized orthoses. Any type of shoes or orthotic devices will not restore the arch, no matter how long we use it. They are only supportive measures to maintain the arch either before or after surgery. Rigid flatfoot most of the times need surgical intervention for correction. Tendoachillis gets shorter with progressive deformity.

Symptomatic flexible flatfoot with heelcord shortening must be treated by stretching and UCBLs.
Those flatfoot who remain symptomatic or worsen even after 6 months period of conservative treatment methods are ideal candidates for corrective surgery.

Goal of surgical correction is to reduce the pain, realign the foot, improve range of motion and function.

Surgical correction is achieved by a combination of one of the following:

• Soft tissue procedures - Heel cord lengthening, Tendon transfer, Medial imbrication
• Arthroreisis - Blocking the ankle eversion by putting implant or bone at Subtalar joint
• Bony reconstrution - Calcaneal tuberosity slide osteotomy, Lateral calcaneal neck lengethening osteotomy, Cuneiform plantarflexion osteotomy, cuboid opening wedge osteotomy.\
• Arthrodesis - Salvage procedures like subtalat or triple fusion

In Tibialis posterior insufficiency stage I casting and debridement can be done. Stage II needs debridement and transfer of one of the foot flexors  with calcaneal osteotomy and heelcord lengethening. Stage III and IV needs fusion as salvage procedure.

Here in Pic: 2a-c an example of Flexible flatfoot is shown, she is symptomatic on right side, hence she was put on medial arch support for 6 months. She complained of worsening of pain hence surgical reconstruction was planned.

She underwent Calcaneal lengethening with , peroneus brevis Z lengthening, gastronemius recession and medial plication. Pic: 4a, 4b shows her foot after 6 weeks post correction. She has a significantly improved arch, the heel line from behind is straight and toes are no more seen from behind.Pic:4c shows her postop xrays.
Postoperatively after 6 weeks it is recommended to use arch support shoes and start gradual weight bearing. The plate needs removal after 6-12 months, if soft tissue irritation causes pain (Pic:4c).

Pic:4a Correction achieved after 6 weeks of surgery, arch improved

Pic:4b Note the heel appears better, plz compare with Pic: 2b 

Pic:4c Post op 6 weeks after calcaneal lengetheing

Pic: 4c

HAPPY FEET!

Trigger thumb

CONGENITAL TRIGGER THUMB

Introduction

It is tenosynovitis of flexor pollicis longus with stenosis at A1 pulley. It simply means the tendon meant for bending the thumb is swollen and finds itself difficult to glide in its tunnel because of a smaller tunnel entry. Though this condition is congenital but usually diagnosed later. It must be differentiated from contractures in Arthrogyrposis and spastic thumb in Cerebral palsy.

Its incidence is 2-3 for every 1000 births. It presents as a bent thumb which sometimes becomes straight when forced but with a sudden release. A small swelling can be noted ocasionally at the base of thumb which is called Notta nodule. It is due to ganglion or cyst formation along the tendon near the metacarpal neck. It is also seen bilaterally in many cases.

Natural history

 Most cases get resolved spontaneously with age. If the triggering doesn't resolve by 3years or if thumb is not extending then surgical intervention is necessary to prevent permanent deformity.

Diagnosis

Clinical examination is sufficient for a diagnosis. Presentation gets delayed till child is 6months to 1 year.

Management

Initially stretching might help but if it fails to resolve then surgery is gold standard. If not corrected by the age of 3 years spontaneous resolution is not expected to happen. The procedure involves release of A1 pulley. There is no evidence that meddling with the nodule or cyst helps. Care must be taken to protect digital nerves to thumb especially the radial one. Sometimes a hyperextension develops after a late release, in such cases proximal advancement of volar plate at PIP joint with A1 pulley release works well.

Attitude of left trigger thumb 

Normal right thumb can extend fully

On manipulation also left thumb fails to straighten out preoperatively 

Notta's nodule seen near base of thumb intraoperatively 

Intraoperative video showing smooth gliding of tendon after A1 pulley release

Surgical scar after 3 months of release and free thumb extension

Cerebral palsy

Cerebral palsy

It is a upper motor neuron disorder due to hypoxic or ischemic injury to the brain of a child during pregnancy or delivery or postnatal period. It results in altered tone in limbs. Early signs include delayed milestones, abnormal posture and gait. As child grows, spastic muscle tendon units fail to catchup with bone growth. So as age advances especially, during periods of rapid growth there can be a deterioration in ambulatory status due to contractures. 

Most of my patients are brought by parents who are aware of the name of the problem but don't know its implications. They continue to think that there is an issue with the upper limb or legs. I always make them understand that the real problem is, in the damaged brain which sends disturbed signals to hands and legs, which result in abnormal posture and gait. Joints and muscles are basically normal, its culprit is the damaged area in brain which controls them. Now that does not mean whole of the brain is damaged. Our brain is magnificently divided in such a way that each of the different part of brain  controls a specific organ or a part or a function. For this reason we may see many variations in presentation of our patients, depending on the part of brain involved.

The numerous causes of this condition are described in literature, a few important ones are mentioned below:

•  Prenatal (75% cases) 

  Maternal infection during pregnancy ex: CMV, rubella
  Cerebral ischemia
  Maternal drug intake
  Congenital cerebral malformation or abnormalities
  Pre-eclampsiais a risk factor

• Perinatal (6 - 8% cases)

  Cord prolapse
  Obstructed labour
  Abruptio placenta
  Meconium staining of amniotic fluid

• Postnatal (10-18%cases)

  Jaundice
  Hypoglycemia
  Neonatal infection ex: meningitis, septicemia

  CP has been classified based on the extent of body involvement, tone, functional and ambulatory capacity. 

  Physiotherapy for keeping the joints free and mobile is mainstay during growth period.  Pharmacological therapy for muscle relaxation to reduce tone may be necessary. When there is a dynamic deformity Botox, casts and stretching might help. However once muscle groups become contracted our physiotherapy, botox and casts may not work efficiently. In severe cases selective posterior rhizotomy may become desirable.  Simultaneously bowel and bladder, speech, intellectual level, oromotor function, hearing, occupation, needs assessment and training to improve it.

  Muscle relaxants are generally used to decrease tone. Baclofen is commonly preferred.

  Botox injections reduce spasticity and effects are temporary and reversible. No major side effects are noted with it and is FDA approved. It must be realized that it is not an isolated treatment and must be integrated with proper rehabilitation. The effect kicks in about 2 weeks after injection and lasts for 3-6 months.

  Doses are again based on weight of the child and muscle group it is intended to be used on. 10 IU/kg per setting is maximum dose to be given. Larger muscles especially biarticular ones in lower limb need 3-6 IU/kg whereas for small muscles of arm and forearm, 1-2 IU/kg may suffice. Botox is available in a freeze dried vial, which needs normal saline for reconstitution. In India vials are available in 200, 100 and 50 IU dose. The site of injection is determined by a qualified physician either clinically, EMG or by ultrasound guidance. Paracetamol or topical local anaesthetic cream if given before botox injection may help reduce the pain after the procedure.

  Soft tissue surgery is key once contractures develop. In olden days single level surgery used to create imbalance as problems in other joints were not dealt with simultaneously. Present trend is to do a single time multilevel surgery (SEMLS), right from hips to ankles that will allow them to balance efficiently. It is necessary to have a video gait analysis done before surgery for better understanding of complex gait patterns.

  They include Psoas lengethening, Adductor release, Hamstrings fractional lengethening, rectus release with or without transfer to hamstrings, Gastronemius recession, Tendoachillis lengethening, Tibialis anterior or tibialis posterior split transfer.

  
  Bony procedures may be required in cases which do not yield to soft tissue surgery. 

  These include pelvic osteotomy, varus osteotomy, derotation osteotomy, Femur extension supracondylar osteotomy,calcaneal lengthening osteotomy, griece green subtalar arthrodesis.

  It is important to understand that all these will improve the child functionally but never cure the basic problem. Physiotherapy must be continued till skeletal maturity, as after that worsening of contractures rarely occurs.

  7 yrs old girl with spastic hemiplegia and equinus gait, she was treated with perutaneous tendoachillis lengthening.

  

  Postop cast in place

  
  

  

  AFO after cast removal for couple of weeks later only night time

  

  8 weeks postop without AFO, plantigrade foot

  Gait after 6 months

  Add caption

   

  

  Fixed knee deformity in CP in 15yr old boy with crouch gait

   

  

  Incision for Distal femoral extension osteotomy, inferiorly insicion for hamstring lengethening can be seen.

  AP view of supracondylar dital femoral extension osteotomy

  
  

   

  

  Lateral view of supracondylar extension osteotomy of femur

  
  

  

  
  

  

  Healed osteotomy after 8 weeks post op

   

  

  Calcaneal lengethening osteotomy with tricortical bone graft insitu for correction of pes planovalgus

   

   

Clubfoot

CLUBFOOT / CTEV

 Introduction

This is a very common deformity noticed immediately at birth and can be diagnosed in pregnancy time through repeat ultrasound examination. It might inadvertently be a cause for parents worry, if diagnosed during pregnancy. It is a surprise that many such parents come to me for advice on termination of pregnancy. I want to make it very clear that it is a 100% treatable condition and such dramatic decisions are not warranted. In India and other developing countries this perfectly treatable condition is commonly neglected, especially in rural setups. Over a period it becomes less amenable to conservative treatments and may result in a rigid foot, whereon surgery becomes a must.

Etiology and Incidence

Prevalence is 1 in 1000 in Indian population, with male child more commonly affected and in approximately 50% cases it is bilateral. Intrauterine overcrowding due to less amniotic fluid, twins, large baby, associated uterine fibroid can cause clubfoot due to mechanical pressure. There is no true reason for this deformity but there is an association with hip and spine disorders. It can also be found with multiple joint contractures or constriction band syndrome. Family history is also a predisposing factor. All babies born with CTEV must be screened on day 1 for Developmental hip dysplasia, spinal disorders or other syndromic associations.

USG study of a clubfoot baby

 Management

Initial treatment is conservative with plaster casts. It must be started as early as possible preferably on day 1. These casts are above the knee level to prevent slipping out of plaster while the baby kicks and to control rotations.  Parents have to be cautious regarding care of casts. They must keep them clean and dry by avoiding spilling of water or urine over the cast. These casts are put after gentle passive manipulation of foot and ankle to a corrected position, gradually the correction is achieved and sometimes even exaggerated to achieve slight over correction. It is important that weekly casts are changed for 4-6 weeks till only equinus deformity is remaining, which can be corrected by a percutaneous tenotomy followed by again casting, this last cast is continued for a total of 3 weeks. Later after removing the cast baby is put on a foot abduction orthosis for 23hrs a day till 3 months after which the splints are worn only at night times. Initially it is important to ensure compliance with braces and their fitting, so your doctor may advise you to come frequently for a month, once all is well followup once in every 3 months is sufficient. These shoes may need change frequently as the baby grows. Followup is necessary till 3-4 years of age to check compliance and detect recurrence early. For residual deformity various surgical procedures are available which can be done at appropriate age. In neglected and rigid clubfoot surgery is required. It can be done before walking age at around 9 months. Surgery involves soft tissue procedures to  release the tight medial and posterior structures. Bony surgery may be needed at later age for residual deformities. Sometimes a tendon transfer is needed to correct a flexible adduction deformity. For more resistant and delayed cases an external fixator in the form of Rings or small rods are applied to slowly correct the deformity by gradual distraction.

Bilateral CTEV 

First Casting in supination  to correct cavus

2nd cast put in abduction to correct forefoot adduction

3rd cast for further abduction

4th cast for still more abduction

Last cast after percutaneous tenotomy in 15* dorsiflexion and 70* abduction

Skin complications due to tight plaster

A fully corrected foot after cast removal

Example of foot abduction orthosis used after final correction for 23 hours per day

Another type of Foot abduction orthosis worn by baby

Monteggia Fracture dislocation

Monteggia Fracture dislocation

Introduction

Fracture of Ulna shaft with dislocation of proximal radioulnar joint is called as monteggia # dislocation. First described by Giovanni Battista Monteggia of Milan. Bado later classified them according to the direction of radial head displacement in relation to capitullum. He also described similar variants of this lesion which are called Monteggia Equivalents. It is commonly seen in children who fall on outstreached hand or sustain a direct blow to the back of forearm.

Letts further subclassified them in 5 subtypes as seen in pediatric age group.

Bado classification

Monteggia equivalents are further subclassified based on direction of radial head.
Type I equivalents is anterior radial head dislocation without ulna # ex: Pulled elbow, radial head dislocation with plastic deformation of ulna, radial head dislocation associated with radial shaft # proximal to ulna #, radial head dislocation with radial neck and ulna shaft #, radial head dislocation with ulna shaft comminuted #. All these must have anterior dislocation of radial head.

Monteggia I equivalents

Monteggia Type II equivalents
ex: Radial neck or physeal fractures with posterior displacement, posterior dislocation of elbow

Monteggia Type III / IV equivalents
Bado did not have in his original series these cases but were added up later based on case reports. They include Supracondylar humerus # or lateral condyle # with associated both bones forearm fracture.

Letts further added 2 subgoups to monteggia fractures in children which include plastic deformation of ulna and ulna greenstick #

Plastic deformation and ulna grrenstick with radial head dislocation

Diagnosis

Clinical suspicion with Full length forearm xrays are key. A line drawn along the proximal radial shaft must pass through the capitullum in any degree of elbow flexion ie radiocapitullar line.

In true lateral view dorsal ulna must form a straight line, if any gap is noted then plastic deformation is present.

Management

Aim of any intervention is to achieve normal ulnar length  and correct any angulation with reduction of radial head. It can be achieved by manipulation by reversing the deformity. If stable after reduction can be managed by cast without surgery, in which case repeat weekly Xrays are necessary for followup. Oblique fractures may need either percutaneous fixation or plating for stability. When dealing with neglected monteggia ulnar osteotomy and internal fixation for reversing the deformity with open reduction of radial head are unavoidable. Early neglected monteggia can also be manged by ulna osteotomy and distraction with external fixator. If radial head reduction is unstable it needs annular ligament reconstruction. 

Case examples

Plastic bowing of ulna with anterior dislocation radial head

7yrs old boy Akhil with prominence in left elbow due to neglected Monteggia #

Akhil' LAT Xray on day of injury which was missed by treating surgeon 

Akhil's LAT Xray forearm on day of injury

Akhil's LAT xray forearm after 3 months : note the # union but radial head dislocated

Akhil's AP xray forearm 3 months post injury

Extension osteotomy for ulna stabilized with 1/3rd tubular plate and open reduction of radial head(below retractor, interval between ECU and anconeus), Forearm fascia prepared for annular ligament reconstruction( in forceps)

Extension osteotomy ulna with dorsal opening( forceps) and volar greenstick

Post op immediate LAT Xray: Radial head reduced with ulnar extn osteotomy

Post op AP xray with radila head reuced and ulnar osteotomy fixed with 1/3rd tubular plate

Another example of a monteggia fracture dislocation in a 15years old girl