Foot and Ankle Natalie Stork, MD

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1 Foot and Ankle Natalie Stork, MD Assistant Professor University of Missouri-Kansas City School of Medicine, Department of Orthopaedic Surgery and Department of Pediatrics Children s Mercy Kansas City, Department of Orthopaedic Surgery and Musculoskeletal Science The official health care provider of Sporting Kansas City The Children s Mercy Hospital, 2017

2 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation 2

3 Practice Gap Many primary care physicians lack training in the diagnosis and management of common lower extremity anomalies in infants and children 3

4 Objectives Discuss the diagnosis, natural history and treatment of common foot and ankle conditions in infants and children Metatarsus Adductus Clubfoot Calcaneovalgus Vertical Talus Growth plate injuries Bunions 4

5 Metatarsus Adductus Common congenital foot deformity Medial forefoot deviation relative to the hindfoot First year of life Etiology Unknown More common: Males, Twin births, Premature births 5

6 Metatarsus Adductus Convex border of the lateral foot Medial crease Prominent base of 5 th metatarsal Normal ankle range of motion Classification Flexibility Severity 6

7 Metatarsus Adductus Treatment Observation Flexible Stretching* Casts Rigid metatarsus adductus Residual deformity 7

8 Talipes Equinovarus Clubfoot 8

9 Clubfoot 1 in 1000 live births Bilateral 50% Etiology is multifactorial Genetics Environmental Syndromic (Non-idiopathic) 9

10 Clubfoot - Genetics Occurrence rate higher in affected relatives Male predisposition Racial variability Increased incidence in polynesians 10

11 Clubfoot - Genetics Unaffected parents Son affected 2.5% chance of having 2 nd son with Clubfoot Daughter affected 6.5% chance subsequent son; 2.5% chance subsequent daughter Affected parent and Child Twins 32.5% rate of concordance in monozygotic 2.9% rate in heterozygotic 11

12 Clubfoot Environmental Smoking Risk increased with number of cigarettes/day Mid to late 90 s amniocentesis b/w weeks Mechanism not proven but there was an increase in clubfoot 12

13 Clubfoot - Exam Cavus Adductus Varus Equinus 13

14 Clubfoot - Diagnosis Clinical Radiographs Generally not needed for diagnosis Consider if other abnormalities (ie 4 toes) Ultrasound False positives 14

15 Clubfoot Exam Complete Physical Exam Head Neck ROM Upper extremities Spine Hips Lower extremities 15

16 Clubfoot - Exam Foot Smaller in length Wider Leg Calf can be smaller in girth 16

17 Clubfoot - Treatment 17

18 Clubfoot - 18

19 Calcaneovalgus Benign soft tissue contracture of the foot 1/1000 live births Females > Males 19

20 Calcaneovalgus - Exam Excessive Dorsiflexion Dorsal aspect of foot may touch shin Passive correction Apex of Dorsiflexion should be through ankle Hip exam Assess shape of LE Posteromedial bowing of tibia Radiographs generally not necessary 20

21 Calcaneovalgus - Treatment Observation Gentle Stretching Often resolves between 3-6 months of age Stretching casts* 21

22 Vertical Talus Disassociation of foot/ankle Dorsal dislocation of navicular on the talus Rare More often associated with neuromuscular/chromosomal abnormality Male > Female 50% bilateral 22

23 Vertical Talus Calcaneovalgus appearance + Rigid deformity Rocker bottom Midfoot breech due to dislocated navicular/adducted forefoot Multiple soft tissue contractures 23

24 Vertical Talus - Diagnosis Radiographs AP/Lateral Lateral Forced plantar flexion 24

25 Vertical Talus - Treatment Serial casts + Surgical intervention Surgical intervention 25

26 Growth Plate Injuries Physeal injuries of distal tibia/fibula are common Sports 8 15 years old Males > Females 26

27 Growth Plate Injuries Salter Harris Classification 27

28 Growth Plate Injuries - Exam Deformity Swelling 28

29 Growth Plate Injuries - Treatment Non-operative Nondisplaced Salter Harris I or II distal fibula Nondisplaced Salter Harris I of distal tibia Other Displaced Salter Harris I or II distal fibula or tibia Closed reduction/casting Salter Harris III/IV/V Closed vs Open reduction Internal Fixation 29

30 Growth Plate Injuries - Treatment Complications Growth arrest Severity/Displacement Physis involved Growth remaining 30

31 Juvenile Hallux Valgus - Bunion Lateral deviation of the hallux Females > Males Etiology - unknown 31

32 Juvenile Hallux Valgus - Presentation Variable presentation Asymptomatic Unhappy with appearance Pain with certain shoewear Pain with activity 32

33 Juvenile Hallux Valgus - Exam Lateral deviation of the Hallux +/- Callus Typically good motion through the MTP joint Associated flat foot Radiographs 33

34 Juvenile Hallux Valgus - Treatment Determining reason for visit important Non operative Modifications of shoewear Toebox Bunion stretchers Orthoses Night time splints Operative Failed conservative measures Poor results/complication rates have been reported between 30-60% 34

35 References Lalonde, F, Pring M. Ankle. Rang s Children s Fractures. Third Ed. Philadelphia. Lippincott Williams and Wilkins, 2005 Mosca, V. The Foot. Lovell and Winter s Pediatric Orthopaedics. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, Shea K.G. Frick S.L. Ankle Fractures. Rockwood and Wilkins Fractures in Children. 8 th ed. Philadelphia: Lippincott Williams and Wilkins, Skaggs, D.L., Flynn J.M. Trauma about the Knee, Tibia, Foot. Staying out of Trouble in Pediatric Orthopaedics. Philadelphia. Lippincott Williams and Wilkins, Skelly AC, Holt VL, Mosca VS, et al. Talipes equinovarus and maternal smoking: a population based case control study in Washington state. Teratology 2002;66:

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