Evaluation of Pediatric Foot Pain

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Maximilian Sims
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1 May 2006 Evaluation of Pediatric Foot Pain John Flibotte, Harvard Medical School Year III

2 Our Patient AP is a 10 year old boy with chronic R foot pain 2

3 Anatomy of the Foot Manusov EG, et al. (1996), Part II 3

4 DDX of Pediatric Foot Pain Forefoot/ Midfoot Foot Pain Structural Abnormality Infectious Repetitive/ Acute Trauma Tumor/ Growth Overlapping/ Curly Toes Accessory Navicular Osteomyelitis Onychocryptosis (Ingrown Nail) Hallux Valgus Turf Toe Sesamoiditis Bone Cysts Ewing s Sarcoma Osteoid Osteoma Synovial Sarcoma Sesamoid Stress Fx Frieberg s Disease (AVN of second metatarsal epiphysis) Stress Fracture Fracture Kohler s Disease (Ischemic Necrosis of Navicular) 4

5 DDX of Pediatric Foot Pain Hindfoot Pain Foot Pain Structural Abnormality Infectious Repetitive/ Acute Trauma Tumor/ Growth Pes Planus (Flatfoot) Osteomyelitis Plantar Fasciitis Bone Cysts Flexible Rigid Tarsal Coalition Os Trigonum Syndrome Calcaneal Apophysitis (Sever s Disease) Calcaneal Stress Fx Retrocalcaneal Bursitis (Haghund s Disease) Ewing s Sarcoma Osteoid Osteoma Synovial Sarcoma Lisfranc Joint Sprain Ankle Sprain Osteochondritis dessicans Fracture Manusov EG, et al. (1996), Parts I & II 5

Anatomy of the Calcaneus http://education.

6 Anatomy of the Calcaneus 6

7 Anatomy of the Talus-1 Lateral View Fibular Facet Medial View Tibial Facet Navicular Facet 7

8 Anatomy of the Talus-2 Inferior Aspect Navicular Facet Middle Articular Facet (for sustentaculum tali) Posterior Articular Facet 8

9 Standard Views of the Foot Lateral Oblique Anteroposterior One Special View: Harris Beath View 9

Obtaining a Lateral View http://www.latrobe.edu.

10 Obtaining a Lateral View 10

Normal Lateral Radiograph of Foot http://www.

11 Normal Lateral Radiograph of Foot 11

12 Normal Lateral Radiograph of Foot 12

Oblique Radiograph of Foot http://www.latrobe.edu.

13 Oblique Radiograph of Foot 13

Normal Oblique Radiograph of Foot http://www.rad.washington.

14 Normal Oblique Radiograph of Foot Labelled.html 14

AP View of the Foot http://www.latrobe.edu.

15 AP View of the Foot 15

Normal AP Radiograph of the Foot http://www.rad.washington.

16 Normal AP Radiograph of the Foot

Obtaining the Harris Beath View http://www.latrobe.

17 Obtaining the Harris Beath View 17

18 Our Patient s Initial Radiographs

19 Our Patient s Lateral Views Loss of Middle Facet Space Narrowed Joint Space Children s Hospital Boston Loss of Foot Arch Narrowed Joint Space 19

20 Our Patient s Oblique Views Normal Appearance Children s Hospital Boston 20

21 Patient s Harris Beath Views Loss of Talocalcaneal Joint Space R L Loss of Talocalcaneal Joint Space Children s Hospital Boston 21

22 Patient s Coronal CT Children s Hospital Boston Bilateral Bony Fusion 22

23 Diagnosis: Talocalcaneal coalition

24 Discussion of Coalition Results from abnormal differentiation and segmentation of primitive mesenchyme with resultant lack of joint formation Postulated autosomal dominant inheritance with variable penetrance 50%-60% are Bilateral Prevalence 1-2% Can occur between any tarsal bone; talocalcaneal and calcaneonavicular coalitions are most common Newman & Newberg (2000) 24

25 Types of Coalition Osseous Fibrous Cartilaginous 25

26 Pathogenesis of Coalition Limitation of Normal Subtalar & Midfoot Motion Inflammation of Involved Joints Irritation of Peroneal Tendon Crossing Subtalar Joint Peroneal Tendon Spasm Peroneal Spastic Rigid Flatfoot Manusov EG, et al. (1996), Part II 26

27 Talocalcaneal Coalition-1 Coalition between the talus calcaneus Most commonly between middle facet of talus and sustentaculum tali of calcaneus Represents 48% of all Tarsal Coalitions Typically become symptomatic in 8-12 y.o. children Imaging Modalities: Difficult to see on standard views May be suggested by loss of foot arch Harris Beath View to demonstrate subtalar joint May need fine-cut CT May also be seen on MRI If a bone scan is done, will show as area of increased uptake Newman & Newberg (2000) 27

28 Talocalcaneal Coalition-2 Secondary Plain Film Signs: Talar beak Narrowing of the subtalar joint Rounding of the lateral talar process Lack of depiction of middle facets on lateral C-sign Secondary Signs on CT: Talar beak Joint Narrowing Broadening and down-sloping of sustentaculum tali Newman & Newberg (2000) 28

29 Middle Facet on Lateral Short solid arrow: middle facet Long solid arrow: posterior facet Open arrow: lateral process of talus (anterior extent of posterior facet) Normal= Open space Companion Normal Case Liu PT, et al. (2003) 29

30 Absence of Middle Facet Curved arrow: talar beak Long arrow: loss of middle facet space Short arrows: C-sign present Loss of posterior facet space Companion Coalition Patient Case Liu PT, et al. (2003) 30

31 Talar Beak Secondary to impaired subtalar joint motion Represents navicular overriding the talus Periosteal elevation occurs at site of talonavicular ligament Osseous repair results in talar beak Companion Coalition Patient Case Newman & Newberg (2000) 31

32 C-Sign Results from bone bridging between talar dome and sustentaculum tali Seen in osseous and non-osseous coalition Varies based on sustentaculum size and orientation Companion Coalition Patient Case Newman & Newberg (2000) 32

33 Another Patient with Coalition 9 year old girl with Chronic R foot pain 33

34 Our Patient 2 Bone Scan Focal Areas of Increased Tracer Uptake Children s Hospital Boston 34

35 Patient 2 Sagittal CT R L Bony Fusion Preserved Joint Space Children s Hospital Boston 35

36 Calcaneonavicular Coalition Coalition between calcaneus navicular Represents 43% of all Tarsal Coalitions Typically become symptomatic in yo children Best Imaging Modality: Plain Film, 45 degree internal oblique May also be seen on CT, MRI, bone scan Ragiographic Signs: Bony Bar (seen with osseous coalition) Bones in close proximity, irregular surfaces, anteromedial calcaneus is widened/ flattened (seen with fibrous or cartilaginous coalition) Hypoplasia of the talus Anteater sign Newman & Newberg (2000) 36

37 Anteater Sign Companion Coalition Patient Case Newman & Newberg (2000) 37

38 How did they come up with that anteater sign?

Anteater Sign Companion Coalition Patient Case www.

39 Anteater Sign Companion Coalition Patient Case Newman & Newberg (2000) 39

40 Anteater Sign Newman & Newberg (2000) 40

41 Performance of Secondary Signs The next slide shows the individual performance of secondary signs evaluated in a retrospective blinded study Table shows that individual stand alone signs have a low sensitivity, but high specificity 41

42 Performance of Secondary Signs Crim & Kjeldsberg (2004) 42

43 Combination of all Secondary Signs Evaluated both retrospectively and prospectively by attending and resident radiologists Results: Calcaneonavicular Coalition Attending (100% sens, 97% spec) Resident (80% sens, 98% spec) Talocalcaneal Coalition Sensitivity 100% Specificity 88% Crim & Kjeldsberg (2004) 43

44 Treatment Initially managed conservatively with steroid injections, orthotics Surgery may be undertaken to separate fused tarsal bones 44

45 Conclusions Coalition is a frequent cause of pediatric foot pain that may present in late childhood or early adulthood There are many secondary signs of coalition that can be seen on plain film radiographs The combination of multiple secondary signs is a sensitive and specific way to screen for coalition CT & MRI may be needed to confirm existence of coalition 45

46 References 1. Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics Mar-Apr;20(2): Liu PT, Roberts CC, Chivers FS, Kile TA, Claridge RJ, DeMartini JR, Kenrich RE, Freed LH. "Absent middle facet": a sign on unenhanced radiography of subtalar joint coalition. AJR Am J Roentgenol Dec;181(6): Manusov EG, Lillegard WA, Raspa RF, Epperly TD. Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot. Am Fam Physician Aug;54(2): Manusov EG, Lillegard WA, Raspa RF, Epperly TD. Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle. Am Fam Physician Sep 1;54(3): , Crim JR, Kjeldsberg KM. Radiographic diagnosis of tarsal coalition. AJR Am J Roentgenol Feb;182(2): Websites:

47 Acknowledgements With thanks to: Muneeb Ahmed, MD Larry Barbaras our Webmaster Pamela Lepkowski 47

Case. 15 Y old boy presented with pain in the foot. No history of injury or any constitutional symptoms. Your diagnosis?

Case. 15 Y old boy presented with pain in the foot. No history of injury or any constitutional symptoms. Your diagnosis? Case 15 Y old boy presented with pain in the foot. No history of injury or any constitutional symptoms Your diagnosis? Diagnosis: Calcaneo-navicular tarsal coalition. C sign Talar beaking Ant eaters nose