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1 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 January 1998 C/. c4m Problem feet in children J A Fixsen MChir FRCS J R Soc Med 1998;91:18-22 SECTION OF ORTHOPAEDICS, 1 APRIL So-called variations of normal, as well as true foot deformities, are very obvious in childhood. They cause considerable parental anxiety, particularly if the child shows any delay in motor development or there is a family history of conditions such as flat feet or hallux valgus. The obvious foot abnormality is often blamed for delay in motor development, whereas in fact even those children with untreated severe abnormalities such as severe talipes equinovarus (club foot) or congenital vertical talus will walk remarkably well despite their foot deformity if their motor development is normal. If, however, they have an underlying neuromuscular problem or other abnormality causing motor delay, then correcting their foot deformity will not of itself correct the motor delay. Misunderstandings about the relation between apparent foot deformity and walking ability are common and require careful, sympathetic handling by the physician or surgeon advising parents and carers. A paediatric physiotherapist skilled in addressing the patient's overall motor abilities can be very helpful. FLAT FOOT There is no accurate definition of flat foot (pes planus). Basically, it is a clinical observation that the medial longitudinal arch of the foot either rests on the ground or appears closer to the ground than the examiner would accept as normal. The condition is much more common in some races than others. It is frequently seen in families and is commonly associated with another inherited condition, familial joint laxity. The simple test for joint laxity described by Carter and Wilkinson1 should always be applied in a child presenting with flat feet, though the wide racial variation of joint laxity must always be borne in mind2. The normal evolution of the medial longitudinal arch in the child must be understood. When a child is born, the commonest position of the foot is calcaneo valgus with no medial arch apparent. When a child starts to walk at around the age of 12 to 18 months, there is usually no longitudinal arch and a pad of fat on the medial side can obliterate the arch (Figure 1). The medial longitudinal arch normally does not develop until around the age of 2-3 years and so when children begin to stand a somewhat flat-footed appearance is now considered entirely normal. The challenge therefore is to distinguish between the common, normal variant and the West Barn, Clamoak Farm Bams, Weir Quay, Bere Alston, Devon PL20 7BU, UK p7-14, Figure 1 The typical foot of a child of 18 months showing the normal flattening of the medial arch and apparent flat foot rare, pathological flat foot in the young child. In an important 25 year prospective study, Rose et al.3 stated that the test for flat feet should be related to function and be dynamic rather than static. They showed that children progressively developed an arch with time so that initially broad feet in preschool children became normal with time, irrespective of any treatment they might have. Far and away the most useful test was the great toe extension test (Jack's test) in which, when the great toe is extended or the child is asked to stand on tip toe, the medial arch appears, the heel goes into varus and the tibia externally rotates (Figure 2). If Figure 2 Jack's test in a child of 3. When the child stands on tip-toe the heel goes into varus, the tibia externally rotates and the medial longitudinal arch is well formed

19755 does not require fusion of any joints in the foot and has become popular for correction of this deformity6.

pathological flat foot. For many years a wide variety of exercises, orthoses and special footwear have been prescribed for the treatment of flat foot. Wenger et al.

Treatment with corrective shoes, inserts or specially designed and expertly fitted insoles did not alter the natural history.

2 19755 does not require fusion of any joints in the foot and has become popular for correction of this deformity6. Figure 3 A child of 10 years with a tarsal coalition causing a fixed valgus everted foot on the right the response is normal then almost certainly one is dealing with a normal variant and not a pathological flat foot. For many years a wide variety of exercises, orthoses and special footwear have been prescribed for the treatment of flat foot. Wenger et al.4, in a prospective study, showed that flexible flat feet in young children improved with growth. Treatment with corrective shoes, inserts or specially designed and expertly fitted insoles did not alter the natural history. In the rare symptomatic idiopathic flat foot without any underlying neuromuscular or local condition such as tarsal coalition, properly moulded and fitted orthoses or supportive footwear may relieve symptoms and excessive shoewear but will not correct the foot deformity. Surgery is occasionally indicated in the older child with severe hypermobility of the subtalar joint. In the past, the classical Grice subtalar arthrodesis was used, but this does throw extra strain in the long term on the ankle and mid foot. The reversed Dilwyn Evans operation described by Evans in TARSAL COALITION Tarsal coalition (peroneal spastic flat foot) commonly occurs in adolescents. The diagnosis is essentially clinical. The child starts walking with the foot fixed in valgus and eversion (Figure 3) and on examination there is no active or passive inversion; often there is evidence of spasm in the peroneal muscles and pain on any attempts at inversion. Plain X-ray of the foot is still useful in the presence of a calcaneo navicular bar. The so-called anteater7 signf-o elongation of the anterior process of the calcaneum-is very useful (Figure 4). Oblique views can also show up this form of coalition (Figure 5). Talo calcaneal coalition is more difficult to see, though computed tomography helps elucidate both the presence and the size of tarsal coalitions, particularly those between the talus and the calcaneum. In some cases, conservative treatment with medial arch supports and occasionally a short period in plaster or an orthosis can be helpful. However, if the symptoms persist and the patient is seriously disabled, then excision of calcaneo navicular bars is reported to give good results8. Talo calcaneal bars are less easy to excise, but if they are clearly localized and the operation is technically satisfactory, good results are again reported9. HALLUX VALGUS Hallux valgus is rare in the young child. It may be associated with Apert's syndrome (acro-cephalo-syndactyly) or myositis ossificans progressiva (Figure 6). In adolescence it causes increasing anxiety, particularly if there is a strong family history of hallux valgus and associated bunions (Figure 7). In the past, ill-fitting shoes were often blamed. The ill-fitting shoe does not cause the deformity but it can certainly cause pressure symptoms over the medial side of the metatarsal head leading to the development of a painful bunion. Figure 4 Lateral X-ray of a patient with a calcaneo navicular bar showing the anteater sign, elongation of the anterior process of the calcaneum Figure 5 Oblique radiographs of the same patient showing the calcaneo navicular bar 19

has stopped growing in the foot, around the age of 13-14 years.

much parental anxiety (Figure 8). In small children, provided the deformity is passively correctable, active treatment is very seldom necessary.

3 has stopped growing in the foot, around the age of years. Figure 6 Severe hallux valgus with shortening of the first ray in a patient with myositis ossificans progressiva Attempts to hold the toes straight with simple splints or toe spacers have not proved successful. Bony realignment surgery by one of the many forms of metatarsal osteotomy can give good results but should be delayed until the child CURLY AND OVER-RIDING TOES Curly toes and overlapping toes cause much parental anxiety (Figure 8). In small children, provided the deformity is passively correctable, active treatment is very seldom necessary. Sometimes gentle stretching by the mother is indicated; occasionally small silastic spacers ('toe pegs') are helpful. If, however, the child acquires a fixed curly toe which is causing troublesome symptoms, then the simple flexor tenotomy described by Menelaus and RossI0 is useful. Before a child starts to walk, the second toe often appears over-riding and crowded out by the big toe on one side, and the lateral toes on the other. Nearly always this will correct spontaneously when the child starts to walk and weight-bear on the foot. The child's shoes should be of adequate width and give plenty of room for the forefoot to spread and the toes to move. Over-riding of the fifth toe is usually a true congenital anomaly in which there has been a maldevelopment of the fifth ray. In these circumstances the condition is usually not correctable by passive means, and if symptoms are bad enough correction by double V-Y plasty (Butler's operation) can be helpful1. CONGENITAL VERTICAL TALUS/CONGENITAL CONVEX PES VALGUS Otherwise known as rocker-bottomed foot, this is a very rare anomaly. It is commonly associated with other major problems in the child, such as arthrogryposis multiplex congenita, myelomeningocele, and dysmorphic syndromes. In this condition there is a complex rigid deformity, with 20 Figure 7 Hallux valgus in a child of 8 with a strong history of hallux va2gus Figure 8 Typical curly and overlapping toes in a child of 18 months

JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 J an u ary 1 9 9 8 the forefoot being in calcaneus and everted, the hindfoot in equinus and the navicular dorsally dislocated on the talus which

This condition must be distinguished from severe calcaneo valgus foot, severe idiopathic flat foot, the severe flat foot associated with neuromuscular disorders such as cerebral palsy and the

4 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 J an u ary the forefoot being in calcaneus and everted, the hindfoot in equinus and the navicular dorsally dislocated on the talus which lies in a vertical or near vertical position (Figure 9). This condition must be distinguished from severe calcaneo valgus foot, severe idiopathic flat foot, the severe flat foot associated with neuromuscular disorders such as cerebral palsy and the mid-foot breech caused by over-enthusiastic conservative treatment of club foot. One should look at the whole child since commonly there will be other abnormalities. The lateral X-ray, particularly with the forefoot in maximum plantarflexion (the Eyre-Brook) view, is most useful, since in true vertical talus the navicular remains dorsally dislocated on the neck of the talus in this view (Figure 10). Conservative treatment may help stretch the forefoot on the hindfoot but surgery is nearly always necessary. Usually a complex operation is necessary to produce three dimensional correction. The navicular is reduced on the head of the talus through a medial approach with pin fixation of the navicular on the talus. The equinus is released posteriorly and, most important, the tightness of the peronei and sometimes the dorsiflexors, as well as the displacement of the calcaneo-cuboid joint, are corrected on the lateral side. Because of its rarity, few orthopaedic surgeons will have more than an anecdotal experience of this condition. Dodge et al. 2, in a retrospective long-term follow-up review of 36 feet stated that, provided the three components of the deformity are satisfactorily corrected, most patients do well though left with stiff feet; their main cause of disability is the underlying condition-e.g. arthrogryposis or meningomyelocele. Most foot problems referred to the children's clinic are normal variants or benign spontaneously resolving condi- Mt Figure 10 Lateral radiograph of a congenital vertical talus in neutral showing the equinus of the hindfoot, vertical position of the talus and the calcaneus of the forefoot. Lower: Eyre-Brook view showing that the position of the forefoot on the hindfoot is not corrected in full plantarflexion tions. However, they do cause great parental anxiety, particularly in the infant before walking and in the toddler who is just starting to walk. Their management requires a clear knowledge of the natural history of foot development and the accepted variability of the normal foot in childhood. Disorders of motor development are often associated with foot anomalies but the foot anomaly is seldom the cause of motor delay; this needs to be appreciated by both the physician/surgeon and the parents. A skilled paediatric physiotherapist can be helpful in assessing function in relation to the foot abnormality and general motor development...':.:'.. 'g..t.'.'.. Fi,gure 9 Congenital vertical talus showing the hindfoot equinus, the forefoot valgus and everted and the rocker-bottomed shape of the foot REFERENCES I Carter C, Wilkinson J. Persistent joint laxity in congenital dislocation of the hip. J Bone Joint Surg 1964;46B: Cheng JCY, Chan PS, Hui Orthopaedics 1991; 11:752-6 PW. Joint laxity in children. J Paediatr 3 Rose GK, Welton, CA, Marshall T. The diagnosis child. J Bone Joint Surg 1986;67B:71-8 of flat foot in the 4 Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flat foot in infants and children. J Bone Joint Surg 1989;71A: Evans D. Calcaneo valgus deformity.j BoneJoint Surg 1975;57B: Mosca VS. Calcaneal lengthening for valgus deformity of the hindfoot. J Bone Joint Surg 1995;77A:

5 7 Oestreich AE, Maze WA, Crawford AH, Morgan RC. The anteater's nose-a direct sign of calcaneo navicular coalition on the lateral radiograph. J Paediatr Orthopaedics 1987;7:709-l 1 8 Macnicol MS, Inglis G, Buxton RA. Symptomatic calcaneo navicular bars. J Bone Joint Surg 1986;68B: McCormack TJ, Olney B, Asher M. Talo-calcaneal coalition resection: a 10 year follow up. J Paediatr Orthopaedics 1997;17: Menelaus MB, Ross ERS. Open flexor tenotomy for hammer toes and curly toes in childhood. J Bone Joint Surg 1984;66B: Cockin J. Butler's operation for over-riding fifth toe. J Bone Joint Surg 1968;60B: Doge LD, Ashler RK, Gilbert RJ. Treatment of the congenital vertical talus: a retrospective review of 36 feet with long term follow up. Foot Ankle 1987;7:326 22

Other Congenital and Developmental Diseases of the Foot. Department of Orthopedic Surgery St. Vincent s s Hospital, The Catholic University

Other Congenital and Developmental Diseases of the Foot Department of Orthopedic Surgery St. Vincent s s Hospital, The Catholic University Contents Metatarsus Adductus Skewfoot Hallux Valgus Hallux Valgus