congenital injury of the foot

1. C. T. E.V.C. T. E.V.

2. CONGENITALCONGENITAL
TALIPESTALIPES
EQUINO VARUSEQUINO VARUS
[CLUB FOOT][CLUB FOOT]

3. DEFINITIONDEFINITION
Congenital dysplasia of musculoskeletal structuresCongenital dysplasia of musculoskeletal structures
distal to knee leading to :distal to knee leading to :
-Forefoot and midfoot-inversion & adduction (varus)-Forefoot and midfoot-inversion & adduction (varus)
-Heel inversion-Heel inversion
-Ankle equinus-Ankle equinus

4. CONGENITAL CLUBFOOTCONGENITAL CLUBFOOT
 IdiopathicIdiopathic  Non- IdiopathicNon- Idiopathic
1.1. Muscle imbalanceMuscle imbalance
2.2. Fibrosis of soft partsFibrosis of soft parts
3.3. Bone and joint anomaliesBone and joint anomalies

5. ETIOLOGYETIOLOGY
TheoriesTheories ::
 Mechanical factor in uteroMechanical factor in utero
 Neuromuscular defectNeuromuscular defect
 Primary Germ Plasma defectPrimary Germ Plasma defect
 Arrest of fetal developmentArrest of fetal development
 HeredityHeredity
 Heredity & environmentHeredity & environment
 Retractile fibrosisRetractile fibrosis

6. MECHANICAL FACTOR INMECHANICAL FACTOR IN
UTEROUTERO
 Oldest theoryOldest theory
 Proposed by HippocratusProposed by Hippocratus
 Believed that foot was held inBelieved that foot was held in
equinovarus by external pressureequinovarus by external pressure

7. Neuromuscular imbalanceNeuromuscular imbalance
theorytheory
 Dominant neurogenic factor.Dominant neurogenic factor.
 Muscle imbalance may produce the deformity.Muscle imbalance may produce the deformity.
 Congenital fiber imbalance between type 1 &Congenital fiber imbalance between type 1 &
2 muscle fibers and atrophy of type 1 fiber2 muscle fibers and atrophy of type 1 fiber
found in peroneal and triceps surae muscle infound in peroneal and triceps surae muscle in
histopathological specimen.histopathological specimen.
 E.g.Cerebral palsy, spina bifida,poliomyelitisE.g.Cerebral palsy, spina bifida,poliomyelitis

8. PRIMARY GERM PLASMPRIMARY GERM PLASM
DEFECTDEFECT
 IraniIrani
 Primary Germ Plasm defectPrimary Germ Plasm defect
affecting the head and neck ofaffecting the head and neck of
talus.talus.
 Defect in cartilaginous talarDefect in cartilaginous talar
analge producing dysmorphicanalge producing dysmorphic
neck and navicularneck and navicular
subluxation.subluxation.

9. ARREST OF FETALARREST OF FETAL
DEVELOPMENTDEVELOPMENT
 Intrauterine mechanical factorsIntrauterine mechanical factors::
 Normally the foot in 6 to 8 wk oldNormally the foot in 6 to 8 wk old
fetus has characteristics of Clubfetus has characteristics of Club
foot and becomes normal at 12 tofoot and becomes normal at 12 to
14 wks14 wks
 Arrest in physiologicalArrest in physiological
developmental phase results intodevelopmental phase results into
equinovarus deformity.equinovarus deformity.

10. GENETIC THEORYGENETIC THEORY
 In otherwise normal infants is the result of aIn otherwise normal infants is the result of a
multifactorial system of inheritance.multifactorial system of inheritance.

11. RETRACTILE FIBROSISRETRACTILE FIBROSIS
 Increased fibrous tissue in muscles andIncreased fibrous tissue in muscles and
ligaments leads to contracture of softligaments leads to contracture of soft
tissues and hence development oftissues and hence development of
deformity.deformity.
 e.g.A.M.C.e.g.A.M.C.

12. EvidenceEvidence ::
1.1. In general population – 1/1000 live birthsIn general population – 1/1000 live births
2.2. 11stst
degree relative - Risk 2%.degree relative - Risk 2%.
3.3. One parent affected - Risk 3-4%.One parent affected - Risk 3-4%.
4.4. Both parents affected - Risk 15%Both parents affected - Risk 15%

13. COMPONENTS OF THECOMPONENTS OF THE
DEFORMITYDEFORMITY
EquinusEquinus
1.1. Ankle joint equinusAnkle joint equinus
2.2. Inversion of talocalcaneonavicular complexInversion of talocalcaneonavicular complex
3.3. Plantar flexion of footPlantar flexion of foot

14. Components of deformityComponents of deformity
 VarusVarus
– Hindfoot is rotated inwards ,Hindfoot is rotated inwards ,
– occur primarily at Talocalcaneonavicularoccur primarily at Talocalcaneonavicular
jointjoint
 AdductionAdduction
– foot is deviated mediallyfoot is deviated medially
– Occurs at talonavicular and calcaneo-cuboidOccurs at talonavicular and calcaneo-cuboid
joint subtalar jointjoint subtalar joint

15.  CavusCavus
– Forefoot plantar flexion in relationship to hindForefoot plantar flexion in relationship to hind
foot causes cavus deformityfoot causes cavus deformity
– Occurs at midtarsal joint.Occurs at midtarsal joint.

16. Osseous deformitiesOsseous deformities
TALUSTALUS
 Body :Body :
– anterior part of talus fail to develop its normalanterior part of talus fail to develop its normal
contour.contour.
 Head & Neck :Head & Neck :
– Broad and flattened.Broad and flattened.
– Head and neck shifted medially.Head and neck shifted medially.

17. – Angle formed by head & neck.Angle formed by head & neck.
– Normal 150-160 degreeNormal 150-160 degree
– In ctev reduced to 115-135 degree.In ctev reduced to 115-135 degree.

18. CALCANEUMCALCANEUM
 It is abnormal position of calcaneus &It is abnormal position of calcaneus & notnot
abnormal shape.abnormal shape.
– posterior tuberosity displaced upwards & laterally.posterior tuberosity displaced upwards & laterally.
– anterior end displaced downwards & medially.anterior end displaced downwards & medially.
– Sustantaculum tali displaced medially to under talarSustantaculum tali displaced medially to under talar
head, may be underdeveloped.head, may be underdeveloped.

19.  NavicleNavicle::
– Navicular articular surface faces laterally toNavicular articular surface faces laterally to
articulate with the medially deviated head andarticulate with the medially deviated head and
neck of talus.neck of talus.
 CuboidCuboid::
– Moves medially with anterior end ofMoves medially with anterior end of
calcaneus.calcaneus.
 Cuneiform and metatarsalCuneiform and metatarsal ::
– Minimal displacementsMinimal displacements

20. SOFT TISSUESOFT TISSUE
CONTRACTURESCONTRACTURES
 PosteriorPosterior
1.1. Tendo AchillisTendo Achillis
2.2. Tibio-talar capsuleTibio-talar capsule
3.3. Talo-calcaneal capsuleTalo-calcaneal capsule
4.4. Posterior talo-fibular ligamentPosterior talo-fibular ligament
5.5. Calcaneo-fibular ligamentCalcaneo-fibular ligament

21. MEDIAL PLANTARMEDIAL PLANTAR
CONTRACTURESCONTRACTURES
1.1. Tibialis posterior tendonTibialis posterior tendon
2.2. Deltiod ligamentDeltiod ligament
3.3. Talo-navicular capsuleTalo-navicular capsule
4.4. Spring ligamentSpring ligament
5.5. Henrys knotHenrys knot
6.6. FHL/ FDLFHL/ FDL

22. SUBTALAR CONTRACTURESSUBTALAR CONTRACTURES
 Talocalcaneal interosseous ligamentTalocalcaneal interosseous ligament
 Bifurcated Y ligamentBifurcated Y ligament

23. PLANTAR CONTRACTURESPLANTAR CONTRACTURES
 Abductor hallucisAbductor hallucis
 Intrinsic toe flexorsIntrinsic toe flexors
 Quadratus plantaeQuadratus plantae
 Plantar aponeurosisPlantar aponeurosis

24. CLINICAL FEATURESCLINICAL FEATURES
 Club like appearanceClub like appearance
 Foot points plantar wards with heel drawn upFoot points plantar wards with heel drawn up
and invertedand inverted
 Feet are usually smallerFeet are usually smaller
 shortened 1shortened 1stst
metatarsal raymetatarsal ray
 Mid, forefoot adducted, inverted & have equinusMid, forefoot adducted, inverted & have equinus
 Anterior end of talus is the most prominentAnterior end of talus is the most prominent
subcutaneous bonesubcutaneous bone
 Deep creases on posteror aspect of ankle joint.Deep creases on posteror aspect of ankle joint.

25. CLINICAL FEATURESCLINICAL FEATURES
 Skin on lateral side is thinned andSkin on lateral side is thinned and
stretched & atrophiedstretched & atrophied
 Deep cleft on the medial planter surfaceDeep cleft on the medial planter surface
 Lateral malleolus is posterior to and moreLateral malleolus is posterior to and more
prominent than the medial malleolusprominent than the medial malleolus

26. CLINICAL FEATURESCLINICAL FEATURES
 Forefoot is in equinusForefoot is in equinus
 On passive dorsiflexion and eversion, tautOn passive dorsiflexion and eversion, taut
TA and post. Tibial tendon can beTA and post. Tibial tendon can be
palpatedpalpated
 Atrophy of calf musclesAtrophy of calf muscles
 Painful callosities and bursa on lateralPainful callosities and bursa on lateral
aspectaspect

28. PATHOGNOMONIC SIGNPATHOGNOMONIC SIGN
 In normal newborn,onIn normal newborn,on
passive dorsiflexion, thepassive dorsiflexion, the
dorsum of the foot willdorsum of the foot will
usually touch or closelyusually touch or closely
approximate the anteriorapproximate the anterior
end of the lower tibiaend of the lower tibia
 In clubfoot , dorsiflexionIn clubfoot , dorsiflexion
is impossible even whenis impossible even when
strong pressure isstrong pressure is
appliedapplied

29. ASSOCIATED CONDITIONSASSOCIATED CONDITIONS
 Paralytic clubfootParalytic clubfoot
1.1. MyelomeningocoeleMyelomeningocoele
2.2. Intraspinal tumorsIntraspinal tumors
3.3. DiastematomyeliaDiastematomyelia
4.4. PoliomyelitisPoliomyelitis
5.5. CPCP
6.6. GB syndromeGB syndrome

30. ASSOCIATED CONDITIONSASSOCIATED CONDITIONS
 Arthrogryposis multiplex congenitaArthrogryposis multiplex congenita
 Congenital Hip/ Knee/ Elbow/ ShoulderCongenital Hip/ Knee/ Elbow/ Shoulder
dislocation or subluxationdislocation or subluxation
 Congenital annular constriction bandCongenital annular constriction band
syndromesyndrome

31. ClassificationsClassifications
 DimeglioDimeglio
 PiraniPirani
 FunctionalFunctional
 GoldnerGoldner
 CarrolsCarrols
 caterallcaterall

32. Dimeglio’s classificationDimeglio’s classification
1.1.The equinus deviation in the sagital planeThe equinus deviation in the sagital plane (0-4(0-4
points).points).
2.2.Varus deviation in the frontal planeVarus deviation in the frontal plane (0-4(0-4
points).points).
3.3.Derotation of the calcaneo-forefront blockDerotation of the calcaneo-forefront block (0-4(0-4
points).points).
4.4.Forefoot adduction in the horizontal planeForefoot adduction in the horizontal plane (0-4(0-4
pointspoints).).

33. Further elementsFurther elements
Posterior creasePosterior crease 11
Medial creaseMedial crease 11
cavuscavus 11
Poor muscle conditionPoor muscle condition 11
Total from elementsTotal from elements- 0-4- 0-4
Total pointsTotal points- 0 -20- 0 -20

34. GRADESGRADES
GRADEGRADE
POINTSPOINTS
II BenignBenign 0-50-5
IIII ModerateModerate 5-105-10
IIIIII SevereSevere 10-1510-15
IVIV Very severeVery severe 15-2015-20

35. PIRANI’S CLASSIFICATIONPIRANI’S CLASSIFICATION
 Medial componentMedial component ::
-medial crease-medial crease
-palpation of talar head-palpation of talar head
-deviation of forefoot from-deviation of forefoot from
midlinemidline
 Post component :Post component :
-post crease-post crease
-empty heel sign-empty heel sign
-equinus-equinus

36.  Curvature of lateral border of footCurvature of lateral border of foot
– Straight -0Straight -0
– Mild distal curve-0.5Mild distal curve-0.5
– Curve at calcaneocuboid joint-1Curve at calcaneocuboid joint-1

37.  medial creasemedial crease
– Multiple fine creases -0Multiple fine creases -0
– One or two deep creases -0.5One or two deep creases -0.5
– Single Deep crease-1Single Deep crease-1

38.  Palpation of lateral part of head of talusPalpation of lateral part of head of talus
– lateral talar head cannot be felt-0lateral talar head cannot be felt-0
– lateral head less palpable-0.5lateral head less palpable-0.5
– lateral talar head easily felt-1lateral talar head easily felt-1

39.  posterior creaseposterior crease
– Multiple fine creases-0Multiple fine creases-0
– One or two deep creases-0.5One or two deep creases-0.5
– Sigle Deep crease-1Sigle Deep crease-1

40.  Emptiness of heelEmptiness of heel
-Tuberosity of calcaneus easily palpable-0-Tuberosity of calcaneus easily palpable-0
-Tuberosity of calcaneus more difficult to-Tuberosity of calcaneus more difficult to
palpate-0.5palpate-0.5
– Tuberosity of calcaneus not palpable-1Tuberosity of calcaneus not palpable-1

41.  Rigidity of equinusRigidity of equinus
– Normal ankle dorsiflexion>90-0Normal ankle dorsiflexion>90-0
– Ankle dorsiflexes 90 -0.5Ankle dorsiflexes 90 -0.5
– Cannot dorsiflex ankle <90-1Cannot dorsiflex ankle <90-1

42.  Total score-0 to 6Total score-0 to 6
 0 score –no deformity0 score –no deformity
 6 score-severe deformity6 score-severe deformity

43. CARROLL’S 10 POINT SCORINGCARROLL’S 10 POINT SCORING
SYSTEMSYSTEM
1.1. Calf atrophyCalf atrophy
2.2. Position of fibulaPosition of fibula
3.3. CreasesCreases
4.4. Curved lateral borderCurved lateral border
5.5. CavusCavus

44. CARROLL’S 10 POINT SCORINGCARROLL’S 10 POINT SCORING
SYSTEMSYSTEM
6. Navicular fixed with medial malleolus6. Navicular fixed with medial malleolus
7. Calcaneum fixed with fibula7. Calcaneum fixed with fibula
8. Fixed equinus8. Fixed equinus
9. Fixed adductus9. Fixed adductus
10.Fixed forefoot supination10.Fixed forefoot supination

45. RADIOLOGYRADIOLOGY
 USES-USES-
1.1. Assessment of severity of deformityAssessment of severity of deformity
2.2. Accurate diagnosis to progress of deformityAccurate diagnosis to progress of deformity
3.3. Analyze composite deformities pre- operativelyAnalyze composite deformities pre- operatively
4.4. To assess reduction of talocalcaneal jt afterTo assess reduction of talocalcaneal jt after
manipulationmanipulation
5.5. To plan operative line of management.To plan operative line of management.
6.6. Post op. confirmation and monitoring of alignmentPost op. confirmation and monitoring of alignment
normal articular surface.normal articular surface.

46. C
AP VIEW
– AP Talocalcaneal angle(20-
50)
– 2nd
Metatarso calcaneal
– 1st
metatarso talar angle(5-15
A
B
B
A
C
AP VIEW

47. – Talo calcaneal angle(20-50)
– 1st
metatarso calcaneal angle
– Tibio calcaneal angle(10-40)
–Tibio talar angle(70-100)
LATERAL VIEW
E
D
F
G
E
D
F
G

48.  Talocalcaneal indexTalocalcaneal index
– Sum of T-C angles in A-P and LateralSum of T-C angles in A-P and Lateral
projections .projections .
– Normal -Normal - >40>40°.

49. C-t scanC-t scan
 To study bony anatomic status of foot inTo study bony anatomic status of foot in
ctev in children of >2 yrs old.ctev in children of >2 yrs old.

50. ArthrographyArthrography
 To study shape and size of talus withTo study shape and size of talus with
respect to its length and medial declinationrespect to its length and medial declination
of talonavicular joint.of talonavicular joint.

51. Foot printsFoot prints
 Serial weight bearing foot prints can serveSerial weight bearing foot prints can serve
an important documentation of deformityan important documentation of deformity
and also help in confirming improvementand also help in confirming improvement
after correctionafter correction

52. MANAGEMENTMANAGEMENT
 Non-operativeNon-operative
1.Manipulation & casting1.Manipulation & casting
2.Manipulation & strapping2.Manipulation & strapping
3.Dennis brown splint3.Dennis brown splint
 OperativeOperative
1.Soft tissue release1.Soft tissue release
2.Bony procedures2.Bony procedures
3.Differential distraction3.Differential distraction

53. IMMOBILIZATION IN CASTIMMOBILIZATION IN CAST
 Ponseti methodPonseti method
 Turco’s method – Simultaneous correctionTurco’s method – Simultaneous correction
 Kites methodKites method

54. PONSETI METHODPONSETI METHOD
 Steps:Steps:
Cavus is corrected byCavus is corrected by
supinating thesupinating the
forefoot andforefoot and
dorsiflexing the 1dorsiflexing the 1stst
metatarsalmetatarsal

55. PONSETI METHODPONSETI METHOD
To correct the varus andTo correct the varus and
adduction, the foot inadduction, the foot in
supination is abducted whilesupination is abducted while
counter pressure is appliedcounter pressure is applied
over head of talus.over head of talus.

56. The calcaneus abducts byThe calcaneus abducts by
rotating and sliding underrotating and sliding under
the talus and as thethe talus and as the
calcaneus is abducted itcalcaneus is abducted it
simultaneously extendssimultaneously extends
and everts and heel varusand everts and heel varus
is corrected.is corrected.
5 –6 serial casts may be5 –6 serial casts may be
required.required.

57. IMMOBILIZATION IN CASTIMMOBILIZATION IN CAST
 As early as 1 weekAs early as 1 week
 Above knee casts are givenAbove knee casts are given
 Plaster cast changed every weekPlaster cast changed every week
 At the end of 3 months, assess the foot that is going toAt the end of 3 months, assess the foot that is going to
corrected by conservative managementcorrected by conservative management

58. TURCO’S METHODTURCO’S METHOD
 Goal : to relocate the navicular in front ofGoal : to relocate the navicular in front of
the talus & evert, dorsiflex the calcaneus.the talus & evert, dorsiflex the calcaneus.
 Correct all deformities simultaneously.Correct all deformities simultaneously.
 Damage during manipulation occurs fromDamage during manipulation occurs from
excess dorsiflexion force.excess dorsiflexion force.

59. KITE’S METHODKITE’S METHOD
 Correction in a sequential orderCorrection in a sequential order
first – foot adductionfirst – foot adduction
then – heel varusthen – heel varus
Finally- equinusFinally- equinus
 Adviced change of cast every 3 weeks tillAdviced change of cast every 3 weeks till
correction is achieved.correction is achieved.

60. ROBERT JONES ADHESIVEROBERT JONES ADHESIVE
STRAPPINGSTRAPPING
 Proposed by Robert jonesProposed by Robert jones
 Principle depends on thePrinciple depends on the
child’s knee motion tochild’s knee motion to
apply an active eversionapply an active eversion
forceforce
 InexpensiveInexpensive
 Easy to useEasy to use
 Dynamic corrective forceDynamic corrective force

61. DENIS BROWN BARDENIS BROWN BAR
 The aim is to maintain the correction that isThe aim is to maintain the correction that is
achieved by serial casting and reduce theachieved by serial casting and reduce the
incidence of recurrenceincidence of recurrence
 Consist of 2 foot pieces connected by a barConsist of 2 foot pieces connected by a bar
 2020°° midfoot and forefoot abdmidfoot and forefoot abd
 0-50-5°° dorsiflexiondorsiflexion
 7070°° ext rotationext rotation
 D-B is worn 24 hrs a day & removed forD-B is worn 24 hrs a day & removed for
exercise and passive stretching or when theexercise and passive stretching or when the
child is bathed&fedchild is bathed&fed
 used as a night splint when child startsused as a night splint when child starts
walkingwalking

62. OPERATIONSOPERATIONS
 1. Soft tissue release1. Soft tissue release
2. Bony procedures2. Bony procedures
3. Differential distraction3. Differential distraction

63. Soft tissue releaseSoft tissue release
– One stage PMR with internal fixation( Turco )One stage PMR with internal fixation( Turco )
– posterolateral ligament complex release mostposterolateral ligament complex release most
often is required for severe posterolateraloften is required for severe posterolateral
deformity.deformity.
– PM & PL releasePM & PL release
 McKay procedureMcKay procedure
 Carroll methodCarroll method
 Manzone methodManzone method

64. TREATMENT OF RESISTANT CLUBTREATMENT OF RESISTANT CLUB
FOOTFOOT
 Basic surgical correction of resistant clubfoot includesBasic surgical correction of resistant clubfoot includes
both soft tissue release & bony osteotomiesboth soft tissue release & bony osteotomies
 Appropriate procedures & combinations depend onAppropriate procedures & combinations depend on
the age of the child, severity of deformity & pathologythe age of the child, severity of deformity & pathology
involvedinvolved

65. NO DEFORMITY TREATMENT
1 Metatarsus
adductus
>5yrs metatarsal osteotomy
2 Hindfoot
varus
<2-3 yrs - Modified Mckay procedure
3-10 yrs -
Dwyer osteotomy
Dillwyn evans procedure
Lichtblau procedure
10-12 yrs - Triple arthrodesis
3 Eqinus >10 yrs – Triple arthodesis
4 All 3
deformities
Tendocalcaneus lengthening and posterior
capsulotomy of subtalar, ankle joint (mild,
moderate)
Lambrudoni procedure (severe)

66. SHORTENING OF THE LATERALSHORTENING OF THE LATERAL
COLUMNCOLUMN
 Ogston:Ogston:
– Enucleation of the cuboid bone,Enucleation of the cuboid bone,
– ant part of calcaneum,ant part of calcaneum,
– head of talus.head of talus.
– Results were disappointing.Results were disappointing.

67. EVANSEVANS
 Evans: medial andEvans: medial and
posterior releaseposterior release
followed by wedgefollowed by wedge
resection ofresection of
calcaneocuboid jointcalcaneocuboid joint
 Age : 4-8 yrsAge : 4-8 yrs

68. LICHTBLAULICHTBLAU
Combined medial releaseCombined medial release
with resection of anteriorwith resection of anterior
end of calcaneum of 1 cmend of calcaneum of 1 cm

69. CUBOID DECANCELLATIONCUBOID DECANCELLATION

70. DWYER’S OSTEOTOMYDWYER’S OSTEOTOMY
 Lateral closed wedge osteotomy or medialLateral closed wedge osteotomy or medial
open wedge osteotomy of calcaneum withopen wedge osteotomy of calcaneum with
bone graftingbone grafting
 Z lengthening of TAZ lengthening of TA
 Medial plantar fasciotomyMedial plantar fasciotomy
 Dependent on the flexibility of subtalar &Dependent on the flexibility of subtalar &
midtalar jointmidtalar joint
 Pre requisite – sufficient ossification ofPre requisite – sufficient ossification of
calcaneum for bone graftingcalcaneum for bone grafting

71. TRIPLE ARTHRODESISTRIPLE ARTHRODESIS
 Salvage procedureSalvage procedure
 Tarsal reconstruction by wedge resectionTarsal reconstruction by wedge resection
and fusion of the subtalar and midtarsaland fusion of the subtalar and midtarsal
jointsjoints
 Results are not good functionally &Results are not good functionally &
cosmeticallycosmetically

72. TALECTOMYTALECTOMY
 Age< 4 yearsAge< 4 years
 Rigid paralytic deformities of the footRigid paralytic deformities of the foot
 Principle is that by excision, sufficientPrinciple is that by excision, sufficient
laxity of soft tissues is provided to correctlaxity of soft tissues is provided to correct
equinus and varus deformities without softequinus and varus deformities without soft
tissue tensiontissue tension

73. JOSHI’S EXTERNAL FIXATORJOSHI’S EXTERNAL FIXATOR
Indications :Indications :
1.1. Neglected casesNeglected cases
2.2. Relapsed casesRelapsed cases
3.3. Known resistant cases eg ArthrogryposisKnown resistant cases eg Arthrogryposis
4.4. Late presentationLate presentation

74. ILIZAROVILIZAROV