The document provides an introduction to pediatric foot conditions. It discusses the anatomy and development of the pediatric foot. It then covers normal variations that can occur, including accessory ossification centers. Two common osteochondroses - Köhler's disease and Freiberg's infraction - are described. Several congenital and developmental foot deformities are outlined, including metatarsus adductus, talipes calcaneovalgus, flexible flatfoot, and tarsal coalition. Treatment approaches for many of these conditions are mentioned, with an emphasis on conservative care.

1. Introduction To
Pediatric Foot
Thamer Alhussainan, M.D.
7/22/2020
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KFSH & RC
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2. Pediatric Foot
• Introduction.
• Normal variations.
• Osteochondroses.
• Congenital and developmental foot deformities.
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3. Introduction
• The foot is a complex and unique structure providing:
– Sufficient support for the body weight
– Flexibility to accommodate the uneven surfaces.
• The movement of the foot is complex and coupled,
starting from the ankle joint and ending in the
forefoot.
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4. Introduction
• This complex foot movement is the resultant of the
unique configuration of the subtalar joint complex.
• The talus, calcaneum, navicular, and cuboid bones are
the hindfoot structures.
• The cuniforms and its articulation with the metatarsals
are considered the midfoot.
• The metatarsals and phalanges are considered the
forefoot segment
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5. Introduction
• Terminology to describe the foot alignment:
– Ankle:
• Equinus.
• Calcaneus.
– Hindfoot:
• Varus.
• Valgus.
– Midfoot:
• Cavus
• Planus.
– Foorefoot:
• Adduction.
• Abduction.
• Supination.
• Pronation
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6. Introduction
• Ossific development of the foot begins in utero.
• At birth, talus, calcaneus, cuboid, metatarsals, and phalanges are
ossified.
• The lateral cuneiform ossifies 4/12-20/12.
• The medial cuneiform ossifies at 24/12.
• The intermediate cuneiform ossifies at 36/24.
• The navicular ossifies last 3-5 yrs.
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7. Introduction
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8. Introduction
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9. Introduction
• The foot has its own growth pattern.
• The foot grows rapidly between birth and 5 yrs and
then slows down
• The girls complete foot growth at 12 yrs, and the
boys at 14 yrs.
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10. Normal variations
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11. Normal variations
• Clinically, the foot position might be affected by the
intrauterine crowding.
• The foot is correctable.
• The most common positional variations are
metatarsus adductus and calcaneovlagus feet.
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12. Normal variations
• Accessory ossification centers are very common and
might be confused with fracture lines…
– Clinical correlation.
– X-ray of the other side.
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13. Os Trigonum
• It is the lateral border for the FHL grove in the back
of the talus
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14. Os Trigonum
• Between the ages 8-11 yrs, the secondary
ossification center appears, and it fuses within 1
year.
• Injury to Os Trigonum occurs with forceful plantar
flexion.
• Clinical and radiological evaluation.
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15. Os Trigonum
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16. Os Trigonum
• Conservative treatment should be tried first.
• Surgical excision for resistant cases.
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17. Accessory Navicular
• It is the most accessory bone associated with
symptoms.
• Prevalence 16-26%.
• Type 1: small ossicle within tibialis posterior tendon
(true sessamoid).
• Type 2: small ossicle medial and plantar to navucular
and connected with cartilage.
• Type 3: fused type 2.
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18. Accessory Navicular
• Symptoms are caused by
repeated micro fractures and
chronic inflammation.
• Originally was correlated to
flatfoot development, but
recently the association is
rejected.
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19. Accessory Navicular
• MRI and bone scans can differentiate the symptomatic
ones.
• Treatment is mainly conservative:
– Shoe wear modification.
– Insoles.
– Casting.
– Local injections.
• Surgical treatment in resistant cases:
– Drilling.
– Excision with tibialis posterior preservation.
– Kinder procedure (excision with tibialis posterior lateral
placement).
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20. Osteochondroses
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21. Köhler's Disease
• Osteochondrosis of the
navicular bone.
• Boys more than girls.
• Age 2-7 yrs.
• Mifoot pain from days to
months.
• Resulted from:
– ? Repeated stresses
– ?AVN
• Treatment is always
conservative with excellent
outcome.
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22. Freiberg's Infraction
• Adolescence disorder affecting the
head of the 2nd Met.
• Occasionly involves other Mets.
• Resulted most likely from AVN.
• More in girls.
• ? Affecting the longest Mets.
• Local symptoms and signs.
• Initial treatment is conservative.
• Surgical treatment includes MTP
debridement, osteotomy, or
excision.
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23. Congenital and Developmental
Foot Deformities
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24. Metatarsus Adductus
• It is considered as a postural foot deformity
secondary to intrauterine crowding.
• In its simple form, the forefoot is adducted in
relation to a neutral and flexible hindfoot.
• It is associated to torticollis and DDH.
• The incidence varies between 0.1%-1%.
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25. Metatarsus Adductus
• The deformity can be classified into:
– Mild: the deformity can be actively corrected.
– Moderate : the deformity can be passively corrected.
– Severe: the deformity is not completely correctable.
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26. Metatarsus Adductus
• Treatment (after exclusion of DDH):
– Mild : observation.
– Moderate: ? Observation ? Stretching ? Casting.
– Severe: serial casting .
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27. Metatarsus Adductus
• Surgical treatment:
• Reserved for resistant cases after the age of 4 yrs.
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28. Metatarsus Adductus Complex
(Skewfoot)
• It a metatarsus adductus
associated with rigid heel
valgus.
• S-shaped foot, serpentine
foot, or Z-foot.
• Very rare foot deformity.
• Treatment is controversial.
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29. Talipes Calcaneovalgus
• It is the commonest foot
postural deformity.
• Excessive dorsiflexion and
limited plantar flexion.
• Associated with DDH (other foot
metatarsus adductus).
• Posteromedial bowing of the
tibia has to be ruled out.
• Natural history is excellent.
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30. Flexible Flatfoot
(Pes Planovalgus)
• Probably, it is the most common “deformity”
evaluated by pediatric orthopedists.
• The parents and pediatricians perceive this foot as an
“abnormal” and “deformed” foot.
• Flexible flatfoot is a normal foot variation.
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31. Flexible Flatfoot
(Pes Planovalgus)
“ flatfeet are usual in infants,
common in children, and within
the normal range in adults”
Lynn Staheli
Staheli LT, Chew DE, Corbett M: The longitudinal
arch. A survey of eight hundred and eighty-two feet
in normal children and adults. J Bone Joint Surg Am
1987; 69:426
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32. Flexible Flatfoot
(Pes Planovalgus)
• Clinical evaluation of flexible flatfoot is
not accurately defined.
• Assessment on standing position:
– Hindfoot valgus.
– Depressed or absent foot arch (head of
the talus is touching the ground).
– Abducted (and secondarily supinated)
forefoot.
• Deformities disappear in sitting position
or standing on tip toe.
• ? Achilles tendon shortening
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33. Flexible Flatfoot
(Pes Planovalgus)
• Radiographic measures for
flatfoot are not clearly defined.
• Lateral Talo-first Met angle
(Meyer’s angle) to measure the
midfoot sagging.
• AP Talo-Calcaneal angle (Kite’s
angle) to measure hindfoot
valgus
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34. Flexible Flatfoot
(Pes Planovalgus)
Should the flatfeet be treated?
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35. Flexible Flatfoot
(Pes Planovalgus)
NO
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36. Flexible Flatfoot
(Pes Planovalgus)
• Flexible flatfeet function as the normal feet with
arch, if there is no shortening in Achilles tendon.
• Rigid deformities should be excluded.
Harris R, Beath T: Army Foot Survey: An Investigation of Foot
Ailments in Canadian Soldiers, Ottawa: National Research
Council of Canada; 1947:1.
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37. Flexible Flatfoot
(Pes Planovalgus)
• Orthotics and shoe insert is only for pain relief not
for foot arch formation.
• Stretching exercises for the patients with Achilles
tendon shortening.
• Surgical treatment should be considered only for
symptomatic patients resistant to conservative
measures.
• Surgical outcomes for flatfeet is not favorable in
49%-77%.
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38. Flexible Flatfoot
(Pes Planovalgus)
• Surgical options:
– Achilles tendon lengthening with
• Arthrodesis (subtalar or triple).
• Lateral column lengthening (Evans procedure).
• Plication of talonavicular joint.
• Calcaneum-cuboid-cuniform (triple C ) osteotomy.
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39. Flexible Flatfoot
(Pes Planovalgus)
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40. Flexible Flatfoot
(Pes Planovalgus)
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41. Flexible Flatfoot
(Pes Planovalgus)
Further Readings
Scott Mubarak,
M.D.
Vincent
Mosca, M.D7/22/2020
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42. Tarsal Coalition
• It is an abnormal connection between 2 or more
bones of the foot that produces limitation in the
ROM.
• The most common is talo-calcaneal coalition.
• Incidence is 0.03%-1.0%.
• “Peroneal Spastic foot”.
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43. Tarsal Coalition
• Familial
• Usually presents as a painful stiff
flatfoot at the age 12-13 yrs.
• Hindfoot valgus is not fully
correctable.
• Plain radiographs (AP, Lateral, oblique,
and Harris calcaneal view).
• Anterior talar beak
• CT scan is the definitive diagnostic
study.
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44. Tarsal Coalition
• Conservative treatment may be successful in almost
70% cases.
– Orthotics and casting.
• Surgical treatment for resistant cases:
– Excision and interposition:
• Calcaneonavicular coalition
– Fusions:
• Talocalcaneal coalition
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45. Vertical Talus
(congenital convex pes valgus)
• The foot resembles “ Rocker
Bottom”.
• ? Due to muscular imbalance.
• Mostly associated with
neuromuscular diseases (50%)
but it can present as isolated
deformity.
• Spina bifida, arthrogryposis,
trisomy 13-15-18.
• Unilateral or bilateral (50%).
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46. Vertical Talus
(congenital convex pes valgus)
• The hindfoot is fixed in equinus.
• The forefoot is fixed in dorsiflexion,
valgus position.
• The apex of the “Rocker” is the
talar head.
• The navicular is dislocated and sets
on top of talar neck.
• Deformity is not passively
correctable.
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47. Vertical Talus
(congenital convex pes valgus)
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48. Vertical Talus
(congenital convex pes valgus)
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49. Vertical Talus
(congenital convex pes valgus)
• Treatment of the vertical talus is usually surgical.
• The extent of the procedure is related to the severity
of the deformity.
– Single or double stage release.
– Dorsal release.
– STR with excision of navicular.
– STR with subtalar fusion.
– Triple arthrodesis or talectomy (salvage).
• Serial casting (reverse Ponseti casting) with minimal
soft tissue release shows promising results..
Dobbs M, et al. J Bone Joint Surg Am. 2006 Jun;88(6):1192-200.
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50. Clubfoot
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51. Clubfoot
• Congenital talipes equinovarus defomity.
• It is one of the commonest pediatric orthopedic
problems (1 :1000 births).
• Male: Female 3:1.
• Up-to 50 % bilateral.
• It can be isolated or associated with other congenital
anomalies.
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52. Clubfoot
• Family history is strongly associated.
• ? Genetics.
• Association with hip dysplasia is debatable .
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53. Clubfoot
Patho-anatomy
• The deformity in clubfoot
is formed by 4 elements :
– Cavus of the midfoot.
– Adduction of the forefoot.
– Varus of the hindfoot.
– Equinus of the ankle.
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54. Clubfoot
Patho-anatomy
• Talo-navicular joint is
subluxated medially .
• The posteromedial soft
tissues are contracted.
• Wide range of
neuromuscular changes
were found.
• Absent dorsalis pedis
vessels is common.
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55. Clubfoot
Clinical Assessment
• Pre natal US can detect clubfoot.
• Child with clubfoot should be examined carefully.
• General examinations should rule out associated
spine anomalies and neurological impairment.
• Other joint deformities can point out presence of
arthrogryposis.
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56. Clubfoot
Clinical Assessment
• Local examination of the clubfoot should focus on the
severity and rigidity of the deformity.
• Classify the clubfoot :
– Typical
– Atypical :
• Rigid deformity
• Associated with neuromuscular and genetic problems.
• Small and chubby foot.
• Short first ray.
• Deep and long medial crease.
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57. Clubfoot
Clinical Assessment
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58. Clubfoot
Clinical Assessment
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59. Clubfoot
Clinical Assessment
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60. Clubfoot
Management
Ignacio Ponseti
1914-2009
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61. Clubfoot
Management
http://www.global-
help.org/publications/books/help_cfponseti.pdf
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62. Clubfoot
Management
• The clubfoot is treated with serial
casting that will take the foot in a
step wise correction.
• The first element of clubfoot
deformity to be corrected is cavus.
• Correction of adduction will follow.
• The last element is equinus, and
usually requires Achilles tendon
tenotomy.
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63. Clubfoot
Management
• The total number of casting varies
between 4-10 according to the
severity of the deformity.
• The best final position that should be
targeted is 60-70 deg of abduction,
and 15 deg of dorsiflexion.
• After the tenotomy, the cast is applied
for 3 weeks to maintain the final
position.
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64. Clubfoot
Management
• The child is then fitted in “boots and
bar” splint that will hold the feet in
70 deg of abduction and 15 deg of
dorsiflexion.
• The splint should be worn for at
least 3 months continuously, and
then at bed times till 4 years.
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65. Clubfoot
Management
• Clubfoot treated by Ponseti method is expected to
have a good to excellent long term outcome in 78%
of patients (compared to 85% in people with no
clubfoot) .
• Additional procedures are required in 93% (usually
Achilles tendon tenotomy alone or with tibialis
anterior tendon transfer).
Cooper DM, Dietz FR. Treatment of idiopathic clubfoot: a thirty year
follow-up note. J Bone Joint Surg 1995;77A:1477e89.
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66. Clubfoot
Management
• Atypical clubfoot should be
recognized and treated with
the modifies Ponseti
technique.
• Response to conservative
treatment is less favorable
and relapse rate is high.
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67. Clubfoot
Management
• Surgical release of the clubfoot is reserved for the
resistant cases to conservative treatment.
• For easier surgical dissection, the procedure is
delayed till the foot reaches a reasonable size.
• It requires a delicate soft tissue dissection to avoid
injury to neurovascular structures.
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68. Clubfoot
Management
• Two types of skin incisions are used
for the complete clubfoot soft tissue
release:
– The posteromedial skin incision
(Turco incision).
– The posterior circumferential skin
incision (Cincinnati incision)
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69. Clubfoot
Management
• Surgical steps:
– Isolate and protect the
posterior NV bundle.
– Release 4 tendons, 4
joints capsule, and 4
ligaments.
– Plantar fasciotomy.
– Relocate and stabilize
the TN joint.
– Repair the tendons in
the corrected position.
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70. Clubfoot
Management
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71. Clubfoot
Management
• Up-to 4yrs, soft tissue releases alone can correct the
clubfoot deformity .
• In older ages bony procedures should be considered
due to the development of permanent bony changes.
– Cuboid wedge osteotomy.
– Midfoot osteotomies.
– Triple arthrodesis.
– Talectomy.
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72. Clubfoot
Management
• Complications:
• Under-correction.
• Relapse (recurrence).
• Overcorrection.
• Dorsal bunion.
• Stiffness.
• Wound problems.
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73. Clubfoot
Management
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74. Cavus foot
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75. Cavus foot
• A foot deformity characterized
by an elevated longitudinal
arch.
• Caused by fixed plantar flexion
of the forefoot (mainly the first
ray).
• Mostly, it is a developmental
foot problem secondary to
neurological conditions.
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76. Cavus foot
• First step in management is to diagnose or role out
an associated neurological diseases:
– Charcot-Marie-Tooth
– Freidreich's ataxia
– Cerebral palsy
– Polio
– spinal cord lesions
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77. Cavus foot
• Muscular imbalance between tibialis anterior and
peroneus longus causes the first ray to drop.
• The heel compensates in to varus position.
• The toe extensors will overact as ankle dorsiflexors to
compensate for Tib.Ant weakness causing clawing of
the toes
• Deformities starts as flexible and correctable, then
end as a rigid non correctable.
• Coleman block test is performed to assess the
hindfoot flexibility.
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78. Cavus foot
Management
• Conservative:
– Semi-rigid insole orthotic.
– Effective in mild cases only.
• Surgical :
– Bony:
• First metatarsal osteotomy.
• Midfoot osteotomy.
• Calcaneal valgus osteotomy.
• Claw toes reconstruction.
• Triple arthrodesis
– Soft tissue:
• Plantar fasciotomy.
• Tendon transfer.
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79. Thank You
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