Orthopedic Review (Pediatric)- Calcaneovalgus Calcaneovalgus: Incidence - 1/1000 live births - Male < female (.

61:1) - More likely in 1st borns; young mothers

Clinical signs Flexible flatfoot Calcaneus posture o (DF, PF) Valgus heel, limited inversion Tight anterior & lateral structures o Feel tight ext. tendons Low arch, prominent medial talus

Etiology Pressure of uterine walls Primigravida (1st pregnancy) Neurologic cause (severe cases) Tethered cord

Treatment Mild in infancy: - daily stretching 20-30X, 4X/day - Strapping/taping, open toed straight last shoes Moderate to severe in infancy: - serial plaster casts (PF & supinate foot, adduct forefoot, mold medial & lateral arches, reduce forefoot varus) Post cast maintenance- open-toes straight last shoes 23 hours/day - Best treated 1st yr of life - Child 1-3 impractical to cast, UCBLs during day (at least 2 years) Surgical (rare)- staged soft tissue release; ligaments 1st, then tendons Early aggressive casting typically results in full correction

Radiographic DP view: talar bisection medial to 1st metatarsal , TC angle > 40 (HIGH) Lateral view: tulus bisects lower or below cuboid, talus plantarflexed, talus often overlaps anterosuperior portion of calcaneus

- Extra skin folds dorsolaterally - Taut skin dorsomedially o up and out - Maintains off weight bearing - Apply ABductory force and all bones except talus move in ABduction - Overstretched Achilles tendon - Forefoot varus noted

Look for other deformities! - Posteromedial bowing (short leg) - Metatarsus adductus on the other foot - Windswept deformity Differential Diagnosis Convex pes valgus (much more rigid) Acquired pes planus (flat foot) Tarsal coalition (wont see until puberty) Neuromuscular disorder (will see hypertonia)

Rationale for treatment - Within 1st year of life! - Left untreated = symptomatic flat foot, permanent muscle imbalance - Severe cases = dislocation of peroneal tendons - Abnormal joint relationships may develop if untreated

:congenital flat foot, type of clubfoot, up and out deformity, postural deformity, non-teratologic

Postural deformities: calcaneovalgus, postural TEV, metatarsus adductus, extension contracture of knee, congenital pelvic obliquity, torticollis

Appleton

Clinical signs Rigid flatfoot Plantar convexity (unlike calcaneovalgus, which is overstretched from DF) Tight heel cord Heel in valgus & equinus Forefoot abducted & DF @ MPJ (rearfoot in equinus) Deep creases on dorsolateral aspect of foot (also seen in CV) Etiology Unknown High incidence (50%) associated with congenital anomalies, genetic syndromes & neuromuscular diseases Myelomeningocoele, spinal dyspraphism, trisomy 13-15, arthrogryposis, marfan syndrome, CDH, TEV Acquired: Static encephalopathy

Pathologic Anatomy Talus fixed in vertical with hypoplasia of head and neck Calcaneus in valgus & equinus with no anterior TC articulation STF facets hypoplastic or absent Calcaneocuboid jnt may or may not be subluxed Lateral column of foot concave Toe extensors, tib ant, peroneals, triceps surae (shortened) Tibionav & talonavic ligament shortened Post ankle & STJ capsules contracted (released in surg) Spring lig & plantar medial TN jt capsule stretched (ONLY thing overstretched, everything else will try to release and stretch) Post tib & peroneal tendons anteriorly displaced (acting as DF rather than PF)

Congenital Convex Pes Valgus: Treatment Incidence - Depends on: age, severity, underlying - RARE: 1/10,000, 1/10 neuromusc disorder, calcaneocuboid frequency of TEV subluxation (poor prognosis) - 50% B/L, right > left Serial Casting: - Male = female
Forefoot PF, inverted, and ADucted (supinated) TA is stretched by pulling calcaneus plantarly into varus while DF anterior aspect of calcan

Radiographic DP view: TC angle >50 (infants) >40 in children 5+ Lateral view: talus vertical below the cuboid, calcaneus in equinus, forefoot DF, soft tissue is convex, dorsal dislocation of nav. on the talus Stress PF view: Convex pes valgus (talus does not bisect metatarsal axis in lateral stress PF lateral; talus does not line up with mets) Oblique talus or calcaneovalgus (malaligned in lateral view but aligned in stress PF view) Tamba & Camba: Used to distinguish flexible oblique talus from congenital vertical talus Used 1st met base & calcaneal axis TAMBA > 60 CAMBA > 20

Differential Diagnosis - Younger child, calcaneovalgus, oblique talus - Older child with rigid flatfoot: Tarsal coalition, peroneal spastic flat foot without coalition, post traumatic rigid flat foot

Open Reduction of TCN jnt in 1 stage procedure in child UNDER 2 Case by case presentation of pathologic anatomy dictates correction Approach: - release or lengthen of contracted structures - Tightening of elongated anatomy (spring ligament, TN jnt capsule) - Maintenance of TN jnt reduction by muscle tendon transfer and pinning Most reconstructions: - Release TN capsule - TAL(possibly deep posterior release if necessary) - Lengthening of ext. and peroneal tendons - Placation of medial and plantar struct - Tib ant lengthened or transferred - Once soft tissue released: talus & navic can be reduced and maintained with Kwire Child over 3: ST extraarticular arthrodesis - Excision of navic (length of med column) - Talectomy, lateral column lengthening, tendon transfers for rebalancing, tiple arthodesis (wait until 12 y/o)

Post-Op management Continued observation, PT, bracing Complications: perioperative-infection, skin slough, wound healing 1-2 yrs post op recurrence usually due to undercorrection Late-

NOT Postural: Congenital vertical talus, Rocker bottom foot, rigid flatfoot, congenital flat foot due to talonavicular dislocation

Appleton