MCQs-peds foot 2
dynamic (seen in swing phase) is best treated with some sort of tendon transfer like a SPLAT (split anterior tibialis transfer) or a tib post transfer through the interosseous membrane.
– the pathoanatomy behind clubfoot deformity includes medial and plantar rotation of the talar neck, relative lateral rotation of the body (the ankle mortise I think is EXTERNALLY rotated), and medial rotation of the calcaneus. There is some controversy about whether there is internal or external rotation of the talus and whether there is internal rotation of the tibia.
– treatment of clubfoot should begin the day of birth with serial casting.
– in terms of some of the abnormalities in clubfoot – the calf circumference is small (and likely will remain so); there is shortening and medial deviation of the neck of the talus; the answers suggest that there is increased thickness of the nerve fibers and dysplasia of the tendons in the foot – but I’m not sure about this – there is no mention in Lovell and Winter about abnormalities of the nerve fibers or of dysplasia of the tendons.
– during serial casting of the clubfoot, the supination and adduction of the forefoot is corrected first; after that, then try to correct the equinus. Don’t try to do both at once – you may get a midfoot break.
– the ideal time for clubfoot surgery is controversial, but probably sometime between 4-12 months.
– beware the neonate with rigid clubfeet and inability to fully extend the hips or knees – probably an arthrogrypotic. Consider congenital dislocations of the knees and hips, but usually the knees are hyperextended in congenital dislocation – ie. extension is not a problem in congenital knee dislocation; nor is a problem in the dislocated hip either (they have incomplete abduction.)
– clubfoot is associated with a number of disorders: PFFD, Pierre Robin, Larsen’s syndrome, amniotic bands, myelodysplasia, arthrogryposis, diastrophic dysplasia); it is not, as far as people have looked, associated with Alpert’s syndrome, Albright’s syndrome, or Alper’s disease, or Apert’s syndrome.
– options for the 16 year old with pain and a tarsal coalition associated with talonavicular arthritis – tough question, but probably this child should have a triple arthrodesis. If you are gonna do the TN joint, then probably should do the subtalar and calcaneocuboid. Her arthritis makes her not a candidate for excision of bar.
– the results of treatment of calcaneal navicular coalition are dependent on the adequacy of resection and interposition of something – usually fat or extensor digitorum brevis origin. Peroneus tertius is way lateral and not available for interposition.
– in congenital metatarsus varus, the navicular is dislocated LATERAL to the talus.
– in congenital calcaneal valgus foot deformity, this is a common finding and is a packaging problem. Most resolve spontaneously or with the help of the parents doing gentle stretching exercises; if not, serial casting can be applied.
– a patient with bilateral pes cavus with a hairy patch on her back, and an ulcer on her one foot likely has a diastematomyelia or some form of myelomeningocele (which almost always has a tethered cord). Clinical findings of diastematomyelia include hair patches, anisomelia (calf or thigh circumference asymmetry) and foot deformities (usually cavus). Interestingly, they have often UNILATERAL foot deformities or calf/thigh asymmetry.
– in terms of predicting a good result from casting a clubfoot – look for divergence of the calcaneus and talus on Kite’s angle (a Kite’s angle of 20-40 is good). Bad findings include a deep medial crease, parallelism of the calcaneus and talus, and a short first ray.
– pathoanatomy of clubfoot: lateral rotation of the talar body, medial rotation of the talar neck, medial rotation of the calcaneus which is in VARUS, not valgus.
– metatarsus adductus is associated with torticollis. The heel is in valgus, not varus. Usually ankle ROM is normal.
– the position of the foot in congenital