Disorders of the Lower Extremity Page 1 of 3

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Disorders Of The Lower Extremity

Normally developed and functional lower extremities permit locomotion with ease and a minimal amount of energy expenditure. A disability resulting from a deformed, shortened, or painful lower limb can be considerable (see Gait and Gait Disturbances, earlier).

Many problems of the lower extremities occurring in childhood are congenital and, if they remain unrecognized or are unsuccessfully treated, can result in lifelong disability. Knowledge of the normal anatomy and function of the hip, knee, ankle, and foot is necessary to accurately recognize and treat abnormalities in this region (see Lower Extremity Examination, earlier).

Developmental Dislocation of the Hip

Developmental dislocation of the hip, formerly referred to as congenital dislocation of the hip, consists of displacement of the femoral head from its normal relationship with the acetabulum. It is a relatively frequent problem, with an incidence of 1 to 2 per 1000 births. It is generally detectable at birth or shortly thereafter. Female infants are affected significantly more frequently than male infants, and unilateral dislocation is twice as frequent as bilateral. Developmental dislocation may be divided into idiopathic and teratogenic types. Idiopathic dislocation is more frequent, and patients often have a positive family history for the defect. Its severity varies from subluxated, to dislocated and reducible, to dislocated and irreducible. This type of developmental dislocation may be related to abnormal intrauterine positioning or restriction of fetal movement in utero, which impedes adequate development and stability of the hip joint complex. The relaxing effect of hormones on soft tissue during pregnancy may also contribute, with affected infants perhaps being more sensitive to the pelvic relaxation effects of maternal estrogen. A history of breech presentation is not uncommon, and these patients often exhibit generalized ligamentous laxity. Teratogenic dislocations of the hip represent a more severe form of the disorder and are probably the result of a germ plasm defect. They occur early in fetal development and result in malformation of both the femoral head and the acetabular socket. Associated congenital anomalies are common in infants whose dislocations are teratogenic, including clubfoot deformity, congenital torticollis, metatarsus adductus, and infantile scoliosis.

The importance of careful hip evaluation in the newborn and at early infant visits cannot be overemphasized. Early diagnosis enables prompt institution of treatment and results in a better outcome. A knowledge of the clinical signs and skill in techniques of examination are necessary.

Typically, the infant with a dislocated hip has no noticeable difference in the position in which the leg is held, although some affected infants may hold the leg in a position of adduction and external rotation. If the dislocation is unilateral, the skin folds of the thighs and buttocks are often asymmetrical and the involved lower extremity appears shorter than the opposite side (Fig. 21-89, A). This foreshortening is accentuated by holding the hips and knees in 90 degrees of flexion (Galeazzi sign). In patients with bilateral dislocations, this asymmetry is not present. In a truly dislocated hip, the most consistent physical finding is that of limited abduction (see Fig. 21-89, B). Additional diagnostic maneuvers may assist in establishing the diagnosis. In patients with reducible dislocations, the Ortolani sign is positive when a palpable clunk is felt on abduction and internal rotation (relocation) of the hip. The Barlow test is positive if, with the knees flexed and hips flexed to 90 degrees, the hips are gently adducted with pressure applied on the lesser trochanter by the thumb. A palpable clunk indicating posterior dislocation is appreciated if the hip is unstable or dislocated. When the hip is dislocated and irreducible, only limitation of abduction is apparent.

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Figure 21-89 Developmental dislocation of the hip. A, In cases of unilateral dislocation, the involved extremity is foreshortened and the thigh and groin creases are asymmetric. B, Limited abduction of the involved hip is seen. This is a consistent finding in infants with a dislocated and irreducible hip. C, In this anteroposterior radiograph obtained in a 3-month-old child, the proximal left femur is displaced upward and laterally, and the acetabulum is shallow. The femoral head is not visible on the radiograph because of the delayed ossification associated with developmental hip dislocation. D, In the frog-leg view, the long axis of the affected left femur is directed toward a point superior and lateral to the triradiate cartilage, in contrast with that of the right, which points directly toward this structure.

The radiographic findings of a developmental hip dislocation are characteristic. The femoral head is generally located lateral and superior to its normal position, and the acetabulum may be shallow, with lateral deficiency and a characteristic high acetabular index or slope (Fig. 21-89, C and D). Reduction of the dislocated hip is apparent if, on abduction of the hip to 45 degrees, a line drawn through the axis of the metaphysis of the neck crosses the triradiate cartilage (Fig. 21-89, diagram). Because ossification is not evident radiographically until 3 to 6 months of age, ultrasound evaluation of the hip is often helpful in determining the acetabular–femoral head relationships. Furthermore, in developmental dislocation, ossification may be delayed even longer, because normal articulation forces are absent.

In teratogenic hip dislocation, there may be hypoplasia of both the acetabular and femoral sides with noncongruent development of one or both of these structures. The early radiographic findings, however, are similar to those already mentioned.

Successful correction of congenital hip dislocation depends on early diagnosis and institution of appropriate treatment. In the first 6 months of life, use of a Pavlik harness, which permits gentle motion of the hip in a flexed and abducted position, may achieve and maintain a satisfactory reduction. Between 6 and 18 months of age, gentle closed reduction and immobilization in a spica cast with or without surgical release of the contracted iliopsoas and adductor muscles is indicated. After the age of 18 months, reduction by manipulative measures is

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difficult owing to contractures of the associated soft tissues. In such instances open reduction is usually indicated. In cases of teratogenic dislocation, underlying maldevelopment makes the outcome less satisfactory, even with optimal management.

With early recognition and appropriate treatment, a relatively normal hip with satisfactory function can be anticipated in cases of idiopathic hip dislocation. Failure of concentric reduction or complications such as avascular necrosis of the femoral head, resulting from overzealous attempts at closed reduction in long-standing cases, may result in a lifelong disability characterized by pain and stiffness in the hip; an antalgic, lurching gait; and shortening of the involved limb.

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Femoral Anteversion

Femoral anteversion may be viewed as a normal variation of lower extremity positioning in the developing child. In utero and at birth, the femoral neck sits in an anteverted position relative to that of the adult. During childhood it remodels to a position of slight anteversion and normal alignment of the lower extremities. In certain children, however, delayed rotational correction may result in persistent intoeing. An unsightly gait, kicking of the heels, and tripping on walking or running are frequent related complaints. There may be a history of sitting on the floor with knees bent and the lower legs turned outward in a reversed tailor position. In general, the condition is bilateral and is not associated with other musculoskeletal problems.

On examination, the child is noted to stand with the thighs, knees, and feet all turned inward. An increase in internal rotation over external rotation is apparent on assessment of range of motion of the hip (Fig. 21-92). Radiographic findings are normal. No treatment is indicated, other than reassurance that the condition will correct with growth and instructions to avoid sitting in the predisposing position.

Figure 21-92 Femoral anteversion. A, The condition occurs bilaterally, and in the standing view, both legs appear to turn inward from the hip down. B, On assessment of range of motion, the degree of internal rotation of the hips is found to be greater than normal. (Courtesy Michael Sherlock, MD, Lutherville, Md.)

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Genu Varum (Physiologic Bowleg)

Genu varum, or bowleg, is usually a normal variation of lower extremity configuration, seen in the 1- to 3-year-old age group. It is generally recognized shortly after ambulation begins and may be associated with laxity of other joints and internal tibial torsion. Examination reveals diffuse bowing of the lower extremities with an increased distance between the knees that is accentuated on standing (Fig. 21-93). Varus positioning of the heel with pronation of the feet may be noted on weight bearing. The child may walk with a waddling gait and kick the heels on running to clear the feet from the ground and avoid hitting the contralateral limb. Laxity of joint capsular structures may be noted with application of a reduction force.

Figure 21-93 Physiologic genu varum. A, The mild symmetrical bowing seen in this 1-year-old boy represents a normal variation of lower extremity configuration that occurs in toddlers; correction occurs with growth and remodeling. The bowing is diffuse and involves the upper and lower portions of the legs. B, This child has more severe physiologic bowing, which resulted in frequent tripping and a waddling gait. He also had associated ligamentous laxity and intoeing on the left.

Radiographs of children with physiologic bowing show normal osseous and physeal development and may reveal a gentle symmetrical bowing of the femur and tibia. Although there may be slight beaking of the medial metaphyses of the femur and tibia adjacent to the knee joint, there is no fragmentation of the epiphyses or irregularity of the growth plate, as is seen in Blount disease (see Fig. 21-96).

Treatment is rarely indicated, as this condition resolves with growth; in fact, a valgus deformity of the knees may be noted later, at approximately 4 to 5 years of age. Casting, bracing, and corrective shoes are unnecessary, and there is no indication for surgery.

Less commonly, genu varum is of pathologic origin. Conditions such as rickets (see Chapter 6) or other metabolic abnormalities, epiphyseal dysplasia, various forms of dwarfism, and pathologic growth disturbances such as Blount disease may be causative and can be diagnosed on the basis of radiographic findings if the diagnosis is not obvious clinically. Unilateral bowing is not a result of intrauterine positioning and should prompt investigation for an underlying disorder (Fig. 21-94).

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Figure 21-94 Pathologic genu varum. A, This 11-month-old child has a unilateral, right-sided bowleg deformity. When unilateral, genu varum is not a result of intrauterine positioning and necessitates radiographs to determine the cause of the deformity. B, In this case the bowing was caused by a congenital pseudarthrosis of the tibia, a condition frequently associated with neurofibromatosis 1 (see Chapter 15).

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Genu Valgum (Physiologic Knock-Knee)

Genu valgum, or knock-knee, is a normal variation of lower extremity configuration, generally noted in children between 3 and 5 years of age. The phenomenon is part of the normal process of remodeling of the lower extremities during growth and development. It is more frequently seen in females and may be associated with ligamentous laxity. While standing, the child is noted to have an increased distance between the feet when the medial aspects of the knees touch one another (Fig. 21-95). Not uncommonly, the child will place one knee behind the other in an attempt to get the feet together. In some cases, valgus alignment of the feet and a pes planus deformity may be noted. Radiographs reveal no osseous or physeal abnormalities, but accentuation of the angular deformity of the knee secondary to ligamentous laxity is seen on weight-bearing views. One must rule out the possibility of an underlying metabolic condition such as rickets or renal disease. Treatment is generally not indicated, as the condition gradually corrects with time.

Figure 21-95 Genu valgum. This -year-old girl shows moderate knock-knee. Ligamentous laxity and mild pes planus are associated problems.

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Blount Disease

Blount disease is an isolated growth disturbance of the medial tibial epiphysis manifested as an angular varus deformity of the proximal tibia with apparent progressive genu varum. Unilateral and bilateral involvement are seen with nearly equal frequency. The etiology of this condition is unknown, although it appears to be more common in African Americans. It may represent a compression injury to the medial growth plate of the proximal tibia.

On careful examination, a localized angular deformity of the proximal tibia is apparent (Fig. 21-96, A and B), in contrast to the diffuse bowing of the lower extremities seen in patients with physiologic bowleg. In general, there is no evidence of the ligamentous laxity commonly associated with physiologic bowing. Radiographs reveal fragmentation of the medial epiphysis of the tibia associated with beaking and loss of height in this region, as well as the characteristic angular deformity (Fig. 21-96, C). A satisfactory response to treatment depends on accurate diagnosis and early recognition, as bracing or surgical osteotomy with realignment of the leg may prevent further progression.

Figure 21-96 Blount disease. A, This patient has a unilateral angular deformity of the proximal left tibia that gives the appearance of genu varum. B, Both proximal tibias are bowed in another patient as a result of fragmentation and loss of height of the medial epiphyses. In contrast with physiologic bowing, the thighs are straight. C, This radiograph shows the typical fragmentation, loss of height, and angular deformity or beaking of the medial portion of the proximal tibia.

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Internal Tibial Torsion

Internal tibial torsion is a nonpathologic variation in the normal development of the lower leg in children younger than the age of 5 years. It is a rotational deformity that is thought to result from internal molding of the foot and leg in utero. The child is usually brought for evaluation because of concern about prominent intoeing on walking and frequent tripping.

On examination, the hips and knees are found to be normally aligned, with the patellas facing anteriorly, but the lower legs and feet are rotated inward. The lateral malleolus, which is normally positioned slightly posterior to the medial malleolus, may be in alignment with it or even anteriorly displaced, thus causing the ankle mortise to shift to a medially directed orientation, resulting in intoeing (Fig. 21-99). The rotational deformity can be detected by having the patient lie prone on the examining table with the knees flexed (see Fig. 21-14, E). Radiographs reveal no osseous abnormalities. Treatment is seldom indicated; remodeling gradually corrects the condition as the child grows and develops. Children who have a habit of sitting on their feet on the floor may inhibit the normal remodeling process and should be discouraged from doing so. Bracing and special shoes have little effect and are not recommended.

Figure 21-99 Internal tibial torsion. A, On weight bearing the hip, thigh, and knee are normally oriented and the patella faces anteriorly, but the lower leg and foot turn inward. The deformity results in prominent intoeing on walking, which may cause the child to trip frequently. B, In this view of the child while sitting, it is easy to appreciate that the lateral malleolus is positioned anteriorly to the medial malleolus. This shifts the ankle mortise and foot to a medially oriented position.

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Congenital Clubfoot

Congenital clubfoot (talipes equinovarus) is a teratogenic deformity of the foot that is readily apparent at birth. It is seen more frequently in male infants than female infants and has an incidence of 1 in 1000 live births. Etiology is probably multifactorial. Findings from familial incidence studies point toward an underlying genetic predisposition. Abnormal intrauterine positioning and pressure at a critical point in development may contribute as well. Neural, muscular, and osseous abnormalities are other proposed predisposing conditions. A near equal frequency of unilateral and bilateral involvement exists. The deformity is characterized by three primary components: (1) the entire foot is positioned in plantar flexion (equinus); (2) the hindfoot is maintained in a position of fixed inversion (varus); and (3) the forefoot exhibits an adductus deformity, often combined with supination (Fig. 21-100, A-C). In the newborn period the deformity may be passively correctable to some extent. With time, however, deformities become more fixed as a result of contracture of soft tissue structures.

Figure 21-100 Clubfoot. This deformity has three primary components. A, The foot is positioned in plantar flexion (equinus). Note the pathologic skin creases over the heel and arch. B, The heels or hindfeet are fixed in inversion (varus). C, The forefeet are fixed in an adducted

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and supinated position. D, In the anteroposterior radiograph, the talus overlies the os calcis (stacking) and the forefoot is adducted. A line drawn through the longitudinal axis of the talus normally aligns with the first metatarsal, and one drawn through the axis of the os calcis normally aligns with the fifth metatarsal. E, This lateral radiograph shows that the foot is in equinus and the axes of the talus and os calcis are nearly parallel. They normally intersect at an approximately 45-degree angle. (Compare with normal shown in Fig. 21-101.)

The primary pathologic finding is that of a rotational deformity of the subtalar joint with the os calcis internally rotated beneath the talus, producing the characteristic varus deformity of the heel and mechanically creating a block to dorsiflexion of the foot. The navicular bone is in a medially displaced position on the head or neck of the talus, producing the characteristic adductus deformity of the forefoot (Fig. 21-100, D and E). Contractures of the Achilles and posterior tibial tendons and of the medial ankle and subtalar joint capsules appear to be secondary factors that contribute to the difficulty in obtaining anatomic reduction. Congenital absence of certain tendinous structures may be found in rare instances. A small atrophic-appearing calf is frequently noted without pathologic change in its osseous or soft tissue structures. The typical congenital clubfoot deformity must be differentiated from similar foot deformities secondary to neurologic imbalance resulting from myelodysplasia, spinal cord tethering, or degenerative neurologic conditions. On occasion, tibial hemimelia with deficiency of this bone may present a similar clinical picture. The condition should not be confused with the nonteratogenic occurrence of isolated metatarsus adductus. Its association with arthrogryposis and congenital dislocation of the hips should also be kept in mind.

The roentgenographic difference between a clubfoot and a normal foot can be appreciated by comparing Figure 21-100, D and E with Figure 21-101, A and B.

Figure 21-101 Normal foot. Anteroposterior (A) and lateral (B) views of the foot of a slightly older child show the normal orientation of the tarsal bones, as compared with the findings in congenital clubfoot (shown in Fig. 21-100, D and E).

Early treatment consists of attempts at manipulation and serial casting or cast wedging with progressive correction. When the child is seen late or closed treatment is unsuccessful, open reduction and surgical release of the contracted soft tissues is indicated. In general, these measures should be undertaken before the age at which walking is expected in order to prevent the deformity from impeding the child's motor and social development.

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Metatarsus Adductus

Metatarsus adductus (metatarsus varus) is a deformity of the forefoot in which the metatarsals are deviated medially. The condition is probably the result of intrauterine molding and is usually bilateral. Other than the deviation, there are no pathologic changes in the structures of the foot. There is a wide spectrum of severity and resultant intoeing, but otherwise patients are asymptomatic. Clinically it should be distinguished from the more severe and complex deformity of congenital clubfoot, as it carries a more benign prognosis.

Examination is best performed with the foot braced against a flat surface or with the patient standing. With the hindfoot and midfoot positioned straight, the affected forefoot assumes a medially deviated or varus position (Fig. 21-102, A and B). A skin crease may be located over the medial aspect of the longitudinal arch. When mild, the deviation may be passively correctable by the physician or actively correctable by the patient. Active correction may be demonstrated by gentle stroking of the foot, stimulating the peroneal muscles to contract. In more severe cases, the deviation may be only partially corrected by these maneuvers. Some patients have an associated internal tibial torsion deformity, but their calf muscle is normal in size. Radiographs demonstrate the abnormal deviation of the metatarsals medially without other osseous abnormalities (Fig. 21-102, C).

Figure 21-102 Metatarsus adductus. A, In this view from above, the forefeet are seen to be deviated medially, but otherwise the feet are normal. B, When the feet are viewed from the plantar aspect, rounding of the lateral border can be appreciated, along with a crease on the medial side. C, In the anteroposterior radiograph, all five metatarsals can be seen to be deviated medially with respect to the remainder of the foot; otherwise, the bony structures are normal. The relationship of the talus and os calcis is normal, unlike the relationship in clubfoot.

Treatment depends on the severity of the condition. In mild cases, passive manipulation of the deformity by the mother several times a day may suffice. In moderate cases, a combination of manipulative stretching and reverse

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or straight-last shoes may be indicated. More severe cases, which are not passively correctable and which exhibit a prominent deformity and skin crease, necessitate serial manipulation and casting for 6 to 8 weeks. If the deformity persists despite these measures, surgical intervention may be required. Treatment should be undertaken before anticipated ambulation so as to prevent impairment of the patient's motor and social development.

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Metatarsus Primus Varus (Adductus)

Metatarsus primus varus is a congenital and often hereditary foot deformity characterized by a broad forefoot with medial deviation of the first metatarsal. It is significantly more frequent in females than in males. Examination reveals a wide forefoot with medial deviation of the first metatarsal and normal orientation of the second through fifth metatarsals. Often an associated varus deviation of the great toe exists (Fig. 21-103, A). Over time, a secondary hallux valgus deformity and bunion may be produced by the abnormal forces exerted on the great toe with weight bearing and ambulation (see Fig. 21-103, B). The heel may seem narrow, but this is more apparent than real. Pronation of the forefoot may be present as well. Radiographs confirm the diagnosis by revealing an increased space between the first and second metatarsals and a large first intermetatarsal angle. The first ray through the tarsometatarsal joint may be medially oriented, forming the basis for the deformity.

Figure 21-103 Metatarsus primus varus. A, The first metatarsal and great toe are deviated medially, and the forefoot is broad. The other metatarsals are normally oriented. B, Bilateral metatarsus primus varus with hallux valgus. The forefeet are broad, and the great toes deviate laterally. (A, Courtesy Michael Sherlock, MD, Lutherville, Md.)

In mild cases no treatment may be necessary. In moderate or severe cases, foot strain symptoms, bunion pain, and shoe-fitting problems may necessitate treatment. Surgical osteotomy of the medial cuneiform or first metatarsal in conjunction with bunion correction can satisfactorily eliminate the deformity.

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Congenital Vertical Talus

Congenital vertical talus is a teratogenic anomaly of the foot noted at birth and characterized by a severe flatfoot deformity. The underlying pathology is a malorientation of the talus, which assumes a more vertical position than normal. The adjacent navicular is dorsally displaced, articulating with the superior aspect of the neck of the talus and causing the forefoot to assume a dorsiflexed and valgus orientation. In effect, these deformities are the opposite of those seen in congenital clubfoot. The etiology of this condition is unknown, although it may be associated with other musculoskeletal or organ system anomalies. Pathologic analysis reveals normal development of the bones but an abnormal relationship. As in clubfoot, associated soft tissue contractures may occur, particularly of the Achilles tendon, toe extensors, and anterior tibial tendon.

Clinically the deformity is recognizable as a calcaneovalgus foot with loss of the arch or, on some occasions, a rocker bottom–type foot with a prominent heel (Fig. 21-104, A and B). The head of the talus is often palpable on the medial plantar aspect of the midfoot. The deformity is usually fixed, but passive correction may be obtainable in some instances, particularly if the talus is oriented in a less severe oblique position. Radiographs mirror the clinical appearance, showing a vertical orientation of the talus, a calcaneus deformity of the os calcis, and valgus orientation of the forefoot (Fig. 21-104, C; see also Fig. 21-101, B for a normal comparison).

Figure 21-104 Congenital vertical talus. A, The normal longitudinal arch of the foot is absent; a rocker bottom–type deformity is present; and the forefoot is fixed in dorsiflexion, which is even more evident in (B). C, On this radiograph the talus is oriented vertically, and its position does not change with flexion or extension of the ankle. The calcaneus is also fixed in equinus position, resulting in a rigid flatfoot deformity (see Fig. 21 -101, B for comparison).

Initially, attempts at manipulation and serial casting are indicated. However, if this is unsuccessful, as is often the case, surgery may be necessary.

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Calcaneovalgus Foot Deformity

Physiologic calcaneovalgus is another deformity of the foot thought to result from intrauterine molding. It is normally a supple deformity that is passively correctable, in contrast with the rigid foot characteristic of congenital vertical talus. The condition is evident at birth and at times is associated with a contralateral metatarsus adductus. No underlying pathologic changes occur in the foot, and no osseous deformities other than the positional one exist. On examination, the foot is noted to be held in a dorsiflexed and everted position with some loss of the normal longitudinal arch (Fig. 21-105). Tightness of the anterior tibial tendon and laxity of the Achilles tendon may be noted in association with the positional deformity. Radiographs reveal no pathologic bony changes. Nonoperative treatment is usually successful and consists of serial casting to eliminate the deformity. Later, wearing shoes with inner heel wedges and longitudinal arch supports may help prevent recurrence and improve ambulation.

Figure 21-105 Calcaneovalgus foot deformity. The right foot is held in a position of eversion and dorsiflexion. This deformity is supple and thus is passively correctable. The contralateral foot exhibits a metatarsus adductus deformity, giving the feet a “windswept” appearance.

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Pes Planus (Flatfoot)

Pes planus, or physiologic flatfoot, is an extremely common condition to which there is a familial predisposition. It is characterized by laxity of the soft tissues of the foot resulting in loss of the normal longitudinal arch, with pronation or eversion of the forefoot and valgus or lateral orientation of the heel (Fig. 21-106). Secondary tightness of the Achilles tendon may exist. In general, the condition is asymptomatic in children, and evaluation is sought primarily because of parental concern about the appearance of the foot and the possibility of future problems. On occasion, affected patients report discomfort after long walks or running.

Figure 21-106 Pes planus (flatfoot). A, Laxity of the soft tissue structures of the foot results in a loss of the normal longitudinal arch and pronation or eversion of the forefoot. B, Viewed from behind, the characteristic eversion of the heels is appreciated more readily.

On examination the characteristic appearance is easy to recognize, and laxity of other joints, particularly the thumb, elbow, and knee, may be noted. Weight-bearing radiographs reveal loss of the normal longitudinal arch without osseous abnormality. Treatment is unnecessary if the condition is asymptomatic. Corrective shoes with arch supports are of no use unless symptoms of foot strain are present.

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Accessory Tarsal Navicular

An accessory tarsal navicular results from formation of a separate ossification center on the medial aspect of the developing tarsal navicular at the insertion site of the posterior tibial tendon. The condition is not uncommon and is usually associated with a pes planus deformity. Clinically, patients exhibit a bony prominence on the medial aspect of the foot that tends to rub on the shoe, thus producing a painful bursa (Fig. 21-107, A). Radiographs reveal either a separate ossification center or bone medial to the parent navicular, or a medial projection of the navicular when fusion has occurred (Fig. 21-107, B and C). Cast immobilization may be helpful in acutely painful cases. Long-term improvement can be obtained by wearing soft, supportive shoes with longitudinal arches and a medial heel wedge. Recalcitrant symptoms warrant surgical intervention.

Figure 21-107 Accessory tarsal navicular. A, A bony prominence produced by the formation of a separate ossification center of the tarsal navicular is present over the medial aspect of the midfoot. It is covered by a painful bursa, produced by chronic rubbing of the prominence against the medial side of the patient's shoe. Patients with this problem usually have a pes planus deformity as well. B and C, Anteroposterior and lateral radiographs of the foot demonstrate the accessory navicular. The posterior tibialis tendon attaches to the small accessory bone and may contribute to continued irritability and tenderness in this area. Similar extra ossicles are often present asymptomatically on the opposite foot.

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Ganglion of the Foot

A ganglion, or synovial cyst, may develop on the foot. These benign masses are similar to those more commonly seen on the wrist. They originate from outpouchings of a joint capsule or tendon sheath. Trauma may be a predisposing factor in their formation. They are most commonly found on the dorsal or medial aspect of the foot. The mass is soft and nontender and transilluminates. It does not produce symptoms, other than difficulty in fitting shoes (Fig. 21-108). If this occurs, surgical excision may be indicated.

Figure 21-108 Ganglion of the foot. A prominent soft tissue mass is present over the medial aspect of the midfoot. This represents a ganglion of the posterior tibial tendon sheath.

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Cavus Feet and Claw Toes

Cavus feet and claw toes are deformities produced by a muscular imbalance within the foot. Although they may occur for unknown reasons, often they are manifestations of an underlying neurologic disorder such as Charcot- Marie-Tooth disease, Friedreich ataxia, or spinal cord tethering (see Chapter 15). These conditions should be considered in evaluating each patient presenting with these deformities, particularly if the problem is unilateral. Cavus feet exhibit a high arch with a varus or inversion deformity of the heel. Usually the metatarsal heads appear prominent on the plantar aspect of the foot (Fig. 21-109). This phenomenon is accentuated by overlying callosities that develop as a result of abnormal weight bearing. With claw toes, the metatarsophalangeal joints are held in extension with the PIP joints in flexion and the distal joint in the neutral or slightly flexed position (Fig. 21- 110). Calluses tend to develop over the PIP joints as the result of rubbing against shoes. Neurologic examination may reveal motor weakness, most often involving the anterior tibial, toe extensor, and peroneal muscles.

Figure 21-109 Bilateral cavus feet. A, The feet are inverted and have high arches. The deformity is often a feature of neuromuscular disorders, as in this case where it is the result of Charcot-Marie-Tooth disease. B, In addition to the high arches and varus (inverted) heels seen in the view of the plantar surface, the prominence of the metatarsal head region is apparent. Callosities have developed over the lateral borders of the feet as a result of abnormal weight bearing.

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Figure 21-110 Unilateral claw toes. This child with a tethered spinal cord has unilateral claw toe deformities. The metatarsophalangeal joints are held in extension while the proximal interphalangeal joints are fixed in flexion.

Logical treatment necessitates identifying and treating the underlying pathologic condition when possible. Nonsurgical measures for managing the deformities and ameliorating the symptoms consist of the wearing of customized shoes and use of a metatarsal bar to relieve pressure on the metatarsal heads and to correct the extension deformities at the base of the toes. However, surgical correction is often necessary.

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