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ANATOMY OF FOOT
28 bones including 2 sesamoids.
14 phalanges 5 metatarsals 7 tarsals
anatomy contd
THE FOOT
pliable platform to support the body weight lever to propel the body forward
The ligamentous bony arrangement of the foot allows considerable flexibility/deformation with weight bearing contact
ARCHES OF FOOT
ARCHES OF FOOT
Distinctive feature in man Present since birth Segmented
Provides concavity
CLASSIFICATION OF ARCHES
LONGITUDINAL ARCH
formed between posterior end of calcaneus and head of the metatarsals highest on the medial side MEDIAL LONG. ARCH lowest on lateral side LATERAL LONG. ARCH
TRANSVERSE ARCH
highest in a coronal plane that cuts through the head of the talus
Summit- superior surface of body of the talus. Pillars- The anterior pillar - formed by the talus, the navicular, the 3 cuneiform and the 1st three metatarsal bones. The posterior pillarformed by the medial part of calcaneum. Joint- talocalcaneonavicular joint.
contd
TRANSVERSE ARCHES
ANTERIOR TRANSVERSE ARCH formed by the head of the five metatarsal bones. complete arch
POSTERIOR TRANSVERSE ARCH formed by the greater part of the tarsus and metatarsus. incomplete
MAINTENANCE OF ARCHES
FACTORS RESPONSIBLE
Bony factors Important for the posterior transverse arch Intersegmental ties-(Ligaments /muscles) The spring ligament-for medial longitudinal arch. The long and short planter ligament-for the lateral longitudinal arch. Interosseous muscle-for transverse arch.
FACTORS RESPONSIBLE
Tie beams-(Bowstrings) It connect the two end of the arch. Longitudinal arch- the planter Aponeurosis. The muscles of the first layer of sole. Transverse archadductor hallucis muscle. Slings They keep the summit of the arch pulled up.
contd.
WINDLASS MECHANICS
Engineering concept Windlass mechanics are absolutely essential for correct foot function
coordinated action of the layers of muscle, tendon, ligament and bony architecture, to maintain arch height and foot rigidity. 1st metatarsal must be allowed to planterflex
PES PLANUS
pes planovalgus, fallen arches, flat feet or pronation of feet.
Pes planus contd.. Acquired conditions1. 2. rheumatoid arthritis plantar fascia rupture tibialis posterior rupture
2.
2. tarsal coaliation
3. calcaneovalgus deformity 4. equinovalgus deformity
5. accessory navicular
axis of subtalar joint becomes more horizontal more inversion and eversion
the longitudinal axis is moved more medially (than the normal 23 deg .) more dorsiflexion and plantar flexion this change in the sub-talar axis greater relative inversion-eversion and dorsiflexion and plantar flexion
CLINICAL MANIFESTATIONS
must distinguish between flexible and rigid flat foot
forefoot varus heel cord contracture. Lateral deviation of Achilles with weight bearing; severe Achilles contracture hyperpronation of hind foot. Supination of the forefoot everted heel with fails to invert with toe raise; abducted forefoot;
X- RAYS
Standing lateral: - normal straight line relationship between talus & first metatarsal; lost - sag at either the talonavicular or naviculocuneiform joint; (Talus- 1st metatarsal angleNormal-0* Mild deformity-<15* Moderate deformity-15-30* Severe deformity->30*) Standing AP views: -degree of heel valgus -degree of talo-navicular uncoverage / subluxation;
TREATMENT
NON OPERATIVE: rarely requires treatment
main emphasis of treatment heel cord stretching SUPINATE the foot while stretching in order to "lock the midfoot in most cases orthotics are ineffective in some cases, patients with a calcaneovalgus deformity medial heel wedge can be used many feet improve as the child ages, at least until 5 to 6 yrs old, so orthotics are unnecessary in them.
OPERATIVE PROCEDURES
1. Durham flatfoot plasty (Caldwell; coleman)
Indications are flexible pes planus, failure of prolonged conservative treatment to relieve foot pain, and abnormal shoe wear. Advancement of the tibialis posterior and osteoperiosteal flap with arthrodesis of the navicular first cuneiform joint.
Calcaneum is lengthen by inserting a corticocancellous bone graft just proximal to the calcaneocuboid joint.
4. Triple arthrodesis when the deformity becomes progressively more fixed and symptomatic after 12 years of age
5.. Kinder procedure excision of the accessory navicular and rerouting the tibialis posterior tendon into a more planter position.
..
Pathology
detected at birth by the presence of a rounded prominence of the medial and plantar surface of the foot produced by the abnormal location of the head of the talus. talus is distorted plantarward and medially vertical the navicular lies on the dorsal aspect of the foot anterior and inferior to the lateral malleolus.
With full weight is bearing, the forefoot becomes severely abducted, and the heel does not touch the floor.
Adaptive changes in soft tissue structures also
CLINICAL PRESENTATION
talar head is prominent medially, convex sole, forefoot is abducted and dorsiflexed, & the hind foot is in equinovalgus;
patient demonstrate peg-leg gait (awkward gait with limited forefoot push off);
RADIOGRAPH
PLANTAR FLEXION VIEW: (LATERAL)
In normal foot the long axis of the first metatarsal passes planter ward to the long axis of the talus. In congenital vertical talus the axis of the first metatarsal remains dorsal to the long axis of the talus, indicating dorsal dislocation of the midfoot and forefoot.
TREATMENT
NON OPERATIVE
Conservative treatment controversial
Gentle manipulation and immobilization in cast will facilitate the surgery planned for later date
OPEARTIVE OPTIONS
Age and the severity of the deformity determines the type of surgery. Child between 1-4 yrs Open reduction and realignment of the talonavicular and subtalar joint (Kumar, Cowell and Ramsay). Child with 4-8 years Open reduction and extra articular subtalar arthrodesis (Grice-green procedure) 12 years or more Triple arthrodesis Joystick method
Grice-green procedure
Open reduction and extraarticular subtalar fusion
TARSAL COALITION
failure of segmentation of the primitive mesenchyme Most common type is calcaneonavicular and talocalcaneal coalition. Calcaneonavicular coalitionages 8-12yrs; may be bony, cartilaginous or fibrous
RADIOGRAPH
for CN coalition oblique view lateral view may show talonavicular beaking talocalcaneal coalition C-sign CT-scan: -best study, especially for talocalcaneal coalition.
beaking of anterior aspect of neck of talus associated with middle facet tarsal coalition
Treatment
Initially conservative-a trial of reduced activity or cast immobilization or both is done for 4-6 weeks. Operative:-for persistent pain after conservative treatment. For talonavicular coalition: Excise coalition with wide bone block Interpose extensor digitorum brevis, gel foam or bone wax into the defect to prevent recurrence. For talocalcaneal coalition: In middle facet tarsal coalition, resection of the bar with interposition of flexor hallucis longus or gel foam or bone wax into the defect. Triple arthrodesis-in older patient with degenerative changes.
PES CAVUS
an abnormally high arch
Hyperextension of the toes at the metatarsophalangeal joints. hyper flexion of the interphalangeal joints. Pronation and adduction of the forefoot. A bony dorsum of the midfoot with wrinkled skin folds on the medial planter aspect. Lengthened lateral border and shortened medial border. Callus beneath the metatarsal head. Varied stiffness of the subtalar joint. Varus deformity of the heel. Tightness of the tendoachillis with or without equinus contracture.
ETIOLOGY
associated with neurologic disorders Exact cause can be determined by thorough history & investigations like EMG, MRI & NCV etc.
Causes are: Charcot Marie Tooth disease Poliomyelitis Spinal dysraphism Cerebral palsy Primary cerebellar disease Arthogyropsis Severe clubfoot Friedreich ataxia Post-traumatic Idiopathic
EXAMINATION
Lateral block test (Coleman and Chesnut block test ) Assesses hind foot flexibility of cavovarus foot (flexible feet correct to normal). Muscle strength and flexibility Scoliosis & thorough neurological examination.
Plantar flexed first metatarsal is allowed to hang free from block; supple hind part of foot then corrects
RADIOGRAPHS
In 1940, Brockway stated that cavus feet should never be operated upon until radiographs with the patient standing have been taken. Standing lateral view : assessment of ankle joint position, calcaneal pitch (measures the degree of Calcaneal deformity) & midfoot and forefoot position, (especially the degree of plantar flexion of the 1st ray) -x-ray of the entire spine
TREATMENT
correction of the separate components within the foot and the ankle.
CLAW FOOT
1. For fixed contracture of the MTP & IP joints Lengthening of the EDL & EHL Tenotomy of the EDB & EHB Dorsal capsulotomy of the MTP joints Resection of the head & neck of the proximal phalanges Release of the planter fascia, if indicated. Arthrodesis of the IP joints of the hallux with temporary fixation with k-wires.
b) Modified Jones procedure for clawing of great toe Tendon suspension of the first metatarsal-the EHL tendon is attached to the neck of 1st metatarsal. IP joint arthrodesis with kwire.
FOREFOOT EQUINUS
a) Proximal metatarsal osteotomy and planter fasciotomies (Gould) Double planter fasciotomies. Closing wedge greenstick dorsal proximal metatarsal osteotomies. Jones procedure can be added. Equinus of the forefoot correction may also require the Hibbs procedure- which involves transfer of the EDL tendon to the 3rd cuneiform
MIDFOOT CAVUS
1. Anterior tarsal wedge osteotomy (Cole)
Midtarsal joints are preserved. Plantar fascial release may be required.
2. V-osteotomy
of the
tarsus (Japas)
no bone is excised
Proximal border of the distal fragment of the osteotomy is depressed planter ward Metatarsal head is elevated, thus correcting the deformity and lengthening the planter surface of the foot.
b) Triple arthrodesis
SUMMARY
Arches of the foot are important in distributing the weight of the body and in the gait cycle, especially in stance phase. It acts as shock absorbers while walking and running and also protects the soft tissue of the sole.
Disorders in the arches not only produce abnormality in the foot but also in the ankle, knee, hip, and spine
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