Talipes Equinovarus

Front 1

Define Talipes Equinovarus

Back 1

-Deformity that is a combination of talipes equinus and talipes varus
-Plantarflexed
-Adducted
-inverted foot

Front 2

Define Talipes Equinovarus

Back 2

-Deformity that is a combination of talipes equinus and talipes varus
-Plantarflexed
-Adducted
-inverted foot

Front 3

What is the incidence of TEV?

Back 3

1/1000

Front 4

What is the Japanese theory of Neuromuscluar dysfunction? What is it's correlation with TEV?

Back 4

Partial interruption of foot innervation and later re-innervation in the intrauterine period.
Theorized to be an Etiological factor of TEV

Front 5

What are the two classifications of clubfeet?
Define them

Back 5

Postural or positional
Fixed or rigid

Front 6

Which classification of TEV is true clubfeet?

Back 6

Fixed or rigid

Front 7

What are the two classifications of fixed or rigid clubfeet?

Back 7

Flexible (correctible w/o surgery)
Resistant (likely requiring surgery)

Front 8

What ethnicity has an abnormally high ratio of TEV births?

Back 8

Polynesians

Front 9

What is the ratio of TEV male: female?

Back 9

2:1

Front 10

What is the bilateral ratio of TEV cases?

Back 10

30-50%

Front 11

What is the chance of a subsequent child having clubbed feet if parents have a prior child born with club-feet

Back 11

1:10, 10%

Front 12

what is TEV incidence in 1st vs second degree relations?

Back 12

First is 1:50, 2% (parents with club feet having children with club feet)
Second- 6%

Front 13

What is the true etiology of congenital clubfoot?

Back 13

The true etiology of congenital clubfoot is unknown. Most infants who have clubfoot have no identifiable genetic, syndromal, or extrinsic cause.

Front 14

What are some extrinsic associations with etiologies of TEV?

Back 14

Extrinsic associations include teratogenic agents (eg, sodium aminopterin), oligohydramnios, and congenital constriction rings.

Front 15

What are some genetic associations associated with etiologies of TEV?

Back 15

Genetic associations include Mendelian inheritance (eg, diastrophic dwarfism; autosomal recessive pattern of clubfoot inheritance).

Front 16

TEV and monozygotic twins:

Back 16

If one monozygotic twin has a CTEV, the second twin has only a 32% chance of having a CTEV

Front 17

TEV is associated with arrest of fetal development in what stage?

Back 17

Fibular Stage

Front 18

What is the main bony deformity in TEV babies?

Back 18

Defective cartilaginous analog of the talus

Front 19

Explain how neurogenic factors are theorized to be a source of TEV in fetuses

Back 19

Histochemical abnormalities have been found in posteromedial and peroneal muscle groups of patients with clubfeet. This is postulated to be due to innervation changes in intrauterine life secondary to a neurological event, such as a stroke leading to mild hemiparesis or paraparesis. This is further supported by a 35% incidence of varus and equinovarus deformity in spina bifida.

Front 20

What was ponsetti's observation of collagen in ligaments . What of the achilles tendon?

Back 20

Ligament and tendons collagen was very loosely crimped and could be stretched.
Achilles tendon was tightly crimped and resistant to stretching

Front 21

What causes Retracting Fibrosis theorized to be involved in TEV?

Back 21

secondary to increased fibrous tissues in muscles and ligaments

Front 22

What did Zimny et al find in medial fascia on electron microscopy that caused medial contracture?

Back 22

Myoblasts

Front 23

Are anomalous tendon insertions a likely factor in the pathophys of clubfeet?

Back 23

No, they may appear anomalous because of the distorted anatomy, but they aren't

Front 24

TEV was observed to be associated with what seasonal disease?

Back 24

Poliomyelitis

Front 25

What two conditions are highly associated with TEV?

Back 25

Spina Bifida
Arthrogryposis (freeman-sheldon syndrome)

Front 26

Myelomeningeocle:

Back 26

Spina bifida, meninges and spinal tissue protruding through a dorsal defect in the vertebrae

Front 27

Lipomeningocele

Back 27

lipoma or fatty tumor located over the lumbosacral spine. Associated with bowel & bladder dysfunction

Front 28

Examine TEV infants with the child prone to visualize___ and supine to ____

Back 28

Examine the feet with the child prone, with the plantar aspect of the feet visualized, and supine to evaluate internal rotation and varus.

Front 29

What is the position of the foot and ankle in TEV?

Back 29

The ankle is in equinus, and the foot is supinated (varus) and adducted (a normal infant foot usually can be dorsiflexed and everted so that the foot touches the anterior tibia).

Front 30

What is the dorsiflexion landmark for TEV?

Back 30

Dorsiflexion beyond 90deg. is not possible

Front 31

What is the position of the calcaneuous in TEV?

Back 31

The calcaneus is not only in a position of equinus, but the anterior aspect is rotated medially and the posterior aspect laterally

Front 32

What is the position of the navicular and cuboid in TEV?

Back 32

The navicular is displaced medially, as is the cuboid.

Front 33

How does the heel feel upon palpation of TEV? as treatment progresses?

Back 33

The heel is small and empty. The heel feels soft to the touch (akin to the feel of the cheeks). As the treatment progresses, it fills in and develops a firmer feel (akin to the feel of the nose or of the chin).

Front 34

Position of the hindfoot, and forefoot to hindfoot in TEV?

Back 34

The hindfoot is supinated, but the foot is often in a position of pronation relative to the hindfoot.
The first ray often drops to create a position of cavus.

Front 35

The position of the Tibia in TEV? Why is this important?

Back 35

The tibia often has internal torsion. This assumes special importance in the casting management of clubfeet, where care should be taken to rotate the feet into abduction, avoiding spurious tibial rotation through the knee.

Front 36

Describe palpation of the talus in TEV.

Back 36

The talar neck is easily palpable in the sinus tarsi as it is uncovered laterally. Normally, this is covered by the navicular, and the talar body is in the mortise.

Front 37

Describe the navicular-malleolar relationship in TEV.

Back 37

The medial malleolus is difficult to palpate and is often in contact with the navicular. The normal navicular-malleolar interval is diminished.

Front 38

Describe the anatomy in TEV: Tibia and fibula

Back 38

Slight shortening is possible
Shortening is common

Front 39

Describe the anatomy in TEV: Talus

Back 39

In equinus in the ankle mortise, with the body of the talus being in external rotation, the body of the talus is extruded anterolaterally and is uncovered and can be palpated. The neck of the talus is medially deviated and plantar flexed. All relationships of the talus to the surrounding bones are abnormal.

Front 40

Describe the anatomy in TEV: Calcaneus (os calcis), Navicular, Cuboid

Back 40

Os calcis: Medial rotation and an equinus and adduction deformity are present.
Navicular: The navicular is medially subluxated over the talar head.
Cuboid: The cuboid is medially subluxated over the calcaneal head

Front 41

Describe the anatomy in TEV: Forefoot

Back 41

The forefoot is adducted and supinated; severe cases also have cavus with a dropped first metatarsal.

Front 42

What leg muscles are especially prone to atrophy in TEV?

Back 42

Peroneal

Front 43

Describe the MM fibers of the leg and foot in TEV.

Back 43

The number of fibers in the muscles is normal, but the fibers are smaller in size.

Front 44

Which muscles are contracted in TEV?

Back 44

The triceps surae, tibialis posterior, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) are contracted.

Front 45

Describe the tendon sheaths of the foot and leg in TEV.

Back 45

Thickening frequently is present, especially of the tibialis posterior and peroneal sheaths.

Front 46

Describe the joint capsules of the foot and leg in TEV.

Back 46

Contractures of the posterior ankle capsule, subtalar capsule, and talonavicular and calcaneocuboid joint capsules commonly are seen.

Front 47

What ligaments are contracted in TEV?

Back 47

Contractures are seen in the calcaneofibular, talofibular, (ankle) deltoid, long and short plantar, spring, and bifurcate ligaments.

Front 48

What is the effect of the contracture of the plantar fascia on the TEV foot?

Back 48

The plantar fascial contracture contributes to the cavus, as does contracture of fascial planes in the foot.

Front 49

What is the classic radiographic feature of clubfeet?

Back 49

Talocalcaneal parallelism
Stacking of the talus and calcaneus. xray should be stimulated weight-bearing

Front 50

Describe the AP lines observed in a radiograph of TEV

Back 50

Measure the talocalcaneal angle in the AP and lateral films.
AP lines are drawn through the center of the long axis of the talus (parallel to the medial border) and through the long axis of the calcaneum (parallel to the lateral border).
They usually diverge by an angle of 25-40°. Any angle less than 15° is considered abnormal.
The AP talocalcaneal lines are almost parallel in clubfeet. As the feet correct with casting or surgery, the calcaneus rotates externally, and the talus reciprocally also derotates to a lesser degree to give a convergent talocalcaneal angle.

Front 51

What position should the foot be in for radiographs when measuring dorsiflexion at the end of tx?

Back 51

AP and lateral views taken in full dorsiflexion and plantar flexion. This is especially important when measuring the total amount of dorsiflexion achieved at the end of treatment, as well as the relative position of the talus and calcaneus

Front 52

A lateral film of untreated TEV will show the calcaneus in what position?

Back 52

A lateral film with the foot held in maximal dorsiflexion is the most reliable method of diagnosing an uncorrected clubfoot since the absence of calcaneal dorsiflexion is evidence that the calcaneus is still locked in varus angulation under the talus.

Front 53

Although abnormalities vary incredibly, what is universal in each clubfoot pt?

Back 53

Nearly Universal - Talus is abnormal in shape and abnormal position related with other bones

Front 54

Which slide has the deformity? Why?

Back 54

Front 55

Diagnosis?

Back 55

Freeman-Sheldon Syndrome

Front 56

Describe the rule of 15s

Back 56

Front 57

What are the four types of clubfoot? (not categories)

Back 57

Front 58

what are the classical landmarks of TEV seen in this image?

Back 58

The simean line (name?)
the crease at the posterior ankle

Front 59

What joint is this? Describe what you see.

Back 59

Front 60

What is the order of the kite method?

Back 60

1- forefoot adduction
2- forefoot supination
3- equinus

Front 61

What is a risk in using the kite method?

Back 61

Attempts to correct equinus first may break the foot, producing a rockerbottom foot. Force must never be used. Merely bring the foot to the best position obtainable and maintain this position by either strapping every few days or by changing casting weekly until either full correction is obtained or until correction is halted by some irresistible force.

Front 62

What is Denham's quote concerning anatomical structures during correction of TEV.

Back 62

“ SOFT TISSUE IS HARD AND BONE IS SOFT”
(DENHAM)

Front 63

According to ponsetti, what causes the cavus deformity in TEV?

Back 63

According to him even though the foot looks in
supination the forefoot is in pronation in relation to
hindfoot. This cause the cavus deformity

Front 64

What is the order of correction with Ponsetti protocol?

Back 64

CAVE
Cavys
Adduction
Varus
Equinus
Start with stretching for 2-3 minutes and then serial weekly casting

Front 65

How to eliminate Cavus deformity in CAVE

Back 65

Foot cavus increases when the forefoot is pronated. If cavus is present, the first step in the manipulation process is to supinate the forefoot by gently lifting the dropped first metatarsal to correct the cavus. Once the cavus is corrected, the forefoot can be abducted.

Front 66

over-all goal of talar movement using CAVE

Back 66

The calcaneal internal rotation (adduction) and plantar flexion is the key deformity.
The foot is adducted and planter-flexed at the subtalar joint, and the goal is to abduct the foot and dorsiflex it.
In order to achieve correction of the clubfoot, the calcaneus should be allowed to rotate freely under the talus, which also is free to rotate in the ankle mortise.
The correction takes place through the normal arc of the subtalar joint.
This is achieved by placing the index finger of the operator on the medial malleolus to stabilize the leg and levering on the thumb placed on the lateral aspect head of the talus while abducting the forefoot in supination.

Front 67

Describe the A of CAVE

Back 67

Correction of adduction:
The forefoot in supination by elevating the first metatarsal and as counter pressure will the be the lateral aspect of talar neck.
When full abduction is achieved the foot is plantigrade.
Usually are needed 6 weekly cast to correct the first three elements of deformity

Front 68

What is the total time requirement to correct TEV?

Back 68

2 months

Front 69

What scalpel blade is used to perform the tenotomy during correction of TEV?

Back 69

61

Front 70

Describe the final cast of the ponsetti method

Back 70

The final cast is applied with the foot in maximum dorsiflexion, and the foot is held in the cast for 2-3 weeks.

Front 71

In a certain %- To maintian lasting correction of the forefoot what procedure can be performed? When?

Back 71

In 10-30% of cases, a tibialis anterior tendon transfer to the lateral cuneiform is performed when the child is aged approximately 3 years. This gives lasting correction of the forefoot, preventing metatarsus adductus and foot inversion. This procedure is indicated in a child aged 2-2.5 years with dynamic supination of the foot. Prior to surgery, cast the foot in a long leg cast for a few weeks to regain the correction.

Front 72

What are the parameters of the Foot abducting bars used at the end of the ponsetti casting?

Back 72

(externally rotated) to 70° with the unaffected foot set at 45° of abduction.
he shoes are worn for 23 hours a day for 3 months and are worn at night and during naps for up to 3 years.

Front 73

What are complications of correcting TEV?

Back 73

Lateral Column Breach
Fracture or crushing of one or more bones

Front 74

What is the correction standard for children over 5 years old?

Back 74

Children older than 5 years require bony reshaping (eg, dorsolateral wedge excision of the calcaneocuboid joint [Dillwyn Evans procedure]) or osteotomy of the calcaneum to correct varus).

Front 75

What is the correction standard if the child is over 10 years old?

Back 75

Lateral wedge tarsectomy or triple fusion (arthrodesis) may be required if the child is older than 10 years (salvage procedures).

Front 76

what is the point of this creepy-ass slide?

Back 76

Front 77

was dis?

Back 77

FAB- foot abduction bars

Front 78

was dis?

Back 78

Wheaton Brace!