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Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine

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Page 1: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Evaluation of Pediatric Foot Radiographs

Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine

Page 2: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

I have no commercial disclosures.

Page 3: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

The Foot Book by Dr. Seuss

Page 4: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Ossification Centers Newborn: • Metatarsals and

phalanges – (fetal 8-12 wks)

• Calcaneus – (fetal 23 wks)

• Talus – (fetal 25 wks)

• Cuboid – (at birth)

C T

Cu

T C

Cu

Page 5: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Navicular bone: •2-5 years •eccentric ossification

Page 6: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 7: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 8: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Terminology

• Talipes: (Latin talus = ankle, pes = foot) congenital foot and ankle deformity

• Pes: (Latin: foot) “acquired” foot deformity

Page 9: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

• Hindfoot: talus and calcaneus • Midfoot: navicular,

cuneiforms, cuboid • Forefoot: metatarsals, phalanges

F

M

H

Terminology

Page 10: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Varus Valgus

midline midline

(eversion, pronation) (inversion, supination)

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Page 11: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Radiologic Evaluation • AP and lateral weight-bearing or

simulated weight-bearing • Additional:

– flexion (dorsal or plantar) – tangential (Harris-Beath) – 45 degree medial oblique views

Page 12: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 13: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal Anatomy Lateral View (weight-bearing)

Page 14: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal Anatomy Lateral View (weight-bearing)

Page 15: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal Anatomy Lateral View (weight-bearing)

• Tibial-calcaneal angle = 70 - 90o

Page 16: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 17: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Equinus

Page 18: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Equinus •Fixed calcaneal plantarflexion •Tibial-calcaneal angle >90o

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Page 19: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 20: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Calcaneus

Page 21: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Calcaneus

• Fixed calcaneal dorsiflexion

• Tibial-calcaneal angle < 60o

Page 22: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

hss.edu

Page 23: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal Anatomy Lateral View (weight-bearing)

Page 24: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

•Talo-calcaneal angle = 30o- 45o

Normal Anatomy Lateral View (weight-bearing)

Page 25: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 26: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal Anatomy AP View (weight-bearing)

Page 27: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

• Talo-calcaneal angle = 30°- 45o (decreases with age)

Normal Anatomy

Page 28: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

turbosquid.com

Page 29: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

turbosquid.com

Everything revolves around the talus

worldofstock.com

Page 30: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal AP View medial lateral

Page 31: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

T C

5

Page 32: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

T C

5

Hindfoot valgus

Page 33: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot valgus

Page 34: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

C T

5

Page 35: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot varus

C T

5

Page 36: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot varus

Page 37: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 38: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot Valgus

• Axis of talus is medial to 1st MT

• Talo-calcaneal angle > 45°

Page 39: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot Valgus

Page 40: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

• Increased talo-calcaneal angle > 45°

Hindfoot Valgus

Page 41: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 42: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

•Axis of talus is lateral to 1st MT

•Talo-calcaneal angle < 30°

Hindfoot Varus

Page 43: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot Varus

Page 44: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

• Talo-calcaneal angle < 30o

Hindfoot Varus

Page 45: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 46: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot Alignment

Normal

midline

Valgus Varus

N

Page 47: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Normal Valgus Varus

N

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midline

Page 48: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

The Foot Book by Dr. Seuss

Page 49: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Metatarsus Adductus

• 10x’s more common than clubfoot • “Intrauterine packing” • 1-10% incidence of developmental

dysplasia of the hip (DDH) • Radiographs: rigidity,

other deformities

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Page 50: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Metatarsus Adductus

• Normal talo-calcaneal angle

• Adducted forefoot

Page 51: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 52: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Clubfoot (talipes equinovarus)

• 1-4:1000 live births • Boys > girls • Unilateral > bilateral • Multifactorial inheritance

modified by intrauterine and environmental factors

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Page 53: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

•Equinus •Hindfoot varus

Clubfoot

Page 54: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Clubfoot

•Hindfoot varus

Page 55: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

•Hindfoot varus •Forefoot varus

Clubfoot

Page 56: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 57: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 58: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

The Foot Book by Dr. Seuss

Page 59: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

• Standard in infants, common in children

• Radiographs for rigidity, loss of subtalar motion

• Treatment for pain, severe progression

• Longitudinal arch reconstitutes

Flexible Flatfoot (pes planus, flattened longitudinal arch)

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Page 60: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

• Normal heel • Hindfoot valgus • “Relaxed talus” • Talonavicular association

on lateral view maintained

Flexible Flatfoot

Page 61: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 62: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Hindfoot Valgus

• Hindfoot valgus

Page 63: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 64: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Congenital Vertical Talus (congenital rigid rocker-bottom foot, congenital flatfoot with

talonavicular dissociation)

• Most severe form of congenital rigid flatfoot

• Plantar surface of foot is convex (rocker-bottom)

• Associated with neuromuscular imbalance • Contracted soft tissues; all eventually

need surgery

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Page 65: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Congenital Vertical Talus

• Equinus heel • Extremely plantarflexed talus • Hindfoot valgus • Talonavicular dissocation

Page 66: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

No change in alignment with plantarflexion (vs pes planus) or dorsiflexion

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Page 67: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Flat Foot

Flexible Flatfoot Congenital Rigid (pes planus) (congenital vertical talus)

Hindfoot valgus Hindfoot valgus

Normal heel Equinus heel

Talonavicular association Talonavicular dissociation

Reconsituted arch No change with flexion

Page 68: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Skewfoot (Z-foot, S-foot)

• Rigid • Hindfoot valgus: resembles flatfoot • Forefoot varus: resembles clubfoot

Page 69: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Skewfoot (Z-foot, S-foot)

• Hindfoot valgus, • Rigid forefoot varus

Page 70: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati
Page 71: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

YOUR TURN: The Foot Book by Dr. Seuss

Page 72: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

QUESTION #1:

Page 73: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

This foot alignment is:

1. Rigid flatfoot

2. Hindfoot varus

3. Normal

4. Metatarsus adductus

QUESTION #1:

Page 74: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

QUESTION #2: This foot alignment is:

a) Hindfoot valgus and forefoot adductus

b) Equinus and hindfoot varus

c) Equinus and hindfoot valgus

d) Due to a post-operative complication

Page 75: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

QUESTION #2:

Page 76: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

This foot alignment is:

a) Hindfoot valgus and forefoot adductus

b) Equinus and hindfoot varus

c) Equinus and hindfoot valgus

d) Due to a post-operative complication

QUESTION #2:

Page 77: Evaluation of Pediatric Foot Radiographs - pedrad.org · Evaluation of Pediatric Foot Radiographs Tal Laor, M.D. Cincinnati Children’s Hospital Medical Center University of Cincinnati

Thank you!