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Cavus Foot

Cavus Foot. N. Craig Stone M.D. F.R.C.S.(C) Discipline of Orthopedic Surgery Sept 29, 2003. Cavus Foot Introduction. Definition Anatomy and Pathomechanics Etiology and differential diagnosis Evaluation Clinical and radiographic Treatment. Cavus Foot Definition.

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Cavus Foot

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  1. Cavus Foot N. Craig Stone M.D. F.R.C.S.(C) Discipline of Orthopedic Surgery Sept 29, 2003

  2. Cavus FootIntroduction • Definition • Anatomy and Pathomechanics • Etiology and differential diagnosis • Evaluation • Clinical and radiographic • Treatment

  3. Cavus FootDefinition • Abnormal elevation of the medial arch in weight bearing • Fore foot equinus relative to hindfoot • ?what’s normal/abnormal

  4. Normal Anatomy and Biomechanics • Forefoot deformity and the windlass mechanism of the plantar fascia causative • Plantar fascia • Calcaneal tuberosity – Transverse metatarsal lig – slips to base of prox phalanx • Medial and central portions strongest • Stabilizes arch and inverts (with tib post) the hindfoot

  5. Anatomy and Biomechanics • Chopart’s joint supple when hindfoot everted • Heel strike – hindfoot inverted • Midstance – hindfoot everted • Shock absorption – now hindfoot supple • Toe off

  6. Anatomy and Biomechanics • Toe off • Toes dorsiflex • Tib post fires • All to lock hindfoot • Gives a rigid, long lever for triceps surae

  7. Pathomechanics • Foot musculature unbalanced • Usually intrinsic muscle weakness • Lumbrical weakness allows EDL to hyperextend the MCP’s and FDL to flex the PIP and DIP’s • Exaggeration of the windlass mechanism

  8. Pathomechanics

  9. Pathomechanics • Same applied to EHL and FHL • 1st ray more mobile – makes it worse, forefoot supinates and may become fixed • Secondary hindfoot varus • Tripod effect

  10. Pathomechanics

  11. Pathomechanics • So why does it hurt? • Inverted hindfoot loses shock absorption ability • Recurrent ankle sprains • Tripod effects (less surface area) • Clawing of toes

  12. Etiology • CNS • Spinal • Peripheral Nerves • Other • Idiopathic

  13. Etiology - CNS • CP esp. hemiplegia • Spastic tib post • Friedreich’s Ataxia (A. Recessive chrom 9) • Triad – ataxia, downgoing Babinski, areflexia

  14. Etiology - Spinal • Myelodysplasia • Syringomyelia • Polio • Spinal cord tumors • Tethered cord • Guillain-Barre syndrome

  15. Etiology – Peripheral Nerves • Hereditary Sensorimotor Neuropathy (HSMN) • Charcot Marie Tooth

  16. Etiology - Other • Traumatic Isolated Tendon Injuries • Partial Sciatic Nerve injury • Volkman’s Contracture

  17. Etiology - Idiopathic • 20-50% of cases - mostly bilateral

  18. Clinical Evaluation • History • Other neuro symptoms • Ulcers, numbness, bowel, bladder, Dev. Delay • Family History • Ankle Instability • Metatarsalgia

  19. Clinical Evaluation • Physical • Dysraphism • Neuro exam • Coleman Block Test

  20. Coleman Block Test

  21. Radiographic Assessment • Standing AP and Lateral of Foot and Ankle • Assess angles (severity) and any evidence of degenerative change • Spinal Imaging as required

  22. A – Meary’s Angle N = 0 – 5 Degrees B – Calcaneal Pitch Angle N = 30 degrees C – Hibbs Angle N = <45 degrees D – Weight Bearing Tibioplantar Angle N = 90 degrees

  23. Management • Blah, Blah, Blah • Orthotics • For mild, non progressive deformity • Lateral forefoot and hindfoot posting • Large toe box shoes

  24. Management • Surgical • Treat underlying problem • Must decide if hindfoot is supple • Everyone gets a plantar fascial release • Fixed – Supple is often subjective • Combination of procedures

  25. Management • Hindfoot supple • Toe deformity correction • Girdlestone-Taylor • Forefoot correction • Metatarsal osteotomies • Midfoot osteotomy • Is there any role for a Jones procedure?

  26. Management • Hindfoot supple • Tendon Transfers • If identifiable muscle imbalance • Split Tib post to peroneus brevis • Peroneus longus to brevis • Be careful in progressive disease

  27. ManagementRigid Hindfoot

  28. ManagementRigid Hindfoot • If deformity severe or Degenerative Changes exist • Triple Arthrodesis

  29. Summary • Rare problem • Know causes and clinical assessment • Principles of treatment

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