docEvaluation of Pediatric Foot Pain
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Evaluation of Pediatric Foot Pain
John Flibotte, MS III Gillian Lieberman, MD May 2006 Evaluation of Pediatric Foot Pain John Flibotte, Harvard Medical School Year III Gillian Lieberman, MD John Flibotte, MS III Gillian Lieberman, MD Our Patient… AP is a 10 year old boy with chronic R foot pain 2 John Flibotte, MS III Gillian Lieberman, MD Anatomy of the Foot Manusov EG, et al. (1996), Part II 3 John Flibotte, MS III Gillian Lieberman, MD DDX of Pediatric Foot Pain Forefoot/ Midfoot Foot Pain Structural Abnormality •Overlapping/ Curly Toes •Accessory Navicular Infectious •Osteomyelitis Repetitive/ Acute Trauma •Onychocryptosis (Ingrown Nail) •Hallux Valgus •Turf Toe Tumor/ Growth •Bone Cysts •Ewing’s Sarcoma •Osteoid Osteoma •Synovial Sarcoma •Sesamoiditis •Sesamoid Stress Fx •Frieberg’s Disease (AVN of second metatarsal epiphysis) •Stress Fracture •Fracture •Kohler’s Disease (Ischemic Necrosis of Navicular) 4 John Flibotte, MS III Gillian Lieberman, MD DDX of Pediatric Foot Pain Hindfoot Pain Foot Pain Structural Abnormality •Pes Planus (Flatfoot) Infectious •Osteomyelitis •Flexible •RigidÆ Tarsal Coalition •Os Trigonum Syndrome Repetitive/ Acute Trauma Tumor/ Growth •Plantar Fasciitis •Bone Cysts •Calcaneal Apophysitis (Sever’s Disease) •Ewing’s Sarcoma •Calcaneal Stress Fx •Osteoid Osteoma •Synovial Sarcoma •Retrocalcaneal Bursitis (Haghund’s Disease) •Lisfranc Joint Sprain •Ankle Sprain •Osteochondritis dessicans •Fracture 5 Manusov EG, et al. (1996), Parts I & II John Flibotte, MS III Gillian Lieberman, MD Anatomy of the Calcaneus http://education.yahoo.com/reference/gray/subjects/subject?id=63 6 John Flibotte, MS III Gillian Lieberman, MD Anatomy of the Talus-1 Lateral View Fibular Facet Medial View Tibial Facet Navicular Facet 7 http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1 John Flibotte, MS III Gillian Lieberman, MD Anatomy of the Talus-2 Inferior Aspect Navicular Facet Middle Articular Facet (for sustentaculum tali) Posterior Articular Facet 8 http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1 John Flibotte, MS III Gillian Lieberman, MD Standard Views of the Foot • Lateral • Oblique • Anteroposterior ----------------------------------------------------------One Special View: Harris Beath View 9 John Flibotte, MS III Gillian Lieberman, MD Obtaining a Lateral View http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html 10 John Flibotte, MS III Gillian Lieberman, MD Normal Lateral Radiograph of Foot http://www.rad.washington.edu/RadAnat/FootLateral.html 11 John Flibotte, MS III Gillian Lieberman, MD Normal Lateral Radiograph of Foot http://www.rad.washington.edu/RadAnat/FootLateralLabelled.html 12 John Flibotte, MS III Gillian Lieberman, MD Oblique Radiograph of Foot http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html 13 John Flibotte, MS III Gillian Lieberman, MD Normal Oblique Radiograph of Foot http://www.rad.washington.edu/RadAnat/FootOblique.html http://www.rad.washington.edu/RadAnat/FootOblique 14 Labelled.html John Flibotte, MS III Gillian Lieberman, MD AP View of the Foot http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html 15 John Flibotte, MS III Gillian Lieberman, MD Normal AP Radiograph of the Foot http://www.rad.washington.edu/RadAnat/FootAP.html http://www.rad.washington.edu/RadAnat/FootAPLabelled.html 16 John Flibotte, MS III Gillian Lieberman, MD Obtaining the Harris Beath View http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html 17 John Flibotte, MS III Gillian Lieberman, MD Our Patient’s Initial Radiographs John Flibotte, MS III Gillian Lieberman, MD Our Patient’s Lateral Views Loss of Middle Facet Space Narrowed Joint Space Narrowed Joint Space Loss of Foot Arch Children’s Hospital Boston 19 John Flibotte, MS III Gillian Lieberman, MD Our Patient’s Oblique Views Normal Appearance Children’s Hospital Boston 20 John Flibotte, MS III Gillian Lieberman, MD Patient’s Harris Beath Views R Loss of Talocalcaneal Joint Space Children’s Hospital Boston L Loss of Talocalcaneal Joint Space 21 John Flibotte, MS III Gillian Lieberman, MD Patient’s Coronal CT Bilateral Bony Fusion Children’s Hospital Boston 22 John Flibotte, MS III Gillian Lieberman, MD Diagnosis: Talocalcaneal coalition John Flibotte, MS III Gillian Lieberman, MD Discussion of Coalition • Results from abnormal differentiation and segmentation of primitive mesenchyme with resultant lack of joint formation • Postulated autosomal dominant inheritance with variable penetrance • 50%-60% are Bilateral • Prevalence 1-2% • Can occur between any tarsal bone; talocalcaneal and calcaneonavicular coalitions are most common Newman & Newberg (2000) 24 John Flibotte, MS III Gillian Lieberman, MD Types of Coalition • Osseous • Fibrous • Cartilaginous 25 John Flibotte, MS III Gillian Lieberman, MD Pathogenesis of Coalition Limitation of Normal Subtalar & Midfoot Motion Inflammation of Involved Joints Irritation of Peroneal Tendon Crossing Subtalar Joint Peroneal Tendon Spasm “Peroneal Spastic” Rigid Flatfoot 26 Manusov EG, et al. (1996), Part II John Flibotte, MS III Gillian Lieberman, MD Talocalcaneal Coalition-1 • Coalition between the talusÆ calcaneus – Most commonly between middle facet of talus and sustentaculum tali of calcaneus • Represents 48% of all Tarsal Coalitions • Typically become symptomatic in 8-12 y.o. children • Imaging Modalities: – – – – – – Difficult to see on standard views May be suggested by loss of foot arch Harris Beath View to demonstrate subtalar joint May need fine-cut CT May also be seen on MRI If a bone scan is done, will show as area of increased uptake Newman & Newberg (2000) 27 John Flibotte, MS III Gillian Lieberman, MD Talocalcaneal Coalition-2 • Secondary Plain Film Signs: – – – – – Talar beak Narrowing of the subtalar joint Rounding of the lateral talar process Lack of depiction of middle facets on lateral C-sign • Secondary Signs on CT: – Talar beak – Joint Narrowing – Broadening and down-sloping of sustentaculum tali Newman & Newberg (2000) 28 John Flibotte, MS III Gillian Lieberman, MD Middle Facet on Lateral • Short solid arrow: middle facet • Long solid arrow: posterior facet • Open arrow: lateral process of talus (anterior extent of posterior facet) • Normal= Open space Companion Normal Case Liu PT, et al. (2003) 29 John Flibotte, MS III Gillian Lieberman, MD Absence of Middle Facet • Curved arrow: talar beak • Long arrow: loss of middle facet space • Short arrows: C-sign present • Loss of posterior facet space Companion Coalition Patient Case Liu PT, et al. (2003) 30 John Flibotte, MS III Gillian Lieberman, MD Talar Beak • Secondary to impaired subtalar joint motion • Represents navicular overriding the talus • Periosteal elevation occurs at site of talonavicular ligament • Osseous repair results in talar beak Companion Coalition Patient Case Newman & Newberg (2000) 31 John Flibotte, MS III Gillian Lieberman, MD C-Sign • Results from bone bridging between talar dome and sustentaculum tali • Seen in osseous and non-osseous coalition • Varies based on sustentaculum size and orientation Companion Coalition Patient Case Newman & Newberg (2000) 32 John Flibotte, MS III Gillian Lieberman, MD Another Patient with Coalition 9 year old girl with Chronic R foot pain 33 John Flibotte, MS III Gillian Lieberman, MD Our Patient 2 Bone Scan Focal Areas of Increased Tracer Uptake Children’s Hospital Boston 34 John Flibotte, MS III Gillian Lieberman, MD Patient 2 Sagittal CT R L Bony Fusion Children’s Hospital Boston Preserved Joint Space 35 John Flibotte, MS III Gillian Lieberman, MD Calcaneonavicular Coalition • • • • Coalition between calcaneusÆ navicular Represents 43% of all Tarsal Coalitions Typically become symptomatic in 12-16 yo children Best Imaging Modality: – Plain Film, 45 degree internal oblique – May also be seen on CT, MRI, bone scan • Ragiographic Signs: – Bony Bar (seen with osseous coalition) – Bones in close proximity, irregular surfaces, anteromedial calcaneus is widened/ flattened (seen with fibrous or cartilaginous coalition) – Hypoplasia of the talus – Anteater sign Newman & Newberg (2000) 36 John Flibotte, MS III Gillian Lieberman, MD “Anteater” Sign Companion Coalition Patient Case www.peeperandfriends.com Newman & Newberg (2000) 37 www.porpoiserecords.com John Flibotte, MS III Gillian Lieberman, MD How did they come up with that anteater sign? John Flibotte, MS III Gillian Lieberman, MD “Anteater” Sign Companion Coalition Patient Case www.peeperandfriends.com Newman & Newberg (2000) 39 www.porpoiserecords.com John Flibotte, MS III Gillian Lieberman, MD “Anteater” Sign www.peeperandfriends.com Newman & Newberg (2000) 40 www.porpoiserecords.com John Flibotte, MS III Gillian Lieberman, MD Performance of Secondary Signs • The next slide shows the individual performance of secondary signs evaluated in a retrospective blinded study • Table shows that individual stand alone signs have a low sensitivity, but high specificity 41 John Flibotte, MS III Gillian Lieberman, MD Performance of Secondary Signs 42 Crim & Kjeldsberg (2004) John Flibotte, MS III Gillian Lieberman, MD Combination of all Secondary Signs • Evaluated both retrospectively and prospectively by attending and resident radiologists • Results: – Calcaneonavicular Coalition • Attending (100% sens, 97% spec) • Resident (80% sens, 98% spec) – Talocalcaneal Coalition • Sensitivity 100% • Specificity 88% 43 Crim & Kjeldsberg (2004) John Flibotte, MS III Gillian Lieberman, MD Treatment • Initially managed conservatively with steroid injections, orthotics • Surgery may be undertaken to separate fused tarsal bones 44 John Flibotte, MS III Gillian Lieberman, MD Conclusions • Coalition is a frequent cause of pediatric foot pain that may present in late childhood or early adulthood • There are many secondary signs of coalition that can be seen on plain film radiographs • The combination of multiple secondary signs is a sensitive and specific way to screen for coalition • CT & MRI may be needed to confirm existence of coalition 45 John Flibotte, MS III Gillian Lieberman, MD References 1. 2. 3. 4. 5. 6. Newman JS, Newberg AH. “Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging.” Radiographics. 2000 Mar-Apr;20(2):321-32. Liu PT, Roberts CC, Chivers FS, Kile TA, Claridge RJ, DeMartini JR, Kenrich RE, Freed LH. "Absent middle facet": a sign on unenhanced radiography of subtalar joint coalition. AJR Am J Roentgenol. 2003 Dec;181(6):1565-72. Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot.” Am Fam Physician. 1996 Aug;54(2):592-606. Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle.” Am Fam Physician. 1996 Sep 1;54(3):1012-26, 1031. Crim JR, Kjeldsberg KM. “Radiographic diagnosis of tarsal coalition.” AJR Am J Roentgenol. 2004 Feb;182(2):323-8. Websites: http://education.yahoo.com/reference/gray/subjects/subject?id=63 http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1 http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html http://www.rad.washington.edu/RadAnat/FootLateral.htm www.porpoiserecords.com www.peeperandfriends.com 46 John Flibotte, MS III Gillian Lieberman, MD Acknowledgements With thanks to: • • • • Muneeb Ahmed, MD Larry Barbaras our Webmaster Gillian Lieberman, MD Pamela Lepkowski 47
