Human-AI Co-Creation of Worked Examples for Programming Classes
Flat foot and Cavus foot
1. Pes Cavus and Pes Planus
Moderator:PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSc(HON)
Director&HOD
Presentor:Dr.Thouseef A Majeed
2. ANATOMY OF THE ARCHES OF FOOT
A) Two longitudinal arches
– Medial longitudinal arch
– Lateral longitudinal arch
B) Transverse arch
• Anterior transverse arch
• Posterior transverse arch
3. USE OF THE ARCHED FOOT
Supports body weight in upright posture
Acts as a lever to propel the body forwards in walking,
running and jumping
Acts as a shock absorber
Concavity of the arches protects the soft tissues of the sole
against pressure
4. Medial longitudinal arch
• Higher than lateral
• Composed of – Calcaneous
- Talus
- Navicular
- 3 cuneiform
- 3 metatarsals
• Talar head is key stone of this arch
5. • Tibialis anterior attached to – 1st metatarsal,medial cuneiform –
strength for this arch.
• Peroneus longus tendon – pass laterally to this arch providing
support
6. Lateral longitudinal Arch
• Flatter than medial longitudinal arch.
• Rests on the ground during standing.
• It is made up of – calcaneous, cuboid, 2 lateral
metatarsals.
7. Transverse arch
• Runs from side to side
• It is formed by – cuboid,
cuneiforms, bases of
metatarsals
• Medial and lateral parts
of longitudinal arch act as
pillars
• Tendons of fibularis
longus and tibialis
posterior
8. Integrity of bony arches
• Maintained by passive factors and dynamic
supports
9. Passive factors
• Shape of the united bones
• Four successive layers of fibrous
tissue – bowstring the longitudinal
arch
– Plantar aponeurosis
– Long plantar ligament
– Plantar calcaneocuboid (short
plantar) ligament
– Plantar calcaneonavicular
(spring) ligament
10. Dynamic supports
• Active bracing action of intrinsic muscles of foot
• Active and tonic contraction of muscles with long
tendons extending in to foot
– Flexor hallusis and digitorum longus – longitudinal arch
– Fibularis longus and tibialis posterior – transverse arch
• Plantar ligaments and plantar aponeurosis bear
greatest stress and important in maintaining arches
11. MECHANISM OF ARCH SUPPORT
SHAPE OF BONES
• Bones are wedge-shaped with the thin edge lying inferiorly
• This applies particularly to the bone occupying the center of
the arch“keystone”
12. MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE
• Medial longtitudinal arch: Tibialis anterior, Tibialis
posterior, medial ligament of ankle joint
• Lateral longtitudinal arch: Peroneus longus, Peroneus
brevis
• Transverse arch: Peroneus longus
16. Defenition
• Cavus is an acquired or congenital deformity
of the foot ,characterized by excessive high
longitudinal plantar arch combined with
clawing of the toes .
20. Development of the deformity
• The intrinsic musculature
normally flexes the
metatarsophalyngeal joint
and extends the
interphalyngeal joint.
21. • When the long flexor contracts on the straight digit it slings
up the heads of the metatarsals and prevents the drop of the
forefoot on the hind foot
• In the absence of lumbricals ,the long flexor pulls the toes
into flexion and no longer supports the metatarsal head.
22. • So the forefoot drops and the lax structures in the sole
contracts and forms claw foot.
• Dropping of fore foot on the hind foot followed by a
contracture of the plantar fascia and clawing of the
toes
23. CLINICAL FEATURES
• High arch.
• Hyper extension of toes at
metatarso-phalyngeal joint
• Hyper flexion at the inter-
phalyngeal joints.
• Pronation and adduction of
the fore foot .
24. • Lengthened lateral border of foot
and shortened medal border.
• Callosities beneath the metatarsal
heads
• A bony dorsum of mid-foot with
wrinkled skin folds on the medial
plantar aspect
25. Radiographic findings –pes cavus
Standing weight bearing Antero –posterior and Lateral views
X Rays taken to
• Demonstrate the apex of the deformity
• Talo calcaneal ankle
• Calcaneal pitch
• Degree of plantar flexion of the great toe
• Asess the contribution of cavus by hind foot,midfoot and
fore foot
26. DEGREES OF PES CAVUS
• 5 degrees
First degree pes cavus
• Child is clumsy with repeated falls
• Foot appears normal
• Deformity appears when foot is relaxed
• Child catches his toes against low objects such as edges of
carpet.
• Mild extensor weakness
27. Treatment of first degree pes cavus
• Daily manipulation –supinating fore foot and everting heel
• Anterior arch bar in shoes
• If not corrected then Girdle stone tendon transfer
operation.
28. • Through an incision on each toe
extending distally from metatarso-
phalyngeal joint .
• Long and short toe flexors are brought
to lateral aspect of proximal phalynx
and sutured to the extensor expansion.
29. Second degree pes cavus
• Flexion of the fore foot
• Plantar fascia is felt to be tense and contracted
• Clawing of great toe .
• Great toe clawing can be corrected by upward pressure on
the ball of great toe.
30. Treatment of second degree Pes cavus
• A shoe fitted with a metatarsal bar may give temporary
relief.
• Stiendlers Procedure : Plantar fascia release
• Jones Procedure:The Extensor hallucis longus tendon is
divided at its insertion and passed though the neck of first
metatarsal + Interphalyngeal joint fusion.
32. Third degree pes cavus
• The arches of foot is markedly raised.
• All toes are clawed .
• Tendocalcaneus may begin to appear contracted.
• Painfull callosities are seen.
• Deformities are rigid and cannot be corrected by finger
pressure under Ist metatarsal head
33. Treatment of third degree Pes cavus
• Stiendlers procedure +Muscle sliding
operation.
• Japas ‘ V‘osteotomy of tarsus : Apex of V is
proximal and highest point of cavus
• Dwayers Calcaneal Ostetomy
35. Fourth degree pes cavus
• In addition to cavus and claw toes
• Adduction at tarsometatarsal joints resulting in varus
deformity.
• Rigid and painful foot
• Walking becomes painful and difficult.
36. Fifth degree-pes cavus
• Seen on paralytic conditions.(poliomyelitis)
• Whole foot is contracted into rigid equino varus with high
arch.
• Tender callosities.
• The patient is very disabled .
37. Treatment of fourth and fifth degree Pes cavus
• Dunns triple arthrodesis
• Lambrinudis arthrodesis
(triple arthrodesis :subtalar+calcneo cuboid +talo
navicular joint fusion)
• Cols Anterior tarsal wedge osteotomy
41. Definition
• Absence of normal medial longitudinal arch
• Instep of the foot collapses and comes in
contact with the ground.
• In some individuals, this arch never develops
42. Other abnormalities
• Heel valgus
• Mild subluxation of subtalar joint(talus tilts medially
and plantarwards)
• Eversion of the calcaneus at the subtalar joint
• Lateral angulation of midtarsal joints (Talo Calcaneal
,Calcaneo Cuboid)
• Supination of forefeet
43. • Flat feet are a common condition.
• In infants and toddlers, the longitudinal arch is not
developed and flat feet are normal.
• The arch develops in childhood
• By adulthood (12-13yrs), most people have
developed normal arches
45. Types
• Flexible –on weight bearing it disappears and
on non weight bearing it reappears
• Rigid – acceptable medial longitudinal arch
does not seen even on non weight bearing
• Flexible, painless is most common
46. Etiology
Flexible
Developmental – the most common
Hypermobile (ligamentous hyperlaxity; Ehlers-Donlos, Marfans)
Neurogenic( rare and usually cause the reverse-Pes Cavus)
Rigid
Congenital (Tarsal coalition,Vertical talus)
Aquired )inflammatory)
47. SYMPTOMS
Deformity
• Foot pain ,ankle pain, leg pain
• Heel tilts away from the midline of the body more than
usual
• Abnormal shoe wear
48. FLAT FEET CAN produce
• Tendonitis. posterior tibial tendon and it can either fail,
rupture, stretch or just hurt. This condition is called
POSTERIOR TIBIAL DYSFUNCTION (PTD OR TPD) .
• Arthritis.
• Plantar fasciitis
• Bunions & Hammertoes
• Corns and callosities
49. Radiography
• Asymptomatic flatfoot radiological evaluation unnecessary
• First Antero posterior and Lateral views of the foot should
be taken to evaluate severity of deformity
• Antero-posterior ankle to rule out valgus at the distal end of
tibia
• Special view - 45 degree eversion oblique for accessory
navicular bone
50. Radiography
• AP standing view is to asses heel valgus , Talocalcaneal
angle more than 35 degree is associated with incresed heel
valgus
• CT scan accurately defines anatomy of subtalar joint ,
allows surgical plannig if it is involved.
51. Meary’s Angle
• Most common angle to indicate
flat foot
• Intersects at apex of the
deformity
• Meary’s angle - between long
axis of talus and long axis of
first metatarsal on a standing
lateral X ray
52. Normal Meary's angle:long axis
of the talus should bisect the
navicular and first metatarsal
0 degrees – normal
0 – 15 degrees – mild
15 – 40 degrees – moderate
> 40 degrees – severe
The long axis of the talus is angled plantarward in relation to
the first metatarsal, consistent with pes planus
53. Treatment
0-3 years old:
No treatment unless very strong family hx of persistent
flatfeet
Orthotic shoes with thomas heels ,medial heel wedges and
navicular pads
Convince the parents.
57. Surgical treatment
• The surgeon , patient, and parents must be willing to
exchange loss of eversion and inversion of the foot
for relief of pain and disability .
58. Surgical treatment
• Arthrodesis for relieving painful flat foot have been
most successful when the subtalar joint is involved .
• Although midtarsal arthtrodesis without inclusion of
the subtalar joint has gained popularity
60. Durham plasty for pes planus
A, Incision.
B, Elevation of posterior tibial
tendon.
C, Elevation of osteo-periosteal
flap from proximal to distal.
D, Arthrodesis of navicular–first
cuneiform joint.
E, Extent of arthrodesis resection
through midfoot.
F, Internal fixation of navicular–
first cuneiform joint.
61. •
pull the posterior tibial tendon taut
into its prepared bed on the plantar
surface of the waist of the
navicular, and tie the suture
dorsally
63. Posterior calcaneal displacement
osteotomy(koutsgiannis)
• Symptomatic patients with excessive heel valgus , a
calcaneal osteotomy is intended to displace the
posterior part of the calcaneum medially , to restore
normal Weight bearing alignment
65. AGE
• Usually done after the age of 12
• Triple arthrodesis tend to have a high (50%) failure rate in
children under 10 years of age;
• contra-indicated in young children (less than 10-12 yrs)
because the procedure limits foot growth
69. Clinical presntation
• Often incidental, many patients are asymptomatic
• Pain
• Prominence of medial aspect of foot
• On attempted inversion of the foot against resistance
, Tibialis posterior tendon is inserted into the bump
and this maneuver produces pain
70. Radiography
• Special view - 45 degree eversion oblique for
accessory navicular bone
• Antero-Posterior view and Lateral weight bearing
views of the foot should be taken to evaluate other
deformities
72. Radiological types
• TypeI–Small ossicle in the substance of Tibialis Posterior
tendon (os tibiale externum or naviculam secondorium )
• Type II –Triangular frangment larger than type I connected
to navicular bone by a cartilaginous synchondrosis
• Type III – Cornuate navicular resulting from fusion of the
accessory navicular with main body of navicular
74. Kidners procedure
• Excision of accessory navicular bone and rerouting of
Tibialis Posterior tendon into a more plantar position
• Parents should be informed before surgery that pain
may not be alleviated completely
75. “Our feet are no more alike than our
faces”
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