SlideShare una empresa de Scribd logo
1 de 75
Descargar para leer sin conexión
Pes Cavus and Pes Planus
Moderator:PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSc(HON)
Director&HOD
Presentor:Dr.Thouseef A Majeed
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
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
Medial longitudinal arch
• Higher than lateral
• Composed of – Calcaneous
- Talus
- Navicular
- 3 cuneiform
- 3 metatarsals
• Talar head is key stone of this arch
• Tibialis anterior attached to – 1st metatarsal,medial cuneiform –
strength for this arch.
• Peroneus longus tendon – pass laterally to this arch providing
support
Lateral longitudinal Arch
• Flatter than medial longitudinal arch.
• Rests on the ground during standing.
• It is made up of – calcaneous, cuboid, 2 lateral
metatarsals.
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
Integrity of bony arches
• Maintained by passive factors and dynamic
supports
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
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
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”
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
MECHANISM OF ARCH SUPPORT
SUSPENDING THE ARCH FROM ABOVE
PES CAVUS
Synonyms for Cavus Foot
• Schaffer Foot
• Lotus Flower Foot
• Bolt Foot
• Claw Foot
• Vault Foot
• Hollow Foot
• Anterior Equinus
• Pes Cavo Varus
• Contracted Foot
• Talipes (Pes)
Arcuatus
• Talipes Plantaris
Defenition
• Cavus is an acquired or congenital deformity
of the foot ,characterized by excessive high
longitudinal plantar arch combined with
clawing of the toes .
Etiology
Neurological Causes
• Charcot Marie Tooth disease
• Friedrich’s Ataxia
• Roussy-Levy syndrome
• Poliomyelitis
• Cerebral Palsy
Congenital
– Spina Bifida
– Talipes Equinovarus
– Myelodysplasia
– Clubfoot
Iatrogenic
– Post surgery or trauma
– Peroneal nerve injury
Etiology
Infection
– Syphillis
– Poliomyelitis
Idiopathic
– Most common
Development of the deformity
• The intrinsic musculature
normally flexes the
metatarsophalyngeal joint
and extends the
interphalyngeal joint.
• 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.
• 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
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 .
• 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
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
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
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.
• 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.
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.
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.
 Flat foot and Cavus foot
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
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
 Flat foot and Cavus foot
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.
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 .
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
 Flat foot and Cavus foot
PES-PLANUS
Synonyms
• Pes planovalgus
• Flat feet
• Fallen arches
• Pronation of feet
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
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
• 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
Types
 Flexible Can be
 Rigid painless
Painful
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
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)
SYMPTOMS
Deformity
• Foot pain ,ankle pain, leg pain
• Heel tilts away from the midline of the body more than
usual
• Abnormal shoe wear
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
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
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.
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
 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
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.
Treatment
3-9 years
• Conservative management
• No surgery
• Custom orthosis inserted with leather ,cork,
propylene .
Treatment
• 10-14 yrs
• No symptom- No treatment
• Symptomatic – conservative management
initially
• Surgical
Surgical treatment
Indications
1.pain
2.failure to respond to orthotic control
3.Ulceration or callus under the head of the plantiflexed talus
4.Excessive shoe wear
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 .
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
Surgeries
• Durham flatfoot plasty
• Posterior calcaneal displacement osteotomy
• Anterior calcaneal lengthening – distraction
wedge osteotomy
• Triple atrhrodesis (triplane)
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.
•
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
Calcaneal osteotomy (Dilwyn-
Evana,Mosca)
• Lengthening of lateral
column of the foot by
inserting a tibial bone graft
and calcaneocuboidal
fusion
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
Triple Arthrodesis
Joints fused are:
• Subtalar joint
• Calcaneo cuboid joint
• Talo navicular joint
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
Complications
• Nonunion
• Degenerative joint disease
• Avascular necrosis
• Lateral instability
• Stiff foot
Accessory navicular bone
• It is a most common accessory bone in the foot
• Listed as a cause of flat foot
Pathoanatomy
• Abnormal insertion of Tibialis Posterior into
accessory navicular bone believe to cause the flat
foot
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
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
 Flat foot and Cavus foot
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
Treatment
INITIAL TREATMENT –
Conservative- stretcing shoes, avoiding activity
that irritates foot
SURGICAL-
Kidners procedure
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
“Our feet are no more alike than our
faces”
THANK YOU

Más contenido relacionado

La actualidad más candente

Piriformis syndrome
Piriformis syndromePiriformis syndrome
Piriformis syndromeAndy Coleman
 
Rotator cuff injuries
Rotator cuff injuriesRotator cuff injuries
Rotator cuff injuriesrajusvmc
 
Plantar fasciitis
Plantar fasciitisPlantar fasciitis
Plantar fasciitismans4ani
 
Frozen Shoulder Physiotherapy Management
Frozen Shoulder Physiotherapy ManagementFrozen Shoulder Physiotherapy Management
Frozen Shoulder Physiotherapy ManagementVishal Deep
 
Shoulder Instability
Shoulder InstabilityShoulder Instability
Shoulder InstabilityAtif Shahzad
 
Shoulder impingement syndrome
Shoulder impingement syndromeShoulder impingement syndrome
Shoulder impingement syndromeRatan Khuman
 
Rotator cuff Tear and its management
Rotator cuff Tear and its managementRotator cuff Tear and its management
Rotator cuff Tear and its managementRohan Vakta
 
Congenital vertical talus BY DR.NAVEEN RATHOR
Congenital vertical talus BY DR.NAVEEN RATHORCongenital vertical talus BY DR.NAVEEN RATHOR
Congenital vertical talus BY DR.NAVEEN RATHORDR.Naveen Rathor
 
GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT
GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT
GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT Shahid Uz Zafar
 
Limb length discrepency
Limb length discrepencyLimb length discrepency
Limb length discrepencyNaveed Jumani
 
Pes cavus (High ArchFoot) - PHYSIO
Pes cavus (High ArchFoot) - PHYSIOPes cavus (High ArchFoot) - PHYSIO
Pes cavus (High ArchFoot) - PHYSIOSaloni Patil
 
Floor reaction orthosis
Floor reaction orthosisFloor reaction orthosis
Floor reaction orthosisIndra Singh
 

La actualidad más candente (20)

Hip osteoarthritis
Hip osteoarthritisHip osteoarthritis
Hip osteoarthritis
 
Piriformis syndrome
Piriformis syndromePiriformis syndrome
Piriformis syndrome
 
Pes cavus
Pes cavusPes cavus
Pes cavus
 
Rotator cuff injuries
Rotator cuff injuriesRotator cuff injuries
Rotator cuff injuries
 
Plantar fasciitis
Plantar fasciitisPlantar fasciitis
Plantar fasciitis
 
Frozen Shoulder Physiotherapy Management
Frozen Shoulder Physiotherapy ManagementFrozen Shoulder Physiotherapy Management
Frozen Shoulder Physiotherapy Management
 
Ankle Sprains
Ankle SprainsAnkle Sprains
Ankle Sprains
 
Genu varus and valgus
Genu varus and valgusGenu varus and valgus
Genu varus and valgus
 
Hammer toes
Hammer toesHammer toes
Hammer toes
 
Shoulder Instability
Shoulder InstabilityShoulder Instability
Shoulder Instability
 
Arthrodesis
ArthrodesisArthrodesis
Arthrodesis
 
Shoulder impingement syndrome
Shoulder impingement syndromeShoulder impingement syndrome
Shoulder impingement syndrome
 
Rotator cuff Tear and its management
Rotator cuff Tear and its managementRotator cuff Tear and its management
Rotator cuff Tear and its management
 
Congenital vertical talus BY DR.NAVEEN RATHOR
Congenital vertical talus BY DR.NAVEEN RATHORCongenital vertical talus BY DR.NAVEEN RATHOR
Congenital vertical talus BY DR.NAVEEN RATHOR
 
ACL rehabilitation
ACL rehabilitationACL rehabilitation
ACL rehabilitation
 
GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT
GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT
GOLFERS ELBOW AND PHYSIOTHERAPY MANAGEMENT
 
Limb length discrepency
Limb length discrepencyLimb length discrepency
Limb length discrepency
 
Genu recurvatum
Genu recurvatumGenu recurvatum
Genu recurvatum
 
Pes cavus (High ArchFoot) - PHYSIO
Pes cavus (High ArchFoot) - PHYSIOPes cavus (High ArchFoot) - PHYSIO
Pes cavus (High ArchFoot) - PHYSIO
 
Floor reaction orthosis
Floor reaction orthosisFloor reaction orthosis
Floor reaction orthosis
 

Similar a Flat foot and Cavus foot

Arches of the foot and plantar fascitiis
Arches of the foot and plantar fascitiisArches of the foot and plantar fascitiis
Arches of the foot and plantar fascitiisDr Nirav Mungalpara
 
arches of foot of lower limb easy for mbbs and dpt student.pptx
arches of foot  of lower limb easy for mbbs and dpt student.pptxarches of foot  of lower limb easy for mbbs and dpt student.pptx
arches of foot of lower limb easy for mbbs and dpt student.pptxTaroTari
 
Rearfoot Podiatry.pdf
Rearfoot Podiatry.pdfRearfoot Podiatry.pdf
Rearfoot Podiatry.pdfOwen342285
 
Flat Foot, Tibialis Posterior Tendon Dysfunction & Accessory Navicularis
Flat Foot, Tibialis Posterior Tendon Dysfunction & Accessory NavicularisFlat Foot, Tibialis Posterior Tendon Dysfunction & Accessory Navicularis
Flat Foot, Tibialis Posterior Tendon Dysfunction & Accessory NavicularisRizqi D Rosandi MD
 
Ankle joint & bones of foot
Ankle joint & bones of footAnkle joint & bones of foot
Ankle joint & bones of footM S
 
Arches of the foot
Arches of the footArches of the foot
Arches of the footpeebujaanu
 
Flat foot By Dr.Mahbub
Flat foot By Dr.MahbubFlat foot By Dr.Mahbub
Flat foot By Dr.Mahbubdr_mhb21
 
Clinical examination of the foot
Clinical examination of the footClinical examination of the foot
Clinical examination of the footGautam Sinha
 
flat foot.ppt [pes planus ] #physio.# rehabilitation
flat foot.ppt [pes planus ] #physio.# rehabilitationflat foot.ppt [pes planus ] #physio.# rehabilitation
flat foot.ppt [pes planus ] #physio.# rehabilitationPriyankaranawat4
 
Ankle & Foot Xray & Surgical Approaches
Ankle & Foot Xray & Surgical ApproachesAnkle & Foot Xray & Surgical Approaches
Ankle & Foot Xray & Surgical ApproachesMirant Dave
 
Congenital vertical talus
Congenital vertical talusCongenital vertical talus
Congenital vertical talusRziUllah
 

Similar a Flat foot and Cavus foot (20)

Arches of the foot and plantar fascitiis
Arches of the foot and plantar fascitiisArches of the foot and plantar fascitiis
Arches of the foot and plantar fascitiis
 
arches of foot of lower limb easy for mbbs and dpt student.pptx
arches of foot  of lower limb easy for mbbs and dpt student.pptxarches of foot  of lower limb easy for mbbs and dpt student.pptx
arches of foot of lower limb easy for mbbs and dpt student.pptx
 
Ctev
CtevCtev
Ctev
 
Pes planus
Pes planusPes planus
Pes planus
 
Rearfoot Podiatry.pdf
Rearfoot Podiatry.pdfRearfoot Podiatry.pdf
Rearfoot Podiatry.pdf
 
Flat Foot, Tibialis Posterior Tendon Dysfunction & Accessory Navicularis
Flat Foot, Tibialis Posterior Tendon Dysfunction & Accessory NavicularisFlat Foot, Tibialis Posterior Tendon Dysfunction & Accessory Navicularis
Flat Foot, Tibialis Posterior Tendon Dysfunction & Accessory Navicularis
 
Cavus foot
Cavus footCavus foot
Cavus foot
 
Ankle joint & bones of foot
Ankle joint & bones of footAnkle joint & bones of foot
Ankle joint & bones of foot
 
Adult Flatfoot.ppt
Adult Flatfoot.pptAdult Flatfoot.ppt
Adult Flatfoot.ppt
 
Adult flatfoot
Adult flatfootAdult flatfoot
Adult flatfoot
 
ARCHES OF FOOT.pptx
ARCHES OF FOOT.pptxARCHES OF FOOT.pptx
ARCHES OF FOOT.pptx
 
Arches of the foot
Arches of the footArches of the foot
Arches of the foot
 
Flat foot By Dr.Mahbub
Flat foot By Dr.MahbubFlat foot By Dr.Mahbub
Flat foot By Dr.Mahbub
 
Clinical examination of the foot
Clinical examination of the footClinical examination of the foot
Clinical examination of the foot
 
Foot Anatomy.pptx
Foot Anatomy.pptxFoot Anatomy.pptx
Foot Anatomy.pptx
 
27.arches of foot
27.arches of foot27.arches of foot
27.arches of foot
 
flat foot.ppt [pes planus ] #physio.# rehabilitation
flat foot.ppt [pes planus ] #physio.# rehabilitationflat foot.ppt [pes planus ] #physio.# rehabilitation
flat foot.ppt [pes planus ] #physio.# rehabilitation
 
Ankle & Foot Xray & Surgical Approaches
Ankle & Foot Xray & Surgical ApproachesAnkle & Foot Xray & Surgical Approaches
Ankle & Foot Xray & Surgical Approaches
 
Congenital vertical talus
Congenital vertical talusCongenital vertical talus
Congenital vertical talus
 
knee ..pptx
knee ..pptxknee ..pptx
knee ..pptx
 

Más de Dr Thouseef Abdul Majeed (12)

POLYTRAUMA
POLYTRAUMAPOLYTRAUMA
POLYTRAUMA
 
Meniscal Injuries
Meniscal InjuriesMeniscal Injuries
Meniscal Injuries
 
Gouty arthritis
Gouty arthritisGouty arthritis
Gouty arthritis
 
Blood supply of long bones
Blood supply of long bonesBlood supply of long bones
Blood supply of long bones
 
Hemiarthroplasty of Hip joint
Hemiarthroplasty  of  Hip joint Hemiarthroplasty  of  Hip joint
Hemiarthroplasty of Hip joint
 
Chondrosarcoma
ChondrosarcomaChondrosarcoma
Chondrosarcoma
 
Cervical disc prolapse
Cervical disc prolapse Cervical disc prolapse
Cervical disc prolapse
 
ANTERIOR TIBIAL SYNDROME AND REYNAUD''S DISEASE
ANTERIOR TIBIAL SYNDROME  AND REYNAUD''S DISEASEANTERIOR TIBIAL SYNDROME  AND REYNAUD''S DISEASE
ANTERIOR TIBIAL SYNDROME AND REYNAUD''S DISEASE
 
paralytic and postural scoliosis
paralytic and postural scoliosisparalytic and postural scoliosis
paralytic and postural scoliosis
 
Gait
GaitGait
Gait
 
Scoliosis
ScoliosisScoliosis
Scoliosis
 
POLIOMYELITIS ORTHO
POLIOMYELITIS ORTHOPOLIOMYELITIS ORTHO
POLIOMYELITIS ORTHO
 

Último

How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17Celine George
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxKatherine Villaluna
 
Diploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfDiploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfMohonDas
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17Celine George
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxheathfieldcps1
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...Nguyen Thanh Tu Collection
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxMYDA ANGELICA SUAN
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRATanmoy Mishra
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationMJDuyan
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17Celine George
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptxSandy Millin
 
Ultra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptxUltra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptxDr. Asif Anas
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?TechSoup
 
How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17Celine George
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxiammrhaywood
 
Quality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICEQuality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICESayali Powar
 
Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...raviapr7
 
How to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesHow to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesCeline George
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesMohammad Hassany
 

Último (20)

How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
 
Diploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfDiploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdf
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptx
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptx
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
 
Benefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive EducationBenefits & Challenges of Inclusive Education
Benefits & Challenges of Inclusive Education
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
 
Ultra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptxUltra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptx
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?
 
How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17How to Add Existing Field in One2Many Tree View in Odoo 17
How to Add Existing Field in One2Many Tree View in Odoo 17
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
 
Quality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICEQuality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICE
 
Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...
 
How to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesHow to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 Sales
 
Personal Resilience in Project Management 2 - TV Edit 1a.pdf
Personal Resilience in Project Management 2 - TV Edit 1a.pdfPersonal Resilience in Project Management 2 - TV Edit 1a.pdf
Personal Resilience in Project Management 2 - TV Edit 1a.pdf
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
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
  • 13. MECHANISM OF ARCH SUPPORT SUSPENDING THE ARCH FROM ABOVE
  • 15. Synonyms for Cavus Foot • Schaffer Foot • Lotus Flower Foot • Bolt Foot • Claw Foot • Vault Foot • Hollow Foot • Anterior Equinus • Pes Cavo Varus • Contracted Foot • Talipes (Pes) Arcuatus • Talipes Plantaris
  • 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 .
  • 17. Etiology Neurological Causes • Charcot Marie Tooth disease • Friedrich’s Ataxia • Roussy-Levy syndrome • Poliomyelitis • Cerebral Palsy
  • 18. Congenital – Spina Bifida – Talipes Equinovarus – Myelodysplasia – Clubfoot Iatrogenic – Post surgery or trauma – Peroneal nerve injury
  • 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
  • 40. Synonyms • Pes planovalgus • Flat feet • Fallen arches • Pronation of feet
  • 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
  • 44. Types  Flexible Can be  Rigid painless Painful
  • 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.
  • 54. Treatment 3-9 years • Conservative management • No surgery • Custom orthosis inserted with leather ,cork, propylene .
  • 55. Treatment • 10-14 yrs • No symptom- No treatment • Symptomatic – conservative management initially • Surgical
  • 56. Surgical treatment Indications 1.pain 2.failure to respond to orthotic control 3.Ulceration or callus under the head of the plantiflexed talus 4.Excessive shoe wear
  • 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
  • 59. Surgeries • Durham flatfoot plasty • Posterior calcaneal displacement osteotomy • Anterior calcaneal lengthening – distraction wedge osteotomy • Triple atrhrodesis (triplane)
  • 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
  • 62. Calcaneal osteotomy (Dilwyn- Evana,Mosca) • Lengthening of lateral column of the foot by inserting a tibial bone graft and calcaneocuboidal fusion
  • 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
  • 64. Triple Arthrodesis Joints fused are: • Subtalar joint • Calcaneo cuboid joint • Talo navicular joint
  • 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
  • 66. Complications • Nonunion • Degenerative joint disease • Avascular necrosis • Lateral instability • Stiff foot
  • 67. Accessory navicular bone • It is a most common accessory bone in the foot • Listed as a cause of flat foot
  • 68. Pathoanatomy • Abnormal insertion of Tibialis Posterior into accessory navicular bone believe to cause the flat foot
  • 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
  • 73. Treatment INITIAL TREATMENT – Conservative- stretcing shoes, avoiding activity that irritates foot SURGICAL- Kidners procedure
  • 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” THANK YOU