Updated: 1/2/2018

Cerebral Palsy - Foot Conditions

Topic
Review Topic
0
0
Questions
5
0
0
Evidence
4
0
0
Techniques
1
https://upload.orthobullets.com/topic/12120/images/cpfa.jpg
https://upload.orthobullets.com/topic/12120/images/equinusheel.jpg
https://upload.orthobullets.com/topic/12120/images/tal.jpg
Introduction
  • See Cerebral Palsy General
  • Foot deformities are common in cerebral palsy and may take several forms including
    • Equinus
    • Hallux Valgus 
    • EquinoPlanoValgus 
    • EquinoCavovarus
Equinus
  • Epidemiology
    • most common deformity in cerebral palsy
  • Pathophysiology
    • imbalance of ankle dorsiflexors and plantarflexors, resulting in plantar flexion of the hindfoot relative to the ankle, with normal mid- and forefoot alignment
    • spasticity/contracture of the gastrocsoleus complex 
  • Presentation
    • symptoms
      • shoe fitting / wear and tear
      • tripping secondary to poor foot clearance
      • instability due to decreased base of support
    • physical exam
      • inspection
        • forefoot callosities
        • toe walking or absent heel strike during gait
        • hyperextended knee with heel contact
      • provacative tests
        • Silverskiold test
          • improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
          • equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
  • Treatment
    • nonoperative
      • serial manipulation and casting
        • indications
          • mild spasticity, dynamic, younger patients
      • botulinum toxin A intramuscular injection into gastrocnemius
        • indications
          • mild spasticity, may delay need for surgery
        • mechanism of action
          • blocks presynaptic release of acetylcholine
      • articulated or hinged AFO
        • indications
          • mild and passively correctible deformity with mild spasticity and no myostatic contractures.
        • contraindication
          • presence of excessive ankle dorsiflexion in midstance 
      • solid AFO 
        • indications
          • mild to moderate foot deformities that are partially correctible with mild to moderate spasticity and with mild myostatic contractures
        • contraindications
          • excessive ankle dorsiflexion during midstance in heavy patients, >=12 years of age and significant rigid foot malalignment
    • operative
      • tendo-Achilles lengthening (TAL)
        • indications
          • rarely indicated as an isolated procedure, except in hemiplegia
Hallux Valgus
  • Epidemiology
    • most common in diplegics with planovalgus feet
    • associated with equinovalgus and external tibial torsion
  • Pathophysiology
    • caused by combination of adductor hallucis overactivity and externally applied forces, such as inadequate clearance resulting from equinovalgus deformity, forcing the great toe into valgus.
  • Presentation
    • symptoms
      • pain and difficulty wearing proper shoes
    • physical Exam
      • inspection
        • painful bunion/callosity over 1st MT head
  • Treatment
    • nonoperative
      • observation
        • indications
          • no pain or difficulty with footwear
    • operative
      • first metatarsophalangeal joint arthrodesis
        • indications
          • painful hallux valgus
        • outcomes
          • has the highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy. 
          • the recurrence rate is unacceptably high with the other procedures 
      • proximal phalanx (Akin) osteotomy  
        • indications
          • hallux valgus with associated valgus interphalangeus
EquinoPlanoValgus
  • Epidemiology
    • incidence
      • common foot deformity seen with 
        • cerebral palsy (spastic diplegic and quadriplegic) 
    • body location
      • typically bilateral
  • Pathophysiology
    • equinus with pronation deformity
    • pathomechanics
      • creates lever arm dysfunction during gait
      • leads to bearing weight on the medial border of the foot and talar head
      • external rotation of the foot creates instability during push off
  • Presentation
    • Symptoms
      • painful callus over talar head secondary to weightbearing
      • shoe wear problems
    • Physical exam
      • inspection
        • typically bilaterally
        • valgus heel deformity seen when viewing feet from posterior 
        • prominent talar head appreciated in the arch
        • midfoot break occurs in attempt to keep foot plantigrade 
        • hallux valgus typically develops over time
      • motion
        • the hindfoot valgus deformity must be manually corrected first before testing for achilles contracture
          • a valgus heel can mask an equinus contracture by allowing a shortened path for the achilles
  • Imaging
    • Radiographs 
      • recommended views
        • weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as cause of deformity
      • findings 
        • decrease in the calcaneal pitch
        • negative talo-first metatarsal angle on lateral view
  • Treatment
    • Nonoperative
      • bracing 
        • indications
          • flexible deformities
    • Operative
      • calcaneal osteotomy with soft tissue procedure
      • indications
        • pain or pressure sores despite bracing
      • subtalar arthroereisis
        • indications
          • controversial
        • technique
          • stabilizes subtalar joint in correct alignment without fusion
  • Techniques
    • Calcaneal osteotomy with soft tissue procedure
      • soft tissue procedures
        • achilles lengthening
        • peroneus brevis lengthening
        • posterior tibial tendon advancement
      • bony procedures
        • calcaneal osteotomy  
          • medial slide osteotomy
          • lateral column lengthening procedure 
        • Grice procedure  
          • extra-articular subtalar arthrodesis via a lateral approach
          • place ICBG in lateral subtalar joint to block valgus
          • does not interfere with tarsal bone growth
        • subtalar arthroereisis 
  • Complications
    • Overcorrection (resultant varus deformity)
      • most common complication
    • Sural nerve injury
      • at risk during calcaneal osteotomy procedures
    • Overlengthening of lateral column 
      • results in a painful lateral forefoot secondary to overload
EquinoCavoVarus
    • Epidemiology
    • Pathophysiology
      • equinus deformity of the hindfoot coupled with supination deformities of the midfoot and forefoot
      • pathomechanics 
        • creates lever arm dysfunction during gait
        • disrupts the second rocker by blocking ankle dorsiflexion, thus compromising stability function in midstance
        • shortens the length of the plantar flexor muscles, compromising their ability to generate tension
    • Presentation 
      • Symptoms
      • Physical exam
        • inspection
        • motion

    • Imaging 
      • Radiographs  
    • Treatment 
      • Nonoperative 

      • Operative 
        • Gastrocsoleus complex lengthening
        • Split Posterior Tibial Tendon Transfer
    • Techniques 
      • Split Posterior Tibial Tendon Transfer
        • between ages of 4 and 7 years with flexible equinovarus deformities.  Tendon transfers in patients with athetosis are unpredictable
      • Complications 
 
 

Please rate topic.

Average 2.1 of 12 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Technique Guides (1)
Questions (5)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (9)
Topic COMMENTS (6)
Private Note