summary Congenital Vertical Talus is a rare congenital condition caused by neuromuscular or chromosomal abnormalities in neonates that typically presents with a rigid flatfoot deformity. Diagnosis is made with forced plantar flexion lateral radiographs that show persistent dorsal dislocation of the talonavicular joint. Treatment is usually serial manipulation and casting followed by surgical release and talonavicular reduction and pinning at age 6-12 months. Epidemiology: Incidence rare, 1:150,000 births Demographics M:F ratio of 2:1 Anatomic location 50% bilateral Etiology Pathoanatomy rigid foot deformity irreducible dorsolateral navicular dislocation vertically oriented talus calcaneal eversion with attenuated spring ligament soft tissue contractures displacement of peroneal longus and posterior tibilais tendon so they function as dorsiflexors rather than plantar flexors contracture of the Achilles tendon Genetics a positive family history is present in up to 20% of patients HOXD10 gene mutation (transcription factor) Associated conditions 50% associated with neuromuscular disease or chromosomal aberrations Myelomeningocele Arthrogryposis Diastematomyelia congenital dislocation of the hip cerebral palsy spinal muscular atrophy Presentation Physical exam rigid rockerbottom deformity fixed hindfoot equinovalgus due to contracture of the Achilles and peroneal tendons rigid midfoot dorsiflexion secondary to the dislocated navicular forefoot abducted and dorsiflexed due to contractures of the EDL, EHL and tibialis anterior tendons prominent talar head can be palpated in medial plantar arch on exam produces a convex plantar surface gait abnormality patient may demonstrate a "peg-leg" or a calcaneal gait due to poor push-off power limited forefoot contact, excessive heel contact neurologic deficits a careful neurologic exam needs to be performed due to frequent association with neuromuscular disorders Imaging Radiographs recommended views AP, oblique and lateral foot findings lateral vertically positioned talus & dorsal dislocation of navicular line along long axis of talus passes below the first metatarsal-cuneiform axis before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation AP talocalcaneal angle > 40° (20-40° is normal) alternative views forced plantar flexion lateral radiograph is diagnostic shows persistent dorsal dislocation of the talonavicular joint oblique talus reduces on this view Meary's angle > 20° (between line of longitudinal axis of talus and longitudinal axis of 1st metatarsal) forced dorsiflexion lateral reveals fixed equinus MRI neuraxial imaging should be performed to rule out neurologic disorder Differential Oblique talus anatomic variant talonavicular subluxation that reduces with forced plantarflexion of the foot treatment is generally observation, shoe inserts vs casting some require surgical pinning of the talonavicular joint and achilles lengthening for persistent subluxation Calcaneovalgus foot deformity Posteromedial tibial bowing Tarsal coalition Paralytic pes valgus Pes planovalgus Treatment Nonoperative serial manipulation and casting indications indicated preoperatively to stretch the dorsolateral soft-tissue structures foot is manipulated into inversion and plantarflexion typically still requires closed vs open pinning of the talonavicular joint with percutaneous achilles tenotomy Operative surgical release and talonavicular reduction and pinning indications indicated in most cases performed at 6-12 months of age technique involves pantalar release with concomitant lengthening of peroneals, Achilles, and toe extensors talonavicular joint is reduced and pinned while reconstruction of the plantar calcaneonavicular (spring) ligament is performed concomitant tibialis anterior transfer to talar neck minimally invasive correction indications new technique performed in some centers to avoid complications associated with extensive surgical releases technique principles for casting are similar to the Ponseti technique used clubfoot serial casting utilized to stretch contracted dorsal and lateral soft tissue structures and gradually reduced talonavicular joint once reduction is achieved with cast, closed or open reduction is performed and secured with pin fixation percutaneous achilles tenotomy is required to correct the equinus deformity talectomy indicated in resistant case triple arthrodesis as salvage procedure Complications Missed vertical talus reconstructive options are less predictable after age 3, and patients may require triple arthrodesis as salvage procedure Prognosis Poor in untreated cases and associated with significant disability
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Percutaneous Achilles Tendon Lengthening Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults
QUESTIONS 1 of 11 1 2 3 4 5 6 7 8 9 10 11 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ13PE.84) A 9-month-old boy is referred for evaluation of bilateral 'rocker bottom' feet. Figure A exhibits a lateral foot radiograph. This diagnosis has a high association with which of the following congenital anomalies? QID: 5243 FIGURES: A Type & Select Correct Answer 1 Cleft lip/palate 11% (409/3662) 2 Neuromuscular disease 60% (2186/3662) 3 Congenital heart disease 14% (528/3662) 4 Deletion on chromosome 22q11 9% (342/3662) 5 Duplication on chromosome 12 5% (166/3662) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.29) What is the preferred treatment for newly diagnosed irreducible congenital vertical talus in a toddler? QID: 2842 Type & Select Correct Answer 1 Casting followed by open reduction and Achillies lengthening 83% (2130/2570) 2 Serial Ponseti method casting 8% (205/2570) 3 Percutaneous achillies lengthening 2% (49/2570) 4 Talectomy with tendon interposition 4% (105/2570) 5 Subtalar fusion with soft tissue release 3% (68/2570) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ07.97) All of the following are known to be associated with the deformity shown in Figure A EXCEPT: QID: 758 FIGURES: A Type & Select Correct Answer 1 Chromosomal deletions 7% (187/2802) 2 Arthrogryposis 5% (154/2802) 3 Amniotic band syndrome 61% (1696/2802) 4 Hip dysplasia 12% (347/2802) 5 Spinal muscular atrophy 14% (380/2802) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.18) Figures 8a and 8b show the clinical photograph and radiograph of a 4-month-old infant who has a left foot deformity. Examination reveals that the foot deformity is an isolated entity, and the infant has no known neuromuscular conditions or genetic syndromes. Which of the following studies will best confirm the diagnosis? QID: 6078 FIGURES: A B Type & Select Correct Answer 1 MRI of the foot 3% (15/454) 2 Static ultrasound examination of the foot in dorsiflexion 5% (24/454) 3 Lateral radiograph of the foot in maximum plantar flexion 68% (308/454) 4 Lateral radiograph of the foot in maximum dorsiflexion 20% (93/454) 5 CT of the foot 3% (12/454) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ07.154) Which of the following is not characteristic of the pathologic process displayed in Figure A. QID: 815 FIGURES: A Type & Select Correct Answer 1 Dislocation of the talonavicular joint 6% (206/3679) 2 Associated with posteromedial tibia bowing 58% (2124/3679) 3 Associated with neural tube defects 15% (538/3679) 4 Associated with arthrogryposis 9% (343/3679) 5 Rigid rocker bottom deformity 12% (441/3679) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ06.127) An 13-month-old boy is evaluated for a foot deformity and asymmetric gait. A clinical photo is shown in Figure A. A plantarflexion lateral radiograph is shown in Figure B. What is the most likely diagnosis? QID: 313 FIGURES: A B Type & Select Correct Answer 1 Talipes equinovarus 4% (83/2110) 2 Congenital vertical talus 55% (1167/2110) 3 Congenital oblique talus 36% (758/2110) 4 Skewfoot 1% (30/2110) 5 Normal radiographic findings 3% (60/2110) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ04.115) A 2-month old infant is born with a rocker-bottom foot deformity. A radiograph is shown in figure A. Why is the initial treatment manipulation and casting? QID: 1220 FIGURES: A Type & Select Correct Answer 1 to help stretch the dorsolateral soft-tissue before surgery 69% (1025/1484) 2 the deformity usually corrects with non-operative treatment 24% (349/1484) 3 surgery is usually deferred until 5 years of age 5% (80/1484) 4 surgery is usually deferred until 10 years of age 0% (5/1484) 5 surgery does not help this condition 1% (14/1484) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
All Videos (1) Podcasts (1) Login to View Community Videos Login to View Community Videos Neglected vertical talus gait Chris Souder Pediatrics - Congenital Vertical Talus C 3/15/2012 11424 views 3.6 (10) Pediatrics | Congenital Vertical Talus Pediatrics - Congenital Vertical Talus Listen Now 20:24 min 4/18/2020 724 plays 3.8 (5)
Neglected Congenital Vertical Talus in 33M (C2140) Julio Morales Pediatrics - Congenital Vertical Talus E 2/6/2015 205 1 13