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5 CME AJR Integrative Imaging

LIFELONG LEARNING
FOR RADIOLOGY

Radiographic Assessment of Pediatric Foot Alignment:


Self-Assessment Module
Mahesh M. Thapa1,2, Sumit Pruthi1,2, Felix S. Chew2
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ABSTRACT 3. Maldjian C, Hofkin S, Bonakdarpour A, Roach N, Mc-


The educational objectives for this self-assessment mod- Carthy J. Abnormalities of the pediatric foot. Acad Ra-
ule are for the participant to exercise, self-assess, and im- diol 1999; 6:191199
prove his or her understanding of the imaging spectrum of 4. Thompson GH, Simons GW III. Congenital talipes equi-
pediatric foot alignment issues. novarus (clubfeet) and metatarsus adductus. In: Dren-
nan JC, ed. The childs foot and Ankle. New York, NY:
INTRODUCTION Raven Press, 1992:97134
This self-assessment module on radiographic assessment 5. Scher DM. The Ponseti method for treatment of con-
of pediatric foot alignment has an educational component genital clubfoot. Curr Opin Pediatr 2006; 18:2225
and a self-assessment component. The educational compo- 6. Napiontek M. Skewfoot. J Pediatr Orthop 2002; 22:130133
nent consists of one required article that the participant 7. Davis LA, Hatt WS. Congenital abnormalities of the
should read. The self-assessment component consists of 14 foot. Radiology 1955; 64:818825
multiple-choice questions with solutions. All of these mate-
rials are available on the ARRS Website (www.arrs.org). To INSTRUCTIONS
claim CME and SAM credit, each participant must enter his 1. Complete the educational and self-assessment compo-
or her responses to the questions online. nents included in this issue.
2. Visit www.arrs.org and log in.
EDUCATIONAL OBJECTIVES 3. Select Self-Assessment Modules from the Lifelong Learn-
By completing this educational activity, the participant will ing box in the lower left of the page.
exercise, self-assess, and improve his or her understanding of: 4. Add the SAM to your shopping cart and order the online
A. The terms used to describe pediatric foot alignment ab- SAM as directed. (The SAM, including questions, must
normalities. be ordered to be accessed even though the activity is free
B. The imaging spectrum of alignment disorders of the pe- to ARRS members.) After purchasing the SAM, click on
diatric foot. OK; you will be returned to the ARRS home page.
5. Click on the My Education tab at the top of the page,
REQUIRED READING then on My Online Products. (Note: You must be logged
1. Thapa MM, Pruthi S, Chew FS. Radiographic assess- in to access this personalized page.)
ment of pediatric foot alignment: case-based review. 6. You can also access the purchased SAM by logging on to
AJR 2010; 194[suppl]:S51S58 http://edu.arrs.org/myProducts/.
7. Answer the questions online to obtain SAM credit.
RECOMMENDED READING
1. Ozonoff MB. The foot. In: Ozonoff MB, ed. Pediatric
orthopedic radiology, 2nd ed. Philadelphia, PA: Saunders,
1992:397460
2. Harty MP. Imaging of pediatric foot disorders. Radiol
Clin North Am 2001; 39:733748

Keywords: foot alignment, pediatrics, radiography


DOI:10.2214/AJR.10.7234
Received February 2, 2010; accepted without revision February 3, 2010.
Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way, NE, Seattle, WA 98105. Address correspondence to M. M. Thapa (mthapa@mac.com).
1

2
Department of Radiology, Seattle Childrens Hospital, Seattle, WA.
AJR 2010;194:S59S63 0361803X/10/1946S59 American Roentgen Ray Society

AJR:194, June 2010 S59


Thapa et al.

QUESTION 1 QUESTION 6
Which tarsal bone has no muscular or tendinous attach-
ments (i.e., it contains only ligamentous attachments)?
A. Navicular.
B. Calcaneus.
C. Talus.
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D. Cuboid.
QUESTION 2
When evaluating hindfoot malalignment on an antero-
posterior view of the foot, which of the following is
important to assess?
A. The precise angle measurement between the talus and calcaneus.
B. The relationship of the distal metatarsals or phalanges to the
talus and calcaneus.
C. The relationship of the cuneiform bones to the talus.
D. The relationship between the talus and navicular.
Fig. 2Weightbearing anteroposterior (AP) and lateral views of foot for
QUESTION 3 question 6. AP and lateral talocalcaneal angles have been drawn.
In general, on the lateral view, a line drawn through the Considering Figure 2, which of the following is the best
long axis of the talus should run through the shaft of description for the alignment of the hindfoot?
which metatarsal?
A. Calcaneus.
A. First. B. Varus.
B. Second. C. Rocker-bottom.
C. Third. D. Cavus.
D. Fourth.
E. Fifth. QUESTION 7
QUESTION 4 Hindfoot varus is a component of which congenital
deformity?
A. Vertical talus.
B. Oblique talus.
C. Clubfoot.
D. Pes planus.

QUESTION 8

Fig. 1Weightbearing anteroposterior (AP) and lateral views of foot for question
4. AP and lateral talocalcaneal angles have been drawn.
With respect to Figure 1, which of the following is the
best description of the alignment?
A. Hindfoot valgus.
B. Hindfoot varus.
C. Congenital vertical talus.
D. Congenital talipes equinovarus.

QUESTION 5 Fig. 3Weightbearing anteroposterior (AP) and lateral views of foot for question
Hindfoot valgus can be present in all the following 8. AP and lateral talocalcaneal angles have been drawn.
conditions EXCEPT which of the following? Considering Figure 3, what is the best diagnosis?
A. Cerebral palsy. A. Planovalgus foot.
B. Skewfoot. B. Cavus foot.
C. Congenital vertical talus. C. Z-foot (skewfoot).
D. Congenital talipes equinovarus. D. Congenital talipes equinovarus.

S60 AJR:194, June 2010


Pediatric Foot Alignment

QUESTION 9 QUESTION 12
Which of the following statements is TRUE regarding On the lateral projection, which of the following distin-
congenital talipes equinovarus? guishes congenital vertical talus from pes planovalgus?
A. The incidence of congenital talipes equinovarus is 1:100 live births. A. The calcaneus alignment is normal.
B. Congenital talipes equinovarus is often recognized on prenatal B. The navicular is dislocated from the talus.
sonography. C. There is increased overlap of the metatarsals.
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C. Bilateral involvement is unusual in congenital talipes equinovarus. D. Only the vertical talus includes flatfoot deformity.
D. Congenital talipes equinovarus affects more females than males.
QUESTION 13
QUESTION 10
If needed, most surgeries to correct clubfoot deformity
are performed at what approximate age?
A. 3 months.
B. 6 months.
C. 1 year.
D. 2 years.

QUESTION 11

Fig. 5Weightbearing anteroposterior (AP) and lateral views of foot for


question 13. Circle represents navicular bone.
With respect to Figure 5, which of the following is the
best diagnosis?
A. Clubfoot.
B. Z-foot.
C. Peroneal spastic flatfoot.
D. Tarsal coalition.

Fig. 4Weightbearing anteroposterior (AP) and lateral views of foot for QUESTION 14
question 11. Star represents navicular bone. AP and lateral talocalcaneal angles
have been drawn. Which statement about skewfoot is TRUE?
Considering Figure 4, which of the following is the best A. Skewfoot is common in otherwise healthy children.
diagnosis? B. Skewfoot is rarely associated with severe cerebral palsy.
C. Hallux valgus is frequently associated with skewfoot.
A. Vertical talus. D. The navicular is usually subluxed medially in cases of
B. Hindfoot valgus. skewfoot.
C. Planovalgus.
D. Bunion deformity.

Solution to Question 1 foot alignment; rather, it is the relationships of the meta-


The talus is the only bone in the foot with no muscular tarsal bases to the mid calcaneal and mid talar lines that are
attachments [1]. This fact is crucial to the understanding of important. Option B is not the best response. Evaluation of
hindfoot alignment. Therefore, option C is the best response, the cuneiforms plays no great role in assessing hindfoot
and options A, B, D, and E are not the best responses. alignment. Option C is not the best response. The position
of the navicular bone with respect to the talus tells us a
Solution to Question 2 great deal about hindfoot malalignment. If the navicular
The relationship between the tibia and the talus is diffi- bone is subluxed laterally or medially, then we suspect hind-
cult to assess on an anteroposterior view of the foot. Option foot valgus or varus, respectively. Another way to think of
A is not the best response. The relationship of the toes to it is that the navicular bone always moves in the same direc-
the talus and calcaneus is not important in assessing hind- tion as the calcaneus [1]. Option D is the best response.

AJR:194, June 2010 S61


Thapa et al.

Solution to Question 3 oblique talus, the navicular can be reduced to its normal
Generally, on a lateral view of the pediatric foot, a line location in front of the talus between the dorsiflexion and
drawn through the long axis of the talus should run through plantar flexion views. Option C is the best response. Clubfoot
the shaft of the first metatarsal [1]. Thus, option A is the is the vernacular term for congenital talipes equinovarus
best response, and options B, C, D, and E are not the best [1], and one of the components of this foot deformity is
responses. An important exception to this rule is in neo- hindfoot varus. Option D is not the best response. Pes
nates, in whom the axis through the talus can normally planus is usually associated with hindfoot valgus because
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pass inferior to the first metatarsal [1]. the plantar arch is flattened [1].

Solution to Question 4 Solution to Question 8


Figure 1 is an example of hindfoot valgus. On the antero- Option A is not the best response. In planovalgus, there
posterior view, the talocalcaneal angle is increased. The an- are varying degrees of hindfoot valgus, flattened arch, and
teroposterior talocalcaneal angle is typically between 35 forefoot pronation (eversion). Option B is not the best re-
and 40 [1]. On the lateral projection, the talus assumes a sponse. With cavus foot, the plantar arch is exaggerated,
more vertical position than normal. Option A is the best re- with the anterior aspect of the calcaneus dorsiflexed (calca-
sponse. Hindfoot varus results in a decrease of the talocal- neus position) and the distal aspect of the metatarsals plan-
caneal angle on the anteroposterior projection. Option B is tar-flexed. Option C is not the best response. Z-foot (skew-
not the best response. On the lateral projection, congenital foot) is a variant of a valgus foot. There is hindfoot valgus
vertical talus has an appearance similar to that of pure with associated forefoot adduction. Option D is the best re-
hindfoot valgus. However, with vertical talus, the navicular sponse. In talipes equinovarus, there is extreme hindfoot
bone is dislocated superiorly. In hindfoot valgus, the talus varus, with the anterior calcaneus situated in an exagger-
assumes a somewhat vertical orientation, but the articular ated planar-flexed position (equinus). In addition, there is
association between the talus and navicular bone is main- forefoot adduction with supination (inversion).
tained [1]. Option C is not the best response. Hindfoot varus
is a feature of congenital talipes equinovarus. Option D is Solution to Question 9
not the best response. Option A is not the best response. Equinovarus clubfoot,
although relatively common, has an incidence of 14:1,000
Solution to Question 5 live births and affects more males than females [1]. Option
Cerebral palsy, skewfoot, and congenital vertical talus B is the best response. Indeed, clubfoot deformity can be
have all been associated with hindfoot valgus deformity. and has been recognized on prenatal sonography [1, 2]. Op-
Congenital talipes equinovarus manifests as hindfoot varus tion C is not the best response. Bilateral involvement is
[1]. Option D is the best response. Options A, B, and C are common. There is also increased risk of equinovarus club-
not the best responses. foot in a first-degree relativeapproximately 30 times
greater than that of the general population [1]. Option D is
Solution to Question 6 not the best response. Males are more commonly affected
Option A is not the best response. Calcaneus position of the than females [1].
hindfoot is determined from the lateral projection. The calca-
neus is abnormally dorsiflexed, with the anterior portion Solution to Question 10
higher. Option B is the best response. Hindfoot varus results in Option B is the best response. Most surgeons wait until a
a decrease of the talocalcaneal angle on the anteroposterior child with congenital clubfoot is 6 months old before perform-
and lateral projections, leading to a near-parallel arrangement ing surgery to correct it [1, 3]. However, there is some contro-
of the two bones. Option C is not the best response. In rocker- versy surrounding this issue. Proponents of earlier surgery,
bottom deformity, the plantar arch is convex instead of con- between the ages of 3 and 6 months old, argue that growth
cave. The anterior calcaneus is in marked plantar flexion and remodeling are most optimal at a younger age and result
(equinus) and the metatarsals are dorsiflexed. Option D is not in a better outcome. Proponents of later surgery, between the
the best response. In cavus arch, the anterior portion of the ages of 9 and 12 months old, believe that the larger size of the
calcaneus is tilted up and the metatarsals are plantar flexed, foot at that age is easier to correct and that there is less risk
leading to increased height of the planar arch. associated with anesthesia at an older age [1, 3].

Solution to Question 7 Solution to Question 11


Options A and B are not the best responses. Both vertical Option A is not the best response. In vertical talus, the
talus and oblique talus deformities have hindfoot valgus de- talus and navicular are dislocated [1]. Option B is not the
formities. In congenital vertical talus, the navicular remains best response. Yes, the patient has hindfoot valgus, but he
superiorly dislocated in any position between maximum also has an associated forefoot or midfoot abnormality, so
dorsiflexion and plantar flexion views. However, with hindfoot valgus alone is not the best diagnosis. Option C is the

S62 AJR:194, June 2010


Pediatric Foot Alignment

best response. The combination of forefoot pronation and spastic flatfoot is associated with peroneal muscle spasm,
hindfoot valgus is termed planovalgus. Option D is not the usually as a result of congenital tarsal coalition [1]. Option
best response. Bunion deformity is another term for meta- D is not the best response. Although tarsal coalition can
tarsus primus adductus with hallux valgus. In our case, the cause a flatfoot deformity, there is no evidence of coalition
first metatarsal is not in varus (i.e., it is not adducted), and in this patient.
the first proximal phalanx is not in valgus [1].
Solution to Question 14
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Solution to Question 12 Option A is the best response. Skewfoot is a variant of


Option B is the best response. The key to differentiating valgus hindfoot that is common in otherwise healthy chil-
planovalgus (or pure hindfoot valgus) from a vertical talus dren [1]. Option B is not the best response. Skewfoot can be
is to examine the relationship between the talus and the quite marked in patients with severe cerebral palsy [1]. Op-
navicular on the lateral projection. With planovalgus, the tion C is not the best response. Although hallux valgus may
talus will assume a more vertical orientation than normal be associated with skewfoot deformity, it typically occurs
but will still maintain an articulation with the navicular. only in those with severe cerebral palsy [1]. Option D is not
However, in vertical talus, the navicular and talus are com- the best response. In skewfoot, the navicular is usually sub-
pletely dislocated [1]. Options A, C, and D are not the best luxed laterally, a common finding in hindfoot valgus.
responses. Both pes planovalgus and congenital vertical ta-
lus can manifest with flatfoot deformity. References
1. Thapa MM, Pruthi S, Chew FS. Radiographic assessment of pediatric foot
Solution to Question 13 alignment: case-based review AJR 2010; 194[suppl]:S51S58
Option A is not the best response. The image depicted is 2. Treadwell MC, Stanotski CL, King M. Prenatal sonographic diagnosis of club-
foot: implications for patient counseling. J Pediatr Orthop 1999; 19:810
not an example of clubfoot. Option B is the best response. 3. Thompson GH, Simons GW III. Congenital talipes equinovarus (clubfeet) and
Skewfoot presents with forefoot adduction associated with metatarsus adductus. In: Drennan JC, ed. The childs foot and ankle. New York,
hindfoot valgus. Option C is not the best response. Peroneal NY: Raven Press, 1992:97134

F O R YO U R I N F O R M AT I O N
The readers attention is directed to the case-based review on which this SAM is based, which begins on page S51.

AJR:194, June 2010 S63