evaluation of pediatric foot pain - lieberman's...

John Flibotte, MS IIIGillian Lieberman, MD

Evaluation of Pediatric Foot Pain

John Flibotte, Harvard Medical School Year IIIGillian Lieberman, MD

May 2006

John Flibotte, MS III Gillian Lieberman, MD

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Our Patient…

AP is a 10 year old boy with chronic R foot pain

John Flibotte, MS III Gillian Lieberman, MD

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Anatomy of the Foot

Manusov EG, et al. (1996), Part II

John Flibotte, MS III Gillian Lieberman, MD

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DDX of Pediatric Foot PainForefoot/ Midfoot

•Overlapping/ Curly Toes

•Accessory Navicular

•Osteomyelitis •Onychocryptosis (Ingrown Nail)

•Hallux Valgus

•Turf Toe

•Sesamoiditis

•Sesamoid Stress Fx

•Frieberg’s Disease (AVN of second metatarsal epiphysis)

•Stress Fracture

•Fracture

•Kohler’s Disease (Ischemic Necrosis of Navicular)

•Bone Cysts

•Ewing’s Sarcoma

•Osteoid Osteoma

•Synovial Sarcoma

Structural Abnormality

Infectious Repetitive/ Acute Trauma

Tumor/ Growth

Foot Pain

John Flibotte, MS III Gillian Lieberman, MD

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DDX of Pediatric Foot Pain

Structural Abnormality

Infectious Repetitive/ Acute Trauma

Tumor/ Growth

Foot Pain

•Pes Planus (Flatfoot)

•Flexible

•Rigid Tarsal Coalition

•Os Trigonum Syndrome

•Osteomyelitis •Plantar Fasciitis

•Calcaneal Apophysitis (Sever’s Disease)

•Calcaneal Stress Fx

•Retrocalcaneal Bursitis (Haghund’s Disease)

•Lisfranc Joint Sprain

•Ankle Sprain

•Osteochondritis dessicans

•Fracture

•Bone Cysts

•Ewing’s Sarcoma

•Osteoid Osteoma

•Synovial Sarcoma

Hindfoot Pain

Manusov EG, et al. (1996), Parts I & II

John Flibotte, MS III Gillian Lieberman, MD

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Anatomy of the Calcaneus

http://education.yahoo.com/reference/gray/subjects/subject?id=63

John Flibotte, MS III Gillian Lieberman, MD

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Anatomy of the Talus-1Lateral View Medial View

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1

Navicular Facet

Tibial FacetFibular Facet

John Flibotte, MS III Gillian Lieberman, MD

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Anatomy of the Talus-2

Navicular Facet

Middle Articular Facet (for sustentaculum tali)

Posterior Articular Facet

Inferior Aspect

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1

John Flibotte, MS III Gillian Lieberman, MD

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Standard Views of the Foot

• Lateral

• Oblique

• Anteroposterior-----------------------------------------------------------One Special View: Harris Beath View

John Flibotte, MS III Gillian Lieberman, MD

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Obtaining a Lateral View

http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html

John Flibotte, MS III Gillian Lieberman, MD

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Normal Lateral Radiograph of Foot

http://www.rad.washington.edu/RadAnat/FootLateral.html

John Flibotte, MS III Gillian Lieberman, MD

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Normal Lateral Radiograph of Foot

http://www.rad.washington.edu/RadAnat/FootLateralLabelled.html

John Flibotte, MS III Gillian Lieberman, MD

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Oblique Radiograph of Foot

http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html

John Flibotte, MS III Gillian Lieberman, MD

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Normal Oblique Radiograph of Foot

http://www.rad.washington.edu/RadAnat/FootOblique.html http://www.rad.washington.edu/RadAnat/FootOblique Labelled.html

John Flibotte, MS III Gillian Lieberman, MD

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AP View of the Foot

http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html

John Flibotte, MS III Gillian Lieberman, MD

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Normal AP Radiograph of the Foot

http://www.rad.washington.edu/RadAnat/FootAPLabelled.htmlhttp://www.rad.washington.edu/RadAnat/FootAP.html

John Flibotte, MS III Gillian Lieberman, MD

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Obtaining the Harris Beath View

http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.html

John Flibotte, MS IIIGillian Lieberman, MD

Our Patient’s Initial Radiographs

John Flibotte, MS III Gillian Lieberman, MD

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Our Patient’s Lateral Views

Children’s Hospital Boston

Loss of Foot ArchNarrowed Joint Space

Narrowed Joint Space

Loss of Middle Facet Space

John Flibotte, MS III Gillian Lieberman, MD

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Our Patient’s Oblique Views

Children’s Hospital Boston

Normal Appearance

John Flibotte, MS III Gillian Lieberman, MD

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Patient’s Harris Beath Views

LR

Children’s Hospital Boston

Loss of Talocalcaneal Joint Space Loss of Talocalcaneal Joint

Space

John Flibotte, MS III Gillian Lieberman, MD

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Patient’s Coronal CT

Children’s Hospital BostonBilateral Bony Fusion

John Flibotte, MS IIIGillian Lieberman, MD

Diagnosis:

Talocalcaneal coalition

John Flibotte, MS III Gillian Lieberman, MD

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Discussion of Coalition• Results from abnormal differentiation and

segmentation of primitive mesenchyme with resultant lack of joint formation

• Postulated autosomal dominant inheritance with variable penetrance

• 50%-60% are Bilateral• Prevalence 1-2%• Can occur between any tarsal bone;

talocalcaneal and calcaneonavicular coalitions are most common

Newman & Newberg (2000)

John Flibotte, MS III Gillian Lieberman, MD

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Types of Coalition

• Osseous

• Fibrous

• Cartilaginous

John Flibotte, MS III Gillian Lieberman, MD

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Pathogenesis of CoalitionLimitation of Normal Subtalar & Midfoot

Motion

Inflammation of Involved Joints

Irritation of Peroneal Tendon Crossing Subtalar Joint

Peroneal Tendon Spasm

“Peroneal Spastic” Rigid Flatfoot

Manusov EG, et al. (1996), Part II

John Flibotte, MS III Gillian Lieberman, MD

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Talocalcaneal Coalition-1• Coalition between the talus calcaneus

– Most commonly between middle facet of talus and sustentaculum tali of calcaneus

• Represents 48% of all Tarsal Coalitions• Typically become symptomatic in 8-12 y.o. children• Imaging Modalities:

– Difficult to see on standard views– May be suggested by loss of foot arch – Harris Beath View to demonstrate subtalar joint– May need fine-cut CT– May also be seen on MRI– If a bone scan is done, will show as area of increased uptake

Newman & Newberg (2000)

John Flibotte, MS III Gillian Lieberman, MD

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Talocalcaneal Coalition-2• Secondary Plain Film Signs:

– Talar beak– Narrowing of the subtalar joint– Rounding of the lateral talar process– Lack of depiction of middle facets on lateral– C-sign

• Secondary Signs on CT:– Talar beak– Joint Narrowing– Broadening and down-sloping of sustentaculum tali

Newman & Newberg (2000)

John Flibotte, MS III Gillian Lieberman, MD

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Middle Facet on Lateral

• Short solid arrow: middle facet

• Long solid arrow: posterior facet

• Open arrow: lateral process of talus (anterior extent of posterior facet)

• Normal= Open space

Liu PT, et al. (2003)

Companion Normal Case

John Flibotte, MS III Gillian Lieberman, MD

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Absence of Middle Facet

• Curved arrow: talar beak

• Long arrow: loss of middle facet space

• Short arrows: C-sign present

• Loss of posterior facet space Liu PT, et al. (2003)

Companion Coalition Patient Case

John Flibotte, MS III Gillian Lieberman, MD

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Talar Beak• Secondary to

impaired subtalar joint motion

• Represents navicular overriding the talus

• Periosteal elevation occurs at site of talonavicular ligament

• Osseous repair results in talar beak

Newman & Newberg (2000)

Companion Coalition Patient Case

John Flibotte, MS III Gillian Lieberman, MD

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C-Sign

• Results from bone bridging between talar dome and sustentaculum tali

• Seen in osseous and non-osseous coalition

• Varies based on sustentaculum size and orientation

Newman & Newberg (2000)

Companion Coalition Patient Case

John Flibotte, MS III Gillian Lieberman, MD

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Another Patient with Coalition

9 year old girl with Chronic R foot pain

John Flibotte, MS III Gillian Lieberman, MD

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Our Patient 2 Bone Scan

Children’s Hospital Boston

Focal Areas of Increased Tracer Uptake

John Flibotte, MS III Gillian Lieberman, MD

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Patient 2 Sagittal CT

R L

Children’s Hospital Boston

Bony Fusion Preserved Joint Space

John Flibotte, MS III Gillian Lieberman, MD

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Calcaneonavicular Coalition• Coalition between calcaneus navicular• Represents 43% of all Tarsal Coalitions• Typically become symptomatic in 12-16 yo children• Best Imaging Modality:

– Plain Film, 45 degree internal oblique– May also be seen on CT, MRI, bone scan

• Ragiographic Signs:– Bony Bar (seen with osseous coalition)– Bones in close proximity, irregular surfaces, anteromedial

calcaneus is widened/ flattened (seen with fibrous or cartilaginous coalition)

– Hypoplasia of the talus– Anteater sign

Newman & Newberg (2000)

John Flibotte, MS III Gillian Lieberman, MD

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“Anteater” Sign

www.peeperandfriends.com

www.porpoiserecords.com

Newman & Newberg (2000)

Companion Coalition Patient Case

John Flibotte, MS IIIGillian Lieberman, MD

How did they come up with that anteater sign?

John Flibotte, MS III Gillian Lieberman, MD

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“Anteater” Sign

www.peeperandfriends.com

www.porpoiserecords.com

Newman & Newberg (2000)

Companion Coalition Patient Case

John Flibotte, MS III Gillian Lieberman, MD

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“Anteater” Sign

www.peeperandfriends.com

www.porpoiserecords.com

Newman & Newberg (2000)

John Flibotte, MS III Gillian Lieberman, MD

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Performance of Secondary Signs

• The next slide shows the individual performance of secondary signs evaluated in a retrospective blinded study

• Table shows that individual stand alone signs have a low sensitivity, but high specificity

John Flibotte, MS III Gillian Lieberman, MD

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Performance of Secondary Signs

Crim & Kjeldsberg (2004)

John Flibotte, MS III Gillian Lieberman, MD

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Combination of all Secondary Signs

• Evaluated both retrospectively and prospectively by attending and resident radiologists

• Results:– Calcaneonavicular Coalition

• Attending (100% sens, 97% spec)• Resident (80% sens, 98% spec)

– Talocalcaneal Coalition• Sensitivity 100%• Specificity 88%

Crim & Kjeldsberg (2004)

John Flibotte, MS III Gillian Lieberman, MD

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Treatment

• Initially managed conservatively with steroid injections, orthotics

• Surgery may be undertaken to separate fused tarsal bones

John Flibotte, MS III Gillian Lieberman, MD

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Conclusions

• Coalition is a frequent cause of pediatric foot pain that may present in late childhood or early adulthood

• There are many secondary signs of coalition that can be seen on plain film radiographs

• The combination of multiple secondary signs is a sensitive and specific way to screen for coalition

• CT & MRI may be needed to confirm existence of coalition

John Flibotte, MS III Gillian Lieberman, MD

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References1. Newman JS, Newberg AH. “Congenital tarsal coalition: multimodality evaluation with emphasis

on CT and MR imaging.” Radiographics. 2000 Mar-Apr;20(2):321-32. 2. Liu PT, Roberts CC, Chivers FS, Kile TA, Claridge RJ, DeMartini JR, Kenrich RE, Freed LH.

"Absent middle facet": a sign on unenhanced radiography of subtalar joint coalition. AJR Am J Roentgenol. 2003 Dec;181(6):1565-72.

3. Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot.” Am Fam Physician. 1996 Aug;54(2):592-606.

4. Manusov EG, Lillegard WA, Raspa RF, Epperly TD.”Evaluation of pediatric foot problems: Part II. The hindfoot and the ankle.” Am Fam Physician. 1996 Sep 1;54(3):1012-26, 1031.

5. Crim JR, Kjeldsberg KM. “Radiographic diagnosis of tarsal coalition.” AJR Am J Roentgenol. 2004 Feb;182(2):323-8.

6. Websites:http://education.yahoo.com/reference/gray/subjects/subject?id=63http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/mo80_laude/laude_us.shtml#1http://www.latrobe.edu.au/podiatry/Radiology/patientpositioningxray.htmlhttp://www.rad.washington.edu/RadAnat/FootLateral.htmwww.porpoiserecords.comwww.peeperandfriends.com

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Acknowledgements

With thanks to:

• Muneeb Ahmed, MD• Larry Barbaras our Webmaster• Gillian Lieberman, MD• Pamela Lepkowski