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T::a:Eo~Tt::D~:Z~:~:~::t=t:;\:~;;~~.!/deformities. In this era of preventive medicine, we take a

. ,~proactive opposition when confronting pediatric foot andankle deformities. We need to educate our patients andinform our medical colleagues. Hopefully we will preventserious pedal problems later in life. The child is not ayoung adult, and periodic examination of the growingchild's foot is essential. Biomechanical faults can be cor-rected. Early treatment of deformities will ensure a morefavorable outcome.

The doctors of Westside Podiatry Group

Dr. Ron Freeling Dr. Dan Caiola Dr. Beth Freeling

THE.PEDJAli~IC-'r' . FOO.

1NstD£-PEDAL

PATHOLOGYSEEN IN

CHILDREN

QUESTIONS &CONCERNS

OF PARENTS

THE PEDIATRICFLATFOOT

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Pedal Pathology Seen in ChildrenBY THE DOCTORSWESTSIDE PODIATRY GROUP

What do PI.antar verrucae, paronychias, juvenile hal-lux abducto valgus and calcaneal apophysitis have

· in common? These are all prevalent pathologiesseen in the age groups of five to sixteen years old. What areplantar verrucae? Plantar pedal warts are caused by thehuman papilloma virus which infects keratinized skin. Itpresents as yellowish papules and plaques with overlyingkeratosis and discrete brown dots. The brown or reddots are thrombosed capillary loops which arepathognomonic for plantar verrucae. Plantar ver-rucae present as isolated lesions, larger motherlesions with surrounding satellite lesions or asa confluence of many small warts resulting ina mosaic configuration.

The human papilloma virus is transmit-ted via skin to skin contact or trauma to thestratum corneum. Common scenarios fortransmission are athletic locker rooms,

·between family members or routinely bare-footed individuals. An immunocompromisedpatient is highly susceptible to contract thevirus. Children fall in the category of theimmunocompromised patient. Teen age stresses,family difficulties and the type A personality allprime the child for a decreased immune system.Add this mental state to the children's gym,dance or' sporting events and, voila, the perfectmedia is created for wart transmission (seeFigure 1). .

Paronychia formation (see Figure 2) isanother common pathology recognized in chil-dren and adolescents. A frequent etiology foringrown toe nails in pediatrics is biomechani-cal imbalance. Abnormal pressures on the later-al nail fold due to hallux valgus deviation orabnormal pressures on the medial nail fold on

·account of excessive pronation forces the nail border tobecome imbedded in the respective nail fold. Ultimatelycontinued pressure or self manipulation creates pain andsecondary infection. Hereditary and congenital nail defor-mities are also a cause of recurrent pediatric paronychia for-mation. An inherited tendency toward incurvation of thegreat toe nails causes the nail borders to penetrate the softtissue of the nail folds and infection may follow.Dermatological genetic. syndromes associated with naildeformity include: nail-patella syndrome, (onycho-

osteodysplasia) Paronychia congenita, (laddassohn -Lewandowsky syndrome) Dyskeratosis congenita, Darier'sdisease, (Darier-White disease) and DOOR syndrome(deafness onychoosteodystrophys mental retardation)

Juvenile Hallux Abducto Valgus (see Figure 3) isacquired or develops in the child during the age one to fouryears and is expressed as a structural bone deformity belowthe age of twenty. The incidence of adolescent hallux abduc-to valgus is reported by various authors to range from twen-ty-two percent thirty-six percent. It is also more commonlyfound in females as well as among individuals of African

American descent. The deformity most commonly pres-ents bilaterally.

Etiological factors include genetic predisposition,congenital abnormalities, neuromuscular disease,

ligamentous laxity, metatarsus primus adductus,metatarsus adductus, flexible flatfoot, ankleequinus and other biomechanical causes ofexcessive pronation. Abnormal subtalar jointarid midtarsal joint pronation creates collapseof the pedal medial longitudinal arch. This cre-

ates hypermobility of the first ray. Concomitantmuscle imbalance pulls the hallux in a valgus

position placing a retrograde force on the firstmetatarsal in an adducted position yielding aprogressive bunion deformity. In addition the

orientation of the first metatarsocuneiformjoint is also significant in the juvenile defor-

mity. An oblique or atavistic metatarsalcuneiform joint is identified in the adoles-

cent encouraging first ray instability.There are distinctive characteristics

between juvenile and adult onset halluxabducto valgus. It is more common to finddegenerative changes around the firstmetatarsal phalangeal joint in adult onset. In

addition a painful adventitious bursa is asso-ciated with adult onset. Juvenile hallux abduc-

to valgus also presents with a smaller medialeminence and less abduction and valgus rotation of

the hallux.Conservative treatment is an important consideration in

the adolescent. Juvenile hallux abducto valgus is most prop-erly corrected by addressing the proximal deforming influ-ence on an ambulatory surgical type basis. However surgi-cal manipulation of the proximal metatarsal shaft is dan-gerous prior to closure of the epiphyseal growth centers.

. Therefore as a precaution it is best to treat adolescent hal-. lux abducto valgus on a conservative basis until sixteen

Manytimes

foot painis simplywritten

off tougrowingpains, "

but growthshould notbe a painful

process.

PAGE 2 FOOTPRINTS / FEBRUARY 2002WESTSIDE PODIATRY GROUP

years of age and closure of the growth centers.Conservative treatments indude larger shoe gear, toespacers and orthotic devices.

Orthotic devices are also the treatment of choice for acommon pediatric pathology known as calcaneal apophysi-tis or severs disease (see Figure 4). The calcaneal bone isthe only bone in the body whose epiphysis assumes thebody's entire weight prior to maturation and fusion to theprimary ossification site. The" calcaneal apophysis firstappears in females at ages four to six and in males at agesseven to eight. The apophysis may present in a unipartite,bipartite or tripartite orientation. The multiple fragmentsof the apophysis may be easily confused as fracture frag-ments; however, it is a normal variant. Fusion of the sec-ondary site to the primary calcaneal bone may be completeas early as twelve years old in females and fifteen years oldin males.

Inflammatory changes to the calcaneal apophysis is acommon condition seen in children between the ages ofeight and twelve years old. Pain and inflammation at theepiphysis is precipitated by acute or chronic trauma, obe-sity and biomechanical abnormalities. Pathomechanicmanifestations including pes plano valgus, torsional defor-mities, calcaneal valgus and tarsal coalition cause exces-

sive subtalar joint and midtarsal joint pronation in chil-dren. Pronation creates tension from the achilles tendonand plantar fascia on the calcaneus. The achilles tendoninserts in -the posterior proximal aspect of the apophysisand the plantar fascia originates at the inferior distalaspect of the apophysis. Pronation essentially creates a tugof war mechanism between the two tendons causinginflammation of the secondary growth center. The painand inflammation is exacerbated by sporting activities,barefoot walking and pediatric obesity. Many times this iswritten off to "growing pains," but growth should not bea painful process.

On examination demonstrable pain is noted on lateralcompression to the posterior aspect of the calcaneus andwith direct pressure to the lower one third of the posteri-or calcaneus. Calcaneal apophysitis is always treated byconservative means as this condition is self limited uponfusion of the epiphysis. Initial treatment includes rest andcessation of sports, heel lifts and padding. Below kneecasting is an option in resistant cases. Custom moldedorthotics are quite beneficial as they stop the traction ofthe plantar fascia and achilles tendon as well as providepadding to the sensitive heel.

FIGURE 1: PLANTAR PEDAL WART FIGURE 2: PARONYCHIA

FOOTPRINTS / FEBRUARY 2002 PAGE 3WESTSIDE PODIATRY GROUP

THE PEDIATRIC FLATFOOTFlatfoot (see Figure 5) is one of the most common and most controversial conditions see in the pediatric podiatry prac-

tice. Flatfoot is a term used to describe a recognizable cliriical deformity created by malalignment and several adjacent joints.Clinicallya flatfoot is one that has a low or absent logitudinal arch. Determining flexibility or rigidity is the first step in man-agement. The anatomic characteristics of the flatfoot are excessive eversion of the subtalar complex during weight bearingwith plantar flexion of the talus, plantar flexion of the calcaneus in relation to the tibia, a dorsiflexed and abducted navicular,and a supinated or' abducted forefoot. '

Normally developing infants have a flexible flatfootand gradually develop a normal arch during the firstdecade of life. However, there are many risk factorsthat have an effect on the normal development. Theserisk factors include ligamentous laxity, obesity, rota-tional deformities, tibial influence, pathological tibialvarum, equinus, presence of an os tibial extern urn(accessory bone), and tarsal coalitions. Proper evalua-tion and treatment early in lifewill prevent progressionof the deformities into the adult state. It will also pre-vent sequential problems as maturity progresses.

The condition of tarsal coalitions are often missed when a complaint of painful foot is presented. Tarsal coalitions are themajor cause of painful, rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalition arethe most common sites. They are often bilateral and may be symptomatic. They represent a failure of fetal mesenchymal dif-ferentiation, and the onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilagi-nous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerizedtomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and inter-position of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, witharthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions .

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FIGURE S:PEDIATRIC FLATFOOT

FOOTPRINTS / FEBRUARY 2002 WESTSIDE PODIATRY GROUP PAGE 4