Metatarsus Adductus (MA)= note

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Questions and Answers

In cases of metatarsus adductus, before what age is non-operative treatment considered MOST ideal?

  • 36 months
  • 6 months
  • 24 months
  • 15 months (correct)

What characteristic distinguishes metatarsus adductus (MA) from adductus of the forefoot (AF)?

  • AF presents with a more severe deformity clinically.
  • MA is characterized by mild adduction of the MT bases.
  • MA shows more significant adduction both radiographically and clinically. (correct)
  • AF is only identifiable through radiographic assessment.

Which plane of deformity is MOST associated with simple metatarsus adductus?

  • Sagittal plane
  • Oblique plane
  • Transverse plane (correct)
  • Coronal plane

What additional plane of deviation is present, along with adduction, in metatarsus adductovarus?

<p>Varus rotation of the forefoot (C)</p>
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Complex metatarsus adductus is also known as:

<p>Skewfoot (A)</p>
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Which of the following is NOT typical of cavoadductovarus?

<p>It is an infant deformity (B)</p>
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According to the content, what factor is MOST important to consider when classifying metatarsus adductus to determine the best course of treatment?

<p>The mobility of the forefoot (A)</p>
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What does a 'fixed and rigid' presentation of metatarsus adductus indicate regarding prognosis?

<p>Attempts to manually reduce the deformity are not successful, indicating a better prognosis. (A)</p>
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In the context of forefoot position in metatarsus adductus, where is concavity typically observed?

<p>Along the medial side of the foot (B)</p>
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What characterizes forefoot adductovarus?

<p>Two plane deformity on the transverse and coronal/frontal planes. (B)</p>
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In the context of rearfoot position, which of the following is NOT typically associated with metatarsus adductus?

<p>Inverted/Supinated (D)</p>
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What is a key characteristic of transitional lesions in the context of metatarsus adductus and talipes equinovarus (TEV)?

<p>They represent a condition somewhere between metatarsus adductus and TEV. (B)</p>
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What additional condition is present in 'forefoot adduction plus fixed heel inversion/supination' EXCEPT ankle equinus?

<p>Some mm imbalance. (C)</p>
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What condition is functional metatarsus adductus MOST likely classified as?

<p>Hallux varus (A)</p>
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What is the approximate incidence of metatarsus adductus in live births?

<p>1:300 (A)</p>
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Which of the following factors is classified as an etiology of Metatarsus Adductus?

<p>Genetic and hereditary. (B)</p>
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Which of the following is an example of 'Position of Comfort' that can result in metatarsus adductus?

<p>Take neonate into quiet warm room, put them back into in-utero position. (A)</p>
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Talipes equinovarus may be nothing more than a congenital forefoot varus.

<p>May be (B)</p>
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Which of the following is associated with skewfoot?

<p>The talonavicular joint is subluxed. (C)</p>
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What is the MOST critical factor for a successful prognosis in non-operative treatment of metatarsus adductus?

<p>Timing of the intervention (B)</p>
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Rigid forms of metatarsus adductus respond better to which type of treatment?

<p>Closed reduction &amp; serial casting (D)</p>
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When is surgical repair considered in the management of metatarsus adductus?

<p>As a salvage therapy when non-operative methods fail (B)</p>
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What is a characteristic clinical sign observed in patients with metatarsus adductus?

<p>Medial concavity, lateral convexity (B)</p>
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In metatarsus adductus, what is the position of the heel?

<p>Either everted or neutral (C)</p>
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What is a defining characteristic of the first interdigital space in a foot with metatarsus adductus?

<p>It is wide (D)</p>
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In the context of metatarsus adductus, where is the apex of concavity located along the medial border of the foot?

<p>At the 1st metatarsocuneiform joint (C)</p>
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What observation can indicate the severity of the deformity?

<p>A deep medial skin crease (B)</p>
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What finding suggests a flexible variant of metatarsus adductus during examination?

<p>The forefoot corrects beyond the midline during passive overcorrection. (B)</p>
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In metatarsus adductus, how does the movement typically respond when the lateral border of the foot is stroked?

<p>The foot remains stationary (D)</p>
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What anatomical feature is unique in metatarsus adductus, causing the first metatarsal to be carried into an adducted position?

<p>The malalignment of the distal surface of the first cuneiform (A)</p>
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What is the most common reason why surgical intervention is needed in pes adductus?

<p>Abductor hallucis is either contracted or malinserted (B)</p>
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What radiographic finding is expected regarding the RF (rearfoot) in metatarsus adductus?

<p>Neutral or pronated - the rearfoot is neutral or pronated on x-ray (B)</p>
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If lines are crossing in the midfoot on the radiograph, what does this indicate?

<p>Supinated RF (A)</p>
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What is the theory behind spontaneous correction in infants with metatarsus adductus?

<p>The foot is naturally flexible and may spontaneously correct (B)</p>
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What is the reasoning mentioned for a radiograph?

<p>Mainly for medico legal reason to have record that deformity has been completely reduced (D)</p>
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What is the recommendation for follow up after casting, with SHOES?

<p>SHOES → Outflare last shoes, 23 hrs/day to maintain achieved reduction for 3 mos (D)</p>
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Surgical intervention is desired in metatarsus adductus, but is it ALWAYS indicated?

<p>Salvage!!! Avoid this at all costs!! (A)</p>
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Why are Thompson procedures not done anymore?

<p>Often results in HAV (B)</p>
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True or False: Tendons have a habit of going back to where they came from. Therefore if you perform metatarsal adductus surgery, the tendon may retreat and the surgery may not last over time.

<p>True (A)</p>
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Before what age is early intervention and non-operative treatment considered ideal for correcting Metatarsus Adductus?

<p>15 months (A)</p>
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Metatarsus Adductus (MA) and Adductus Forefoot (AF) both indicate the same degree of overall forefoot adduction.

<p>False (B)</p>
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In the Agnew classification of Metatarsus Adductus, what is the defining characteristic of the most common type, Simple Metatarsus Adductus?

<p>All metatarsals are adducted at the Lisfranc level, with the forefoot adduction plane parallel to the weight-bearing surface.</p>
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In Metatarsus Adductovarus, in addition to adduction of the metatarsals, there is also a ______ plane varus rotation of the forefoot.

<p>frontal</p>
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Match the Metatarsus Adductus classification with its corresponding characteristic:

<p>Simple Metatarsus Adductus = All metatarsals adducted at Lisfranc level Metatarsus Adductovarus = Adduction and frontal plane varus rotation Complex Metatarsus Adductus = Also known as Skewfoot Cavoadductovarus = Associated with neurological issues and muscle imbalance</p>
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Which statement is true regarding Cavoadductovarus?

<p>It is often associated with neurological issues and muscle imbalance. (D)</p>
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In cases of fixed and rigid metatarsus adductus, attempts to manually reduce and over-correct the deformity are more likely to be successful.

<p>False (B)</p>
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What physical finding along the medial side of the foot is indicative of forefoot adduction?

<p>Concavity</p>
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In forefoot varus, the deformity presents in the ______ plane.

<p>coronal</p>
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Match the rearfoot position with the associated foot condition:

<p>Inverted/Supinated = Talipes Equinovarus (not metatarsus adductus) Neutral/Slight Pronation = Metatarsus Adductus Everted/Hyper-pronated = Skewfoot</p>
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What does forefoot adduction plus fixed heel inversion/supination suggest?

<p>Underlying muscular imbalance (D)</p>
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Forefoot adduction plus ankle equinus with heel varus is a common presentation.

<p>False (B)</p>
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Functional Metatarsus Adductus may be better classified as what other condition?

<p>Hallux Varus</p>
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The incidence of Metatarsus Adductus is approximately 1 in every ______ live births.

<p>300</p>
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Match each term with its description relevant to Metatarsus Adductus:

<p>Oligohydramnios = Reduced amniotic fluid, potential cause of intrauterine packing Uterine Deformity = Potential cause of intrauterine packing Position of Comfort = Fetal position that can contribute to deformity</p>
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What finding suggests that Talipes Equinovarus may be present on one side with Metatarsus Adductus on the contralateral side?

<p>FF supination and muscle imbalance. (D)</p>
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Casting Metatarsus Adductus is responsible for creating Skewfoot.

<p>False (B)</p>
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When is the best time to treat Metatarsus Adductus non-operatively, assuming it does not spontaneously resolve?

<p>6 months</p>
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In the clinical picture of Metatarsus Adductus, the medial border of the foot has a ______ and the lateral border of the foot has a ______.

<p>concavity, convexity</p>
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Match the radiographic finding with its description in Metatarsus Adductus:

<p>Gun Sight Deformity = Wide first interdigital space Simons' Angle = Used to assess talometatarsal alignment Increased MT Adductus Angle = Deviation from normal metatarsal alignment</p>
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Why is it not a good idea to do nothing when a patient presents with a significant deformity?

<p>You could miss your chance of being able to correct it non-operatively. (A)</p>
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Shoes are the primary method of correction in Metatarsus Adductus.

<p>False (B)</p>
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What specific action is performed during manipulation for serial casting of Metatarsus Adductus?

<p>Abduction of the Metatarsals</p>
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The fundamental laws of bone and cartilage remodeling state that bone and cartilage grow more slowly when subjected to ______ load.

<p>compressive</p>
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What must be present to succeed with the technique?

<p>Sufficient growth that remains. (C)</p>
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A 5-year-old child presents with persistent hallux varus despite previous cast therapy. What is the most appropriate next step in management?

<p>Surgical exploration of the abductor hallucis insertion (B)</p>
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Which of the following is a complication unique to the Berman-Gartland procedure compared to the Heyman-Herndon-Strong procedure?

<p>Non-union (B)</p>
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A neonate is diagnosed with postural metatarsus adductus. Which characteristic is true for this condition?

<p>Forefoot is easily manipulated to neutral (B)</p>
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A 6-year-old child presents with complex metatarsus adductus. Which radiographic finding is expected in this condition?

<p>Calcaneal bisection line in the medial third of the cuboid (B)</p>
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A 2-year-old child with a history of oligohydramnios presents with talipes equinovarus. Which associated condition is most likely to be present?

<p>Metatarsus adductus on the contralateral side (B)</p>
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Flashcards

Metatarsus Adductus (MA)

MA is a distinct deformity with more adduction, noted radiographically and clinically.

Simple Metatarsus Adductus

All metatarsals are adducted at the Lisfranc level; FF adduction plane is parallel to weight-bearing surface. A true one plane (transverse plane) deformity.

Metatarsus Adductovarus

Two-plane deformity with metatarsals adducted (transverse plane) and frontal plane varus rotation of the forefoot.

Cavoadductovarus

Not an infant deformity, presents in late childhood; associated with neurological issues causing muscle imbalance.

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Fixed and Rigid Metatarsus Adductus

If the attempts to manually reduce and over-correct the deformity are not successful during assessment.

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Easily Reducible Metatarsus Adductus

This is when the foot is flexible and easy to reduce but difficult to keep reduced without manual assistance.

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Forefoot Position in MA

Look for concavity along the medial side of the foot and convexity on the lateral side.

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FF Adductus (ForeFoot)

One plane deformity on the transverse plane.

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FF Adductovarus

Two plane deformity on the transverse and coronal/frontal planes.

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FF Varus

One plane deformity on the coronal plane (could be congenital forefoot varus).

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Rearfoot Position Associations

Inverted/Supinated rearfoot = Talipes Equinovarus; Neutral/slight pronation = MT adductus; Everted/Hyper-pronated = Skewfoot.

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Transitional Lesions

Neither metatarsus adductus nor TEV, somewhere in between, suggests an underlying muscular imbalance.

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Functional Metatarsus Adductus

Hallux Varus can be a primary deformity or can be caused by pulling of the toe via the abductor hallucis muscle.

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Wide First Interdigital Space

Gun sight deformity is present and associated with Hallucis.

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Medial Border of the Foot

Apex of the first metatarsocuneiform joint (1st MT base).

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Lateral Border of the Foot

Apex is at the 5th metatarsal base; Tuberosity of the 5th metatarsal base is very prominent (apophysis can be irritated).

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Deep Medial Skin Crease

Deep vertical crease at the apex of the concavity near the base of the 1st metatarsal. Indicates severity of deformity.

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Rigid Form of MA

The forefoot will not passively correct to any great extent.

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Flexible Form of MA

The foot shows significant metatarsus adductus unloaded but fully corrects (or overcorrects) when passive overcorrection is attempted.

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Failure of Active Overcorrection

The movement described where foot abducts when stroking the lateral border does NOT occur.

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Metatarsal Alignment in MA

The bases of the 2nd-5th metatarsals align with their respective tarsal structures, but the very proximal portions of the shafts are bowed so that the distal shafts are deviated medially.

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1st Metatarsocuneiform Segment in MA

The distal surface of the 1st cuneiform is malaligned so that it directs medially, carrying the first metatarsal into an adducted position.

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Abductor Hallucis Issues

The abductor hallucis frequently is either contracted or is malinserted

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Joint Surfaces in MA

The articulations are congruous; The ligaments are not contracted in an abnormal position; The ligaments may be lax in the flexible form.

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Increased MT Adductus Angle

Bisect 2nd cuneiform and 2nd MT and the abnormality resides in the lesser MT bases.

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Talometatarsal Angle Abnormal

Simons lines cross in prox 1st MT base is MA; Lines crossing in mid foot = supinated RF.

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Anterior Surface of First Cuneiform

1st MT is normal, adductus of the 1st MT comes from misshapen 1st cuneiform.

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Bebax Shoes

Show with bar on the bottom that allows manipulation of the FF into Ab/Ad, Varus/Valgus and is used as post-cast reduction modality.

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Patient selection criteria

Age (developmental, not calendar) is important criterion for patient selection.

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Tincture of Benzoin

Glues the cast on so that it doesn't slide off

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Outflare last shoes

Apply to maintain achieved reduction for 3 mos.

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Criteria to look for reduction

Inspect for straight medial and lateral borders.

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Thompson procedure

Total extcision of the abductor hallucis wich historical purposes only.

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Transfer Abductor Hallucis considerations

Tendons have a habit of going back to where they came from

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Berman-Gartland Procedure

Describe as Crescentic osteotomies of MT bases;Avoids injuring the physis of 1st MT

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Steytler-Van der Walt

Lateral base closing osteotomies of 1-5 mts, Concern for the physis of the 1st MT

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Major overhauls requirements

Opening wedge osteotomy of lesser metatarsals;Abducting osteotomies of lesser metatarsals

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Tarso-metatarsal release

Opening up the medial, dorsal, and plantar capsules of the TMTjt, abducting them, and allowing them to heal in this position

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Rigid vs Flexbile Form TX

Rigid forms do better w/ closed reduction & serial casting than flexible forms (flexible – high recurrence).

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MA treatment timeframe

Early intervention, before 15 months, is ideal for treating Metatarsus Adductus (MA).

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Cavoadductovarus timeframe

Seen later in childhood and associated with neurological problems.

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Fixed MA prognosis

If the foot cannot be manually corrected, this indicates a better prognosis.

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Supple MA challenge

Supple MA is easy to reduce, but difficult to keep that way.

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Heel Bisection

A line bisecting the heel relative to 1st, 3rd, and 5th MTs

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FF Adductus

MA, with the transverse plane being the only plane affected.

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FF Adductovarus planes

Two plane deformity on the transverse and coronal/frontal planes.

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Rearfoot position check

Assess which structure is in line relative to the talus, calcaneus, and navicular

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Underlying issue in Transitional Lesions

Consider possible underlying muscular imbalance

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Functional MA origin

Hallux varus or abductor hallucis, primary or associated

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Medial structure of distal foot

The apex of the concavity is at the base of the 1st metatarsal.

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Rigid passive movement

Rigid forefoot cannot be passively corrected.

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Clinical Picture of Metatarsus Adductus

All metatarsals are adducted in this condition.

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Where do simons lines cross

Lines crossing in mid foot.

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Hallucis

The abductor hallucis is contracted or malinserted.

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Should you do nothing

Not a good idea if there is a significant deformity

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Can be used with

Can be used with children that are already walking

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real management

Manipulate b/w casts

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Medico Legal Documentation

Mainly for medico legal reason to have record that deformity has been completely reduced

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Described as Crescentic

Berman-Gartland Procedure

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Study Notes

Agnew Classification & Berg

  • Distinguishes Simple vs Complex types depending on structures involved

Postural Metatarsus Adductus

  • Forefoot can be manipulated to neutral with ease and spontaneous correction is likely

Congenital Metatarsus Varus

  • Medial subluxation or TMJ complexes are noted where NOT subluxed, they are congruent
  • Bone distal to the joint is misshapen (bending in the bone near the met base or in the shaft)

Rearfoot & Tarsal Relationships

  • Hindfoot neutral or slightly everted, TNJ normal

the metatarsus

  • The metatarsus & Talometatarsal angle (Simons' angle) assessed for severity

Radiological Aspects

  • AP talocalcaneal angle (Kite's angle) assessed where: Normal- 20-35 degrees
  • Lateral talocalcaneal angle: Normal- 25-45 degrees

Definite Indications for Surgical Intervention

  • Persisting hallux varus is a key indication that the abductor hallucis is either contracted or malinserted.
  • Non surgical treatment of this presents mainly in children over the age of 3 where After age 3, the success rate of cast therapy is so small that it probably should not be attempted
  • The skeletal age suggests that there is insufficient cartilage remodeling to take place by casting alone
  • Large physical size presents difficulties in cast
  • Late recurrence & Failure of nonoperative therapy will influence treatment
  • No surgery is indicated for metatarsus adductus until an effort to correct the deformity nonoperatively has failed

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