Pes Cavus Foot Deformity

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Questions and Answers

In the context of pes cavus deformity, which statement most accurately differentiates between direct pes cavus and cavovarus deformity?

  • Cavovarus deformity exclusively occurs in conjunction with neuromuscular disorders, whereas direct pes cavus is typically idiopathic.
  • Cavovarus deformity is primarily a sagittal plane deformity, whereas direct pes cavus always involves a triplane deformity with adduction.
  • Direct pes cavus involves uniplanar (sagittal plane) deformity, while cavovarus deformity encompasses multiplanar rotation of the foot and calcaneus relative to the talus. (correct)
  • Direct pes cavus is characterized by compensatory supination, while cavovarus deformity results from isolated plantarflexion of the first ray.

When evaluating pediatric pes cavus, which radiographic parameter offers the MOST SPECIFIC insight into underlying ankle and/or rearfoot equinus?

  • Tibiotalar Angle
  • Tibiocalcaneal Angle (correct)
  • Lateral Talocalcaneal Angle
  • Calcaneal Inclination Angle (CIA)

In the assessment of combined (mixed) pes cavus deformity, which statement accurately reflects the utility of the Meary angle?

  • The apex of the Meary angle typically intersects between the Chopart and Lisfranc joints, with an anterior apex correlating with increased metatarsal declination. (correct)
  • The Meary angle is consistently normal, negating its diagnostic relevance in combined deformities.
  • The apex of the Meary angle intersects proximal to the Chopart joint, exclusively indicating a calcaneonavicular coalition.
  • The Meary angle is exclusively increased in the presence of marked talar declination, irrespective of the location of the apex.

Which of the following statements accurately describes the utility of weight-bearing computed tomography (WBCT) in evaluating pes cavus deformity, especially in the context of surgical planning?

<p>WBCT provides enhanced assessment of osseous alignment, hindfoot alignment, and compensatory mechanisms, as well as evaluates occult osteoarthritic joints or tarsal coalitions. (C)</p> Signup and view all the answers

What imaging modality is MOST sensitive for detecting early signs of peroneal tendon pathology associated with adult-acquired pes cavus secondary to lateral ankle sprain?

<p>Magnetic Resonance Imaging (MRI) (D)</p> Signup and view all the answers

Which of the following is the MOST accurate description of the "anteater nose sign" concerning tarsal coalitions associated with pes cavus?

<p>Hypertrophic enlargement of the anterior calcaneal process, indicative of calcaneonavicular coalition. (B)</p> Signup and view all the answers

What is the MOST specific radiographic finding indicative of a middle facet tarsal coalition in a patient with pes cavus?

<p>Absent middle facet sign. (B)</p> Signup and view all the answers

In evaluating potential intraosseous or interosseous deformity contributing to pes cavus, what is the MOST significant advantage of advanced multiplanar computed tomographic (CT) imaging and three-dimensional (3D) reconstructions?

<p>Enhanced ability to delineate the extent and presence of subtle bony malformations and spatial relationships. (A)</p> Signup and view all the answers

Which statement accurately describes the imaging technique best suited to assess hindfoot alignment, specifically coronal plane tibiocalcaneal alignment in the context of pes cavus?

<p>Saltzman view. (B)</p> Signup and view all the answers

How does the "Magic Angle Artifact" MOST significantly impact MRI evaluation of peroneal tendons in patients with pes cavus and lateral ankle instability?

<p>It creates falsely increased signal intensity, potentially mimicking tendon tears or ruptures. (D)</p> Signup and view all the answers

In assessing muscle involvement using MRI in cavovarus deformity secondary to Charcot-Marie-Tooth disease (CMT), which finding MOST accurately differentiates between CMT1A and CMT2A subtypes?

<p>CMT1A shows a selective fatty infiltration with preference for anterior and lateral compartment muscles, whereas CMT2A favors superficial posterior compartment muscles. (A)</p> Signup and view all the answers

When evaluating pes cavus, especially focusing on Meary's angle, which statement BEST describes the significance of this measurement?

<p>Quantifies the alignment between the longitudinal axes of the talus and first metatarsal, indicating the severity of the deformity. (B)</p> Signup and view all the answers

What is the MOST accurate method for ensuring the reliability of hindfoot alignment assessments when using radiographic techniques, considering inherent limitations related to leg rotation and subject posture?

<p>Employing a modified technique enabling the patient to assume a natural weight-bearing (WB) posture, capturing the relative angle and base between both feet. (A)</p> Signup and view all the answers

Which of the following statements accurately reflects the diagnostic significance of T2* relaxation time mapping when assessing ankle joint cartilage in pes cavus?

<p>Elevated T2* relaxation times in the medial ankle compartment correlates with radiographic evidence of ankle arthrosis and symptomatic ankle joints. (A)</p> Signup and view all the answers

In cases of suspected tarsal coalition in patients with pes cavus, medial oblique radiographs are particularly useful for visualizing which specific anatomical structure?

<p>The anterior process of the calcaneus and the presence of a calcaneonavicular bar. (D)</p> Signup and view all the answers

Which factor is MOST crucial in distinguishing between compensatory alignment and true deformity when evaluating hindfoot alignment?

<p>Assessment of joint motion and response to stress. (A)</p> Signup and view all the answers

Which of the following statements accurately describes the PRIMARY advantage of using 7-Tesla MRI over lower-field MRI in evaluating intrinsic foot muscles in pes cavus?

<p>Enhanced resolution, facilitating superior segmentation of individual muscles, improved muscle volume assessment and clearer identification of fat infiltration. (D)</p> Signup and view all the answers

When assessing the clinical significance of the lateral talocalcaneal angle, which factor is MOST critical in its interpretation regarding clubfoot correction or pes cavus subclassification?

<p>Evaluating the angle in conjunction with calcaneal inclination and talar declination angles, as geometric relationships can indicate pronation or supination. (C)</p> Signup and view all the answers

In the context of radiographic imaging of pes cavus, what is the MOST accurate description of the C-sign and its clinical significance?

<p>Signifies an apparent continuity of structure between the talus and calcaneus where a continuous line can be traced leading to subtalar joint tarsal coalition. (B)</p> Signup and view all the answers

Which statement accurately describes the potential utility of ultrahigh-resolution MRI in evaluating subtle abnormalities in foot and ankle alignment within cavovarus deformities?

<p>Can potentially reveal relationships between skeletal alignment and the development of arthritic changes. (A)</p> Signup and view all the answers

What is the MOST common type of pes cavus deformity encountered?

<p>Direct pes cavus deformity. (B)</p> Signup and view all the answers

Which radiographic view is considered the cornerstone for imaging evaluation of direct pes cavus foot deformity?

<p>Lateral weight-bearing radiograph. (D)</p> Signup and view all the answers

What does the apex of the Meary talo-first metatarsal angle on a lateral radiograph represent in the context of pes cavus deformity?

<p>The pinnacle of the cavus deformity. (C)</p> Signup and view all the answers

In evaluating pes cavus deformity, what information can be gained from ancillary radiographic imaging techniques like the modified Saltzman view or the modified Coleman block test?

<p>Insight into deformity assessment and surgical planning. (C)</p> Signup and view all the answers

What is the PRIMARY advantage of using multiplanar computed tomographic (CT) imaging with 3D reconstructions in evaluating pes cavus deformity?

<p>Greater precision in delineating intraosseous and interosseous deformity. (D)</p> Signup and view all the answers

In the context of radiographic interpretation, what does an increased calcaneal inclination angle (CIA) typically indicate?

<p>Pes cavus. (D)</p> Signup and view all the answers

Which of the following conditions is MOST frequently associated with forefoot-driven hindfoot varus in anterior cavus deformity?

<p>Charcot-Marie-Tooth disease (CMT). (D)</p> Signup and view all the answers

What is the MOST likely compensatory mechanism in the subtalar joint when there is a sagittal plane depression of the medial forefoot column?

<p>Supination. (D)</p> Signup and view all the answers

In radiographic assessment, which condition is suggested by a tibiocalcaneal angle that tends to decrease with increasing values of calcaneal pitch/CIA?

<p>Ankle joint dorsiflexion. (A)</p> Signup and view all the answers

What radiographic finding is indicative of a calcaneonavicular coalition?

<p>Anteater nose sign. (C)</p> Signup and view all the answers

What is the PRIMARY role of MRI in evaluating adult-acquired pes cavus secondary to an ankle sprain?

<p>Evaluating the integrity of ankle ligaments and peroneal tendons. (D)</p> Signup and view all the answers

Why is it important to plantarflex the ankle by about 20 degrees during an ankle MRI when evaluating for peroneal tendon pathology?

<p>To reduce the impact of magic angle artifact on tendon signal. (C)</p> Signup and view all the answers

In the context of combined (mixed) cavus deformity, where is the typical intersection point of the apex of the Meary angle?

<p>Somewhere between the Chopart and Lisfranc joint. (B)</p> Signup and view all the answers

What key information is provided from weight-bearing CT scans that cannot be obtained from standard radiographs in evaluating pes cavus?

<p>The ability to evaluate compensatory rearfoot motions and positions. (D)</p> Signup and view all the answers

How does the presence of high-arched/cavus feet affect the reliability of Harris views (Harris-Beath view) in imaging tarsal coalitions?

<p>It can lead to unreliable imaging of subtalar joint features due to horizontal orientations. (B)</p> Signup and view all the answers

In the context of using MRI to evaluate muscle involvement in pes cavus due to Charcot-Marie-Tooth disease (CMT), what is a key difference in muscle involvement patterns between CMT1A and CMT2A patients?

<p>CMT1A shows a preference for anterior and lateral compartment muscles, while CMT2A affects superficial posterior compartment muscles. (D)</p> Signup and view all the answers

What is the MOST significant limitation of hindfoot alignment studies that assess coronal plane alignment of the calcaneus relative to the tibia?

<p>They do not account for leg rotation, unnatural posture, and x-ray beam obliquity. (A)</p> Signup and view all the answers

In cavovarus foot deformities, which statement accurately describes how muscle imbalance significantly contributes to the mentioned deformity?

<p>Resultant muscle imbalance arises mostly from PB musculotendinous unit dysfunction following an acute injury, leading to unopposed tibialis posterior function. (D)</p> Signup and view all the answers

While lateral weigthbearing radiographs are accurate in the assessing of direct cavus deformities, for accuracy, what additional method is needed when subclassifying a complex triplanar deformity?

<p>None of the above (D)</p> Signup and view all the answers

If a patient presents with a decrease in subtalar joint motion, which deformity is most likely to occur?

<p>The hindfoot will reflect the varus ankle/varus plafond and also assume the varus position (B)</p> Signup and view all the answers

In assessing a direct pes cavus deformity, what is the PRIMARY focus when using a lateral weight-bearing radiograph?

<p>Assessing the sagittal plane deformity. (B)</p> Signup and view all the answers

What is the TYPICAL radiographic presentation of neurologic cavus foot deformities regarding the calcaneal inclination angle (CIA)?

<p>CIAs tend to be excessive, often 40° or greater. (A)</p> Signup and view all the answers

In radiographic analysis of pes cavus, an increased first metatarsal declination angle typically indicates what specific type of cavus deformity?

<p>Anterior Cavus (B)</p> Signup and view all the answers

Concerning the tibiocalcaneal angle in the pediatric population, what condition is generally associated with increased angles?

<p>Ankle and/or rearfoot equinus (B)</p> Signup and view all the answers

Which radiographic finding is MOST indicative of a calcaneonavicular coalition?

<p>Anteater nose sign (D)</p> Signup and view all the answers

In the context of anterior cavus deformity, what is the PRIMARY characteristic?

<p>Sagittal plane deformity associated with excessive plantarflexion of either the first ray or forefoot equinus. (D)</p> Signup and view all the answers

What is a COMMON clinical presentation in instances where the forefoot demonstrates valgus relative to the rearfoot?

<p>Compensation at the subtalar joint via supination. (B)</p> Signup and view all the answers

Following an acute lateral ankle sprain, what muscle imbalance is MOST likely to contribute to a resultant cavus foot deformity?

<p>Weakness of the peroneus brevis. (B)</p> Signup and view all the answers

What specific information does multiplanar CT scanning add to the evaluation of triplanar cavovarus deformity, beyond what plain film radiographs provide?

<p>Detailed three-dimensional reconstruction of the foot and ankle. (A)</p> Signup and view all the answers

In assessing for tarsal coalitions, particularly when using the Harris view (Harris-Beath view), what factor limits the reliability of this view in patients with high-arched/cavus feet?

<p>Markedly decreased declination angles of both the posterior and middle subtalar joint facets (D)</p> Signup and view all the answers

Why is an ankle MRI typically performed with the foot plantarflexed by about 20 degrees when evaluating for peroneal tendon pathology?

<p>To reduce the magic angle artifact and provide a straighter course for the peroneal tendons around the distal fibula/malleoli (B)</p> Signup and view all the answers

What is the MOST LIKELY underlying etiology if AP ankle views reveal a ball-and-socket ankle joint deformity in a pes cavus presentation?

<p>Underlying syndrome (C)</p> Signup and view all the answers

In the context of hindfoot alignment, what is the primary limitation of studies assessing coronal plane alignment of the calcaneus relative to the tibia?

<p>Inconsistencies of osseous morphology and differing joint compensatory capacity between individuals (C)</p> Signup and view all the answers

What does the apex of the Meary talo-first metatarsal angle represent, and why is it clinically significant in the subclassification of pes cavus?

<p>The location of maximal deformity; aids in distinguishing forefoot-driven from hindfoot-driven cavus. (B)</p> Signup and view all the answers

How might MRI demonstrate altered bone marrow edema patterns and a predilection for lateral stress reactions or fractures in the context of pes cavus/cavovarus deformity?

<p>Indicating altered weight-bearing patterns. (C)</p> Signup and view all the answers

Which statement accurately describes the influence of the subtalar joint in instances of varus ankle/varus plafond?

<p>It can compensate for the extrinsic varus if sufficient motion is available in the direction of eversion. (C)</p> Signup and view all the answers

A patient presents with radiographic findings of a Meary angle of nearly 0°, increased CIA, and increased tibiotalar angle. What type of pes cavus deformity is MOST likely?

<p>Posterior pes cavus (C)</p> Signup and view all the answers

In a combined (mixed) cavus deformity, if the apex of the Meary angle intersects somewhere between the Chopart and Lisfranc joints, what component of the deformity is generally reflected?

<p>The degree or magnitude of increased metatarsal declination associated with the anterior component of the deformity (C)</p> Signup and view all the answers

In extremely severe cases of pes cavus, plain film lateral radiographs may not be sensitive enough to evaluate the condition. According to the experts, advanced 3D weight bearing CT and MRI studies are beginning to show a previously unseen relationship in the rearfoot. That previously unseen condition is:

<p>The divergence of the subtalar joint facet axis creates a &quot;buttressing&quot; response, essentially creating 2 separate hindfeet. (D)</p> Signup and view all the answers

Weight-bearing CT (WBCT) allows for a more detailed assessment of pes cavus deformity. Beyond identifying different types of pes cavus and evaluating compensatory rearfoot motions, what additional analysis does WBCT facilitate?

<p>Analyses of rotational movements of foot and ankle bones (A)</p> Signup and view all the answers

Which type of pes cavus deformity is most commonly encountered?

<p>Direct pes cavus (B)</p> Signup and view all the answers

A lateral weight-bearing radiograph is NOT a key component in imaging evaluation of a direct pes cavus foot deformity.

<p>False (B)</p> Signup and view all the answers

What radiographic angle represents the pinnacle of the cavus deformity and aids in its subclassification?

<p>Meary talo-first metatarsal angle</p> Signup and view all the answers

The apex of the Meary talo-first metatarsal angle assists in ___________ of the deformity.

<p>subclassification</p> Signup and view all the answers

Match the following radiographic views with their primary diagnostic use in pes cavus evaluation:

<p>Lateral weight-bearing radiograph = Sagittal plane deformity assessment AP foot radiograph = Transverse plane malalignment assessment Modified Saltzman view = Hindfoot alignment Calcaneal axial view = Calcaneal alignment</p> Signup and view all the answers

Which advanced imaging technique shows promise in improving the precision and accuracy of delineating intraosseous and interosseous deformity in pes cavus?

<p>Multiplanar CT imaging with 3D reconstructions (B)</p> Signup and view all the answers

The calcaneal inclination angle (CIA) is formed by the intersection of the longitudinal axis of the talus and the first metatarsal.

<p>False (B)</p> Signup and view all the answers

What is the normal range for the calcaneal inclination angle (CIA)?

<p>25° ± 5°</p> Signup and view all the answers

Values greater than ______ degrees for the calcaneal inclination angle (CIA) are indicative of moderate pes cavus/increase in pitch.

<p>30</p> Signup and view all the answers

Match the radiographic finding with its description in pes cavus:

<p>Anteater nose sign = Hypertrophic enlargement of the anterior calcaneal process C-sign = Continuity of structure between the talus and calcaneus. Talar neck beaking = Dorsal talar neck osseous spur Absent middle facet sign = Loss of conspicuity of the middle facet of the subtalar joint.</p> Signup and view all the answers

In anterior cavus deformity, which of the following is a common radiographic finding?

<p>Increased declination angles of the metatarsal bones (C)</p> Signup and view all the answers

The usefulness of the Calcaneal-first metatarsal (Hibbs) angle has not been questioned in that it does not aid in the determination of the apex of the deformity.

<p>False (B)</p> Signup and view all the answers

What is the primary imaging modality for demonstrating typical coronal plane features in subtalar joint coalition when Harris views cannot reliably image subtalar joint features in subjects with pes cavus deformity?

<p>CT scanning</p> Signup and view all the answers

The ________ angle is formed by the intersection of the longitudinal axes of the calcaneus and first metatarsal bones.

<p>Calcaneal-first metatarsal</p> Signup and view all the answers

Match the muscle group with its associated cavus deformity pattern:

<p>Weakness of gastrocnemius = Posterior cavus deformity Peroneus brevis insufficiency = Acquired pes cavus</p> Signup and view all the answers

Which of the following is NOT a typical finding in a secondary weight-bearing lateral radiographic assessment associated with pes cavus deformity?

<p>Increased posterior facet declination angle (C)</p> Signup and view all the answers

The tibiocalcaneal angle generally increases with increasing values of calcaneal pitch/CIA in pes cavus deformities.

<p>False (B)</p> Signup and view all the answers

What specific imaging feature, observable via MRI, can demonstrate altered patterns of bone marrow edema in pes cavus/cavovarus deformity?

<p>lateral patterns of bone marrow edema</p> Signup and view all the answers

In the context of adult-acquired pes cavus secondary to chronic sequelae of a peroneus brevis (PB) injury, imaging begins with weight-bearing plain film imaging of the foot and ankle, AP and lateral of the foot, axial views of the _________, and AP mortise and lateral of the ankle.

<p>calcaneus/tibia</p> Signup and view all the answers

Match the following parameters of pes cavus with their typical values or characteristics:

<p>Normal range for Talo-first metatarsal (Meary) angle = 0° to 5° Meary (Tomeno) line = Disrupted Severe Pes Cavus Meary angle = Greater than 10</p> Signup and view all the answers

Which of the following is considered the cornerstone of imaging evaluation for direct pes cavus foot deformity?

<p>Lateral weight-bearing radiograph (C)</p> Signup and view all the answers

Direct-type cavus foot deformities are most commonly triplane deformities.

<p>False (B)</p> Signup and view all the answers

What angle, when assessed on a lateral radiograph, represents the pinnacle of the cavus deformity?

<p>Meary talo-first metatarsal angle</p> Signup and view all the answers

The calcaneal inclination angle is formed by a tangent to the inferior calcaneal surface and the ______ reference line.

<p>WB</p> Signup and view all the answers

Match the following radiographic views with their primary use in evaluating pes cavus:

<p>Lateral weight-bearing radiograph = Assessment of sagittal plane deformity AP foot radiograph = Insight into transverse plane malalignments Calcaneal axial view = Evaluating hindfoot alignment</p> Signup and view all the answers

What does the term 'pes cavus' refer to?

<p>A high-arched foot deformity. (A)</p> Signup and view all the answers

The Meary angle is formed by the intersection of the calcaneal and talar longitudinal axes.

<p>False (B)</p> Signup and view all the answers

In the context of imaging pes cavus, what is the significance of multiplanar CT scanning?

<p>Provides precision in delineating intraosseous and interosseous deformity</p> Signup and view all the answers

Severe pes cavus deformities may demonstrate decreased ______ angles approaching 90 degrees.

<p>Hibbs</p> Signup and view all the answers

In anterior cavus deformity, which of the following muscles is typically weakened?

<p>Peroneus brevis (B)</p> Signup and view all the answers

In the evaluation of flatfoot, loss of visualization of the middle facet is a sin qua non for a middle facet coalition.

<p>True (A)</p> Signup and view all the answers

What radiographic finding is indicative of CN coalition?

<p>Anteater nose sign</p> Signup and view all the answers

Typical findings demonstrated utilizing coronal plane features in subtalar joint coalition includes dysmorphic sustentaculum tali, altered middle facet angulation (``drunken ______'' sign), presence of incorporated os sustentacula, and the degree of posterior facet involvement in the coalition.

<p>waiter</p> Signup and view all the answers

What is the most common acute musculoskeletal injury of the body?

<p>Ankle sprain (B)</p> Signup and view all the answers

MRI is the standard imaging technique for direct cavus deformities.

<p>False (B)</p> Signup and view all the answers

What is the significance of the "bullet-hole" sinus tarsi in radiographic findings related to pes cavus?

<p>Secondary plain radiograph finding associated with pes cavus deformity</p> Signup and view all the answers

Anterior cavus is primarily a sagittal plane deformity associated with excessive plantarflexion of either the first ______ or the forefoot equinus

<p>ray</p> Signup and view all the answers

Which of the following statements regarding the use of subtalar joint vertical axis for assessing varus/valgus configuration of the subtalar joint posterior facet is true?

<p>Provides a reliable and consistent method for assessment. (C)</p> Signup and view all the answers

The tibiocalcaneal angle typically decreases with increasing values of calcaneal pitch and/or with ankle dorsiflexion.

<p>True (A)</p> Signup and view all the answers

What type of imaging can cause the 'magic angle artifact'?

<p>MRI (D)</p> Signup and view all the answers

Flashcards

Pes Cavus

A foot deformity with a high arch, giving a hollow or cave-like appearance.

Direct Pes Cavus

Direct pes cavus is primarily a sagittal plane deformity and is the most common type of cavus foot.

Meary Talo-First Metatarsal Angle

An angle measured on a lateral radiograph, formed by the intersection of the talus and first metatarsal axes; assesses cavus deformity.

Calcaneal Inclination Angle (CIA)

The angle formed by a tangent to the inferior calcaneal surface and the weight-bearing reference line.

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Cavovarus Deformity

A deformity involving foot rotation on the distal tibia-fibula, resulting in calcaneal varus, equinus, and forefoot adduction.

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Modified Coleman Block Test

Used to differentiate flexible from rigid forefoot deformities. Plantarflexion of the first ray disappears upon heel correction.

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Modified Saltzman View

A radiographic view useful in assessing hindfoot alignment.

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Imaging for Pes Cavus

Weight-bearing lateral radiograph of the foot is the primary choice.

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AP Foot Radiographs

Indicates transverse plane malalignments in cavus foot deformities.

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Standard Plain Radiographs

Standard views include AP, lateral, and calcaneal axial views.

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Calcaneal-First Metatarsal (Hibbs) Angle

Angle formed by the intersection of longitudinal axes of calcaneus and 1st metatarsal; indicates cavus.

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Tibiotalar Angle

Angle formed by the longitudinal axes of talus and tibia.

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Anteater Nose Sign

Enlargement of the anterior calcaneal process seen in CN coalition.

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Peroneus Brevis (PB) Acute Injuries

Directly injured due to mechanical trauma to the tendon.

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MRI in pes cavus/cavovarus deformity

Can demonstrate altered bone marrow edema patterns and predilection for lateral stress reaction/fracture.

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Apex of Meary angle.

Represent the summit of cavus deformity and helps in subclassification.

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Cavovarus deformity details

Rotation of foot/calcaneus on distal tibial-fibular unit via subtalar joint, excluding talus itself.

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AP radiograph benefit

AP foot radiograph assesses transverse plane issues, valuable in evaluating cavovarus deformities.

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Tibiocalcaneal angle significance

Describes the angle of the talus relative to the tibia.

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Anterior Cavus

Increased declination angles of metatarsal bones, useful for local 1st ray deformity identification.

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Cause of Anteater nose sign

Hypertrophic enlargement of the anterior calcaneal process.

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Inconspicuous middle facet

Loss of visibility of middle facet of the subtalar joint, particularly in cavus feet.

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Peroneus Brevis (PB) injuries

Can be injured mechanically or through traction forces via peroneal nerve.

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CT scanning for tarsal coalition

Imaging modality demonstrating typical features in subtalar joint coalition: dysmorphic tali etc..

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Lateral Radiographs

Evaluation cornerstone - lateral weight-bearing radiograph confirms, classifies deformity, aids surgical planning.

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Calcaneal Inclination Angle

Normal values 25 degrees +/- 5. >30 indicate moderate deformity

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Talo-first metatarsal (Meary) angle

Normal range 0-5 degrees. Measures relationship between talus and 1st metatarsal

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Lateral TC Angle

Normal values are 35° to 50°. Geometrically equal to the sum of the calcaneal inclination and talar declination angles

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First Metatarsal Declination Angle

Angle formed by longitudinal axis first metatarsal and weight-bearing reference line

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Classifying Pes Cavus

Pes cavus is classified based on apex of deformity as forefoot/anterior rearfoot/hindfoot or combined.

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Increased Lateral TC Angle

Lateral TC angle can show paradoxically increase in value in the presence of normal talar declination secondary to markedly increased CIAs.

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Ancillary Radiographic views

Designed to estimate the moment arm between the WB axis of the leg and the contact point of the heel.

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Uncommon Tarsal Coalitions

Talonavicular, Naviculocuboid, or calcaneo-cuboid

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Lateral Weight-Bearing Radiograph

Lateral radiograph is integral to evaluating sagittal plane deformity in direct pes cavus.

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Tibiocalcaneal Angle

Angle formed by tangent to inferior calcaneal surface & tibia’s longitudinal axis; elevated in rearfoot equinus.

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Secondary Pes Cavus Radiographic Signs

Horizontal talus, posterior fibula displacement, “bullet-hole” sinus tarsi.

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Ankle Sprain

The plantarflexion/inversion injury of the foot.

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Cavus Foot Muscle Imbalance

Muscle imbalance from peroneus brevis (PB) weakness.

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MRI for Pes Cavus

To confirm and identify underlying peroneal tendon pathologic conditions and concomitant conditions

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Medial Oblique Imaging

High-angle medial oblique confirms CN coalitions, direct synostosis may be noted.

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Triplane Cavovarus Deformity

Triplane cavovarus deformity involves foot rotation with calcaneal varus and forefoot issues.

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Tibiocalcaneal Angle Increase

Increased angle due to ankle dorsiflexion or calcaneus position.

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Horizontal Talus

Horizontal talus orientation is a secondary radiographic indication of pes cavus.

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Talar Neck “Beaking”

Dorsal talar neck osseous “spur.”

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Peroneal Tendon Deformations

Loss of tendon function associated with significant changes of tendon.

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Study Notes

  • Direct-type cavus foot deformities are most commonly encountered and are primarily sagittal plane deformities
  • Direct deformities should be delineated from rarer triplane pes cavovarus deformities
  • The lateral weight-bearing radiograph is the cornerstone of imaging evaluation of direct pes cavus foot deformity
  • Ancillary radiographic imaging techniques give valuable insight into deformity assessment and surgical planning, like the modified Saltzman view or the modified Coleman block test
  • Advanced multiplanar computed tomographic (CT) imaging techniques along with 3-dimensional reconstructions promise to improve precision and accuracy in delineating the presence and extent of intraosseous and interosseous deformity
  • Weight-bearing CT can facilitate hindfoot alignment and compensatory motions in pes cavus deformity
  • Pes cavus is perceived as a pedal deformity with elevation of the medial and lateral longitudinal foot arches, imparting a cave-like appearance
  • Lateral weight-bearing radiograph is integral to the evaluative process for the sagittal plane deformity seen in direct pes cavus, whether for confirming clinical diagnosis, classifying the deformity, or planning surgical correction
  • The lateral radiograph is essential in assessing the sagittal plane component of the triplanar cavovarus deformity
  • Multiplanar CT scanning with 3D reconstruction appears better suited for preoperative and postoperative evaluation of cavovarus deformity
  • Primary WB lateral radiographic determinations comprise the main measurements and/or determinations in pes cavus deformity
  • Calcaneal inclination angle (CIA) (aka calcaneal “pitch” angle) is formed by a tangent to the inferior calcaneal surface and the WB reference line. 25° ± 5° is normal, greater than 30° indicates moderate pes cavus/increase in pitch. Severe cavus often demonstrates excessive CIAs of 40° or greater
  • A talo-first metatarsal (Meary) angle is formed by the intersection of longitudinal axes, ranging 0°-5° normally. As first metatarsal declination increases, the Meary angle generally increases, with values greater than 15°-18° in pes cavus
  • Sagittal apex of pes cavus deformity is determined by where the apex of the Meary talo-first metatarsal angle is positioned, and is a key guideline used in helping to subclassify pes cavus deformities
  • A calcaneal-first metatarsal (Hibbs) angle is formed by the intersection of longitudinal axes of the calcaneus and first metatarsal bones. Hibb angles less than 150° are indicative of pes cavus, possibly approaching 90°
  • A lateral TC angle is formed by the intersection of the calcaneal and talar longitudinal axes. Normal values are 35°-50°, tending to increase with pronation and decrease with supination, classifically used to evaluate clubfoot correction
  • First metatarsal declination angle is formed by the longitudinal axis of the first metatarsal and the WB reference line. Normal values range from 15°-23°, and angles commonly increase beyond 25° in cavus deformity
  • Tibiotalar angle is formed by the longitudinal axes of the talus and tibia, which normally measures 110°, and decreases with cavus deformity associated with ankle joint dorsiflexion and vice versa
  • Tibiocalcaneal angle is formed by a tangent to the inferior calcaneal surface and the longitudinal axis of the tibia, ranging 60°-90° normally in pediatric cases
  • Increased angles are generally associated with ankle and/or rearfoot equinus, and tends to decrease with increasing values of calcaneal pitch/CIA and/or with ankle dorsiflexion
  • Anterior cavus ("forefoot driven hindfoot varus") is primarily a sagittal plane deformity associated with excessive plantarflexion of either the first ray or the forefoot equinus
  • General radiographic findings for anterior cavus deformity include increased declination angles of the metatarsal bones

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