Pes Cavus Imaging Techniques

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Questions and Answers

In the context of direct pes cavus deformity, which of the following statements most accurately characterizes the orientation of the foot and calcaneus relative to the distal tibial-fibular articulation?

  • The foot and calcaneus rotate as a unit on the distal tibial-fibular articulation via the subtalar joint, excluding the talus, contributing to compensatory supination of the calcaneal-pedal unit.
  • The foot and calcaneus do not entail rotation on the distal tibial-fibular articulation; instead, the deformity is primarily uniplanar (sagittal) and does not involve the subtalar joint. (correct)
  • The foot and calcaneus exhibit rotational changes as a unit at the distal tibial-fibular articulation, with the talus serving as the central axis of rotation within the sagittal plane.
  • The foot and calcaneus rotate as a unit via the talocalcaneal joint, independently of the subtalar joint, leading to a uniplanar deformity primarily in the axial plane.

In assessing a patient with suspected pes cavus, which radiographic view is MOST critical for evaluating the degree of metatarsus adductus and transverse plane malalignments, especially in the context of cavovarus deformities?

  • Calcaneal axial view.
  • Modified Coleman block test.
  • Anteroposterior weight-bearing radiograph. (correct)
  • Lateral weight-bearing radiograph.

Which statement BEST describes the relationship between the calcaneal inclination angle (CIA) and the lateral talocalcaneal angle in the context of varying degrees of pronation and supination?

  • The lateral talocalcaneal angle is geometrically equivalent to the sum of the calcaneal inclination and talar declination angles; it tends to increase with pronation and decrease with supination. (correct)
  • The lateral talocalcaneal angle is geometrically equivalent to the sum of the calcaneal inclination and talar declination angles; it decreases with pronation and increases with supination.
  • The lateral talocalcaneal angle is inversely proportional to the calcaneal inclination angle, increasing as the calcaneal inclination angle decreases, irrespective of pronation or supination.
  • The lateral talocalcaneal angle remains constant regardless of changes in the calcaneal inclination angle, providing a stable reference point for deformity assessment.

Which of the following statements BEST characterizes the radiographic apex location in combined (mixed) pes cavus deformity?

<p>It typically intersects somewhere between the Chopart and Lisfranc joint, its anterior position reflecting the degree of increased metatarsal declination. (D)</p>
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In the context of ancillary radiographic imaging for pes cavus deformities, what is the MOST accurate rationale for using the Saltzman and el-Khoury view, and how is it technically executed?

<p>To evaluate coronal plane varus and valgus malalignments; it requires a 20-degree beam inclination to the weight-bearing surface with a long leg-plate image receptor angled 20 degrees from the vertical. (A)</p>
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Which of the following statements accurately characterizes the impact of adult-acquired pes cavus on the peroneus brevis (PB) tendon, and what pathophysiological mechanisms are MOST commonly involved?

<p>The PB tendon commonly undergoes significant tendon deformations, such as attenuated splaying or longitudinal split tears, due to a muscle imbalance and repetitive ankle injuries. (D)</p>
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In the context of MRI evaluation for adult-acquired pes cavus, what is the significance of the 'magic angle artifact,' and how can it be mitigated to ensure accurate interpretation of peroneal tendon pathology?

<p>The magic angle artifact affects the signal intensity of ordered collagen within tendons, potentially leading to false-positive interpretations of tendon pathology; it can be minimized by plantarflexing the ankle by about 20 degrees during imaging. (C)</p>
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While MRI has shown an increased application to pes cavus deformities, which statement accurately reflects its limitations relative to conventional methods?

<p>Despite evolving applications, MRI's sectional and 3D imaging capabilities have not yet supplanted standard weightbearing multiplanar and 3D CT scanning for pretreatment/preoperative reconstruction in pes cavus and cavovarus deformities. (D)</p>
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In the context of tarsal coalitions associated with pes cavus, which radiographic finding is considered a sine qua non for diagnosing a middle facet coalition, and under what specific conditions is this finding most reliable?

<p>A loss of conspicuity of the middle facet, which is most reliable in cavus-type architecture in the absence of severe symptomatic flatfoot. (D)</p>
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Which of the following statements accurately characterizes the rationale and methodology for using high-resolution T2* relaxation time mapping of ankle joint cartilage in patients with pes cavus?

<p>To quantify subtle changes in cartilage composition and detect early arthrosis by measuring T2* relaxation times, correlating them with clinical symptoms and radiographic findings. (B)</p>
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What are the key differentiating features depicted by 3D weight-bearing CT analysis when comparing Charcot-Marie-Tooth (CMT) cavovarus foot deformities with idiopathic cavovarus feet?

<p>CMT feet exhibit increased forefoot supination and hindfoot malalignment compared to idiopathic cavovarus feet. (C)</p>
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Given the diverse etiologies of pes cavus, which of the following statements BEST encapsulates the utility of MRI in differentiating between various underlying causes?

<p>MRI is instrumental in assessing soft tissue structures; it can identify muscle atrophy patterns suggestive of neuropathic conditions like CMT, as well as tendon pathology from trauma. (B)</p>
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Which statement accurately characterizes the relationship between hindfoot alignment, ankle osteoarthritis, and subtalar joint orientation as revealed by imaging studies?

<p>Varus ankle osteoarthritis is correlated with increased valgus subtalar joint alignment as a compensatory mechanism, and vice versa. (C)</p>
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Under what conditions would one consider advanced multiplanar computed tomographic (CT) imaging techniques along with 3D reconstructions indispensable in the assessment of pes cavus deformity?

<p>For delineating the presence and extent of triplane cavovarus deformity. (D)</p>
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How does the Meary-Tomeno line, and its disruption, factor into the radiographic evaluation of Pes Cavus?

<p>The apex would be at the level of the cuneiforms or the cuneiform-metatarsal (first metatarsal/Lisfranc) joints. (A)</p>
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What role does the Harris (Harris-Beath) view play when imaging tarsal coalition?

<p>Useful in the coronal plane imaging of the posterior and middle subtalar joint facets. (D)</p>
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How does the average fibula position vary, between subjects of cavus and control?

<p>Is more % posterior. (D)</p>
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In pediatric pes cavus, what is the normal range for the Tibiocalcaneal angle, and it's relation to equninus?

<p>Normal pediatric angle range is 60° to 90°. Increased angles generally associated with ankle and/or rearfoot equinus. (D)</p>
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What is the position that the patient should be placed for ankle MRI, and why?

<p>Prone position, with the ankle plantarflexed by about 20°. In this way, the peroneal (and other ankle) tendons approximate a straighter course around the distal tip of the fibula/malleoli. (B)</p>
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What is the Tibiocalcaneal angle generally?

<p>Tibiocalcaneal can be useful in delineating combined findings associated with compensated forefoot (global) equinus. (B)</p>
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In the context of triplane cavovarus deformity, what is the MOST accurate description of the relative movement and positioning of the foot and calcaneus in relation to the tibial-fibular articulation?

<p>The foot and calcaneus rotate as a single, unified calcaneopedal unit around the subtalar joint, excluding the talus, leading to compensatory supination, eventual calcaneal varus, talo-tibfibular unit external rotation, and forefoot adduction. (C)</p>
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In assessing the etiology of adult-acquired pes cavus, which of the following pathophysiological mechanisms is LEAST likely to be directly evaluated and differentiated using MRI?

<p>Compromise and architectural disruption of the plantar fascia at its calcaneal insertion site. (A)</p>
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Which advanced imaging modality provides the MOST comprehensive assessment for pre-operative planning in complex triplanar cavovarus foot deformities?

<p>Weight-bearing multiplanar computed tomography (CT) in conjunction with 3D reconstructions. (B)</p>
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When evaluating a lateral weight-bearing radiograph of a patient with pes cavus, a tibiocalcaneal angle significantly exceeding the normal pediatric range (60°-90°) is MOST indicative of which underlying condition?

<p>Ankle and/or rearfoot equinus. (B)</p>
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In the context of ancillary radiographic imaging for pes cavus deformities, which of the following statements BEST describes the primary objective for using the Saltzman and el-Khoury view?

<p>To estimate the moment arm between the weight-bearing axis of the leg and the contact point of the heel in the coronal plane tibiocalcaneal alignment. (D)</p>
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Which technical modification to traditional ankle MRI protocols is MOST critical to minimize the 'magic angle artifact' when evaluating peroneal tendon pathology in patients with adult-acquired pes cavus?

<p>Positioning the patient prone with the ankle plantarflexed approximately 20 degrees. (D)</p>
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Which of the following statements BEST characterizes the clinical utility of high-resolution T2* relaxation time mapping of ankle joint cartilage in patients with pes cavus?

<p>It enables precise quantification of glycosaminoglycan (GAG) content within the cartilage matrix, aiding in early detection of chondral degeneration. (B)</p>
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In the context of tarsal coalitions associated with pes cavus, which of the following statements accurately describes a characteristic radiographic finding?

<p>An anteater nose sign, characterized by hypertrophic enlargement of the anterior calcaneal process, most indicative of a calcaneonavicular coalition. (B)</p>
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In instances of adult-acquired pes cavus secondary to progressive deterioration of peroneus brevis (PB) function, lateral weight-bearing radiographs may demonstrate what?

<p>Bell-shaped cuboid (D)</p>
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When assessing a suspected calcaneonavicular coalition, which of the following radiographic findings is MOST reliable on a medial oblique view?

<p>An apparent synostosis, or bony bridge (bar), between the calcaneus and navicular. (A)</p>
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Which statement accurately reflects a limitation of Harris views in imaging subtalar joint coalitions in the presence of pes cavus deformity?

<p>Harris views cannot reliably image subtalar joint features in subjects with pes cavus deformity. (D)</p>
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When evaluating a lateral weight-bearing radiograph of a patient with Anterior Cavus, the tibiotalar angle would demonstrate what?

<p>Decreased Tibiotalar Angle (D)</p>
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Which statement accurately reflects the average fibula position, between someone with pes cavus and a control?

<p>Pes Cavus has a fibula that is, on average, 72% more posterior than the average fibula in the control group. (C)</p>
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Which statement accurately reflects the range of the typical First metatarsal declination angle?

<p>Normal values range from 15° to 23°. (A)</p>
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If the apex/vertex of the Meary angle is typically proximal to the Chopart joint, what type of cavus is most likely?

<p>This is typical of posterior cavus. (C)</p>
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In anterior cavus, what is the general trend of the declination angles of the metatarsal bones?

<p>Increased. (D)</p>
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Which statement regarding subtalar joint in patients with ankle osteoarthritis, is most accurate?

<p>In patients with varus ankle osteoarthritis, the posterior process will exhibit varus orientation in about half of the cases. (D)</p>
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In anterior cavus, it is best to consider depression of which foot aspect being primarily involved?

<p>Either the sagittal plane depression of the medial forefoot column or pillar, or both the medial and the lateral pillars of the forefoot. (C)</p>
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What is the normal range for the lateral talocalcaneal angle?

<p>Normal values are 35° to 50° (A)</p>
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In a radiographic findings of secondary WB lateral radiographic findings, what might be seen?

<p>All of the above (D)</p>
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Which type of pes cavus deformity is most commonly encountered?

<p>Direct-type pes cavus (A)</p>
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What is the cornerstone of imaging evaluation for direct pes cavus foot deformity?

<p>Lateral weight-bearing radiograph (B)</p>
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On a lateral radiograph, what does the apex of the Meary talo-first metatarsal angle represent?

<p>The pinnacle of the cavus deformity (C)</p>
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Which ancillary radiographic imaging techniques give valuable insight into deformity assessment and surgical planning?

<p>Both A and B (C)</p>
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What do advanced multiplanar computed tomographic (CT) imaging techniques promise to improve?

<p>Precision and accuracy in delineating deformity (C)</p>
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Pes cavus is characterized by which of the following?

<p>Grossly apparent elevation of the medial and lateral longitudinal foot arches (C)</p>
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Calcaneal varus with external rotation of the talo-tibfibular unit is MOST characteristic of which deformity?

<p>Cavovarus (D)</p>
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Where is the longitudinal talar axis directed in triplanar cavus foot deformity associated with clubfoot?

<p>Through the lateral rays (A)</p>
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What does a calcaneal inclination angle (CIA) greater than 30° typically indicate?

<p>Moderate pes cavus/increase in pitch (D)</p>
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What is the normal range for the talo-first metatarsal (Meary) angle on a lateral radiograph?

<p>0° to 5° (A)</p>
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In anterior cavus, what general trend is observed in the declination angles of the metatarsal bones?

<p>Increased declination angles (D)</p>
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What radiographic finding is associated with posterior cavus deformity?

<p>Increased tibiotalar angle (D)</p>
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What is the inclination angle of the beam used for a modified Saltzman view?

<p>20° (A)</p>
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How should a patient be positioned for an ankle MRI to minimize magic angle artifact?

<p>Prone with ankle plantarflexed (C)</p>
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What statement is true regarding Harris views in imaging subtalar joint coalitions in the presence of pes cavus deformity?

<p>Harris views cannot reliably image subtalar joint features (A)</p>
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What is one of the primary problems in a cavus foot deformity, in regards to the Peroneus Brevis?

<p>Muscle imbalance secondary to weakness or complete loss of the PB musculotendinous unit (B)</p>
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Which of the following best describes the radiographic appearance of the anterior calcaneal process in the presence of a calcaneonavicular coalition?

<p>Hypertrophic enlargement, known as the &quot;anteater nose sign&quot; (C)</p>
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Which MRI sequence(s) will demonstrate increased intratendinous signal or signals leading to an erroneous false positive interpretation of tendon rupture or ruptures, due to the peroneal tendons changing direction from leg to foot around the distal tip of the fibula?

<p>Short echo time images (eg, T1-weighted) (B)</p>
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What is the general consensus on classifying pes cavus using weight-bearing computed tomography (WB CT)?

<p>Currently there are sparse validated studies regarding classifying pes cavus using WB CT. (C)</p>
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In the context of adult-acquired pes cavus secondary to muscle imbalance, which muscle is MOST central to structural changes?

<p>Peroneus Brevis (C)</p>
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A lateral weight-bearing radiograph is not useful in the imaging evaluation of direct pes cavus foot deformity.

<p>False (B)</p>
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What does the apex of the Meary talo-first metatarsal angle represent on the lateral radiograph?

<p>the pinnacle of the cavus deformity</p>
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The angle formed by the intersection of the longitudinal axis of the talus and the first metatarsal is known as the ______ angle.

<p>meary</p>
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Match the radiographic findings with their corresponding tarsal coalition:

<p>Anteater nose sign = Calcaneonavicular coalition Loss of conspicuity of the middle facet = Middle facet subtalar joint coalition Talar neck beaking = Talar neck coalition</p>
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Why has the usefulness of the calcaneal-first metatarsal (Hibbs) angle been questioned?

<p>It does not aid in the determination of the apex of the deformity. (C)</p>
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What is the normal range for the tibiotalar angle?

<p>110 degrees (C)</p>
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In cases of forefoot valgus combined with depression of the lateral forefoot pillar, compensation would result in decreased lateral TC angle and increased CIA.

<p>True (A)</p>
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What are the two most commonly encountered tarsal coalitions?

<p>calcaneonavicular (CN) and middle facet subtalar joint</p>
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What is one of the most common acute musculoskeletal injuries?

<p>Ankle sprain (C)</p>
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In instances of progressive deterioration of PB function, the ______ eventually, and essentially, functions unopposed, and the adult-acquired pes cavus deformity develops.

<p>tibialis posterior</p>
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Routine ankle MRI is best accomplished with the patient in a supine position.

<p>False (B)</p>
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What is the typical range of normal values for the calcaneal inclination angle (CIA)?

<p>25° ± 5° (D)</p>
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What is the primary imaging modality for demonstrating typical coronal plane features in subtalar joint coalition when Harris views cannot reliably image these features in subjects with pes cavus deformity?

<p>CT scanning</p>
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Which of the following is a typical radiographic finding in anterior cavus deformity?

<p>Increased declination angles of the metatarsal bones (B)</p>
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The subtalar joint vertical axis is used to assess the varus/valgus configuration of the ______ facet.

<p>subtalar joint posterior</p>
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In triplane cavovarus deformity, rotation of the foot and calcaneus occurs on the distal tibial-fibular articulation as a unit (calcaneopedal unit) via the subtalar joint, including the talus.

<p>False (B)</p>
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In the context of ankle sprains, what does the 'magic angle artifact' primarily affect in MRI imaging?

<p>Peroneal tendon signal interpretation (C)</p>
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Explain the concept of the 'calcaneopedal unit' in the context of triplane cavovarus deformity, detailing which bone is excluded.

<p>the calcaneopedal unit includes the rotation of the foot and calcaneus on the distal tibial-fibular articulation via the subtalar joint, excluding the talus.</p>
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Which specific MRI technique has been used to potentially differentiate between CMT1A and CMT2A patients based on muscle involvement patterns?

<p>Fat fraction calculation with T1-weighted images (B)</p>
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What is the primary characteristic that distinguishes direct pes cavus deformity from triplane pes cavovarus deformities?

<p>Direct pes cavus is fundamentally a sagittal plane deformity, whereas triplane pes cavovarus involves rotations and adductions across multiple planes. (B)</p>
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In cases of neurological cavus foot deformities, a calcaneal inclination angle (CIA) greater than 40° is pathognomonic and definitively indicates the presence of an underlying neuromuscular disorder.

<p>False (B)</p>
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Explain the biomechanical rationale behind why a forefoot valgus, when combined with depression of the lateral forefoot pillar, leads to a specific compensatory pattern involving both decreased lateral talocalcaneal (TC) angle and increased calcaneal inclination angle (CIA).

<p>Forefoot valgus with lateral forefoot pillar depression results in subtalar joint supination, decreasing the lateral TC angle, while the compensatory increase in plantarflexion increases the CIA.</p>
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The Harris view is utilized for coronal plane imaging of the subtalar joint, but its reliability diminishes in pes cavus feet due to the ______ of the subtalar joint facets.

<p>horizontal orientation</p>
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Match the following radiographic findings with their corresponding tarsal coalition:

<p>Anteater nose sign = Calcaneonavicular coalition Absent middle facet sign = Middle facet subtalar coalition Talar neck beaking = Talonavicular coalition Continuous C-sign = Subtalar coalition</p>
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In the assessment of adult-acquired pes cavus secondary to peroneal brevis (PB) tendon pathology, which imaging modality is considered the 'workhorse' for evaluating the tendon's condition and integrity?

<p>Magnetic resonance imaging (MRI) (D)</p>
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The 'magic angle artifact' in ankle MRI, particularly affecting the peroneal tendons, is best mitigated by performing the MRI with the patient supine and the ankle dorsiflexed.

<p>False (B)</p>
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Describe how 3D weight-bearing computed tomography (WBCT) analyses differentiate cavovarus foot deformities associated with Charcot-Marie-Tooth disease (CMT) from idiopathic cavovarus feet in terms of forefoot and hindfoot alignment.

<p>3D WBCT reveals that CMT feet exhibit increased forefoot supination and notable hindfoot malalignment compared to idiopathic cavovarus feet.</p>
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In combined (mixed) cavus deformity, the apex of the Meary angle characteristically intersects ______ relative to the Chopart and Lisfranc joints.

<p>somewhere in between</p>
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Match the imaging modality with its primary role in evaluating pes cavus deformity:

<p>Lateral weight-bearing radiograph = Cornerstone for imaging direct sagittal plane deformity AP foot radiograph = Evaluating transverse plane malalignments and cavovarus deformities Weight-bearing CT scanning = Advanced assessment of hindfoot alignment and compensatory motions MRI = Evaluating soft tissue pathology and muscle involvement</p>
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Which of the following is the most accurate description of Meary's angle in the context of pes cavus deformity radiographic assessment?

<p>It represents the sagittal plane relationship between the longitudinal axes of the talus and the first metatarsal, where increased angles suggest greater cavus deformity. (A)</p>
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A decreased tibiotalar angle, as observed in some cavus deformities, is solely indicative of ankle joint dorsiflexion and does not reflect any underlying osseous adaptation or deformity within the ankle joint itself.

<p>False (B)</p>
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Explain the biomechanical rationale underlying the use of the modified Coleman block test in evaluating the flexibility of the first ray plantarflexion in a cavus foot, and how this influences surgical planning.

<p>The Coleman block test assesses the reducibility of the forefoot valgus/varus by eliminating the influence of the first ray, thereby determining if the first ray is a primary driver of the cavus deformity.</p>
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In evaluating cavus foot for potential surgical correction, advanced multiplanar computed tomographic (CT) imaging, specifically with ______, enhances accuracy in delineating intraosseous and interosseous deformities and hindfoot alignment.

<p>3-dimensional reconstructions</p>
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Match the following radiographic findings with its clinical implication in pes cavus deformity:

<p>Decreased lateral talocalcaneal (TC) angle = Compensatory supination at the subtalar joint Increased calcaneal inclination angle (CIA) = Increased plantarflexion force on the calcaneus Increased first metatarsal declination angle = Plantarflexed first ray Decreased Tibiocalcaneal angle = Ankle joint dorsiflexion or equinus</p>
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What underlying condition should be suspected when encountering uncommon tarsal coalitions, involving the midfoot (e.g., talonavicular, naviculocuboid, or calcaneocuboid joints) in conjunction with pes cavus?

<p>An underlying syndrome or genetic disorder (C)</p>
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In cases of adult-acquired pes cavus secondary to peroneal brevis tendon pathology, direct surgical repair of the tendon alone is typically sufficient to correct the cavus deformity and restore normal foot biomechanics, negating the need for any additional reconstructive procedures.

<p>False (B)</p>
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Explain the relationship between a rigid plantarflexed first ray and the potential for compensatory changes at the subtalar joint, and discuss how these compensatory changes might manifest radiographically. What radiographic findings would you expect?

<p>A rigid plantarflexed first ray leads to compensatory subtalar supination, which can manifest radiographically as a decreased lateral talocalcaneal angle and a high or normal calcaneal inclination angle.</p>
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The Saltzman view estimates the moment arm between the weight-bearing axis of the leg and the contact point of the heel and is particularly useful in capturing ______ malalignments of the leg and foot.

<p>coronal plane</p>
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Match each radiographic term with its most accurate definition within the context of imaging the pes cavus foot:

<p>Tibiocalcaneal Angle = Angle formed by a tangent to the inferior calcaneal surface and the longitudinal axis of the tibia. Hibbs Angle = Angle formed by the intersection of the longitudinal axes of the calcaneus and first metatarsal bones. First Metatarsal Declination Angle = Angle formed by the longitudinal axis of the first metatarsal and the weight-bearing reference line. Lateral TC Angle = Angle formed by the intersection of the calcaneal and talar longitudinal axes.</p>
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Match the following radiographic findings with their corresponding interpretations in the context of cavus foot deformities:

<p>Increased calcaneal inclination angle (CIA) = Indicates an increase in the pitch of the foot, often associated with moderate to severe pes cavus. Decreased lateral talocalcaneal (TC) angle = Suggests supination and can be encountered with pes cavus deformities, especially in the context of clubfoot correction. Increased first metatarsal declination angle = Commonly seen in anterior cavus, indicating a plantarflexed position of the first metatarsal relative to the weight-bearing surface. Decreased tibiotalar angle = May indicate cavus deformity associated with ankle joint dorsiflexion, altering the normal alignment between the tibia and talus.</p>
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Match each of the following 'secondary' radiographic findings with its corresponding implication in assessing pes cavus:

<p>Horizontal orientation of the talus = Suggests altered bony positions associated with pes cavus, reflecting a change in the talar alignment within the ankle mortise. Double overlap of the talar dome = Indicates a distortion or misalignment within the ankle joint complex, often associated with cavus foot and related structural changes. 'Bullet-hole' sinus tarsi = Associated with alterations in bony positions in cavus foot deformity, indicating the presence of abnormal anatomical relationships. Markedly decreased posterior facet declination angle = Implies altered bony alignment in the hindfoot, frequently observed in cavus foot, impacting the subtalar joint mechanics.</p>
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Match the following classifications of pes cavus deformity with their primary characteristics or associated conditions:

<p>Anterior cavus = Characterized by excessive plantarflexion of either the first ray or the entire forefoot, often linked to conditions involving peroneus brevis weakness. Posterior cavus = Tends to be associated with weakness of the gastrocnemius muscle or varus deformities of the distal tibia, affecting the hindfoot primarily. Combined cavus = Features both increased Meary angle and calcaneal inclination angle, reflecting a complex interplay between forefoot and hindfoot components. Triplane cavovarus = Involves rotation of the foot and calcaneus on the distal tibial-fibular articulation, typical in conditions like Charcot-Marie-Tooth disease or clubfoot.</p>
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Match the following tarsal coalition findings seen on imaging with their corresponding anatomical implications:

<p>Anteater nose sign = Hypertrophic enlargement of the anterior calcaneal process indicating a calcaneonavicular coalition. Inconspicuous/absent middle facet sign = Loss of conspicuity of the middle facet of the subtalar joint, indicating a middle facet coalition. C-sign = This sign suggests continuity of structure between the talus and calcaneus, indicating a subtalar coalition. Talar neck beaking = Dorsal talar neck osseous spur that spans the width of the neck between anterior ankle and talonavicular joints</p>
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Match the following MRI findings in pes cavus with their clinical relevance:

<p>Attenuation and splaying of the peroneus brevis tendon = Indicates partial or complete rupture, or tendinosis of the peroneus brevis, often associated with muscle imbalance in cavus foot. Fatty infiltration of intrinsic foot muscles = Suggests chronic neurologic denervation, commonly observed in Charcot-Marie-Tooth disease and other neuropathic conditions. Increased bone marrow edema in lateral rays = May indicate stress reaction or fracture due to altered weight-bearing patterns, often seen in cavovarus foot with lateral column overload. Alterations in subtalar joint facet configuration = Can suggest osteoarthritis or coalition affecting joint mechanics</p>
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Match the following imaging modalities with their corresponding strengths in evaluating pes cavus and related conditions:

<p>Weight-bearing radiographs = Excellent for assessing angular deformities, such as Meary angle and calcaneal inclination, and providing a global view of foot alignment. Computed tomography (CT) = Superior for evaluating bony architecture, tarsal coalitions, and three-dimensional relationships in complex cavovarus deformities. Magnetic resonance imaging (MRI) = Ideal for assessing soft tissues including tendons, ligaments, and muscles, helping to identify peroneal tendon pathology and neuropathic changes. Ancillary radiographic views (e.g., Saltzman view) = Valuable for assessing hindfoot alignment and compensatory mechanisms by visualizing lower extremity alignment and the contact point of the heel.</p>
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Match the method to correct heel varus using the oblique block test by Wicart:

<p>Oblique block under the lateral forefoot = Restores transverse plane alignment and enables accurate Meary angle measurement on lateral radiographs. Posterior approach = Assessment from a posterior position. Dorsoplantar radiograph view = Note restored TC divergence. Lateral radiograph view = Oblique block corrects abnormalities allowing appropriate measurement of Meary angle.</p>
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Match the primary plane of the deformity to the type of Pes Cavus:

<p>Direct Pes Cavus = Primarily a sagittal plane deformity. Triplane Pes Cavovarus = Involves rotation of the foot Anterior Cavus = Associated with excessive plantarflexion Posterior Cavus = Associated with weakness of the gastrocnemius</p>
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Match the classification of the pes cavus with the characteristics of the Meary angle:

<p>Anterior Cavus = Meary angle &gt; 10 degrees disruption of Meary line. Posterior Cavus = Meary angle basically 0 degrees. Combined Cavus = Apex intersects between Chopart &amp; Lis-Franc. Normal foot = Normal (rectus) foot alignment demonstrates colinear talar and first metatarsal axes</p>
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Match the normal values of First Metatarsal Declination to its characteristics:

<p>Normal Value 15-23 degrees = Angle formed by longitudinal axis of first metatarsal axis and reference line. Anterior Cavus Value over 25 degrees = First metatarsal declination increase. Abnormal results = Pronation increases this value, supination decreases. WB Reference Line = Formed between most posteroinferior points of os calcis and the inferior-most point of the fifth metatarsal head</p>
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Match the normal values of Calcaneal Inclination Angle (CIA) to its characteristics:

<p>Normal 25 +/- 5 degrees = Angle is formed by a tangent to the inferior calcaneal surface and the WB reference line. Mild Pes Cavus over 30 degrees = Values greater than 30 indicate moderate pes cavus/increase in pitch. Severe Pes Cavus over 40 degrees = Often presents in neurologic cavus foot. Also known as = Calcaneal pitch angle</p>
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Match the method to correcting heel varus with the use of an oblique block:

<p>Lateral radiograph w/block = Enables correct measurement of Meary angle. Dorsoplantar radiograph w/block = Restoration of TC divergence is noted. Oblique block = Corrects heel varus by supporting lateral side. Meary Measurement = Measured to determine changes in structure.</p>
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Match the MRI findings associated with adult-acquired pes cavus to the corresponding tendon issue:

<p>Early onset = More severe Fatty atrophy in leg Lateral Ankle Image = Attenuation is noted. Chronic = Involved skeletal muscle atrophies and is progressively replaced by fat. Gaeta Used MRI = Describe patterns of disease distribtion.</p>
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Match the angles indicated in anterior pes cavus using the provided references angles to its characteristics:

<p>Inreased Meary angle = Can be visually noted. Increased CIA = Increase can also be noted. Decreased tibiotalar angle = Tibiotalar is normal to one hundred degrees. Pes Cavus = Cavus can demonstrate the changes</p>
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Match the following characteristic of the hindfoot-alignment view with the following descriptions:

<p>20 Degree inclined angel = Inclination angle of beam to WB Surface Coronal plane = Tibiocalcaneal alignment was defined by meausring the horizontal distance between a line representing the anatomic axis of the tibia. Tibia Fell 8 or 15 mm within = Saltzman said these ranges apply w/ respect to calcaeneal point. Accuracy Questionable = Inconsistencies of osseous morphology + differing joint capacity</p>
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Match the classification to types of hindfoot mal-alignment with the following views:

<p>Hindfoot studies = Do no yield angular differences. Ellipse use = Angle between the axes of the ellipse and tibia defined coronal hind foot aliment. Reilingh Study = Concluded axial to be more reliable. Irrespective = Used to assess frontal plane position.</p>
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Associate the injury with conditions acquired Pes Cavus patients obtain:

<p>Common = Peroneal nerve injuries. Associated conditions = Impacts and pressure increases. Associated = ankle sprain. MRI assists = assess Extent of peronal tendon disease.</p>
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Match the characteristics of the tibiocalcaneal angle with the following descriptions:

<p>Increase with Ankle / rearfoot = Angle generally associated with ankle and or rearfoot equinus Normal peds = Peds range from 60 to 90 degrees. Decreases = Calcaeneal pitch/CIA and Dorsiflexion of the Ankle with this angle. Angle type = Angle is formed by a tangent of the inferior calcaneal surface, longitudnal axis of tibi.</p>
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Match the type of Tarsal Coalitions with the following features:

<p>Uncommon Type = Uncommon and underlyning syndrome rule our. 2 Common Coalition are = Calcaneonavicular (CN), middle facet subtalar joint. Rule of Joint Type = Rule out ball and socket. Coalition Types Affect = Midfoot,such as talonavicular, navicubiaoid.</p>
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Associate the types with general characteristics that help categorize the plane of deformity involved in a Pes Cavus:

<p>Direct/Sagittal = Delineated from rarer triplan pes cavovarus deformities. Cavovarus = Entails rotation of Foot. Lateral WB Radiography = cornerstone of imaging eval direct pes cavus foot deformity. Apex location = Pinnacle of cavurs</p>
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Flashcards

Pes Cavus

A pedal deformity with elevation of the medial and lateral longitudinal foot arches, giving a hollow/cave-like appearance.

Direct-type cavus foot deformities

Most commonly encountered and are primarily sagittal plane deformities.

Lateral weight-bearing radiograph

Cornerstone of imaging evaluation for direct pes cavus foot deformity.

Apex of Meary talo-first metatarsal angle

Represents the pinnacle of the cavus deformity and assists in subclassification of the deformity.

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Ancillary radiographic imaging techniques

Can give valuable insight into deformity assessment and surgical planning.

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Multiplanar CT imaging techniques

Promise to improve precision and accuracy in delineating deformity.

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Cavovarus deformity

Entails rotation of the foot and calcaneus on the distal tibial-fibular articulation as a unit via the subtalar joint, minus the talus.

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Standard WB plain radiographic imaging

These plain radiographs include WB pedal anteroposterior (AP), lateral, and calcaneal axial views, along with ankle studies.

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AP foot radiographs

Provide essential insight into transverse plane malalignments in cavus foot deformities.

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Lateral WB radiograph

Integral to evaluate the sagittal plane deformity seen in direct pes cavus.

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Calcaneal inclination angle (CIA)

The angle formed by a tangent to the inferior calcaneal surface and the WB reference line.

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Talo-first metatarsal (Meary) angle

The angle formed by the intersection of the longitudinal axis of the talus and the first metatarsal.

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Sagittal apex of pes cavus deformity

Determined by where the apex of the Meary talo-first metatarsal angle is positioned.

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Calcaneal-first metatarsal (Hibbs) angle

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

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Lateral TC angle

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

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First metatarsal declination angle

The angle formed by the longitudinal axis of the first metatarsal and the WB reference line.

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Tibiotalar angle

The angle formed by the longitudinal axes of the talus and tibia.

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Tibiocalcaneal angle

The angle formed by a tangent to the inferior calcaneal surface and the longitudinal axis of the tibia.

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Anterior cavus

A sagittal plane deformity associated with excessive plantarflexion of either the first ray or the forefoot equinus.

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Posterior (hindfoot) cavus deformity

Associated with weakness of the gastrocnemius or triceps surae muscles, or varus deformities of the distal tibia.

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Hindfoot/rearfoot deformity

Hindfoot and/or rearfoot is deformed.

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Tibiocalcaneal use

Can delineate combined findings associated with compensated forefoot (global) equinus.

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Anteater nose sign

Hypertrophic enlargement of the anterior calcaneal process; indicates CN coalition.

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Inconspicuous/absent middle facet

A loss of conspicuity of the middle facet of the subtalar joint.

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C-Sign

Apparent continuity of structure between talus and calcaneus.

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Lateral talar process blunting

A dysmorphic rounding of the normally "V-shaped" lateral talar process.

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Talar neck "beaking"

A dorsal talar neck osseous "spur" that spans the neck width.

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Cavovarus deformity result

Compensatory supination of the calcaneopedal unit.

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Advanced CT Imaging

Can determine presence/extent of intraosseous and interosseous deformity.

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Saltzman view objective

Measure distance between leg's weight-bearing axis and heel contact.

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Harris (Harris-Beath) view

Provides coronal plane imaging of posterior and middle subtalar joint facets.

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Adult acquired pes cavus workhorse

Evaluation of soft tissue; assesses the integrity of ligaments and tendons, crucial in diagnosis.

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Best way to think of deformities

Involves either sagittal plane depression of the medial forefoot column or pillar, or both the medial and the lateral pillars of the forefoot.

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Ancillary plain radiographic views

Helpful in capturing coronal plane varus and valgus malalignments of the leg and foot.

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MRI potential ability

Useful to assess and monitor the magnitude and progression of neuropathic disease.

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Tibiotalar angle and deformity

Typically increased in posterior cavus deformity.

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Apex of Meary angle reflection

Typically intersects between Chopart and Lisfranc joints.

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Primary problem in cavus foot deformity

The resultant muscle imbalance secondary to weakness or complete loss of the perineal brevis musculotendinous unit.

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Best way to use MRI

Dorsiflex the ankle by about 20 degrees.

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Weight-bearing CT Use

Examine coronal plane alignment with foot loaded for detail.

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Ankle Studies

Standard ankle studies are recommended to assess associated extra-pedal causes and associations such as ankle/tibia plafond varus deformities.

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Adult acquired pes cavus MRI capability

Muscle evaluation. Aids in identifying subtle tendon tears.

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Direct pes cavus plane

In direct pes cavus, deformity occurs uniplanar (sagittal plane).

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MRI use

Can demonstrate altered patterns of bone marrow edema, and predilection for lateral stress reactions.

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Meary angle apex location

When the apex of the Meary angle is located at the cuneiforms or cuneiform-metatarsal joints.

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Subtalar joint alignment

Provides a reliable method to asses varus/valgus alignment of the subtalar joint posterior facet.

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Total forefoot equinus compensation

The talus and calcaneus act as a unit, are suggested by increased calcaneal inclination angle with a normal lateral talocalcaneal angle.

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Anterior Cavus deformity finding

Lateral radiographs demonstrating increased declination angles of the metatarsal bones.

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Study Notes

Key points for imaging

  • Lateral weight-bearing radiographs are essential for evaluating direct pes cavus foot deformity.
  • The Meary talo-first metatarsal angle apex helps in subclassifying the deformity.
  • Ancillary radiographic techniques like the modified Saltzman view or Coleman block test provide insight for assessment and surgical planning.
  • Advanced CT imaging along with 3D reconstructions improves precision in delineating intraosseous and interosseous deformity.
  • Weight-bearing CT can aid hindfoot alignment and compensatory motions evaluation in pes cavus.
  • Direct-type cavus foot deformities are most often seen and are sagittal plane deformities

Imaging of pes cavus

  • Pes cavus is a pedal deformity has a hollow or cave-like appearance.
  • This appearance results from elevation of the medial and lateral longitudinal foot arches.
  • Direct pes cavus is the most common form and is defined as a sagittal plane deformity. Direct pes cavus should not be confused with rarer, triplane cavovarus deformities

Triplane Cavovarus Deformity

  • Triplane cavovarus deformity is distinct from uniplanar direct pes cavus which is a sagittal plane deformity.
  • Cavovarus deformity involves rotation of the foot and calcaneus on the distal tibial-fibular articulation, minus the talus.
  • Cavovarus deformity results in compensatory supination of the calcaneopedal unit.
  • This supination causes calcaneal varus, external rotation of talo-tibfibular unit, forefoot/metatarsal equinus, and forefoot-midfoot adduction.
  • Advanced modalities like weight-bearing CT scanning shows promise as potential future adjuncts.
  • Plain radiographs are the cornerstone for imaging this deformity.
  • Plain radiographs, along with modified specialized views, confirm clinical diagnosis, classify deformity, and aid surgical planning.
  • Standard weight-bearing plain radiographic imaging includes anteroposterior, lateral, and calcaneal axial views.
  • Ankle studies assess associated extrapedal causes like ankle/tibia plafond varus deformities or rotational malalignments.
  • Triplane cavovarus deformity can be associated with CMT disease or clubfoot

Anteroposterior Weight-Bearing Radiographic Assessment

  • Anteroposterior foot radiographs is essential to gain insight into transverse plane malalignments in cavus foot deformities.
  • Anteroposterior foot radiographs help evaluate cavovarus deformities and is potentially valuable
  • Metatarsus adduction can be assessed
  • Forefoot adduction or displacement can be identified in clubfoot
  • Degree of midfoot and subtalar joint supination (talocalcaneal and talonavicular) can be examined
  • Overlap of midfoot and rearfoot bones and parallelism of talus and calcaneus can be reviewed
  • Marked decrease of TC angle (<5°; normal values 25°–30°) is notable in triplanar cavus foot deformity from a clubfoot.
  • The longitudinal talar axis is directed through the lateral rays in these cases.

Lateral Weight-Bearing Plain Radiographic Assessment

  • Lateral weight-bearing radiograph is integral in evaluating sagittal plane deformity in direct pes cavus, and aids in clinical diagnosis and surgical planning.
  • The lateral radiograph is essential in assessing sagittal plane component of triplanar cavovarus deformity.
  • Multiplanar CT with 3D reconstruction of the foot and ankle are suitable for preoperative and postoperative cavovarus deformity evaluation.

Calcaneal Inclination Angle (CIA):

- Angle is a tangent to the inferior calcaneal surface and the weight-bearing reference line. 
- The normal range is 25° ± 5°.
- Values over 30° indicate moderate pes cavus.
- Severe cavus often has CIAs of 40° or higher and neurologic cavus foot deformities show CIAs in this range.

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