Good morning everyone. Thank you for logging in so bright and early. I hope everyone had a nice long holiday weekend. Just gonna wait for a handful more people to log in before we get started. All right. So before I introduce our speaker for today I just want to draw everyone's attention here to the first slide where we have the Q. R. Code down at the bottom. Um It's quick and easy to just use your cell phone now to scan that QR code. It's for CMU survey which we use to curate future talks and also for CMI credit. So I will also post the survey link directly to the survey in the chat a couple of times during the talk in case you lose track of it. And if anybody has questions during this morning's talk, if you could just drop them in the Q. And A. And then we will try to get to as many of them as we can at the end of the talk. Um So I'm going to now introduce our speaker for today. Um We have dr Colleen Sabbatini. Doctor Sabbatini is a professor of orthopedic surgery and pediatrics at UCSF and is the Vice chair of Health Equity and Academic Affairs at the UCSF department of Orthopedic Surgery. She received her undergraduate degree from UC SAn Diego and her M. D. And Masters of Public Health from Harvard Medical School and the Harvard T. H. Chan School of Public Health. She then completed her residency at the Harvard combined orthopedic surgery residency program and fellowship training in pediatric orthopedic surgery at C. H. L. A. She joined the faculty of UCSF in 2010 and came to Oakland in 2012 and served from 2012 to 2019 as director and chief of the division of Orthopedic Surgery at Children's Hospital. Oakland, Dr Sabbatini has a particular clinical interest in pediatric trauma and fractures, Club foot and other pediatric foot and limb deformities. She's very active in global health, health equity and diversity. Um and her global health work has a particular emphasis in education, research and capacity building. She focuses the majority of her time and effort in Uganda, where she spends about four months a year including helping to run a pediatric orthopedic fellowship and where she leads a pediatric musculoskeletal health research initiative. So without further ado dr Sabbatini take it away. Thank you very much, dr raja for that introduction. Um I have been asked today to talk about, we were sort of given the option of some standard pediatric orthopedic conditions. So, um we're gonna talk about pediatric foot today uh and the pediatric foot is something that I think can be a little confusing for some people. It's an adorable little structure. Right? It's so cute that when their babies are born we take little stamps of their feet and um save those for posterity. But it's not always a normal a normally formed structure. It's not always a normally developing structure. And so the purpose of today's um talk is to talk about sort of the range of things that can happen in pediatric foot. I have no particular financial disclosures relevant to this presentation today. So it is in fact just a foot. And what could possibly go wrong. Um If we have the chat open, I'd love for people to start to throw in. Some things that you know happen in pediatric foot. Um and I of course cannot see the chat. Um. Oh good. We got a club foot. Excellent. Anybody else? Club Foot? We got our third hypothesis. Hopefully dr spine. Nazi is not the only person on the yes missing toes and missing feet. So um holy God, actively. Hm Amelia's absence of feet. Amniotic bands. I appreciate the participation of my friend and colleague dr spin Nazi overriding toes. Excellent. Gonna Give one More Moment. Okay thank you. Dr Stone Nazi. Oh thank you my P. A. A. Me polly. Exactly, exactly. So a variety of things can go wrong. Perhaps there's a delay in responses. I will move on for the purposes of keeping this going um in the newborn foot. There are a number of things actually that can go wrong, Right? So everything from metatarsals abducted Falconio, vargas foot. You see the list there were going to go through some of these today and then the older child, we see a whole host of conditions that kids have um that we need to know about and um and potentially refer and treat. So let's first talk about the foot and we're gonna remind ourselves a bit about anatomy. Um for the foot is made up of three different sort of areas, right? We call, we talk about the four ft, the mid foot and the hind foot. And the four ft is the phalanges and metatarsals. The mid foot is the navicular, the cue Boyd and the cuneiform, otherwise known as the torso bones or the mid torso bones. And then the hind foot is the taylors and the cal que nous. When we're examining the foot of a child's from your perspective, our our exam is quite intense and it would take me more within an hour to explain all the details of it to you and what we're looking for with the different things. But in general, when a child comes with a foot problem, um we do want to acknowledge first of all that the exam will differ depending on the age and functional ability of the child, always in a child who's walking that has a foot problem. We do want to look at their gate. And then just with regard to the foot, you want to inspect the foot? You want to look at the skin and the folds of the skin to see, you know, is there a mid foot crease. Is there is there a hind foot crease creases indicate that something is tight or abnormal and you want to be aware that we really shouldn't have creases deep creases in the foot? You want to assess the resting position of the foot, see if the foot moves up and down normally. If they can move their foot side to side normally, right? So up and down motion is to be a tailor joint, side to side motion as sub taylor joint. Does that foot and ankle move easily? Or is it very stiff and rigid? Obviously, a vascular exam is very important anytime we're examining a limb. Um And then in kids who are coming with pain, um they will often say their foot hurts and their parent will say their foot hurts, but they can't tell you where that pain is. They can't point with one finger where the pain is until they get you know to be 678 or older? And so paul patient is really important on physical exam of a foot. And so you want to understand what the an atomic structures of the foot are and feel those different areas to determine um what might actually be the source of pain. And then when we're inspecting the foot, we really we want to look from the side, we want to look at, is the foot resting in dorsal flexion? Or is it plantar flex? And those that can indicate different conditions. Is it neutrally aligned? If you look at the foot from the bottom. Is it curving inward? Is it curving outward? Is it neutrally positioned? And then when you look from the back, is the hind foot in various, is it in val Ghous those are all things that we need to look at when we're examining the foot, these are a couple of take home points. So physical exam alone is usually all that's necessary to determine if there's a problem in a newborn foot. And x rays are not usually helpful because x rays um show bone, and in a newborn in particular, most of the bones of the foot are not yet ossified. So it just shows up as sort of an open space on the X ray. Um We only get x rays in newborn foot if it's one of a particular set of conditions that we are concerned about, and then we order specific X ray views to assess that. So, um getting a random X ray of a newborn foot is not usually helpful. So this is where we're gonna try to do a little bit of interactive engagement of the audience, the 69 of you who have wonderfully joined us this morning, thank you. Right after a long weekend. Um and I just want everybody to look at this foot and to think for yourselves what this foot is. So if this was a newborn that you were evaluating and you saw this foot deformity, what is it, and what I think about what you would do for it? Um And I'm gonna give everybody a few seconds to think about it. Usually if we were in a large audience, I'd be calling on somebody right now. Um But hopefully most of you looked at this foot and you said that is a foot that in which the top of the foot is basically almost touching the tibia, The foot is Dorsey flexed and evert ID. And this is a newborn and that is a cal Canio val Ghous foot. Um So the foot is in val Ghous, the hell is the presenting structure? That's why it's called Falconio valdas foot. This is reasonably common about 0.4 to one of of 1000 live births per year around the world. Um The classic position is this um hind foot that's externally rotated in Dorsey flex, so the for the foot itself is inverted. Um and the foot often touches the tibia when the baby comes out. And so actually of all of the foot deformities, even though you'll see that this is probably one of the most benign. This is actually one of the sort of most aesthetically Unpleased sing um and causes a fair amount of consternation on the part of the parents when they see it because it can it's quite grossly deformed. Um And so when you examine this foot, you'll try to bring the foot down and you'll find that there's limited plantar flexion of the foot because those anterior structures of the foot are tight. This condition is a packaging problem. So this was this developed because of the way that the baby was positioned in utero. And the foot was was sort of planted back like that. Um And the treatment for his reassurance really just telling the parents that this in fact will get better because in the vast vast majority of cases with Falconio Vegas foot it does if you have a parent who really feels like they need to do something um Then gentle stretching is something that they can do. So they feel like they're helping the foot is up and out so the stretch is simply to bring the foot down and in. Um And all that's doing is is sort of accelerating the stretch of the anterior structures. Even if they do nothing, you do nothing. I do nothing. Um This will resolve on its own usually in the first 3 to 6 months and pretty much all cases of cocaine you know Vegas foot resolved by about nine months of age. Um And the only reason to refer for this is for the foot itself is if if by six months or so it's not improved. Um Or if you're the parent need reassurance and and we're happy to do reassurance visits if needed for families who are overly stressed about this condition. The one thing that I would say is that of all of the foot deformities. Cal Kania valdas foot is the one that's most highly associated with developmental dysplasia of the hip. Um We're about 66 to 7% of kids with cal kenya Vegas foot will have D. D. H. Based on a few different studies. And so even though that's not a huge amount you don't want to miss D. D. H. Um And so with Kakenya Vegas foot just like with breech presentation, I would recommend a screening hip ultrasound at six weeks of life. Um And obviously a good hip exam which you guys would all do anyway in a baby when they come to you. But definitely any foot deformity should elicit a very focused hip exam and then a screening ultrasound. Um If there's any concerns on exam or with Falconio vargas foot I would just do the ultrasound even if the exam is normal. The one thing to really understand is that there are two different conditions that can look quite similar. One is cal cano vargas foot alone which is the one that you see on the left which is the deformity at the actual ankle joint itself. So the tibia is normal. The ankle joint is Dorsey flexed versus post remedial Boeing where it's actually the tibia that's boned bowed. This is the ankle joint. Um This is the tibia bone and post remedial Boeing can have an associated Falconio vargas foot. And that cal kenya vargas foot will correct just like it does without poster remedial Boeing. But the one thing to know is if the leg is bowed. Um That condition long term is associated with the leg length discrepancy, whereas Calcagno Vegas foot is not. So if it's a post remedial Boeing we would want to see it and provide education. If it's strictly a Calcagno Vegas foot, it will resolve on its own um If you're not sure right away, it's okay to give that foot sometime to see if it comes down and if the tibial explode, you would refer if the tibia does not look bowed once the foot is corrected, then you do not need to refer. Um What condition is this? Think about it please. Um Here's another version of it and so hopefully what you all are seeing with this is um you're looking at two little people with who are newborn whose feats appear to be um in cannabis abductees various and Aquinas um which of course um is the definition of club foot. Thank you Nate bomb Levine. Um For guessing correctly. So what is club foot? So club foot is probably the most important condition we're gonna talk about today. It's the thing in life, I'm probably most passionate about orthopedic lee? Um myself and uh Amy Teodoro who's on this um we run the club foot program here. Amy is one of our fantastic ps um We have a very robust club foot program here at Oakland Children's um And it's important for everybody to understand that club foot is a structural deformity of the foot related to abnormal lower leg development. So even though it's called club foot, the whole lower leg, like knee down, um is actually abnormal where the muscles have a congenital muscular atrophy and the and the foot deformity is a result of that overall abnormality, not the intrinsic problem itself. And that is why um we have the sort of long bracing program that we're going to talk about in a second, because even though we can correct the foot position, the underlying musculature is abnormal. Sometimes the nerve, the peroneal nerve is actually abnormal. There can be congenital underdevelopment of the nerve or even absence um in club foot. And so um this is a structural problem that that needs to be addressed with a long term solution. So very common. This is the number one most common muscular skeletal congenital anomaly that Children are born with around the world happens in about 1 to 3 or four. So of out of 1000 live births globally on on average. So that accounts for about 200,000 new cases per year. Boys are more affected than girls. We used to think it was about 4 to 1. Now it's maybe more like 2 to 1 in the epidemiology studies that we've seen And it is bilateral and we tell people in about 50% of cases. So it depends on sort of what group and what part of the world you're looking at, but around 50% are bilateral. So the other 50% are unilateral. There's a fair amount of variation among ethnic groups with the Polynesian. So, Samoan Tongan populations at the highest risk. And we have a fairly large community um here in the bay area, so we take care of a number of Children from um from those communities and then the lowest in the um in asian populations with some range then in between of um all other ethnic groups within that range of 0.57 to seven live out of 1000 live births. Uh Family history of Club foot is the main risk factor for club foot, but also a history of maternal smoking during the first three months of pregnancy increases the odds of Club foot by about 20 fold. Um Having said that I probably had one patient ever in my practice who mother whose mother was a smoker. Um and everybody else are spontaneous genetic mutations or family history or history of club foot in the family. Um About 80% of kids with Club foot are idiopathic meaning there's no reason for it other than the fact that they have Club Foot, but the other 20% are non idiopathic and there's a number of associated conditions with club foot. So um trisomy 18 or Edwards syndrome. Now, I'm sure you all are astutely looking at this picture and saying, but wait, that baby doesn't have club foot those look like. Um we're gonna talk about in a second, which is in general vertical tails. And so this is actually included this because I think this is a terrible schematic. Um And either these are over treated club feet or somebody just didn't know what they were drawing. Um These pictures are better examples of club foot. This is a club foot in the setting of Arthur. Great posts, you can tell it's arthur guide posts because there's no creases um at the knee. And arthur proposes of course, is a condition associated with limited range of motion of the joints. And this is a baby with all the classic findings of diastolic dysplasia. So cauliflower ears, hitchhiker thumbs, um the shortened limbs and the classic club feet. Um And so but there's a range of conditions that we see club foot associated with when we talk about the condition of club foot regardless of whether it's idiopathic or um or syndrome related. Um It is a four part deformity. And so this shows you what those four pieces of the deformity are. So there's a high arch foot, ATC avis um of the foot add duct. This with the foot pulled in towards the midline varies which is the heel rolled in immediately and a queen is which is the achilles tendon being tight and causing a plantar flexion deformity of the foot. So club foot by definition is those four things que vous adductor varies and kindness I have this slide only to show you all of the things that are abnormal in a club foot structurally. That lead to that deformity, which we have to fix in order to correct the foot. Um And so just these are all of the bone, things that are in the wrong place, all the soft tissue contractors. Um and all of the parts of the foot deformity that have to be corrected. It doesn't necessarily matter to you if you're not treating it, but it matters to us who are clinically on your examination of a newborn foot. If they look like they might have a club foot. And you're trying to decide is this club foot? Or is this a metatarsal adductor is, for example, the most important finding is a tight achilles tendon. If the achilles tendon is not tight, this is not a club foot. Um It could be a metatarsal seductress or what we might consider a postural club foot. Um But so for example, this is a child who has what looks very much like a club foot deformity, but it's quite flexible. I can stretch the foot but I cannot get that foot anywhere near 90 degrees. Um And in a non club foot this would be able to be Dorsey flex to 20 degrees or more. So if you cannot get easily, cannot get normal Dorsey flexion out of a foot. That is a foot deformity that needs to be referred because a tight achilles tendon in the setting of this resting posture is highly concerning for club foot. And if you're not sure, we would rather see the patient and determine ourselves whether or not their club foot um than to have you not be sure and to have us miss a club foot early on. So what is the treatment for club foot? Well, the standard of care around the world is the pancetta method. Up until about 30 years ago, these kids had extensive surgical releases around the age of 6 to 12 months of age, huge amounts of surgery to the foot were basically the foot. All those structures that I showed you in that slide that we're tight. We're all released and we essentially cut most of around most of the foot, leaving just an anti erskine bridge and the anterior extensive attendance. Everything else was either released or lengthened. Um The outcomes for those kids were not great. They had a foot that they could walk on but they had stiffness and pain over time. And so an extraordinary man by the name of Nacio Ponsetto uh developed a technique that originally was not well accepted by the orthopedic world. Um and for 50 years, he, he worked on his technique and and trying to get other people to embrace it. And finally, in the 1990s we did and now it's used again all over the world for the treatment of club foot and it's a method that uses weekly serial casting the performance of a heel cord sonata me. So cutting the achilles tendon, another few weeks of casting where the achilles tendon grows back in a lengthened position and then a cycle of bracing. And those things in combination are the pancetta method. And then if there's a recurrence, there's a certain amount of a certain way that we address that recurrence, which is also part of the pancetta method. The important thing is that the earlier we start, the better the outcome usually and that weeks don't matter but months do so. A child that's referred to treatment in the first few weeks of life, it's better than a child who is not referred until a few months of life. So it's important to assess for this early on when the child was born and refer if there's any concerns. Um, and then the severity of club foot is very different. So I told you it's a it's related to the underlying musculature, abnormalities of the leg. And some kids have near normal muscle development and other kids have very severe atrophy. The ones with the most severe atrophy with like the very skinny little calf are much more likely to have recurrence and have a harder foot to fix in the first place. This is a classic picture of the ponts, et method of casting, where each week we're doing a series of manipulations of the foot putting a cast on and holding it in place for a week and then they come and each week we do more and more correction of the foot to swing the foot from cannabis abductees and various to a foot that is no longer has Davis is abducted and the hind foot is actually in Vegas or evert ID. Um And then the final step is to cut the heel cord which here's a child. Then that has full correction of everything. There's no caveats abducted. Sor varies. But you can see this very deep behind foot crease and you can see that we cannot bring the foot up at all anywhere near neutral through a small incision in the back of the ankle and release a full release of the achilles tendon. We are then able to bring the foot up and you can see in like 20 degrees of dorsal flexion. So just releasing the achilles tendon, this child resulted in like a 50 degree improvement in their uh in their dorsal flexion. Again, that's a very small incision. We usually close it just with a steri strip. Um Half the kids are more we do awake um without anesthesia. Just with topic called numbing medicine. And the other. Another group that's either very active during kicking. I mean during casting where they kick at us. Um So it's not safe to cut their achilles tendon with them kicking around or if they have other reasons to undergo anesthesia anyway will combine with other services to do it under anesthesia. This particular child was as you can see under anesthesia. Um the foot abduction brace, The bracing phase of club foot is the most important parts. We've done our serial casting, we did our heel courts anatomy were in a cast for three weeks after our heel courts anatomy and then we go to a brace phase. This is by far the most difficult for the family because the compliance is totally on them. Um With the casting they just have to come every week we put the cast on, they just have to make sure it stays on. There's nothing really for them to do the brace. They are actively participating in it all day every day. Um And so this is incredibly important for them um to to be on board with. So without bracing they there will 100% be recurrence of the club foot. So bracing is imperative. Um the schedule for bracing is somewhat Sergent dependent but in general um all of us do full time where until except for bath time, at least for the first 3 to 4 months after the anatomy. And many of us until they're starting to pull to stand um which you know can be between eight and 12 months of age. Once they're standing on their feet. During a wake times they do not need to be in the braces but during sleep time. So nap time and all night overnight every night we wear the braces until they're four years old. If they've had a recurrence If we've had to do additional casting or surgery anytime um after their initial round then we will brace for longer. Um This is a brace that I use with our program in Uganda on this little baby here and then the brace here is um the one that's most commonly used these days in the us. Anything that holds the feet Dorsey flexed externally and externally rotated is what we're going for. This is a range of different kinds of braces used around the world. And again, that's what we're using now. Uh It doesn't matter what it's made from. It just matters that it holds the feet in the corrected position. Um About 50% of kids will need some additional intervention in those first few years of life. So whether that be additional casting or actual surgical intervention. Um and that can be up to 40% of kids that need some additional surgery. Whether that be a heel cords, anatomy are second most common surgery is a TB allis anterior tendon transfer, which we'll talk about in a moment um or the full releases that we used to do when they were um When like before Ponsetto method. The number one risk factor for more surgery is families not wearing the brace is the way that they're supposed to. Um And it's very important that you all hear that the studies have shown that wearing the brace does not compromise the development of these Children. Perhaps it delays they're walking by a couple of weeks at most. Um, and I have had unfortunately way more cases than I would like of families who were told by their pediatrician that they should either stop wearing the brace because it was holding up their child's development or um, something, something totally counter to what we had told the family. Um, and, and please, if you have concerns about the patient, please call your child's club foot clinician. Um, and don't change the bracing schedule because that can have horrible consequences for their club foot. Um, and get them nothing for their development. So a couple of things just to know when we're talking about club foot two families that, um, if it is a unilateral club foot, the involved foot and calf will always be smaller than the other side, both in terms of like calf girth as well as the length of the foot. Um, it's not always easy. So we've had families that have been, you know, told like, oh, this is not really a big deal basically. They just put your kid in socks for a few weeks and then it's totally fine, that's not always the case. So some kids do have tougher feet than others with more long term functional limitations. And so we want to set up realistic expectations for the families. Again, it's so important that you hear this, the bar does not slow down their development. So please don't look at the bar is some sort of evil structure because it is the only thing that's keeping their foot from going back and then if they have recurrence it can be a big deal. Some just correct really nicely with casting some, we have to do a revision sonata me, there's some kids where their muscle imbalances so significant from the underlying muscle problem that the tbs anterior over pulls their foot and when they walk their foot poles in, so we have to transfer their tbs anterior tend into the mid portion of their foot to balance the foot. And then like I said before, sometimes we have to do the full releases. So that's club foot. Um I spent my life on this condition but I just tried to cover it in about 15 minutes. Um and I'm happy to take some questions at the end if there are any and now we're gonna go through a whirlwind tour of some other things. So meta tarsus add duct issues. Heard that term already because I told you it was one of the four parts of a club foot deformity. But metatarsal said doctors can exist on its own in a child, it's an inward deviation of the four ft relative to the hind foot and that's at the level of the Tarso metatarsal joint. And on exam it is differentiated from club foot because the achilles tendon is not tight. So the achilles tendon is normal. Um In this, in this age group we assess it clinically by the heel by sector line. So drawing this line, we bisect the heel and then you draw the line straight down the foot. Normal is either up to second or between the 2nd and 3rd web space. And then we assess the severity of the abductees by how far the hell by sector line is lateral to that normal line. And so here's a normal foot with the heel by sector line. You see going through the 2nd and 3rd web space and the metatarsals abductees. That foot is deviated inwardly, it's add ducted and so that he'll by sector line is actually going in this case between the 4th and 5th web space. That's a really great way for you all to like that we record in our notes each time we see a kid with metatarsal duct is what the hell by sector line is because then you can tell it's it's a it's a measurable way of telling if it's getting better over time. So again the heel court is not tight. This is relatively common. One out of about 100 kids are born with some amount of metatarsal adductor although it's not really confirmed exactly what causes metatarsal adductor. It like Falconio vargas foot is thought to be a packaging problem. So inter uterine compression. Um So all the risk factors for packaging problems. First pregnancy, oligarch, hydra. Meows, multiple gestation are more likely to have meta tarsus abducted. And despite that it is controversial whether it is associated with D. D. H. Or toward a callous but a good hip neck and hip exam is really important. Um And do a good deed th risk factor assessment and certainly consider an ultrasound if there's any concern on their hip exam again at six weeks of age, not earlier unless you're concerned, there's actually a hip dislocation, metatarsal duct issue also know because it is one of the three contributors to in towing and walking aged Children. So when you have a child who is in towing, you know that is either from femoral anti version internal tibial torsion or metatarsal adductor or a combination of the three of those. Because if your foot is shaped like this then when you walk it's going to turn in. Um And here on this child you can see that hell by sector line is up the fourth. Uh the important thing about metatarsal practices that in the vast majority of cases it will spontaneously correct on its own usually within six months to four years. Again, if this if you have a parent who feels like they need to do something then they can stretch the foot. If the foot is inward, they simply stretch it outward um to stretch those media structures and only in a very small percentage I put 5 to 15 but really the data is probably closer to 5% of patients might need some form of intervention. Um And that would be casting if if the deformity is severe and not improving specifically, there are some kids with a very rigid metatarsals, abductees and a heel crease on the inside of the foot. And if it's a rigid deformity with the heel crease, we often will do a few casts early on in life just to kick start its correction and make sure it's going to move for us. Um So here's just a schematic. Whereas if you have a flexible metatarsal adductor which is about 95% of the cases, we're just going to observe and educate the family. If it is a rigid metatarsals, abductees and their older um we're gonna move on to surgery which is to do an aussie the economy through the mid foot and correct the abducted abducted. But if they're younger then we're gonna cast. Usually casting corrects it and we observe and some kids will cast and make it better. And then that foot might pull back in in which case we'll cast again and then do some bracing, the brace being similar to the club foot brace. Alright, I'd like everybody to think about what this is. What are you seeing with this foot. So you see a foot that's Dorsey flex, you see an abnormal post here, he'll crease. We might define this as like a rocker bottom foot for example. So this is congenital vertical tailors. And there's two examples there of what that those can look like when the baby is born. This is rare about one out of 10,000 or in some areas. One out of 100,000 kids. I feel like it's much more common than that because I have a bunch of my um clinic. But this is defined as an irreducible dorsal dislocation of the navicular on the tailless. They have a rigid flat foot deformity, otherwise known as a rocker bottom foot because um we'll talk about in a second. It's the achilles is lifted up in the back because the achilles tendon is tight. But then all the anterior structures, all the anterior dorsal structures are tight. So it's holding the foot up and that gives us little boat shape. This is a genetic condition that's been mapped to the hawks T. 10 DJing. Um Unlike club foot, where again it was 80% idiopathic 20% syndrome. IQ CVT is about 50 50 so 50% can be idiopathic and 50% have underlying neuromuscular condition associations. The most common ones being our third hypothesis, spina bifida saturnalia or tether cord. Um The diagnosis is made by X ray. We're here. Um This is the tailor's here on this X ray and you can see that it's pointed basically directly down. Hence it being a vertical tail us. For those who don't like a lot of pediatric foot X rays, It should be more horizontally positioned. Um And then when we do a maximum plantar flexion X ray, it does not correct its alignment with the forefoot. And that by definition that makes it a congenital vertical. Tell us this is why I told you at the beginning that sometimes X rays are are um not helpful unless you get specific views. And then congenital vertical tail us. We have to get a maximum plantar flexion view in order to make the diagnosis just like with club foot, there's a ton of abnormalities um both bony and soft tissue which we have to fix in order to fix the condition. Um With congenital vertical tail is same as club foot. There is no non operative or non treatment option. It will not get better on its own which makes it different than metatarsals, abductees and Falconio valdas foot. CVT club foot Both require treatment. Usually with CVT we start treatment around 3 to 12 months. It's later than club foot because it's often missed in newborns. But the earlier they're diagnosed and sent in the better. Um And this to light Club foot is casting followed by surgery. Um And so we actually do what we call a reverse Ponsetto method which is sort of opposite casting the feeder are out and up. And so we bring them down and in and then we do uh more of a surgical procedure than what exists in club foot. But we have to get the tailor's um here up and the navicular in line with it. So we do an opening incision there align the bone pin it. Um and then the child's casted post operatively for a longer period of time, usually around 6-8 weeks. Um compared to club foot, which is only three weeks. And then we do club foot bracing, that's the same type of brace but positioned in a different way um to help maintain the correction here. All right, that's all I'm going to get into with the general vertical tail is just because um it is a rather complicated condition and from a pediatrician perspective, what we really need people to understand is that it exists. It has to be diagnosed and it has to be referred because treatment is imperative real quick on another sort of, the other common foot problem in in newborns is Polydor, actually. Um And I'm gonna tell you something that you probably could teach me more, which is for these policies that have the little skin bridge and nothing else, no structural um materials in place. Like there's no bone, there's really no like um nothing more than basically being some sort of skin tag. Um If that connection is very narrow and you can tie it off obviously to do this as early in life as possible. That's why we as orthopedic surgeons. Don't even see these kids, you guys, the fabulous pediatricians and neonatologists take care of these ones um using nylon or silk tie. And the only thing I would say because we do see some complications from these that we do have to treat is that you really want to get the future all the way to the base of the little pentacle. Um because if you make it too um too far away from the base, that's where you get, you can get residual skin nubbins or painful aromas. Um and then you also need to make sure it's really tight. So this is the only example that I could find. Um again, I don't see these. So I don't have examples of these myself, but this is an example. This is obviously a hand. I do realize that. Um but this is not a good tie off. Right? So yes, it resulted in necrosis of the skin tag. But then this child's gonna have this long pentacle here, which may or may not fall off on its own. And so we're more more likely to have a little painful mass here. And even on aroma where the nerve didn't get tied off if there's nerve tissue going into that, so you really want to get the future right at the base um in order to to not have any long term problems and then to tie it really tightly because the more the tighter you tie it and the more security is the more rapid than necrosis. So the quicker it goes away and less likely you are to have infection. So just a couple of things on that. Now what we see are obviously the ones you can't tie off in the nursery. Um And the one a couple things to know about policy actually of the foot is different genetically than Polydor actually of the hand. Um And uh and it's less common. Um It is also less frequently bilateral. Um And it is most commonly post axial meaning it's on the little toe side, not the big toe side. We can also have central policy actually. So you can have people that are born with you know 89 10 toes. With multiple polyps actually in the center. Um Here is pre axial Polydor actually which is most like more likely to be associated with other conditions. And so um I often will refer post pre axial policy actually patients to genetics for genetic evaluation. Post axial Polydor. Actually we do not. Um And the indication for surgical intervention here really is because we all wear shoes in the world today that having six toes for example makes it very hard um to find appropriately fitting shoe wear. And these kids often come in, you know once they start wearing shoes with some irritation on the side of their on the side of the foot. Um And then the pre axial politifact allies um can have some growth problems. Um if the most medial toe is not growing at the rate that it should. So we often will respect those. But you can see here like these two toes are sharing a metatarsal and when you take this toe off you're not alone. We have to correct in this case the Sindh actively and get soft tissue coverage but also come through. Um We have to remove part of this metatarsal in order to not leave the not leave part of the bone there that then will grow and cause problems in the future. So the policy is that we see tend to require a bit more surgical intervention. Um And we don't usually do that surgery until at least one year of age and often we'll wait until they're three or older but ideally before they start school because on the toes are bigger we have a better chance of doing what we need to with all of the an atomic structures and avoiding recurrence problems or need for additional surgery. So a quick summary of the newborn foot conditions. The things we want people to refer right away or club foot congenital vertical taylor's things that we can wait to see if they improve on their own or volcano vargas foot and metatarsal adductor. And thanks to refer within the first year or so of life. Our policy actually um curly toe is another common congenital deformity. Um It is due to a contracture of the flexor tendons of the foot, we don't actually know how common it is but it's ridiculously common, It's just not symptomatic in most people, so it's not recorded and so we don't know. Good epidemiologic data usually involves a lateral three toes. So some people have 334 and five curly toes. Some people just have four or five, but it can be all three or some combination can be a little bit vexing to the parents. So that's usually why we see these kids is because the parents are bothered by the fact that they're curl, their toes curl. Um but importantly it is usually asymptomatic. Um and uh and um the only thing that we tend to see is that there can be some pressure symptoms from shoe wear later in life. Um About 20% of them will get better on their own. We don't usually do anything for these. Um So asymptomatic requires no treatment. And like strapping the toes are tapping the toes is not usually been found to be beneficial. We do it and some kids only again because the parents feel like they need to do something. If we do operate, then it's cutting the tendon and um sometimes pinning the toe while the tendon scars down into a lengthened position. We would only do that usually in kids older than age three and often older than age five or six when we do that, it's reasonably effective. Sometimes it does not fully correct or it goes back, but again, surgery is incredibly rare in these kids and they do not need to be referred, you know, when their age 12 or so only if they're, you know, 34 older and having symptoms. So what is this? Hopefully you are looking at in the interest of time. I will not let you think very much about this. Hopefully you all look at that and say that is a flat foot. And my message to you is flat is not bad. Alright, so first of all, in young Children, they might not even develop an arch until about six years of age. So a one year old, a two year old, a three year old with a non painful flatfoot does not need referral to us, please God, not podiatry to nobody. Um If the foot does not hurt, it does not need to be evaluated. Um And so here, for example, is a picture of a child who at the age of three had flat foot and at the age of 15 has a nice normal arch development. Um and so uh flat feet, we should know as a normal human, an atomic variant. 20% of the US population, really, 20% of the world's population has flatfoot. Um clinically you want to assess for ligament laxity because if somebody is generally ligaments relaxed, they probably have flat foot and that's all part of the same spectrum, but they can be non ligaments relax and still have a flat foot. The only things we know we have to do is make sure we rule out congenital partial coalition which talk about in a second and a tight achilles. Um and so tight achilles, you should check every kid with a flat foot to make sure that their achilles is not tight, that they can Dorsey flex to over 20 degrees. Although in America it's probably more like over 15 degrees because everybody's got tight achilles in this country because we don't squat. Um and then plantar flexion to more than 40°, which rules out in general vertical tailors when you are looking at a child and trying to decide is this a flatfoot, I should be concerned about or not. You have them stand up and they should not have an arch if they have flat foot and then have them go up on their toes. If when they go up on their toes they constitute an arch, they get an arch that by definition is a flexible flat foot and does not need treatment. Right? So here's that kid that we just got tested on and you see there we go up on the toes. Beautiful archery constitution on both sides compared to the other picture you see there where there is no archery constitution. So that's the difference between a flexible and a not flexible flat foot um flexible flat feet are not abnormal, right? So the vast majority of them are totally normal. They don't need any treatment if they have a tight heel cord, we stretch their achilles tendon, which we'll talk about in a second. If it's a rigid flat foot, then that gets referred to orthopedics. We rule out parcel coalition vertical tailors and potentially operate. These are a variety of ways to stretch the achilles tendons so kids can stretch themselves on a stair or doing a squat holding onto something. They can do this classic stretch or for kids who are not able to do it themselves and somebody else, their parent can stretch them. Lots of ways to do achilles stretches. We all should probably do these more often in our life. Um This is my opinion. The two things that I would tell you again without a whole lot of evidence though is do not ever give rigid orthotics to flat feet. Um I can't tell you the number of kids that I have seen that have painless, flexible flat feet, who gets referred to a podiatrist. The family then spends $500 on custom orthotics. The child then develops pain because the orthotics are unnecessary and hard and painful and they come to me and I basically take the orthotics out of their shoes, give them to the parents and say don't ever use them again and the pain goes away and we never see the kid again. So painless flat feet do not need anything. If they have pain, then we can do orthotics, but not rigid one soft over the counter. Much more affordable ones. And the other thing that I hate is flip flops. And I think a lot of little young people's pain um can be directly related to their shoe wear. And if they're wearing flip flops where they're gripping their feet and they have no support to their feet at all, they get um foot pain. So no flip flops. Um When flat foot should be referred as if they have pain if its unilateral if they have a very tight achilles um or if they have a mile achilles that isn't improving with stretching or if that foot is stiff or rigid at all. 11 reason for rigid flat feet are parcel coalitions which are a failure of segmentation that can give you a rigid flatfoot. These usually become symptomatic around eight years. And girls 10 and boys, as the bones become more ossified, right? So when the child is young it's more cartilaginous, that's a softer um uh tissue. And so it can compensate for the coalition. But as the bones ossified in a coalition which is a failure of segmentation. So two bones are connected that shouldn't be um that can cause a rigidness of the of the foot and some pain. The most common one is the Falconio navicular coalition which you see here where the balconies and the navicular are connected. There should be a space here and there's not. And the other more common, more common one is a tailor Falconio coalition. So these kids can present with a painful flatfoot limited sub taylor motion. Um And uh for them um they the important thing is to get an internal oblique X ray here in addition to your ap and lateral and all X rays of of walking. Children of Children who can walk should all be weight bearing X rays. Only in the setting of trauma. Do we not want a weight bearing X ray? Just so you know, so you should always order your foot X rays for foot pain that wasn't trauma. Um Weight bearing. Alright, so coalitions if they're symptomatic um we we try to do non operative treatment for them. We will do a period of immobilization, will do a period of physical therapy and stretching. If they are symptomatic then we will do surgery to take out the coalition or in some cases to actually like just fuse the bone completely. If you have a child that comes in with pain and they're pointing to pain at their hell. Maybe it's been there for several months, it's activity related. Um That could then be Seaver's disease which is a common cause of heel pain and a growing child. It is an overuse problem like Osgood slaughters of the knee. So it's attraction apophis itis an inflammation of the growth plate of the Calacanis which you see here on this X ray. Um And you diagnose it really by squeezing directly over that growth plate so side to side squeezing the heel bone if that's where their pain is and when you squeeze it that's what hurts. They likely have seaver's. You do also want to palpate the achilles because sometimes they can it can be an achilles problem. Not an actual growth plate problem. And the achilles tendon may or may not be tight in seaver's if it's tight that could be contributing to why the growth plate is so inflamed. Right? We don't usually get imaging for this if you get X rays or M. R. E. S. That's sort of what you see but it's not necessary. This is a clinical diagnosis and there's absolutely no role for tree for surgery and seaver's disease. It is all non operative management so slowing them down from their activities giving it a bit of rest. Um Finding out what they're doing. That led to this overuse in the first place doing some ice before and after activities Using an over the counter heel cup or a heel pad which just lift the heel up a little bit, takes a little bit of the pull off of the achilles. Um Using some incense. We do see kids who come in that have had several months of pain. They're walking up on their toes because they're he'll hurt so bad or their achilles is contracted because um they've been trying to release the pressure off the off the balconies. And in those cases we might do some either a boot or a stretching cast. Um And then physical therapy with a slow return back to activity. Um Just a couple other things to know about. If you have a child that comes in with non traumatic mid foot pain um you wanna think about koehler's disease. So this is an X ray that shows a vascular necrosis of the navicular happens more commonly in boys than girls and usually between the ages of four and seven. Sometimes we see it incidentally on an X ray obtained for you know, a different reason. But this is a self limiting condition. Activity modification is necessary for when it's painful. Um And then it goes on to to resolve. And there's no known cases of Kohler's disease causing problems into adulthood. Um This is another thing which you need to know about and hopefully you're looking at that X ray and saying, I see this mid mid foot prominence here um with an abnormal looking navicular and these are accessory navicular. We see these in about 12% of the overall population and the majority of people with these are asymptomatic. Um But you can see this real prominence is enlargement on the medial side of the foot. This does tend to be autism all dominant. Um and you can get pain right in that area. And so in Children who have persistent pain which is usually related to micro fracturing across what we call the Cine con Drusus, the the soft tissue connection between the two parts of the bone um and the posterior tibial tendon connects right there. So with activity it really pulls on that area. So the first thing that we would do after we confirm with X ray again this is an external oblique X ray, ap lateral external oblique. When we did the calculation and vehicular coalition, it was an internal oblique. The tree, this is non operative, we do activity modifications, we we change our shoe wear, we can do some heel cups. Um And only in kids where this is continues to be symptomatic despite a lot of attempts at non operative treatment um then we will go in and take out the accessory navicular, shaved down the prominence of the existing navicular and advance the posterior tibial tendon. Hopefully when you look at this foot, you recognize that this is a cabo various foot. So the arch that's hollowed out like a cave and this is an elevation of the medial longitudinal arch. That does not correct with weight bearing. The thing, I need everybody to know about this is that in 75% of the cases of a cave of various foot, there's an underlying neurologic problem. Um And that's why this is important to recognize and refer. So if this is a kid who's had high arches their whole life and everybody in their family has high arches and they don't have associated hammer toes or worsening high arches, that's probably fine. But if the arches very high or if they have progressive deformity, um, you want to be concerned about things like shark, oh, Marie tooth and Friedrichs ataxia. Or if it's a unilateral deformity, then we'd be worried about a tethered cord or potentially even a spine tumor. But in bilateral cable, various feet. And the vast majority of cases, this is charcoal Marie tooth. And that's a progressive neurologic problem with worsening coronavirus feet over time. And this does need evaluation and treatment. So if you have a child with a cable, there's foot, it should be referred usually to orthopedics and neurology. We will do the exam, the diagnostics and then if it is a progressive cavaliers foot, we will definitely do surgery. Last couple things bunions. Nobody likes to talk about them, but since people send them to me, I feel like I need to acknowledge them. So Alex Valdez, this is basically a Vegas mala alignment of the first ray. Um, and everybody's pretty familiar with that. The thing to know in young people is that it is usually bilateral females more common than males, Often a family history tends we think to pass down the maternal side. Um, and there's a variety factors associated with the development and worsening of bunyan's. Um importantly, there's not any real consensus on what the best treatment is, but uh, in the pediatric orthopedic world, there is general acceptance that we do not operate on skeletal immature bunions because there's such a high recurrence rate. So if you if you have a 10 year old with bad bunions, we're not going to operate on them. We'll do not, we'll do a nonsurgical treatment. Um and we do not operate for Kaz Missus. Right? So if the if the kid doesn't like how their feet look, we're sorry, we're not gonna do big bunion surgery for Kaz Missus, but we will help if there's pain, but only when their skeletal immature. So we avoid surgery and the skeletal immature. We use wide toe box shoes. We avoid high heels, toe spacers and other splints can be tried, but they're not usually effective. And those with flat feet can benefit from a soft arch support and those with tight achilles benefit from stretching. So non operative management is the way to go with these. We try very hard never to operate on bunions and only if it totally fails non operative treatment. They have persistent pain that they can't make better. Despite all the modifications, then we would consider surgery. Uh and there's more than 100 25 different surgeries that are done for bunions. They are not without complications. And in fact bunion surgery has a pretty high complication rate, which is why we try not to operate. So we're gonna actually end there in summary basically who to refer. So, for newborns and infants right away, we want to see club foot and in general vertical taylor's. Um if not improving over the first few months. We want to see cal Camilo vargas foot and stiff metatarsal adductor towards the end of the first year. The poly dactyl is the Sendak please. And the metatarsals abductees that are not getting better. And then the older kids then the painful flatfoot, the flatfoot with the tight achilles tendon, the high arched feet at any age. Um That's not um that's not the same as their parents. Symptomatic curly toe breaking metatarsal which I just skipped. But is a shortening of one of the metatarsals due to premature growth arrest. And then symptomatic accessory navicular. And with that I will happily answer any questions. Sorry in these six minutes that we have left. Thank you so much. I just took a photo of that last slide there. I'm gonna I'm gonna use that. I'm gonna share it with the residents to um We have a few questions from dr ross outstanding presentation. As always wondering if you have encountered families who have a parent who is resistant to political interventions because it's just part of the family traits particularly from the parent whose side it comes from while the other parent is ready to pick a surgery date. Yeah that's a great question dr ross. And always always good to hear from you. I miss seeing you. Um So not so much in the U. S. These days. Um I think we uh we are so focused on shoe wear and cosmetics that I I rarely encounter a parent who doesn't want Pollitt actually addressed. If anything we have to convince them that they it's okay to wait a while to treat the pollen actually. Um But honestly I tell every family like this doesn't need surgery, right? So we could wait until the child gets older and if they have pain in the future then we could take the tow off. Um Actually, as I just said that I do have one family who there is a long line of six toes in the family and that family never came back now that I think about it. So it does happen. Um And it only truly needs treatment if it's symptomatic, but we just assume based on available data that any kid would see, you know, wide six toes. Um in a shoot culture which the majority people are in the world these days um that that toe might eventually cause shoe wear problems. And so we tend to take them off. But I'm always happy to have a family who um wants to keep the toe as long as it's not causing a growth disturbance or a growth abnormality of the adjacent toast. And that's totally fine. Thank you. Next question. Could you address flatfoot in people with Down syndrome who will not grow out of their flatfoot will develop Alex vargas will develop pain and develop knee and hip hip problems. This is from dr Spinotti, she says I give my patients with Down syndrome over the counter orthotics and I like Kids Souls Brand because they are cheap and available in pediatric sizes. Yes, I know you do that. Um So yeah, so I think that there's not um there's not actually data that shows that every child with Down syndrome that has flat foot is going to develop pain or problems in the future, flexible flat feet is not associated with uh knee or hip problems specifically. Um And so in Down syndrome, Children just like any child with flat foot, we do not have to use orthotics. I think it's fine. Um If if in your practice you wish to that's fine. I appreciate that you use an over the counter soft orthotic and not the rigid podiatric orthotics because I think those again cause more problems than they're worth, but that is doctor cannot see the one population um where I would be more likely to use an orthotic than others because they won't ever develop their medial longitudinal arch and there can be some associated great toe abnormality. So, for that reason for the great toe problem, um I think that's a very reasonable thing to do. But I don't think we're avoiding. I don't think we're preventing hip Bernie problems from using those. Um I think if anything the one thing that we would be helping is avoiding that the medial deviation of the great toe. Um So more power to you if you wish to keep using those. Um and thank you for not doing rigid ones because those would be bad. Um Your question um from anonymous. Any thoughts on foot stretchers used in dance and gymnastics? Oh yeah. Um I have no particular problems with those. Um As long as the child is not doing it to excess, I have never seen, I run the dance medicine program here from the uh orthopedic surgery side. Um Having been a dancer myself in the past and probably used a few of those things in the past, and I haven't seen a kid come in with a problem from using the stretchers. Um So I I don't have an issue with it, but like anything in the growing human, too much of a of a not bad thing can become bad. So as long as they're not doing it to excess, so if they're giving themselves paint, then we gotta peel back on it. And another question, how does renal ultrasound play into the work up of these foot abnormalities specifically? Can abnormalities in urine production in utero lead to foot deformities. Um And therefore how often do you recommend kidney evaluation? Yeah. So I don't recommend kidney evaluation. What I recommend is genetics evaluation for the kids that have known genetic associations, like for example, pre axial policy actively, which again we know more commonly in the hand. Pre axial policy actually is associated with other genetic problems but I don't want to miss something. So I often will ask our geneticists to weigh in on our pre pre axial policy actively foot patients. Um And then they sometimes will order the renal ultrasounds based on their genetic assessment of the child. Um But the only kids that I actually recommend that I personally as the orthopedic surgeon would ever recommend like abdominal imaging in is kids with hemi hypertrophy for which would be concerned about the development of Wilms tumor. But that's the only time that I sort of navigate into that space. I did say that somebody asked about with the tendon grow back and I assume you mean the achilles tendon and club foot and absolutely yes. So that's we cut the achilles tendon like literally cut it in half and it pulls apart so that you can't even see the two ends anymore because it's through a tiny little incision. Um And then we put a cast on in a fully corrected position and during that time the achilles tendon grows back and it follows its own path and it will become a fully normal achilles tendon. Again it's remarkable. Nice. I think there are a few questions about kind of reviewing some of the slides but this will be posted because it is being recorded so feel free to check that out later. And I think um one more question that we can squeeze in even though it's 9:00. Um do you ever get concerned for hip issues with asymmetrical crawling? And how long do you observe that? But if once they begin walking and that's normal, are you completely reassured? Y'all this is a foot talk, not a hip talk. Um Yes, so asymmetric crawling. I actually don't like the scooting thing where they like lead with one side and they sort of drag their other one behind. If you guys are concerned about developmentally for other reasons, that's fine. From a hip perspective, the only thing I would do in that situation is do a good hip exam and make sure that we have wide symmetric abduction of the hips, that we have symmetric range of motion of the hips otherwise, um that we are Galiazzo negative, right? Meaning that when the hips are flexed at 90 degrees, that the length of the femurs are the same so that we're rolling out a hip dislocation or severe subluxation. But if I have wide symmetric abduction, I have symmetric range of motion and I'm Galiazzo negative. Um I don't worry about the hip. I think many, many kids do asymmetric crawling. Um And that corrects itself on its own. So that does not, that does not get a hip ultrasound from me. If my exam is abnormal, or if the child had risk factors for hip dysplasia? Like if they were breech. Um And nobody got a hip ultrasound when they were six weeks old, I would I would get imaging then, but not because of the crawling, but just because of the risk factors. Um And then with shoes, I'm gonna answer this question if that's okay. So shoes um you know, there is not great data on what to wear, what not to wear. There's not great data on, you know, does do particular shoes help an arch develop or not despite a lot of research into this. The only thing I would say about shoes is that um they're not needed unless a child is walking outside. Um And that's to protect their feet. The shoes are not worn to make our feet the right position or the right shape or the right size. In fact, they can actually cause problems. So we wear shoes for the purpose of protecting our feet when we're outside in the elements. Um And so Children in the house do not need to wear shoes and in fact we want them not to, so they develop their appropriate receptive ability and they don't get toe abnormalities from their shoes. And the shoes that they wear should be a wide shoe um that is wide enough for their foot. So they don't get some of these toe problems that many kids in our culture do get. Um And that's really the only thing that they, and they should tie or have good velcro again, no flip flop type of shoes if they're gonna wear sandals that should have a heel capture on the back so that they're not gripping their toes and coming to us for foot pain because their toe flexors are all um in fuego from having to hold their shoes on all day. So those would be my, my shoe recommendations. A nice wide shoe, which usually is not some of the brand name brand names that parents like to wear. Awesome. Thank you so much. Doctor Sabbatini, awesome. I think we got to all the questions actually. So we'll close it there and just a reminder to click that survey link before we close the meeting. If you didn't get a chance to do that already and we will see you all next week. Thank you so much. Thanks everybody.