"Coxa pedis" today.

UNLABELLED: Coxa pedis is the talocalcaneonavicular joint and is the distal enarthrosis of the lower limb. It is defined coxa because of: (1) the enarthrosic meaning from an anatomical point of view, (2) the analogy to the hip. The stabilising devices are structural, passive and active; the corresponding pathology is the "Coxa pedis destabilising syndrome". During walking, release and stiffening of the foot are related to the opening and closure of the kinetic chain of the coxa pedis: it is mutually reversible, while opening is a passive event, closure is an active one. Considering the importance of the flexor digitorum longus muscle in stabilising the coxa pedis, is it logical transferring it in the tibialis posterior disfunction? During walking, opening and closure of the kinetic chain of the coxa pedis intervene in the opening and closure of the kinetic chain of the entire lower limb. The kinetic chain closes starting from the bottom and moving upwards in the foot-knee-hip progression, and opens starting from the top and moving downwards. Even rotations along the orthogonal plane of the segmental axes of the limb contribute to the closure of the kinetic chain, coxa pedis dysmorphism (cavovalgus foot: false flat foot) can cause, during growth, dysmorphism of the hip (residual anteversion) and of the knee (condyles or tibial tuberosity) instead of the reverse. ISSUES: subtalar joint; anomalous subtalar pronation syndrome; flexor digitorum longum transfer pro tibialis posterior tendon; coxa pedis actor or participant in the functional integration of the lower limb; anterior knee pain syndrome.

Concurrent dorsal dimelia in 160 consecutive patients with congenital anomalies of the hands and feet.

This study was designed to investigate the prevalence of dorsal dimelia in a series of 160 consecutive patients with congenital anomalies of the hands and feet, and to investigate the distribution of dorsal dimelia and the concurrent anomalies. Five cases (3.1%) showed evidence of dorsal dimelia and the distribution of dorsal dimelia was similar to the distribution of concurrent anomalies in all five cases. Another 11 cases of concurrent dorsal dimelia with other congenital anomalies have been reported previously with a positive match in the distributions in all cases. This similarity in the distribution in all 16 reported cases (including the five cases in the current study) is statistically significant. It is concluded that dorsal dimelia in humans is not as rare as it is generally thought to be, and that it may be viewed as an error of dorso-ventral patterning, which occurs in the same distribution as other concurrent anomalies.

An unusual case of fibular (postaxial) polydactyly: extrametatarsal head with fused duplication of the proximal phalanx.

Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. A number of morphologically and anatomically based classifications exist. We present an unusual case of fibular (postaxial) polydactyly characterized by an extrametatarsal head with fused duplication of the proximal phalanx. We describe the method of surgical correction and emphasize the need for careful preoperative planning to achieve a good functional and cosmetic outcome.

The spectrum of preaxial polydactyly of the foot.

BACKGROUND: Polydactyly is a common congenital anomaly of the foot classified as preaxial, central, or postaxial depending on the location of the duplication. Approximately 15% of all duplications of the toes are preaxial. The purpose of this study is to report our experience in the management of preaxial polydactyly of the foot over a period of 30 years at a single institution. PATIENTS AND METHODS: This is a retrospective institutional review board-approved descriptive case series of 21 children representing 28 feet with preaxial foot polydactyly seen at our institution from 1977 to 2009. All subjects were analyzed in terms of sex, laterality, anatomic patterns of polydactyly, associated anomalies, family history, clinical features, surgical indications, details of surgical procedures, and outcomes after surgical interventions, using data collected from medical records, radiographs, and clinical photographs. Clinical outcomes were evaluated at the most recent examination, according to the format published by Phelps and Grogan. RESULTS: There were 21 patients (28 feet) including 11 male and 10 female subjects. Duplications were bilateral in 7 patients and unilateral in 14. The average age at surgery was 1.8 years (range: 0.8 to 4.6 y). The average follow-up was 81.7 months (range: 5 to 180 mo). According to the Watanabey classification, the distal phalangeal type occurred in 4 feet, the proximal phalangeal type in 10 feet, the metatarsal type in 10 feet, the tarsal type in 2 feet, a combined tarsal and metatarsal type in 1 foot, and a mirror type in 1 foot. All patients had associated anomalies in the affected feet. Congenital hallux varus was the most common associated anomaly (20 feet). A longitudinal epiphyseal bracket was observed in 4 feet. Clinical outcomes after the initial surgery were excellent in 8 feet, good in 15 feet, and poor in 5 feet. The 5 feet rated as poor were because of residual deformities and required additional surgery. Good results were subsequently obtained at final follow-up in all 5 feet. CONCLUSIONS: In our opinion, the Watanabe classification is more useful than the Venn-Watson for surgical planning. However, we have added an additional type, representing a mirror foot which we feel is within the overall spectrum of preaxial polydactyly. Good or better results were obtained in all feet at final follow-up. Early detection and adequate excision of the longitudinal bracket affecting the phalanges or metatarsal can reduce residual deformity and the need for revision surgery.

The nosology of Richieri-Costa/Guion-Almeida syndrome(s).

Richieri-Costa/Guion-Almeida syndrome type 1 (RCGAS1) is a rare MR/MCA syndrome comprising developmental and growth delay, microcephaly, prominent supraorbital ridges, asymmetric ptosis and eyebrows, esotropia, nystagmus, eye colobomas, and cleft lip/palate. It was originally described in three brothers and an additional sporadic male. The same authors also described a further family with a partially overlapping condition in two sisters (Richieri-Costa/Guion-Almeida syndrome type 2, RCGAS2). We report on a sporadic, mentally retarded patient strongly resembling those of the original report of RCGAS1, but lacking some manifestations such as short stature and, possibly, some ocular changes. Results of 200 kb CGH-array study were normal. By comparing the present and previously reported patients with RCGAS1 and 2, we tried to contribute to syndrome delineation and to separate them from conditions with similar facial anomalies.

Congenital cleft foot deformity.

Cleft foot or ectrodactyly is a rare congenital anomaly. It is often associated with cleft hands. Most early authors advised non-operative treatment but more recently surgical treatment has been advised. However the last two decades have seen a trend towards surgical management of these deformities. Most authors agree that whilst cosmesis is an important consideration, the main aim of correction is to provide feet which could fit into normal shoes and to provide or maintain a normal functional foot. We describe our experience with five feet in three patients treated surgically as a one step procedure as opposed to a staged approach.

Central ray deficiency with extensive syndactyly: a dilemma for classification.

Split Hand Foot Malformation (SHFM) (cleft hand/foot, central ray deficiency) is a complex, highly variable anomaly involving the hands and/or feet. A clinical epidemiologic study of split hand/foot (central ray deficiency) of the Manitoba population identified a subset of patients who did not present with either typical or atypical split hand. Clinically, some patients presented with "mitten hand" syndactyly; the deficiency was not recognized before imaging. In this paper, we identify additional similarly affected literature cases, review existing classifications of split hand and syndactyly and attempt to classify these patients. This group presents a challenge for classification and genetic counseling. General classifications permit inclusion of patients with diverse phenotypes; however, details are overlooked. Osseous fusions and disorganization of osseous components complicate classification. Many of these patients had findings that overlapped different subtypes within existing classifications. This cohort highlights the importance of imaging patients with distal limb anomalies. An effective classification scheme should include relevant clinical and radiographic findings in order to assist clinicians following these patients.

Foot problems in children presented to the family physician: a comparison between 1987 and 2001.

BACKGROUND: In recent decades, studies on the management of common foot problems in children have suggested that in many cases, there is no indication for treatment. It is not known whether these studies have changed daily practice. OBJECTIVE: Our aim was to establish and compare incidence and referral rates for foot problems in children in 1987 and 2001. METHODS: A comparison was made of two large consecutive surveys in Dutch general practice performed in 1987 (86 577 children aged 0-17 years) and 2001 (87 952 children aged 0-17 years), which were carried out by The Netherlands Institute for Health Services Research. Both surveys included a representative sample of the Dutch population. Incidence and referral rates were calculated and, data were stratified for age group and gender. RESULTS: Compared to 1987, in 2001 the overall incidence rate of foot problems presented to the family physician (FP) decreased substantially from 80.0 [95% confidence interval (CI) 77.0-84.7] to 17.4 (95% CI 16.5-18.3) per 1000 person-years (P < 0.0001). The incidence rate of flat feet decreased from 4.9 (95% CI 4.0-5.9) per 1000 person-years in 1987 to 3.4 (95% CI 3.0-3.8) per 1000 person-years in 2001 (P = 0.001). The distribution of referrals to other primary health care professionals and medical specialists has almost reversed in favour of primary health care professionals. CONCLUSION: Total incidence rate of musculoskeletal foot problems seen by the FP has decreased substantially, between 1987 and 2001.

Elements of morphology: standard terminology for the hands and feet.

An international group of clinicians working in the field of dysmorphology has initiated the standardization of terms used to describe human morphology. The goals are to standardize these terms and reach consensus regarding their definitions. In this way, we will increase the utility of descriptions of the human phenotype and facilitate reliable comparisons of findings among patients. Discussions with other workers in dysmorphology and related fields, such as developmental biology and molecular genetics, will become more precise. Here we introduce the anatomy of the hands and feet and define and illustrate the terms that describe the major characteristics of the hands and feet.

[Results of surgical treatment of congenital convex pes valgus (10 non-idiopathic feet)]. / Résultats du traitement chirurgical du pied convexe congénital.

PURPOSE OF THE STUDY: Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome. MATERIAL AND METHODS: Ten feet presenting congenital convex valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, a multiple malformative syndrome in four and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber. RESULTS: Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogyrposis feet. Undercorrection was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two. DISCUSSION: Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis several months postoperatively to avoid recurrence.

Unique case of polydactyly and a new classification system.

Polydactyly of the hands or feet is a common birth deformity. We recently encountered a female infant with a case of a crossed type 1 polydactyly with a mixed polydactyly of the feet. A mixed and crossed polydactyly is a rare finding with only one other reported case. This is the first report of crossed and mixed polydactyly of the feet presenting with 7 complete toes on each foot without syndactyly. In addition to a discussion of the treatment, this case has lead us to propose a more complete and less confusing classification system.

The expanding panorama of split hand foot malformation.

The split hand/foot malformation is a developmental defect of the extremities resulting from errors in the initiation and maintenance of the apical ectodermal ridge. The phenotype is genetically heterogeneous, and it can be identified either as an isolated phenotypic manifestation or as a constituent component of a malformation syndrome. This overview describes the clinical phenotype, related animal models, and the evolving genetic heterogeneity of the malformation.

Classification of postaxial polydactyly of the foot.

BACKGROUND: The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options. METHODS: We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head. RESULTS: Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5th metatarsal medial deviation occurred. CONCLUSIONS: Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.

[Clinical signs and diagnosis of hallux valgus]. / Klinische Untersuchung + Röntgenbild. So funktioniert die Hallux-valgus-Diagnostik.

The hallux valgus deformity (fibular deviation of the big toe) is one of the most common deformities affecting lower limbs. If the hallux crosses over the second toe, the condition may be termed hallux valgus superductus, if it moves under the second toe, the term hallux valgus subductus applies. Mechanical pressure on the pseudoexostosis results in a bunion and possibly fistulization. Hallux valgus is often combined with a splay foot. Overloading of the second to fourth metatarsal heads may cause midfoot pain. As a result of the increased load, the second to fifth toes may deform into hammer or claw toes. Therefore hallux valgus should usually not be considered in its own. Apart from the anamnesis and clinical examination, X-ray diagnosis is very important for the treatment planning. A.p. and lateral X-rays should be obtained of the entire foot in the standing patient, as also an oblique view. While the latter permits evaluation of the extent of an arthrosis of the metatarsophalangeal joint of the big toe, the lateral films allow the longitudinal arch and the stability of the first tarsometatarsal articulation to be assessed. On the a.p. film the hallux valgus angle and the intermetatarsal (rays 1/2) angle can be determined.

The newborn foot: diagnosis and management of common conditions.

An assessment of the foot should be a part of every newborn physical examination. The newborn foot, although complex in structure, can be examined quickly in any office setting. Many foot deformities are diagnosed immediately after birth, allowing for earlier and often more successful treatment. A neonate with a foot deformity can be a source of anxiety to parents. Adequate knowledge of commonly encountered neonatal foot problems enables the nurse to give appropriate anticipatory guidance to the parents. Foot abnormalities usually occur as isolated findings in an otherwise healthy newborn. However, these deformities can also be seen in newborns with underlying neuromuscular disorders and syndromic conditions. Common newborn foot abnormalities include equinovarus deformity (clubfoot), metatarsus adductus, calcaneovalgus, congenital vertical talus, polydactyly (supernumerary digits), and syndactyly (webbed toes). These common foot disorders, their treatment, and their prognosis are discussed. This article also discusses fundamental nursing implications needed to care for these young patients and their families.

Split hand foot malformation (SHFM).

The nomenclature describing the phenotype of missing central rays in the hand and/or foot in the genetics and surgical literature is heterogeneous and confusing. Split hand/foot malformation (SHFM) is the most common term for this phenotype in the genetics community; however, other names such as the offensive 'lobster-claw malformation' and the non-specific 'ectrodactyly' are still utilized to describe this malformation. In this article, we briefly review the nomenclature associated with SHFM and its classifications.

Analysis of anatomic variations in cleft hands.

PURPOSE: This study presents an overview of the clinical and x-ray findings observed in 54 cleft hands of 31 patients. The emphasis was on a detailed analysis of typical malformation-associated x-ray patterns such as aplasia and synostosis, with findings arranged as a function of cleft location and of the Manske and Halikis classification. METHODS: The charts and radiographs of 31 patients with 54 cleft hands were reviewed retrospectively and compared with data reported in the literature. Important clinical and x-ray findings as well as the typical morphology of cleft hands were analyzed. Cleft hands were differentiated according to their location and according to the Manske and Halikis classification. In the different locations the deformities were arranged in teratologic sequences. RESULTS: In cleft hands syndactylies were seen in 30 of the 54 hands, most commonly between the ring and the small finger. In 3 hands polydactylies were noted. Analysis of the x-ray morphology showed 2 typical patterns: aplasia and synostoses. Location-specific teratologic sequences showed that radial cleft hands were bilateral more frequently and were associated significantly more frequently with cleft feet. Aplasias predominated in radial cleft hands, whereas synostoses were more common in central cleft hands. In terms of the Manske and Halikis classification the unilateral cleft hands often corresponded to type I whereas bilateral cleft hands with cleft feet mainly were type IV and type V deformities. Cleft hands with synostoses often were seen in types I to III whereas cleft hands with aplasias were classified most frequently as type V. CONCLUSIONS: Analysis of the patients' clinical data and x-rays showed differences between radial and central cleft hands, as well as between the different Manske and Halikis types.

[Congenital quintus varus supraductus: surgical procedure]. / Quintus varus supraductus congénital : technique chirurgicale.

Quintus varus supraductus is a congenital malformation that associates a hyperextension, a varus and an external rotation of the fifth toe coming over the fourth. The goal of this study is to explain an easy, reproducible and efficient surgical procedure to correct that malformation. Our procedure is only about soft tissues. It comprises a fifth toe extensor tenolysis, a circular capsulotomy and lateral ligament section of the fifth metacarpophalangeal articulation. The glenoid plaque is desinserted only if the peroperative reduction did not seem sufficient. The stabilization is achieved through a cutaneous plasty of modified BUTLER, with a cutaneous lengthening VY plasty. Exceptionally, an axial broaching of the articulation has been done. On about 20 children, aged 4-17 years, operated with this procedure, we have noticed a complete and definitive correction in 19 patients. Only one patient showed an incomplete resurgence, but without any functional disturbance. We did not notice any failure. This procedure seems efficient, and all the more interesting that it is technically easy to perform.