PHV (Pediatric Hallux Valgus) CNBC..pptx

Here's ppt on most wanted topic Pediatric Hallux Valgus. Suggestion welcomed at [email protected]. it's a rare but easy to treat entity

1. PEDIATRIC HALLUX VALGUS Dr JAINAM SALOT CNBC

2. INTRODUCTION One of the Most common forefoot pathology Medial deviation of M1 Lateral deviation of hallux Female: Male – 10:1 Symptoms occur at around 10 yrs of age

3. Differences from adult variety Less valgus deformity No joint degeneration Smaller medial exostosis Hypermobility is frequent Metatarsus adductus is frequently present

4. Etiology Genetic factors strongly contribute Hyperlaxity that alters muscle balance 2/3 rd patients have family history

5. Pathogenesis Static medial structures which stabilize M1P1 are Medial sesamoid bone Medial collateral ligament Flat M1 head Alteration of balance between static and dynamic stabilizer makes first ray unstable

6. Medial and dorsal displacement of M1 Relative lateral displacements of sesamoids with FHB tendon Attenuation of medial structures/MCL rupture Valgus at P1 --  Also , altered pull of EHL , FHL leading to bowstringing LCL and lateral capsule contracture along with adductor hallucis Abductor hallucis also shifts planter and laterally as it gives away This all leads to pronation deformity of big toe So , It’s a 3D deformity

7. A foot with spherical M1 head is more likely to progress to Hallux valgus. Similarly , Metatarsocuneiform joint is usually in transverse direction. In Some children with PHV , It is found crescent and slopong medially.

8. CAUSES OF HALLUX VALGUS

9. Radiology Weight bearing Xray of foot in 3 views taken AP Lateral Oblique Angles calculated are Hallux valgus angle(HVA) Distal metatarsal articular angle (DMAA) 1 st and 2 nd Intermetatarsal angle

10. Hallux valgus is defined when HVA >15*. Intersection of line drawn along P1 shaft and M1 shaft. 15-30* - mild >30* - moderate >40* -severe In PHV , Often there is lateral tilt of articular facet of M1 head which manifests as DMAA Intersection of line along articular surface of metatarsal head at MTP joint and another line along M1 shaft Normally , its <15* IMA is used to assess presence of Metatarsus primus varus. Normally , its <9*.

11. Treatment PHV patients should avoid surgical treatment, atleast until the first metatarsal physis has closed. Risk of recurrence after surgery is higher. Conservative helps relieving pain. Using of wide toe box shoes Using arch support in patients with assoc. pes planus

12. Surgical Treatment Distal Soft tissue realignment ( Mcbride procedure) Distal metatarsal Osteotomy(Mitchell and chevron) Proximal first metatarsal Osteotomy Double Metatarsal osteotomy Metatarsal-cuneiform fusion Decision making depends on Congruency of MTP joint Presence or absence of MPV Severity of bunion

13. Distal Soft tissue Realignment Mcbride procedure Done if MTP joint is incongruous Restores normal joint alignment Reduces risk of arthritis Should be combined with osteotomy to prevent recurrence V-Y Plasty of medial capsule with distal advancement Release of adductor contracture Removal of lateral sesamoids Medial and lateral aspect of Metatarsal should be dealt separately to prevent AVN of metatarsal head.

14. II. Distal Metatarsal Osteotomy Usually performed in conjunction with Mcbride procedure Mitchell Osteotomy

15. Internal fixation of osteotomy site is recommended Produces M1 shortening MTP Stiffness , hence shouldn’t be performed for Adolescent hallux Valgus 2 nd and 3 rd Metatarsal stress fractures can occur after shortening M1 Chevron Osteotomy V osteotomy , distal fragment Translated laterally and fixed with K-wires

16. III. Proximal First Metatarsal Osteotomy Mainly used in adolescents Allows correction of MPV Can be Medial Opening wedge , Lateral closing wedge(preferred) or crescent osteotomy IV. Double Metatarsal Osteotomy Done in case of severe HV in skeletally mature patients Provides best correction Distally medial closing wedge osteotomy and proximally open wedge osteotomy was done Helps correcting DMAA and IMA both.

17. V. Metatarsal Cuneiform fusion(Lapidus Procedure) Done in skeletally mature patients with hypermobile first ray Having ligamentous laxity and flatfeet M1 is slightly plantarflexed to share weight bearing forces and then fused VI. Scarf Osteotomy Diaphyseal osteotomy Transverse Osteotomy Dorsal limb distally , Plantar Limb Proximally.