5/7/2017 ClubfootImaging:Overview,Radiography,ComputedTomography

ClubfootImaging
Updated:Nov04,2015
Author:EllenMChung,MDChiefEditor:JohnKarani,MBBS,FRCRmore...

OVERVIEW

Radiography
The3maincomponentsofthedeformityareevidentonradiographsandcanbereproducibly
quantified.Withproperpositioningandexposure,quantificationofalignmentabnormalitiesonplain
radiographsisreliable.Noconfirmatoryimagingisroutinelyused.Obliquepositioningoftheheel
ontheDPviewcansimulatehindfootvarus.Ifthelateralviewisoneofthefootratherthanthe
ankle,theflattalardomehasaspuriousappearance.[4]

Hindfootequinusisplantarflexionoftheanteriorcalcaneus(similartoahorse'shoof)suchthatthe
anglebetweenthelongaxisofthetibiaandthelongaxisofthecalcaneus(tibiocalcanealangle)is
greaterthan90(seetheimagebelow).

Lateralviewintalipesequinovarusdemonstratesanabnormallyelevatedtibiocalcanealangle.Anormalangle
is6090.
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Inhindfootvarus,thetalusisassumedtobefixedrelativetothetibia.Thecalcaneusisconsidered
torotatearoundthetalusintoavarus(towardmidline)position.Onthelateralview,theangle
betweenthelongaxisofthetalusandthelongaxisofthecalcaneus(talocalcanealangle)isless
than25,andthe2bonesaremorenearlyparallelthaninthenormalcondition(seetheimages
below).

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Normallateralviewshowsthemeasurementofthetalocalcanealangle.Thecalcaneallongaxisisdrawnalong
theplantarsurface.Thenormalrangeis2545.Notethenormaloverlapofthemetatarsalsonthelateral
view.
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Lateralviewofclubfootshowsthenearlyparalleltalusandcalcaneus,withatalocalcanealangleoflessthan
25.
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OntheDPview,thetalocalcanealangleislessthan15,andthe2bonesappeartooverlapmore
thannormal.Also,thelongitudinalaxisthroughthemiddleofthetalus(midtalarline)passeslateral
tothebaseofthefirstmetatarsal,becausetheforefootismediallydeviated(seetheimages
below).

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Dorsoplantarprojectionofahealthyfootshowsthatthelinethroughthelongaxisofthetaluspassesjust
medialtothebaseofthefirstmetatarsal.Thetalocalcanealanglemeasurementisshown.Thenormalrangeis
1540.
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Dorsoplantarviewsobtainedinapatientwithunilateralclubfootshowthatthetalusandcalcaneusaremore
overlappedthaninthenormalcondition.Thetalocalcanealangleis15orless.Notethatthelinethroughthe
longaxisofthetaluspasseslateraltothefirstmetatarsalduetothevaruspositionoftheforefoot.
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ForefootvarusandsupinationincreasetheconvergenceofthebasesofthemetatarsalsontheDP
view,comparedwiththenormalslightconvergence(seetheimagebelow).

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Dorsoplantarviewoftalipesequinovarusshowsthattheconvergenceofthebasesofthemetatarsalsis
abnormallyincreasedcomparedwiththenormalconvergence.
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Onthelateralview,insteadofhavingthenormaloverlappedappearance,themetatarsalsare
arrangedinaladderlikeconfiguration,withthefirstbeingmostdorsal(seetheimagebelow).

Lateralviewofshowstheladderlikeconfigurationofthemetatarsalsinforefootvarusinclubfoot.
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Thefollowingtablecontainsasummaryofthenormalandclubfootmeasurements.

Table.ASummaryoftheNormalandClubfootMeasurements(OpenTableinanewwindow)

Measurement NormalFoot Clubfoot

Tibiocalcaneal
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Tibiocalcaneal
angle 6090onlateralview >90(hindfootequinus)onlateralview

Talocalcaneal 2545onlateralview, <25(hindfootvarus)onlateralview,<15

angle 1540onDPview (hindfootvarus)onDPview

Metatarsal Slightonlateralview, None(forefootsupination)onlateralview,

convergence slightonDPview increased(forefootsupination)onDPview

Inanincompletelycorrectedorrecurrentclubfoot,characteristicabnormalitiesareobserved.[5]
ThetalocalcanealangleisnormalontheDPview(seetheimagebelow),buttalocalcaneal
parallelismpersistsonthelateralview.

Imageofclubfootobtainedafterrepairshowsrestorationofanormaltalocalcanealangleonthedorsoplantar
view.Thelinealongthelongaxisofthetalusnowpassesmedialtothefirstmetatarsalthisfindingindicates
overcorrectionoftheforefootvarus.
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Flatteningofthetalardomepersistsonthisviewaswell(seetheimagebelow).

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Postoperativelateralviewofaclubfootshowspersistentparallelismofthetalusandcalcaneus.Notethe
characteristicflatteningofthetalardomeonthistruelateralviewoftheankle.
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Cavusoftheplantararchmaybepresent,particularlyifnoplantarreleasewasperformed.Also,a
periostealreaction,sclerosis,orfractureofthelateralmetatarsalsmayoccurasaresultof
abnormalweightbearingonthissideofthefootincasesofinadequatecorrectionofforefootvarus
(seetheimagesbelow).

Lateralradiographsobtainedina12yearoldgirlaftersurgicalclubfootrepairshowspersistentforefootvarus
andresultantstresschanges(corticalthickening)inthemostlateralmetatarsals.
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DPradiographsobtainedinthesamegirlasinthepreviousimageaftersurgicalclubfootrepairshows
persistentforefootvarusandresultantstresschangestothelateralmetatarsals.
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TarrafandCarrollfoundthatresidualforefootadductionandsupinationwere,byfar,themost
commondeformitiesthatleadtorepeatsurgeryforclubfoot.Inadditiontohindfootalignment,
thesedeformitiesshouldbeactivelyevaluatedonintraoperativeradiographs.[6]

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