Slide 035 — Congenital vertical talus

Clean FRCS notes with inline figures

Clinical photograph

•Midfoot: Rocker bottom deformity

•Equinus hind foot

•Dorsiflexion and abduction of forefoot

Rigid flatfoot ddx:

•Tarsal coalition

•CVT

•Accessory navicular

•+/- stage 3 or 4 PTTD in adults

Radiographic description

**Fig 1.** Radiograph / imaging - CVT radiographmiddle left

•Vertically pointed talus

•Long axis of talus passes below the 1st ray axis (NOT navicular as it is not ossified yet)/ TAMBA (Talus axis MT bone angle)

•Increase in talocalcaneal angle

•Take plantarflexion lateral XR to distinguish between CVT and COT

Diagnosis – CVT

Differential diagnosis

Congenital oblique talus (plantarflexion lateral XR)

•Calcaneovalgus (Calcaneus instead of equinus, break at hindfoot instead)

•Tarsal coalition

•Paralytic pes planus

How will you assess this child?

•Systemically screen for associations

•50% +ve neuromusclular disease (spina bifida), syndromal (arthrogryposis, Larsen syndrome), maltreated CTEV, look for DDH

•Genetic: 20% +ve family Hx

•Locally confirm rigid deformity

•Rocker bottom foot

•Hind foot: equinovalgus deformity, tight TA and peroneus

•Chopart joint: Dorsiflexion with navicular dorsal dislocation

•Forefoot: abduction and dorsiflexion (EDL/ EHL, tib ant contractures)

•Prominent talar head at plantar region

•Check LL neurology

•“peg leg” gait

Xray:

•Lat: Vertically pointed talus, long axis of talus passes below the 1st ray axis (Dorsally dislocated navicular, navicular ossify at 3 y.o.)

•AP: Increase in talocalcaneal angle >40

•Differentiate between CVT and COT: try to reduce TNJ in plantarflexion view

Management

•r/o association

•r/o oblique talus (planter flexed Xray, if reducible → oblique talus)

•Counselling: May try reverse Ponseti but need to tell parents majority eventually need OT

•Preop stretching of dorsolateral structure + reverse ponsetti x 3 mths (identify the talar head, push forefoot in plantar medial direction)

•After reduction perform talonavicular pinning (MIS) + release peroneus and extensors +/- lengthening +/- spring ligament recon + percutaneous achilles tenotomy 6 to 12 months after casting

•JBJS (Am) 2006 Dobbs: 11 patients treated with stretching + reverse ponseti + percutaneous pinning and achilles tendon tenotomy, good result in appearance, foot function and Xray at minimum 2 years

•If present late: talus + navicular excision and lateral column lengthening

•Salvage: triple arthrodesis

•Vertical talus

•Irreducible dorsal dislocation of the navicular on the talus producing a rigid flatfoot deformity

What is the pathoanatomy?

•Soft tissue: Tight Achilles, displaced PT and peroneal both function as dorsiflexor, attenuated spring ligament

•Bony: dorsally dislocated navicular

•COT

•No need serial casting

•Treated with TA release

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Describe Photo:
2	0	171450	-171450	1	Midfoot: Rocker bottom deformity
3	0	171450	-171450	1	Equinus hind foot
4	0	171450	-171450	1	Dorsiflexion and abduction of forefoot
5	0	0	0	0	Rigid flatfoot ddx:
6	0	171450	-171450	1	Tarsal coalition
7	0	171450	-171450	1	CVT
8	0	171450	-171450	1	Accessory navicular
9	0	171450	-171450	1	+/- stage 3 or 4 PTTD in adults
10	0	None	None	0	Describe Xray:
11	1	628650	-171450	2	Vertically pointed talus
12	1	628650	-171450	2	Long axis of talus passes below the 1st ray axis (NOT navicular as it is not ossified yet)/ TAMBA (Talus axis MT bone angle)
13	1	628650	-171450	2	Increase in talocalcaneal angle
14	0	None	None	0	Take plantarflexion lateral XR to distinguish between CVT and COT
15	0	None	None	0	Diagnosis – CVT
16	0	None	None	0	Ddx:
17	0	228600	-228600	1	Congenital oblique talus (plantarflexion lateral XR)
18	0	228600	-228600	1	Calcaneovalgus (Calcaneus instead of equinus, break at hindfoot instead)
19	0	228600	-228600	1	Tarsal coalition
20	0	228600	-228600	1	Paralytic pes planus
21	0	None	None	0	How will you assess this child?
22	0	None	None	0	Systemically screen for associations
23	0	0	0	0	50% +ve neuromusclular disease (spina bifida), syndromal (arthrogryposis, Larsen syndrome), maltreated CTEV, look for DDH
24	0	0	0	0	Genetic: 20% +ve family Hx
25	0	None	None	0	Locally confirm rigid deformity
26	0	None	None	0	Rocker bottom foot
27	1	628650	-171450	2	Hind foot: equinovalgus deformity, tight TA and peroneus
28	1	628650	-171450	2	Chopart joint: Dorsiflexion with navicular dorsal dislocation
29	1	628650	-171450	2	Forefoot: abduction and dorsiflexion (EDL/ EHL, tib ant contractures)
30	1	628650	-171450	2	Prominent talar head at plantar region
31	0	171450	-171450	1	Check LL neurology
32	0	171450	-171450	1	“peg leg” gait
33	0	None	None	0	Xray:
34	1	628650	-171450	2	Lat: Vertically pointed talus, long axis of talus passes below the 1st ray axis (Dorsally dislocated navicular, navicular ossify at 3 y.o.)
35	1	628650	-171450	2	AP: Increase in talocalcaneal angle >40
36	1	628650	-171450	2	Differentiate between CVT and COT: try to reduce TNJ in plantarflexion view
37	0	None	None	0	Mx:
38	1	None	None	1	r/o association
39	1	None	None	1	r/o oblique talus (planter flexed Xray, if reducible → oblique talus)
40	1	None	None	1	Counselling: May try reverse Ponseti but need to tell parents majority eventually need OT
41	1	628650	-171450	2	Preop stretching of dorsolateral structure + reverse ponsetti x 3 mths (identify the talar head, push forefoot in plantar medial direction)
42	1	628650	-171450	2	After reduction perform talonavicular pinning (MIS) + release peroneus and extensors +/- lengthening +/- spring ligament recon + percutaneous achilles tenotomy 6 to 12 months after casting
43	1	628650	-171450	2	JBJS (Am) 2006 Dobbs: 11 patients treated with stretching + reverse ponseti + percutaneous pinning and achilles tendon tenotomy, good result in appearance, foot function and Xray at minimum 2 years
44	1	628650	-171450	2	If present late: talus + navicular excision and lateral column lengthening
45	1	628650	-171450	2	Salvage: triple arthrodesis
46	0	None	None	0	==============================================
47	0	None	None	0	Vertical talus
48	0	None	None	0	Irreducible dorsal dislocation of the navicular on the talus producing a rigid flatfoot deformity
49	0	0	0	0	What is the pathoanatomy?
50	0	171450	-171450	1	Soft tissue: Tight Achilles, displaced PT and peroneal both function as dorsiflexor, attenuated spring ligament
51	0	171450	-171450	1	Bony: dorsally dislocated navicular
52	0	0	0	0	COT
53	0	0	0	0	No need serial casting
54	0	0	0	0	Treated with TA release

#	semantic level	section?	rewritten line
1	0	yes	Clinical photograph
2	1		Midfoot: Rocker bottom deformity
3	1		Equinus hind foot
4	1		Dorsiflexion and abduction of forefoot
5	0	yes	Rigid flatfoot ddx:
6	1		Tarsal coalition
7	1		CVT
8	1		Accessory navicular
9	1		+/- stage 3 or 4 PTTD in adults
10	0	yes	Radiographic description
11	2		Vertically pointed talus
12	2		Long axis of talus passes below the 1st ray axis (NOT navicular as it is not ossified yet)/ TAMBA (Talus axis MT bone angle)
13	2		Increase in talocalcaneal angle
14	1		Take plantarflexion lateral XR to distinguish between CVT and COT
15	0	yes	Diagnosis – CVT
16	0	yes	Differential diagnosis
17	0	yes	Congenital oblique talus (plantarflexion lateral XR)
18	1		Calcaneovalgus (Calcaneus instead of equinus, break at hindfoot instead)
19	1		Tarsal coalition
20	1		Paralytic pes planus
21	0	yes	How will you assess this child?
22	1		Systemically screen for associations
23	1		50% +ve neuromusclular disease (spina bifida), syndromal (arthrogryposis, Larsen syndrome), maltreated CTEV, look for DDH
24	1		Genetic: 20% +ve family Hx
25	1		Locally confirm rigid deformity
26	1		Rocker bottom foot
27	2		Hind foot: equinovalgus deformity, tight TA and peroneus
28	2		Chopart joint: Dorsiflexion with navicular dorsal dislocation
29	2		Forefoot: abduction and dorsiflexion (EDL/ EHL, tib ant contractures)
30	2		Prominent talar head at plantar region
31	1		Check LL neurology
32	1		“peg leg” gait
33	0	yes	Xray:
34	2		Lat: Vertically pointed talus, long axis of talus passes below the 1st ray axis (Dorsally dislocated navicular, navicular ossify at 3 y.o.)
35	2		AP: Increase in talocalcaneal angle >40
36	2		Differentiate between CVT and COT: try to reduce TNJ in plantarflexion view
37	0	yes	Management
38	1		r/o association
39	1		r/o oblique talus (planter flexed Xray, if reducible → oblique talus)
40	1		Counselling: May try reverse Ponseti but need to tell parents majority eventually need OT
41	2		Preop stretching of dorsolateral structure + reverse ponsetti x 3 mths (identify the talar head, push forefoot in plantar medial direction)
42	2		After reduction perform talonavicular pinning (MIS) + release peroneus and extensors +/- lengthening +/- spring ligament recon + percutaneous achilles tenotomy 6 to 12 months after casting
43	2		JBJS (Am) 2006 Dobbs: 11 patients treated with stretching + reverse ponseti + percutaneous pinning and achilles tendon tenotomy, good result in appearance, foot function and Xray at minimum 2 years
44	2		If present late: talus + navicular excision and lateral column lengthening
45	2		Salvage: triple arthrodesis
46	0		——
47	1		Vertical talus
48	1		Irreducible dorsal dislocation of the navicular on the talus producing a rigid flatfoot deformity
49	0	yes	What is the pathoanatomy?
50	1		Soft tissue: Tight Achilles, displaced PT and peroneal both function as dorsiflexor, attenuated spring ligament
51	1		Bony: dorsally dislocated navicular
52	1		COT
53	1		No need serial casting
54	1		Treated with TA release

035. Congenital vertical talus

Clean FRCS notes with inline figures

Clinical photograph

Rigid flatfoot ddx:

Radiographic description

Diagnosis – CVT

Differential diagnosis

Congenital oblique talus (plantarflexion lateral XR)

How will you assess this child?

Xray:

Management

What is the pathoanatomy?

Direct Q&A

Midfoot: Rocker bottom deformity

Systemically screen for associations

r/o association

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes