1.

5 CME AJR Integrative Imaging

LIFELONG LEARNING
FOR RADIOLOGY

Radiographic Assessment of Pediatric Foot Alignment:

Self-Assessment Module
Mahesh M. Thapa1,2, Sumit Pruthi1,2, Felix S. Chew2
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ABSTRACT 3. Maldjian C, Hofkin S, Bonakdarpour A, Roach N, Mc-

The educational objectives for this self-assessment mod-
ule are for the participant to exercise, self-assess, and im-
prove his or her understanding of the imaging spectrum of
pediatric foot alignment issues.
INTRODUCTION
This self-assessment module on radiographic assessment
of pediatric foot alignment has an educational component
and a self-assessment component. The educational compo-
nent consists of one required article that the participant
should read. The self-assessment component consists of 14
multiple-choice questions with solutions. All of these mate-
rials are available on the ARRS Website (www.arrs.org). To
claim CME and SAM credit, each participant must enter his
or her responses to the questions online.
EDUCATIONAL OBJECTIVES
By completing this educational activity, the participant will
exercise, self-assess, and improve his or her understanding of:
A. The terms used to describe pediatric foot alignment ab-
normalities.
B. The imaging spectrum of alignment disorders of the pe-
diatric foot.
REQUIRED READING
1. Thapa MM, Pruthi S, Chew FS. Radiographic assess-
ment of pediatric foot alignment: case-based review.
AJR 2010; 194[suppl]:S51S58
RECOMMENDED READING
1. Ozonoff MB. The foot. In: Ozonoff MB, ed. Pediatric
orthopedic radiology, 2nd ed. Philadelphia, PA: Saunders,
1992:397460
2. Harty MP. Imaging of pediatric foot disorders. Radiol
Clin North Am 2001; 39:733748
Carthy J. Abnormalities of the pediatric foot. Acad Ra-
diol 1999; 6:191199
4. Thompson GH, Simons GW III. Congenital talipes equi-
novarus (clubfeet) and metatarsus adductus. In: Dren-
nan JC, ed. The childs foot and Ankle. New York, NY:
Raven Press, 1992:97134
5. Scher DM. The Ponseti method for treatment of con-
genital clubfoot. Curr Opin Pediatr 2006; 18:2225
6. Napiontek M. Skewfoot. J Pediatr Orthop 2002; 22:130133
7. Davis LA, Hatt WS. Congenital abnormalities of the
foot. Radiology 1955; 64:818825
INSTRUCTIONS
1. Complete the educational and self-assessment compo-
nents included in this issue.
2. Visit www.arrs.org and log in.
3. Select Self-Assessment Modules from the Lifelong Learn-
ing box in the lower left of the page.
4. Add the SAM to your shopping cart and order the online
SAM as directed. (The SAM, including questions, must
be ordered to be accessed even though the activity is free
to ARRS members.) After purchasing the SAM, click on
OK; you will be returned to the ARRS home page.
5. Click on the My Education tab at the top of the page,
then on My Online Products. (Note: You must be logged
in to access this personalized page.)
6. You can also access the purchased SAM by logging on to
http://edu.arrs.org/myProducts/.
7. Answer the questions online to obtain SAM credit.

Keywords: foot alignment, pediatrics, radiography

DOI:10.2214/AJR.10.7234
Received February 2, 2010; accepted without revision February 3, 2010.
Department of Radiology, University of Washington, Box 354755, 4245 Roosevelt Way, NE, Seattle, WA 98105. Address correspondence to M. M. Thapa (mthapa@mac.com).
1

2
Department of Radiology, Seattle Childrens Hospital, Seattle, WA.
AJR 2010;194:S59S63 0361803X/10/1946S59 American Roentgen Ray Society

AJR:194, June 2010 S59

 Thapa et al.

QUESTION 1 QUESTION 6
Which tarsal bone has no muscular or tendinous attach-
ments (i.e., it contains only ligamentous attachments)?
A. Navicular.
B. Calcaneus.
C. Talus.
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D. Cuboid.
QUESTION 2
When evaluating hindfoot malalignment on an antero-
posterior view of the foot, which of the following is
important to assess?
A. The precise angle measurement between the talus and calcaneus.
B. The relationship of the distal metatarsals or phalanges to the
talus and calcaneus.
C. The relationship of the cuneiform bones to the talus.
D. The relationship between the talus and navicular.
Fig. 2Weightbearing anteroposterior (AP) and lateral views of foot for
QUESTION 3 question 6. AP and lateral talocalcaneal angles have been drawn.
In general, on the lateral view, a line drawn through the Considering Figure 2, which of the following is the best
long axis of the talus should run through the shaft of description for the alignment of the hindfoot?
which metatarsal?
A. Calcaneus.
A. First. B. Varus.
B. Second. C. Rocker-bottom.
C. Third. D. Cavus.
D. Fourth.
E. Fifth. QUESTION 7
QUESTION 4 Hindfoot varus is a component of which congenital
deformity?
A. Vertical talus.
B. Oblique talus.
C. Clubfoot.
D. Pes planus.

QUESTION 8

Fig. 1Weightbearing anteroposterior (AP) and lateral views of foot for question
4. AP and lateral talocalcaneal angles have been drawn.
With respect to Figure 1, which of the following is the
best description of the alignment?
A. Hindfoot valgus.
B. Hindfoot varus.
C. Congenital vertical talus.
D. Congenital talipes equinovarus.

QUESTION 5 Fig. 3Weightbearing anteroposterior (AP) and lateral views of foot for question
Hindfoot valgus can be present in all the following 8. AP and lateral talocalcaneal angles have been drawn.
conditions EXCEPT which of the following? Considering Figure 3, what is the best diagnosis?
A. Cerebral palsy. A. Planovalgus foot.
B. Skewfoot. B. Cavus foot.
C. Congenital vertical talus. C. Z-foot (skewfoot).
D. Congenital talipes equinovarus. D. Congenital talipes equinovarus.

S60 AJR:194, June 2010

 Pediatric Foot Alignment
QUESTION 9
Which of the following statements is TRUE regarding
congenital talipes equinovarus?
A. The incidence of congenital talipes equinovarus is 1:100 live births.
B. Congenital talipes equinovarus is often recognized on prenatal
sonography.
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C. Bilateral involvement is unusual in congenital talipes equinovarus.
D. Congenital talipes equinovarus affects more females than males.
QUESTION 10
If needed, most surgeries to correct clubfoot deformity
are performed at what approximate age?
A. 3 months.
B. 6 months.
C. 1 year.
D. 2 years.
QUESTION 11
Fig. 4Weightbearing anteroposterior (AP) and lateral views of foot for
question 11. Star represents navicular bone. AP and lateral talocalcaneal angles
have been drawn.
Considering Figure 4, which of the following is the best
diagnosis?
A. Vertical talus.
B. Hindfoot valgus.
C. Planovalgus.
D. Bunion deformity.
Solution to Question 1
The talus is the only bone in the foot with no muscular
attachments [1]. This fact is crucial to the understanding of
hindfoot alignment. Therefore, option C is the best response,
and options A, B, D, and E are not the best responses.
Solution to Question 2
The relationship between the tibia and the talus is diffi-
cult to assess on an anteroposterior view of the foot. Option
A is not the best response. The relationship of the toes to
the talus and calcaneus is not important in assessing hind-
AJR:194, June 2010 S61
QUESTION 12
On the lateral projection, which of the following distin-
guishes congenital vertical talus from pes planovalgus?
A. The calcaneus alignment is normal.
B. The navicular is dislocated from the talus.
C. There is increased overlap of the metatarsals.
D. Only the vertical talus includes flatfoot deformity.
QUESTION 13
Fig. 5Weightbearing anteroposterior (AP) and lateral views of foot for
question 13. Circle represents navicular bone.
With respect to Figure 5, which of the following is the
best diagnosis?
A. Clubfoot.
B. Z-foot.
C. Peroneal spastic flatfoot.
D. Tarsal coalition.
QUESTION 14
Which statement about skewfoot is TRUE?
A. Skewfoot is common in otherwise healthy children.
B. Skewfoot is rarely associated with severe cerebral palsy.
C. Hallux valgus is frequently associated with skewfoot.
D. The navicular is usually subluxed medially in cases of
skewfoot.
foot alignment; rather, it is the relationships of the meta-
tarsal bases to the mid calcaneal and mid talar lines that are
important. Option B is not the best response. Evaluation of
the cuneiforms plays no great role in assessing hindfoot
alignment. Option C is not the best response. The position
of the navicular bone with respect to the talus tells us a
great deal about hindfoot malalignment. If the navicular
bone is subluxed laterally or medially, then we suspect hind-
foot valgus or varus, respectively. Another way to think of
it is that the navicular bone always moves in the same direc-
tion as the calcaneus [1]. Option D is the best response.
 Thapa et al.
Solution to Question 3
Generally, on a lateral view of the pediatric foot, a line
drawn through the long axis of the talus should run through
the shaft of the first metatarsal [1]. Thus, option A is the
best response, and options B, C, D, and E are not the best
responses. An important exception to this rule is in neo-
nates, in whom the axis through the talus can normally
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pass inferior to the first metatarsal [1].
Solution to Question 4
Figure 1 is an example of hindfoot valgus. On the antero-
posterior view, the talocalcaneal angle is increased. The an-
teroposterior talocalcaneal angle is typically between 35
and 40 [1]. On the lateral projection, the talus assumes a
more vertical position than normal. Option A is the best re-
sponse. Hindfoot varus results in a decrease of the talocal-
caneal angle on the anteroposterior projection. Option B is
not the best response. On the lateral projection, congenital
vertical talus has an appearance similar to that of pure
hindfoot valgus. However, with vertical talus, the navicular
bone is dislocated superiorly. In hindfoot valgus, the talus
assumes a somewhat vertical orientation, but the articular
association between the talus and navicular bone is main-
tained [1]. Option C is not the best response. Hindfoot varus
is a feature of congenital talipes equinovarus. Option D is
not the best response.
Solution to Question 5
Cerebral palsy, skewfoot, and congenital vertical talus
have all been associated with hindfoot valgus deformity.
Congenital talipes equinovarus manifests as hindfoot varus
[1]. Option D is the best response. Options A, B, and C are
not the best responses.
Solution to Question 6
Option A is not the best response. Calcaneus position of the
hindfoot is determined from the lateral projection. The calca-
neus is abnormally dorsiflexed, with the anterior portion
higher. Option B is the best response. Hindfoot varus results in
a decrease of the talocalcaneal angle on the anteroposterior
and lateral projections, leading to a near-parallel arrangement
of the two bones. Option C is not the best response. In rocker-
bottom deformity, the plantar arch is convex instead of con-
cave. The anterior calcaneus is in marked plantar flexion
(equinus) and the metatarsals are dorsiflexed. Option D is not
the best response. In cavus arch, the anterior portion of the
calcaneus is tilted up and the metatarsals are plantar flexed,
leading to increased height of the planar arch.
Solution to Question 7
Options A and B are not the best responses. Both vertical
talus and oblique talus deformities have hindfoot valgus de-
formities. In congenital vertical talus, the navicular remains
superiorly dislocated in any position between maximum
dorsiflexion and plantar flexion views. However, with
S62 AJR:194, June 2010
oblique talus, the navicular can be reduced to its normal
location in front of the talus between the dorsiflexion and
plantar flexion views. Option C is the best response. Clubfoot
is the vernacular term for congenital talipes equinovarus
[1], and one of the components of this foot deformity is
hindfoot varus. Option D is not the best response. Pes
planus is usually associated with hindfoot valgus because
the plantar arch is flattened [1].
Solution to Question 8
Option A is not the best response. In planovalgus, there
are varying degrees of hindfoot valgus, flattened arch, and
forefoot pronation (eversion). Option B is not the best re-
sponse. With cavus foot, the plantar arch is exaggerated,
with the anterior aspect of the calcaneus dorsiflexed (calca-
neus position) and the distal aspect of the metatarsals plan-
tar-flexed. Option C is not the best response. Z-foot (skew-
foot) is a variant of a valgus foot. There is hindfoot valgus
with associated forefoot adduction. Option D is the best re-
sponse. In talipes equinovarus, there is extreme hindfoot
varus, with the anterior calcaneus situated in an exagger-
ated planar-flexed position (equinus). In addition, there is
forefoot adduction with supination (inversion).
Solution to Question 9
Option A is not the best response. Equinovarus clubfoot,
although relatively common, has an incidence of 14:1,000
live births and affects more males than females [1]. Option
B is the best response. Indeed, clubfoot deformity can be
and has been recognized on prenatal sonography [1, 2]. Op-
tion C is not the best response. Bilateral involvement is
common. There is also increased risk of equinovarus club-
foot in a first-degree relativeapproximately 30 times
greater than that of the general population [1]. Option D is
not the best response. Males are more commonly affected
than females [1].
Solution to Question 10
Option B is the best response. Most surgeons wait until a
child with congenital clubfoot is 6 months old before perform-
ing surgery to correct it [1, 3]. However, there is some contro-
versy surrounding this issue. Proponents of earlier surgery,
between the ages of 3 and 6 months old, argue that growth
and remodeling are most optimal at a younger age and result
in a better outcome. Proponents of later surgery, between the
ages of 9 and 12 months old, believe that the larger size of the
foot at that age is easier to correct and that there is less risk
associated with anesthesia at an older age [1, 3].
Solution to Question 11
Option A is not the best response. In vertical talus, the
talus and navicular are dislocated [1]. Option B is not the
best response. Yes, the patient has hindfoot valgus, but he
also has an associated forefoot or midfoot abnormality, so
hindfoot valgus alone is not the best diagnosis. Option C is the
 Pediatric Foot Alignment
best response. The combination of forefoot pronation and
hindfoot valgus is termed planovalgus. Option D is not the
best response. Bunion deformity is another term for meta-
tarsus primus adductus with hallux valgus. In our case, the
first metatarsal is not in varus (i.e., it is not adducted), and
the first proximal phalanx is not in valgus [1].
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Solution to Question 12
Option B is the best response. The key to differentiating
planovalgus (or pure hindfoot valgus) from a vertical talus
is to examine the relationship between the talus and the
navicular on the lateral projection. With planovalgus, the
talus will assume a more vertical orientation than normal
but will still maintain an articulation with the navicular.
However, in vertical talus, the navicular and talus are com-
pletely dislocated [1]. Options A, C, and D are not the best
responses. Both pes planovalgus and congenital vertical ta-
lus can manifest with flatfoot deformity.
Solution to Question 13
Option A is not the best response. The image depicted is
not an example of clubfoot. Option B is the best response.
Skewfoot presents with forefoot adduction associated with
hindfoot valgus. Option C is not the best response. Peroneal
F O R YO U R I N F O R M AT I O N
The readers attention is directed to the case-based review on which this SAM is based, which begins on page S51.
AJR:194, June 2010 S63
spastic flatfoot is associated with peroneal muscle spasm,
usually as a result of congenital tarsal coalition [1]. Option
D is not the best response. Although tarsal coalition can
cause a flatfoot deformity, there is no evidence of coalition
in this patient.
Solution to Question 14
Option A is the best response. Skewfoot is a variant of
valgus hindfoot that is common in otherwise healthy chil-
dren [1]. Option B is not the best response. Skewfoot can be
quite marked in patients with severe cerebral palsy [1]. Op-
tion C is not the best response. Although hallux valgus may
be associated with skewfoot deformity, it typically occurs
only in those with severe cerebral palsy [1]. Option D is not
the best response. In skewfoot, the navicular is usually sub-
luxed laterally, a common finding in hindfoot valgus.
References
1. Thapa MM, Pruthi S, Chew FS. Radiographic assessment of pediatric foot
alignment: case-based review AJR 2010; 194[suppl]:S51S58
2. Treadwell MC, Stanotski CL, King M. Prenatal sonographic diagnosis of club-
foot: implications for patient counseling. J Pediatr Orthop 1999; 19:810
3. Thompson GH, Simons GW III. Congenital talipes equinovarus (clubfeet) and
metatarsus adductus. In: Drennan JC, ed. The childs foot and ankle. New York,
NY: Raven Press, 1992:97134