1. Assess before treatment

• Standing and gait assessment, callosities, ankle instability, peroneal weakness, claw toes, sensory loss, ulcers.
• Weight-bearing AP, lateral, and hindfoot alignment radiographs.
• Coleman block test:
  • Hindfoot varus corrects: it is largely forefoot-driven, usually from a plantar-flexed first ray.
  • Varus remains: there is a fixed/independent hindfoot varus, requiring hindfoot correction in addition to forefoot correction.
• Determine whether ankle equinus is gastrocnemius-only or Achilles contracture with the Silfverskiöld test.

2. Nonoperative treatment

• Physiotherapy: calf stretching, strengthening of weak dorsiflexors/evertors, gait training.
• Custom orthosis: accommodate the cavus arch, first-ray recess/cutout, and lateral hindfoot posting to reduce varus loading.
• Lace-up ankle brace for instability; an AFO when there is foot drop, substantial weakness, or fixed deformity.
• Wide, deep toe-box footwear and padding for claw toes/callosities.
• Regular skin and neuropathy surveillance.

3. Operative treatment

A. Flexible deformity

B. Stiff but joint-preserving deformity

• Combined first-ray, midfoot, and/or calcaneal osteotomies.
• Tendon balancing and soft-tissue release as required.
• Address equinus concurrently if it prevents a plantigrade foot.

C. Rigid deformity, arthritis, or failed reconstruction

• Triple arthrodesis is a salvage option for a completely rigid cavovarus foot, particularly when joints are painful or degenerated.
• It may be combined with Achilles lengthening and tendon transfer where appropriate.
• Fusion sacrifices hindfoot motion, so joint-preserving correction is preferred when feasible. Campbell's Operative Orthopaedics, 15th ed., p. 1740.

Practical principle

1. Clinical manual examination

• hindfoot varus toward neutral/valgus
• forefoot pronation and plantar-flexed first ray
• ankle dorsiflexion, with knee extended and flexed, to identify gastrocnemius versus Achilles contracture
• Flexible cavovarus: the heel can be manually brought to neutral or valgus, and the forefoot/first ray is correctable.
• Rigid cavovarus: the heel and/or forefoot cannot be brought to plantigrade neutral alignment. Check for subtalar arthritis, tarsal coalition, prior trauma, contracture, and fixed muscle imbalance.

2. Coleman block test: key dynamic test

• Patient stands with the heel and lateral border of the foot on a block, usually about 1 inch high.
• The medial forefoot and first metatarsal are unsupported, so the plantar-flexed first ray can drop freely.
• Observe heel alignment from behind, and compare with normal standing.

Why it matters

• Flexible, forefoot-driven deformity: correction can focus on the plantar-flexed first ray and muscle balance, such as first-metatarsal dorsiflexion osteotomy with indicated soft-tissue or tendon procedures.
• Persistent hindfoot varus on the block: hindfoot correction, commonly a lateralizing or lateral closing-wedge calcaneal osteotomy, is generally needed in addition to forefoot correction.
• Completely rigid foot with arthritic joints: may require joint-sacrificing reconstruction such as triple arthrodesis in selected patients.

Manual assessment

• Hindfoot varus
• Forefoot pronation and plantar-flexed first ray
• Ankle equinus, including the Silfverskiöld test
• Flexible deformity: heel and forefoot can be corrected manually to a plantigrade, neutral position.
• Rigid deformity: correction to neutral is not possible because of fixed bony deformity, joint stiffness/arthritis, contracture, or longstanding muscle imbalance.

Coleman block test

• Heel varus corrects to neutral or valgus: flexible, forefoot-driven hindfoot varus. The plantar-flexed first ray is driving the heel into varus.
• Heel varus remains unchanged: rigid or hindfoot-driven varus.
• Partial correction: combined forefoot-driven deformity and a stiff hindfoot component.

Neurogenic clubfoot: age-wise treatment

Practical treatment sequence

1. Early Ponseti casting for all reducible neurogenic clubfeet, including many with myelomeningocele.
2. Achilles tenotomy is frequently needed to obtain dorsiflexion.
3. Long-term bracing and follow-up are mandatory.
4. Recast early at relapse, while the foot is still flexible.
5. Use limited soft-tissue balancing and joint-preserving osteotomies for resistant or fixed deformity.
6. Reserve arthrodesis/talectomy-type salvage for exceptional severe, rigid feet.

Important difference from idiopathic clubfoot

• Formation: bone necrosis and sequestrum formation usually begin at about 10-14 days after onset of acute osteomyelitis, due to vascular thrombosis and periosteal stripping.
• Visible on plain X-ray: usually only after several weeks, classically around 3-4 weeks. It appears as a dense bony fragment surrounded by a radiolucent rim of granulation tissue/pus, often with involucrum in established chronic osteomyelitis.

Sequestrum forms by about 2 weeks and becomes apparent on radiograph by about 3-4 weeks.

Cubitus valgus

• Normal physiological carrying angle: usually about 5-15° in males and 10-20° in females.
• It is considered pathological when clearly greater than the opposite side, progressive, cosmetically unacceptable, or associated with tardy ulnar nerve palsy.

Examination

1. Inspection

• Increased carrying angle and asymmetry compared with the opposite elbow
• Healed scars or deformity from an old lateral condyle/supracondylar fracture
• Prominence around the medial epicondyle
• Wasting of hypothenar muscles and first dorsal interosseous muscle, suggesting ulnar neuropathy
• Clawing of ring and little fingers in advanced ulnar palsy

2. Measure the carrying angle

• Use a goniometer.
• One arm follows the longitudinal axis of the humerus; the other follows the axis of the forearm.
• Record the angle on both sides and the side-to-side difference.
• Ensure the elbow is fully extended and forearm supinated, as rotation alters the apparent angle.

3. Palpation

• Palpate medial and lateral epicondyles, distal humerus, and ulnar nerve in the cubital tunnel.
• Look for tenderness, instability, crepitus, or a palpable nonunion around the lateral condyle.

4. Range of movement and stability

• Flexion and extension
• Pronation and supination
• Varus-valgus stability
• Functional effect during activities

5. Ulnar nerve examination

• Tingling/numbness in the little finger and ulnar half of ring finger
• Hand weakness, clumsiness, weak grip
• Symptoms worsened by sustained elbow flexion

• Sensation in the ulnar one-and-a-half digits
• First dorsal interosseous and hypothenar bulk
• Finger abduction/adduction
• Froment sign
• Tinel sign over cubital tunnel
• Ulnar nerve subluxation during elbow flexion

6. Investigations

• AP and lateral radiographs of both elbows: measure carrying angle, identify lateral condyle nonunion, malunion, growth arrest, deformity, or arthritis.
• CT may assist surgical planning in complex deformity/nonunion.
• Nerve-conduction studies and EMG are useful when ulnar neuropathy is suspected.

Causes

Common acquired causes

1. Nonunion of a lateral humeral condyle fracture in childhood
   • The classic and most important cause.
   • The lateral condyle migrates proximally, increasing valgus and predisposing to tardy ulnar palsy.
2. Malunion of distal humeral fractures
   • Especially lateral condylar fractures.
   • Less commonly a supracondylar fracture.
3. Lateral distal humeral physeal arrest or growth disturbance
   • Due to trauma, infection, surgery, or osteonecrosis.
4. Post-traumatic deformity after elbow dislocation or fracture.

Congenital/systemic causes

• Physiological familial increased carrying angle
• Turner syndrome
• Skeletal dysplasias or congenital hypoplasia of the lateral distal humerus
• Post-infective growth disturbance

Management

Observation

• The deformity is mild and non-progressive
• It is painless
• Elbow motion and function are normal
• There is no ulnar nerve dysfunction
• The main issue is only minor cosmetic asymmetry

Treat the underlying cause

• Established lateral condyle nonunion: evaluate for fixation with bone grafting and stable internal fixation where feasible.
• Growth disturbance or malunion: assess progression and functional impact.

Indications for surgery

• Significant or progressive cosmetic deformity
• Symptomatic tardy ulnar nerve palsy
• Functional limitation or elbow instability
• Painful nonunion/malunion
• Marked deformity, commonly a difference of roughly 15-20° or more, though the decision is primarily clinical rather than based on one absolute angle.

Operative treatment

1. Corrective distal humeral supracondylar osteotomy
   • Usually a lateral closing-wedge, dome, step-cut, or other planned corrective osteotomy.
   • Restores the carrying angle toward the contralateral side.
   • Fixed with plate-and-screw, K-wire, or external fixation depending on age and technique.
2. Ulnar nerve decompression and usually anterior transposition
   • Indicated in established tardy ulnar palsy, severe valgus correction, or an unstable/tethered ulnar nerve.
   • Often combined with corrective osteotomy.
3. Lateral condyle nonunion surgery
   • Debridement/freshening of the nonunion, bone grafting, and fixation may be performed, sometimes with valgus correction.

Key principle

Post-polio residual paralysis (PPRP): foot deformities, examination, and age-wise treatment

Common deformities and muscle imbalance

Examination of the foot in PPRP

1. History

• Age at poliomyelitis and duration of paralysis
• Progression of deformity
• Pain, callosity, ulceration, footwear difficulty
• Walking endurance, frequent falls, use of calipers/AFO
• Previous casting, tendon transfer, osteotomy, or arthrodesis
• New weakness, fatigue, or pain suggesting post-polio syndrome

2. Inspection: standing and walking

• Limb shortening, muscle wasting, scars
• Foot posture: equinus, calcaneus, varus, valgus, cavus, planus, adduction
• Callosities under metatarsal heads, lateral border, heel, or toes
• Claw toes and shoe wear pattern
• Whether heel contacts the ground
• Gait: foot drop, steppage gait, knee hyperextension, varus/valgus thrust, instability

3. Determine whether deformity is flexible or fixed

• Passively correct the hindfoot, forefoot, ankle equinus, and toe deformities.
• A flexible deformity can be brought to plantigrade alignment manually.
• A fixed deformity cannot be fully corrected because of contracture, bony deformity, or joint stiffness.

4. Muscle charting

5. Joint examination

• Ankle dorsiflexion and plantarflexion
• Subtalar inversion/eversion
• Midfoot mobility
• Toe flexibility
• Knee and hip deformities, since these influence gait and orthotic planning

6. Investigations

• Weight-bearing AP and lateral foot radiographs, plus hindfoot alignment view.
• Assess cavus, calcaneal pitch, hindfoot varus/valgus, arthritis, and bony deformity.
• Gait assessment and orthotic review when available.

Age-wise treatment

1. Infant and very young child: under about 2-3 years

Aim

Treatment

• Gentle stretching and physiotherapy
• Serial manipulation and plaster casting for a flexible equinus/equinovarus or other correctable deformity
• Night splints and appropriate footwear
• AFO or caliper when needed for foot drop or ankle instability
• Regular reassessment because the imbalance may change with growth

2. Preschool child: about 3-5 years

Flexible deformity

• Continue physiotherapy, stretching, serial casts, and orthoses.
• Treat recurrence early with repeat casting.
• Limited soft-tissue release may be considered for a resistant contracture, but avoid overlengthening weak muscles.

Principles

• Do not operate merely for appearance.
• Surgery is considered if the foot is progressively deforming, cannot be braced, causes skin pressure, or impairs walking.

3. Child: about 5-10 years

Flexible equinus / foot drop

• AFO if dorsiflexors are weak.
• Achilles or gastrocnemius lengthening only if a true fixed equinus contracture is present.
• Selected tendon transfer may restore active dorsiflexion when there is a suitable donor muscle.

Flexible varus/equinovarus

• Release/lengthening of contracted structures as indicated.
• Tendon transfer to neutralize deforming forces, such as transfer of a functioning tibialis posterior or peroneal tendon, depending on the individual muscle chart.
• Correct associated cavus and claw toes.

Flexible calcaneus

• AFO to control calcaneus and stabilize the ankle.
• Tendon balancing/transfer or tenodesis may be considered in selected ambulatory children.

4. Older child: about 10-12 years to skeletal maturity

Fixed deformity with preserved joints

• Calcaneal osteotomy for hindfoot varus or valgus
• First metatarsal or midfoot osteotomy for cavus
• Supramalleolar osteotomy for ankle malalignment
• Combined soft-tissue balancing plus osteotomy for multi-level deformity

5. Adolescent or skeletally mature patient

Rigid deformity, recurrent deformity, painful arthritic foot, or non-braceable foot

• Corrective osteotomy if joint preservation remains possible
• Triple arthrodesis for severe, rigid hindfoot deformity when other reconstruction cannot give a stable plantigrade foot
• Selected ankle or midfoot fusion only for major pain/instability or severe deformity

Treatment by deformity

Important principles

1. Correct contracture before tendon transfer.
2. Balance the deforming forces, rather than simply correcting the visible position.
3. Preserve joints whenever possible.
4. Provide an AFO or caliper when muscle weakness remains despite surgical correction.
5. Treat associated knee, hip, limb-length, and rotational deformities because foot treatment alone may not normalize gait.
6. In an adult with new progressive weakness or fatigue, assess for post-polio syndrome and avoid overly aggressive strengthening that produces prolonged fatigue.

Detailed treatment of foot deformity in post-polio residual paralysis

Treatment goals

1. Plantigrade foot
2. Stable foot during stance
3. Painless, shoeable and braceable foot
4. Foot with preserved useful motion where possible
5. Correction that is matched to the patient's remaining muscle power and ambulatory needs

• Age and skeletal maturity
• Exact pattern of paralysis on muscle charting
• Flexible versus fixed deformity
• Presence of equinus, cavus, varus/valgus, calcaneus, and claw toes
• Strength of possible donor muscles
• Whether the patient walks independently, with calipers, or uses a wheelchair
• Limb-length discrepancy, knee instability, and hip deformity

1. Nonoperative treatment

Physiotherapy

• Daily stretching of tendo-Achilles, plantar fascia, toe flexors, and contracted invertors/evertors.
• Maintain ankle, subtalar, midfoot, and toe range of motion.
• Strengthen muscles with useful residual power, without fatiguing weak post-polio muscles.
• Gait training and fall prevention.
• Skin-care education, especially under orthoses and at callosities.

Serial manipulation and casting

• Gentle serial casting can correct flexible equinus, equinovarus, and some cavovarus deformities.
• Cast in progressive correction, avoiding forceful manipulation and skin pressure.
• Follow with night splint or AFO to maintain correction.

Orthoses and footwear

2. Treatment according to age

A. Infant and child younger than about 3 years

Main approach

• Stretching
• Manipulation and serial casting
• Night splints
• AFO when the child begins standing/walking
• Monitor every few months for recurrence and change in muscle imbalance

Surgery

• Tendo-Achilles lengthening for true fixed equinus
• Limited posterior or medial release for resistant equinovarus
• Plantar fascia release for significant fixed cavus

B. Young child, about 3-6 years

Flexible deformity

• AFO/appropriate caliper
• Repeat casting if deformity recurs
• Stretching and footwear modification

Soft-tissue balancing

• Release a contracted tendon/fascia only if it is preventing plantigrade alignment.
• Transfer a muscle only if it has reliable power, commonly MRC grade 4 or greater.
• Balance forces across both the ankle and subtalar joints.

C. Older child, about 6-10 years

Indications for surgery

• Progressive fixed equinus or varus/valgus
• Inability to fit an AFO or shoe
• Repeated callosities or ulceration
• Recurrent falls or impaired gait
• Foot becoming non-plantigrade
• Pain from abnormal loading

D. Older child near maturity and adolescent

Fixed or recurrent structural deformity

• Calcaneal osteotomy for hindfoot varus or valgus
• First metatarsal dorsiflexion osteotomy for cavus caused by a plantar-flexed first ray
• Midfoot/tarsal wedge osteotomy for rigid cavus, adduction, or complex deformity
• Supramalleolar osteotomy if ankle malalignment is a major component
• Combined soft-tissue release plus osteotomy for multi-level deformity

Severe rigid or painful foot

• Subtalar arthrodesis in selected deformities
• Triple arthrodesis for severe rigid hindfoot deformity
• Ankle arthrodesis only in exceptional cases of severe ankle instability, deformity, or painful arthritis

3. Deformity-specific treatment

A. Equinus deformity

Cause

Flexible equinus

• Stretching
• Serial casting
• AFO with plantarflexion control
• Night splint

Fixed equinus

• Gastrocnemius recession if tightness corrects with knee flexion on Silfverskiöld testing
• Tendo-Achilles lengthening if true Achilles contracture persists with both knee positions
• Posterior capsular release only for severe residual ankle contracture

Caution

B. Foot drop

Cause

Nonoperative

• AFO is first-line for many patients.
• Shoe modifications and physiotherapy.

Operative

• Tendon transfer to restore active dorsiflexion and reduce inversion.
• The exact donor and insertion are selected from the muscle chart. Posterior tibial tendon transfer is one common concept when the muscle is strong and a balanced foot can be achieved.

• Correct contracture first.
• Use an AFO, osteotomy, or, in selected mature patients with severe instability, arthrodesis.

C. Equinovarus deformity

Cause

Flexible equinovarus

1. Serial casting if appropriate.
2. Lengthen/release contracted tendo-Achilles if equinus is fixed.
3. Release contracted medial soft tissues or plantar fascia only as required.
4. Tendon balancing:
   • Transfer or rebalance a functioning tendon to counter inversion and/or plantarflexion.
   • The procedure must account for both ankle and subtalar mechanics.

Fixed equinovarus

• Soft-tissue release plus calcaneal or tarsal osteotomy if the hindfoot/forefoot remains structurally deformed.
• Triple arthrodesis is considered only for a severe rigid, unbraceable foot near skeletal maturity.

D. Cavus and cavovarus deformity

Cause

Flexible cavovarus

• Custom orthosis with first-ray accommodation and lateral posting
• Stretching of plantar fascia and calf
• Treat ankle instability with brace/AFO
• Plantar fascia release if contracture prevents correction
• Tendon balancing based on muscle chart
• First metatarsal dorsiflexion osteotomy if a persistent plantar-flexed first ray is the main structural driver

Fixed hindfoot varus

• Add lateralizing or lateral closing-wedge calcaneal osteotomy.
• A Coleman block test helps decide whether hindfoot varus is forefoot-driven or fixed.

Severe rigid cavovarus

• Multi-level osteotomy or, in a mature painful foot with degeneration, triple arthrodesis.

E. Calcaneus or calcaneovalgus deformity

Cause

Nonoperative

• AFO with plantarflexion restraint
• Shoe modification, such as heel elevation where appropriate
• Correct limb-length discrepancy
• Gait training

Operative

• Tendon balancing or tenodesis in carefully selected patients
• Calcaneal osteotomy where hindfoot valgus/structural malalignment predominates
• Stabilizing fusion in severe rigid deformity near maturity

F. Planovalgus deformity

Cause

Treatment

• Medial arch-support orthosis or AFO
• Achilles/gastrocnemius stretching when equinus contributes
• Tendon balancing if a suitable donor exists
• Calcaneal osteotomy and selected midfoot osteotomy for fixed symptomatic deformity
• Fusion is reserved for severe rigid or painful deformity in a mature patient.

G. Claw toes

Flexible claw toes

• Wide toe-box footwear
• Toe pads and accommodative orthoses
• Stretching
• Flexor/extensor tendon balancing or transfer if symptomatic

Fixed claw toes

• Tendon lengthening/release
• Interphalangeal joint arthrodesis or resection arthroplasty in selected older patients
• Correct the proximal cavus/equinus driver, otherwise toe deformity may recur.

4. Principles of tendon transfer in PPRP

1. Paralysis has been stable.
2. The foot is fully or nearly passively correctable.
3. The donor muscle has useful strength, preferably MRC grade 4 or more.
4. The donor is not essential for stance, crutch walking, or another vital function.
5. The line of pull will correct the actual deforming force.
6. Contractures and major bony deformity have been corrected first.
7. The patient will follow postoperative immobilization and rehabilitation.

5. Postoperative care

• Immobilization in a well-padded below-knee or long-leg cast, depending on the procedure
• Strict skin surveillance
• Protected weight-bearing until osteotomy/fusion healing is confirmed
• Gradual physiotherapy after cast removal
• Temporary, and sometimes lifelong, AFO use
• Gait re-education
• Reassessment for recurrence during growth

Exam summary

In post-polio residual paralysis, foot deformities are treated according to age, flexibility, muscle charting, and ambulatory requirement. In young children, treatment consists of stretching, serial casting, splintage, and limited soft-tissue release. In flexible deformities of older children, tendon lengthening, release, and carefully selected tendon transfers are used after correction of contracture. In fixed deformity, joint-preserving osteotomy is preferred. Triple arthrodesis or other fusion is reserved for severe rigid, painful, unstable, or unbraceable deformity near skeletal maturity.

Sciatic nerve palsy: examination, deformities, and treatment

1. Clinical anatomy and pattern of paralysis

• Tibial division: hamstrings, plantarflexors, invertors, toe flexors, and intrinsic muscles of the sole.
• Common peroneal division: short head of biceps femoris, dorsiflexors, toe extensors, and evertors.

2. Examination

A. History

• Trauma: posterior hip dislocation, acetabular fracture, penetrating injury, pelvic or femoral fracture
• Hip surgery or injection in the gluteal region
• Lumbar disc disease, pelvic mass, prolonged compression, or neuropathy
• Onset: immediate, delayed, progressive, or painful
• Falls, foot slap, difficulty clearing toes, inability to push off
• Numbness, burning pain, ulcers, footwear problems
• Duration of palsy and evidence of recovery

B. Inspection and gait

Inspect

• Gluteal, hamstring, calf, anterior compartment, and intrinsic foot muscle wasting
• Foot posture: foot drop, equinus, equinovarus, cavus, claw toes
• Callosity over the lateral border, metatarsal heads, or dorsum of toes
• Skin injury or ulcers in sensory loss
• Limb shortening, scars, or evidence of hip trauma/surgery

Gait

• Steppage gait: exaggerated hip and knee flexion to clear a dropped forefoot.
• Foot slap: uncontrolled plantarflexion after heel strike.
• Reduced push-off or inability to toe walk indicates tibial-division involvement.
• Varus thrust or lateral-border weight-bearing suggests evertor weakness with relatively preserved invertors.

C. Motor examination and muscle chart

Distinguish incomplete from complete palsy

• Predominantly peroneal division palsy: dorsiflexion, toe extension, and eversion weak; plantarflexion and inversion relatively preserved.
• Complete sciatic palsy: weakness of hamstrings plus loss of dorsiflexion, eversion, plantarflexion, inversion, and toe movements.

D. Sensory examination

E. Reflexes and special tests

• Ankle jerk: reduced or absent in tibial-division/sciatic involvement.
• Knee jerk: usually preserved because the femoral nerve is intact.
• Straight-leg raise may be positive if there is an associated radicular lesion.
• Examine the lumbar spine, hip, pelvis, and common peroneal nerve at the fibular neck.

F. Differentiate sciatic palsy from common mimics

3. Deformities

A. Foot drop

• Plantarflexed ankle during swing
• Toe dragging
• Steppage gait
• Foot slap at heel strike

B. Equinovarus deformity

• Equinus from unopposed Achilles tendon
• Inversion/varus from unopposed tibialis posterior
• Lateral border overload and recurrent ankle instability

C. Calcaneus or calcaneovalgus deformity

• Excessive ankle dorsiflexion during stance
• Weak push-off
• Heel overload
• Knee may fall into flexion during stance due to loss of plantarflexion control

D. Cavus/cavovarus

• High arch
• Plantar-flexed first ray
• Hindfoot varus
• Claw toes
• Callosities under metatarsal heads and lateral foot border

E. Claw toes

• Hyperextension at metatarsophalangeal joints
• Flexion at interphalangeal joints
• Dorsal toe pressure in footwear and painful corns

4. Investigations

• Serial clinical examination and muscle charting: most important to document recovery.
• EMG and nerve-conduction studies: help localize lesion, determine severity, identify denervation/reinnervation, and distinguish sciatic neuropathy from root/plexus disease. These are usually informative after approximately 3-4 weeks from injury.
• X-rays: hip/pelvis and foot/ankle as indicated after trauma or for established deformity.
• Ultrasound or MRI neurography: for nerve continuity, hematoma, scar, mass, entrapment, or focal compression.
• CT: particularly useful after acetabular or hip surgery when hardware or fracture fragments could be impinging on the nerve.

5. Treatment

A. Acute sciatic palsy

Immediate measures

1. Identify and treat the cause.
2. Document motor and sensory status before and after any reduction or surgery.
3. Maintain the ankle in neutral with a posterior splint or AFO.
4. Protect the anaesthetic foot from heat, pressure sores, and injury.
5. Analgesia and treatment of neuropathic pain if present.
6. Physiotherapy to maintain range of motion and prevent equinus contracture.

Indications for urgent exploration/decompression

• Open injury or penetrating trauma
• Suspected nerve laceration
• Entrapment by fracture fragment
• Expanding hematoma
• New palsy after hip surgery with suspected hardware, cement, lengthening, or compression
• Progressive severe neurologic deficit
• A compressive mass identified on imaging

B. Conservative management during nerve recovery

Orthosis

• AFO is first-line for foot drop.
• A solid AFO is useful when there is significant ankle instability or combined tibial and peroneal weakness.
• An articulated AFO may be appropriate if plantarflexion strength/control is adequate.
• Custom footwear and accommodative insoles for callosity or cavus.

Physiotherapy

• Maintain passive ankle dorsiflexion, subtalar movement, and toe mobility.
• Strengthen recovering muscles without over-fatiguing them.
• Gait training, balance training, and fall prevention.
• Electrical stimulation may be used in selected rehabilitation programs, though it does not replace reinnervation or tendon transfer.

C. Nerve repair or reconstruction

• Primary nerve repair, when clean ends can be approximated without tension
• Nerve grafting if a gap prevents direct repair
• Neurolysis/decompression for selected scarred or compressed nerves
• Nerve transfer in specialized peripheral nerve centers

6. Treatment of established foot deformity

Principle

1. Contracture
2. Bony deformity
3. Muscle imbalance

A. Flexible foot drop

• AFO if adequate function is achieved with bracing.
• Tendon transfer if there is no meaningful recovery and a suitable functioning donor muscle is present.

Tendon transfer

• The foot is supple and can reach neutral
• Posterior tibial tendon is strong enough, generally MRC grade 4 or more
• There is no major fixed equinus, cavus, or varus
• The patient has adequate rehabilitation potential

B. Flexible equinovarus

• Stretching/casting if early
• Tendo-Achilles or gastrocnemius lengthening only for a true fixed equinus contracture
• Selective tendon balancing if a functioning donor exists
• Orthosis if no donor muscle is available

C. Fixed cavovarus or equinovarus

• Plantar fascia release for fixed cavus if needed
• Achilles/gastrocnemius lengthening for fixed equinus
• Calcaneal osteotomy for fixed hindfoot varus/valgus
• First-ray dorsiflexion osteotomy for a plantar-flexed first ray
• Midfoot osteotomy for major structural cavus/adduction

D. Severe rigid, painful, unstable, or unbraceable foot

• Subtalar or triple arthrodesis may create a stable plantigrade foot.
• Ankle arthrodesis is reserved for exceptional severe ankle instability, deformity, or painful arthrosis.
• Fusion provides stability but sacrifices movement and should follow careful assessment of knee strength, contralateral limb function, and gait needs.

Exam summary

Sciatic nerve palsy is examined by assessing gait, hamstring function, ankle and toe movements, sensory loss over the dorsum and sole of the foot, ankle jerk, and associated hip/spine pathology. Common deformities include foot drop, equinovarus, cavovarus, calcaneus/calcaneovalgus, and claw toes. Acute compression or laceration requires prompt identification and possible nerve exploration. During recovery, treatment consists of splintage/AFO, physiotherapy, skin protection, and serial EMG. In established palsy, flexible deformity is treated by contracture release and selected tendon transfer where a strong donor exists; fixed deformity requires osteotomy, while severe rigid unbraceable deformity may need arthrodesis.

Lower-limb movements and root values

Quick myotome sequence for examination

• L2: hip flexion
• L3: knee extension
• L4: ankle dorsiflexion
• L5: great-toe extension
• S1: ankle plantarflexion
• S2: knee flexion and toe flexion

Skyline view / Merchant view of the knee

Position and technique

• Patient is usually supine or semi-recumbent.
• Both knees are flexed, commonly around 45° for the classic Merchant technique.
• X-ray beam is directed tangentially through the patellofemoral joints, classically about 30° caudad from horizontal.
• Both knees are often imaged together for comparison.

What it shows

• Patellofemoral joint space
• Patellar tilt
• Lateral patellar subluxation/displacement
• Trochlear dysplasia, including a shallow trochlear sulcus
• Patellar fracture, especially vertical fracture
• Patellofemoral osteoarthritis: joint-space narrowing, osteophytes, sclerosis
• Bipartite patella and separation at the bipartite site

Indications

• Recurrent patellar dislocation or instability
• Anterior knee pain / suspected patellofemoral disorder
• Suspected patellar maltracking, tilt, or subluxation
• Patellofemoral osteoarthritis
• Suspected patellar fracture

Terms

• Skyline view = general name for tangential/axial patellofemoral view.
• Merchant view = a specific standardized bilateral skyline projection.
• Sunrise view = often used interchangeably with skyline view, though exact patient position and beam angle vary by technique.

Patellar axial (skyline/sunrise) views and angles

High-yield exam points

• Merchant: knee flexion 45°, X-ray beam 30° caudad.
• Laurin: knee flexion 20°, useful for subtle lateral patellar maltracking.
• Settegast: knee flexion 90-105°, useful for patellar fracture.
• For patellofemoral instability, lower flexion views such as Laurin can reveal maltracking better, because greater flexion tends to reduce the patella into the trochlea.

Beighton score

Scoring: total = 9 points

Interpretation

• Children and adolescents: ≥ 6/9
• Adults aged 18-50 years: ≥ 5/9
• Adults over 50 years: ≥ 4/9

Important limitation

Lateral humeral condyle fracture in children: classifications

1. Milch classification

2. Jakob classification

• Stage I: often managed in cast with close radiographic follow-up.
• Stage II and III: usually need fixation after confirming articular reduction.

3. Weiss classification

4. Song classification

High-yield summary

• Milch = fracture line relative to trochlea.
• Jakob = displacement and rotation.
• Weiss = displacement plus articular congruity, useful for treatment.
• Song = radiographic stability, especially in minimally displaced fractures.

Timing of surgery in cubitus varus and cubitus valgus

1. Cubitus varus

When to operate

• Significant cosmetic deformity unacceptable to child/family
• Functional limitation, elbow pain, or instability
• Progressive deformity due to growth disturbance
• Associated rotational deformity or hyperextension that is clinically important
• Recurrent lateral condyle fracture or posterolateral rotatory instability

Timing

• Not an emergency.
• Allow the original fracture to unite and elbow motion to recover first.
• Corrective osteotomy is usually done after about 6-12 months from injury, once the deformity is established and range of motion has returned.
• It can be performed in childhood when indicated. Earlier correction, once motion is recovered, may be technically easier and may avoid a long period of cosmetic concern.
• It does not have to wait until skeletal maturity if the deformity is substantial or symptomatic.
• Mild, asymptomatic deformity can be observed.

2. Cubitus valgus

When to operate

• Tardy ulnar neuropathy: paresthesia in ring/little fingers, intrinsic hand weakness or wasting, clawing
• Progressive or marked valgus deformity, often approximately >20° or clearly greater than the opposite side
• Pain, elbow instability, loss of function, or unacceptable cosmesis
• Symptomatic lateral condyle nonunion

Timing

• Cubitus valgus without symptoms: observe if mild and non-progressive. Corrective osteotomy may be planned electively once the deformity is established, particularly for a large cosmetic deformity.
• Valgus with symptomatic lateral condyle nonunion: treat when diagnosed, rather than waiting for skeletal maturity. Treatment may include fixation and bone grafting of the nonunion, with or without valgus corrective osteotomy.
• Tardy ulnar nerve palsy: operate promptly after diagnosis, because recovery becomes less predictable once denervation and intrinsic muscle wasting are longstanding. Treatment usually includes ulnar nerve decompression/anterior transposition, and correction of marked valgus by supracondylar osteotomy where indicated.
• In an older child, adolescent, or adult with a longstanding rigid deformity, corrective osteotomy can still be done if symptoms or major deformity justify it.

Comparison

Cubitus varus correction is an elective corrective osteotomy after fracture union and recovery of elbow movement, usually around 6-12 months after injury if the deformity is cosmetically or functionally significant. Cubitus valgus is observed if mild and asymptomatic, but should be corrected when severe, associated with lateral condyle nonunion, or when tardy ulnar nerve palsy develops.

Clinical examination for suspected lateral humeral condyle nonunion

1. Inspection

• Cubitus valgus: increased carrying angle compared with the other side
• Prominent or proximally migrated lateral condyle
• Lateral elbow fullness/deformity
• Muscle wasting of the hand, especially hypothenar and interossei, suggesting late ulnar neuropathy
• Scars of old injury or surgery

2. Palpation

• Palpate the lateral condyle and radiocapitellar region for:
  • Local tenderness
  • Irregular bony prominence
  • A palpable gap or abnormal mobility over the old fracture site
• In a mobile nonunion, gentle pressure over the lateral condyle during elbow movement may reproduce pain or reveal motion at the pseudarthrosis. Do not force this manoeuvre.

3. Range of movement

• Flexion and extension
• Pronation and supination

4. Test elbow stability

• A lateral condyle nonunion can produce lateral instability and abnormal valgus/varus movement.
• Pain, apprehension, or increased movement during stress testing supports instability, but a normal stress test does not exclude nonunion.

5. Ulnar nerve examination: essential

• Tingling or numbness in the little finger and ulnar half of ring finger
• Weak grip or poor hand dexterity
• Progressive clawing of ring and little fingers

• Sensation over the little finger and ulnar side of ring finger
• First dorsal interosseous and hypothenar wasting
• Finger abduction/adduction
• Froment sign and Wartenberg sign
• Tinel sign at the cubital tunnel
• Ulnar nerve subluxation during elbow flexion

6. Neurovascular examination

• Radial pulse and capillary refill
• Median, radial, and ulnar nerve motor and sensory function

Examination finding summary

“Old lateral elbow injury with increased carrying angle/cubitus valgus, lateral condylar prominence and tenderness, painful or unstable elbow on stress testing, and assess specifically for tardy ulnar nerve palsy.”

Confirmation

Instruments used for anterolateral decompression of spine

Core instrument set

Instrument recognition

1. Kerrison rongeur

2. Pituitary rongeur

3. Curettes

• Straight curette: debrides accessible disc and vertebral-body cavity.
• Angled/ring curette: removes material from corners of a cavity while avoiding excessive traction on the dura.

4. Leksell rongeur

5. High-speed burr

High-yield operative sequence and instruments

Safety points

• The goal is adequate anterior decompression without dural traction or cord manipulation.
• Do not use a Kerrison or curette blindly within the canal.
• Protect the pleura, segmental vessels, dura, and nerve roots.
• In tuberculous spine, obtain tissue for histopathology, AFB testing, culture, and molecular testing when feasible.
• Surgical approach, extent of debridement, and need for reconstruction depend on spinal level, neurological status, instability, kyphosis, and disease extent.