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2.5 y.o girl with Pes Cavus...What's going on here??

Discussion in 'Pediatrics' started by Kym, Dec 3, 2009.

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  1. Kym

    Kym Active Member


    Members do not see these Ads. Sign Up.
    Please Help me diagnose what's going on!?!.

    A 2.5 year old girl presented with intoeing and unusal gait...(not so uncommon!!). She is hyperflexible....REALLY flexible...best I've ever seen in all my years of practice!! She has genu recurvatum, no equinus, extreme hip R.O.M. 90 degrees internal AND external!, and chronic "W" sitter.....and she has really poor core stability also! BUT:
    When in a non- weight bearing position, both feet are very cavoid...the left with a dorsal enlargement noticeable just proximal to the MTJ. When weight bearing the feet have such a well defined arches, one would assume you were looking at an 8 year old foot.

    There is no family history of muscle/nerve/foot problems that mum is aware of.
    The little girl walked at 14 months, but did not crawl properly until after she began walking. She was a normal birth, normal gestation, no clicky hips, and no talipes.
    Her gait is with bent knees (I'm thinking for stability) and it's a real walk and bounce type of stryde.

    I am concerned more for the feet presentation than the intoeing, as I believe attention to her sitting position will help this intoeing in the long term. Pes Cavoid is not what I would assume normal in a 2.5 year old child........what else could this be??? What else have I missed??? Thanks Kym:dizzy:
     
  2. SarahR

    SarahR Active Member

    Do you have photos/gait you could post? I had a flexible Marfan's patient who didn't come out with the diagnosis until after his orthotics came in. He had no Marfan's history in either parent. He had high arched WB flexible feet which was very strange considering his NWB exam, but he was quite older than your patient. I also suspect possible birth injury in this patient, along with fetal alcohol syndrome which may have contributed to his typically neuro related gait issues. Very bizarre presentation, but responded very well to his orthotics.
     
  3. HJR

    HJR Welcome New Poster

    Any history of Cerebal Palsy?
     
  4. Kym

    Kym Active Member


    None known, but thanks for the suggestion. Kym
     
  5. Kym

    Kym Active Member


    I did take photos but I am unsure how to post them on this arena!!
    Shall monitor for orthoses, as this is all new to the child's mum and I am having to take "small steps", if you get my meaning! Some one also suggested C.P. so I will add your suggestion of marfan's to my list. Thanks so much for your post! Kym
     
  6. Paul Bowles

    Paul Bowles Well-Known Member

    CP is hard to diagnose up until the ages of 7-8 I think from memory of a recent article. An article a few years back (sorry haven't got the reference handy) reported a drop off rate of 60+% if I remember correctly from mild cases diagnosed at birth to 8 years of age. i.e. 60+% were incorrectly diagnosed. I will try and hunt that reference down.

    Ever considered it is just normal?

    Just food for thought.

    With a little bit of luck Josh Burns might jump in on this thread with an opinion.
     
  7. Kym

    Kym Active Member

    Thanks for the info re:C.P. I would be grateful of it if you can hunt it down.
    As far as considering it normal.....well no, as something tells me in those dark depths of memory that cavus is not a normal finding in one so young, and with no family history,......my memory has been wrong before, but it just doesn't even look right!!! thanks for your reply. Kym
     
  8. Josh Burns

    Josh Burns Active Member

    Dear Kym (and Paul Bowles for dobbing me in),
    Pes cavus is abnormal in children under 5 (some references below). If there is any neurological involvement (e.g. absent tendon reflexes, unable to heel walk, problems with balance, foot weakness/imbalance) refer to a paediatric neurologist to investigate a peripheral neuropathy such as CMT.
    Regards,
    Josh Burns


    References:
    1. Rose KJ. Burns J. North KN. Factors associated with foot and ankle strength in healthy preschool-age children and age-matched cases of Charcot-Marie-Tooth disease type 1A. Journal of Child Neurology 2009, doi:10.1177/0883073809340698.
    2. Burns J. Ryan MM. Ouvrier RA. Evolution of foot and ankle manifestations in children with CMT1A. Muscle & Nerve 39(2) 158-66, 2009
     
  9. Paul Bowles

    Paul Bowles Well-Known Member

    Josh thanks for chipping in......good to hear from you!



    ......and Kym - if it doesn't look right, it probably isn't! Good Call!
     
  10. Kym

    Kym Active Member


    Thank you soooo much for your input, what you've mentioned has rung some bells for me! The little girl will be in next week so I will do further assessment and refer on to Melbourne....I think this is the only close city i will find a Peadiatric neurologist! I am grateful that Paul dobbed you in...Thx Paul too for your help! Cheers, Kym
     
  11. Bug

    Bug Well-Known Member

    Kym,

    If you need help with where to go for paed neuro's in Melbourne, give me a yell and I can fill you in on the main ones. They are few and far between.

    Paul, that is interesting with what you mentioned about CP, if you could find that reference I would really appreciate it. I have been seeing an increase lately in presentations that end up with a CP diagnosis in the 2-4 population, far easier than was in the past simple as I think we are getting better at identifying the abnormal muscle tone, gait and know more about history leading to the insult causing this.
     
  12. Kym

    Kym Active Member


    Thanks Cylie, I would like to know where to go for Neuro paeds, did do a search and found one who might do the job but would like further info. I am still at BCHC, have you got the number for here? Kym
     
  13. Paul Bowles

    Paul Bowles Well-Known Member

    Yes the older the better due to motor skills development apparently. I had an 11 year old boy in on Saturday who is off for evaluation. Am still trying to remember where I found that reference!
     
  14. HJR

    HJR Welcome New Poster

    Hi Sarah,
    any update on the little girl?
     
  15. Kym

    Kym Active Member

    No update as yet, mum was taking her to Neuro paed in Melb, and that was about Dec 2009. I am still waiting. Thanks for your interest.

    Cheers, Kym
     
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