Clubfoot

Clubfoot: Excerpt from The 5-Minute Pediatric Consult

Richard S. Davidson, MD

Clubfoot - BASICS

Clubfoot - description

Clubfoot is a congenital or neuromuscular deformity in which the hindfoot is fixed in equinus and varus and the forefoot is fixed in varus and often cavus.

Clubfoot - epidemiology

• The risk of deformity increases by 20–30 times where there is an affected 1st-degree relative.
• Male > Female (2:1)

Clubfoot - incidence

Incidence is 1–1.4/1,000 live births, but can vary among different ethnic groups.

Clubfoot - pathophysiology

• Many anatomic abnormalities have been postulated as causing clubfoot:
  • Anomalous or deficient muscles, myoblasts, mast cells, abnormal primary bone formation, joint and muscle contractures, vascular anomalies (absent dorsalis pedis artery), nerve anomalies
  • Abnormalities of the fibrous connective tissue
• Interruption of the development of the embryonic foot has also been suggested.

Clubfoot - etiology

• Most cases are idiopathic (multifactorial inheritance pattern with significant environmental influence).
• Infrequently, neuromuscular imbalance may underlie the deformity (cerebral palsy, myelomeningocele, lipomas of the cord, caudal or sacral agenesis, polio, arthrogryposis, fetal alcohol syndrome).

Clubfoot - DIAGNOSIS

Clubfoot - signs & symptoms

Clubfoot - history

• Family history of clubfoot (3%)
• Onset of deformity (congenital or developmental)

Clubfoot - physical exam

• Careful examination of:
  • The neuromuscular system for neuromuscular etiologies such as lumbosacral sinuses, dimples, and lipomas
  • The hips for hip dysplasia
  • The neck for torticollis
• Physical examination trick:
  • Push the foot into a corrected position. Is the deformity fully correctable? Overcorrectable?

Clubfoot - tests

Clubfoot - lab

• Radiographs (after 3 months of age)
• Tarsal bones are poorly ossified in the newborn; therefore diagnosis is clinical.
• At 3–6 months of age, anteroposterior (AP) and lateral radiograph films in dorsiflexion (maximal correction) may help in defining residual deformity. The beam should be focused on the hindfoot for both the anteroposterior and lateral radiographs, as the measured angles will be hindfoot angles.
• Decreased talocalcaneal angle on the anteroposterior and lateral views (≤25°) confirm persistent deformity.
• Medial displacement of the cuboid on the calcaneus and persistent plantar flexion of the forefoot on the hindfoot (talar to 1st metatarsal angle) indicate more complex deformities.

Clubfoot - differencial diagnosis

Distinguish other deformities of the foot:

• Metatarsus adductus or varus (heel is in neutral position)
• Calcaneovalgus (foot is in valgus)
• Vertical talus (foot is in valgus, heel in equinovalgus)
• Many children with clubfoot also have tibial torsion.

Clubfoot - TREATMENT

Clubfoot - general measures

• Emergency care:
  • Care can begin in the 1st week after birth.
• Initial treatment is serial (weekly) manipulation and casting.
• Taping may be useful for treatment of the infant requiring ICU care; access to the feet should be maintained for blood tests.
• Failure to correct the deformity completely by manipulation within 3–9 months requires surgical treatment.
• Long-leg serial casting by the Ponseti technique improves results so that in most clubfeet little more than heel cord lengthening is required.

Clubfoot - FOLLOW UP

Clubfoot - patient monitoring

• Realignment of the deformity is the goal and should be achieved at surgery or by casting.
• Most surgeons cast the feet for 3 months postoperatively.
• Some brace the feet for 6 months. With the Ponseti technique, bars and shoes are recommended full time for 3 months and nights for 3 years to maintain the correction.
• Remember, the cause of the deformity is not corrected. Only the alignment of the bones and lengthening of the soft tissues are corrected.
• Depending on the severity of the deformity, all corrected clubfeet can be expected to demonstrate varying amounts of calf narrowing and weakness, ankle and subtalar stiffness, a difference between the feet of 1–2 shoe sizes, and even a leg-length discrepancy.
• There also will be decreased ankle and subtalar motion as compared to the normal.
• Adolescent children with clubfeet often will get leg cramps and will tire easily while doing sports.
  • Recurrence of heel cord tightness is common, especially during periods of rapid growth. Additional heel cord stretching, casting, and infrequently, additional surgery may be needed.
• All true recurrences should lead to further evaluation for neuromuscular or syndromic causes that might have been missed in the infant.

Clubfoot - bibliography

1. Hamel J, Becker W. Sonographic assessment of clubfoot deformity in young children. J Pediatr Orthop B. 1996;5:279–286.
2. Johnston CE II, Hobatho MC, Baker KJ, et al. Three-dimensional analysis of clubfoot deformity by computed tomography. J Pediatr Orthop B. 1995;4(1):39–48.
3. Napiontek M. Clinical and radiographic appearance of congenital talipes equinovarus after successful nonoperative treatment. J Pediatr Orthop. 1996;16:67–72.
4. Ponseti I. Treatment of congenital clubfoot. J Bone Joint Surg. 1992;74:448–454.
5. Roye BD, Hyman J, Roye DP Jr. Congenital idiopathic talipes equinovarus. Pediatr Rev. 2004;25:124–130.
6. Scherl SA. Common lower extremity problems in children. Pediatr Rev. 2004;25:52–62.
7. Yamamoto H, Muneta T, Morita S. Nonsurgical treatment of congenital clubfoot with manipulation, cast, and modified Denis Browne splint. J Pediatr Orthop. 1998;18:538–542.

Clubfoot - CODES

Clubfoot - icd9

• 754.70 Talipes, unspecified (Congenital deformity of foot not otherwise specified)
• 754.79 Talipes equinus

Clubfoot - FAQ

• Q: How can a rigid clubfoot be distinguished from a positional clubfoot?
• A: During initial evaluation of the child, it is important to assess the amount of flexibility in a clubfoot. This can be most easily done by flexing the hip to 90°, flexing the knee to 90°, and then gently trying to turn the forefoot into a straight position lined up with the thigh. If the foot easily spins around into a normal position, it can be assumed that this is a flexible or positional clubfoot. If deformity persists, this is a rigid deformity. If possible, the examining physician should palpate the heel to see if the os calcis comes out of its equinus position filling the heel pad. In some children, particularly with a rocker bottom sole, the heel pad looks as if it is in the correct position, but the os calcis remains in equinus with the posterior aspect of the os calcis proximal to the heel pad.
• Q: What percentage of clubfeet are successfully treated by casting?
• A: To some extent, the amount of success depends on how much correction is desired. Occasionally, cast correction will provide a partial correction. Some feet, after casting, can be held in the corrected position, only to spin back to the clubfoot deformity when released. Positional clubfeet are likely to improve with casting in perhaps 80% of cases. Rigid clubfeet are much less likely to be corrected by casting. The success rate in the rigid feet is likely to be ~10–20%.
• Q: What will be the permanent disability of a congenital clubfoot deformity?
• A: Although casting and surgical correction of a congenital clubfoot can realign the bones, the surgery does little to correct the underlying neuromuscular problems. As a result, all children with rigid clubfeet are likely to have a leg-length inequality (usually <1.5 inches), a smaller foot (usually 1–2 sizes), calf narrowing that cannot be significantly improved with exercise, and joint stiffness (ankle, subtalar, and midfoot). Even children with optimal realignment of the deformity will notice their inability to perform gymnastic activities or running activities requiring normal range of motion of the ankle and foot. Many will complain of the inability to keep up with their peer group during adolescent and young-adult sports activities.
• Q: How soon should an infant with congenital clubfoot be referred to an orthopedic surgeon?
• A: If casting is to be even partially successful, cast treatment should begin within the 1st to 2nd week of life. Clearly, medical and life-threatening conditions will take precedence over the treatment of the clubfoot. Access to the feet for IV or blood studies will interfere with a casting regimen. Casting should begin as soon as is practical. It may even be possible to begin taping of the foot as an alternative to casting, which will still allow IV access to the feet. Referral to an orthopedic surgeon should, therefore, follow as soon as is practical.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Clubfoot

• Back to disease: Clubfoot: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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