A clubfoot deformity involves the entire leg, not just thefoot. It affects 1 in 1000 newborns and is bilateral in one half of cases. The tarsals in the affected foot are hypoplastic;the talus is most affected. The muscles of the limb are hypo-plastic because of the abnormal tarsal interactions, whichleads to a generalized limb hypoplasia, mainly affectingand shortening the foot. There is usually atrophy of the calfmusculature.
Family history is important. Club foot can be congenital, teratologic, or positional. Although congenital clubfoot (75% of all cases) is usually an isolated abnormality, every infant should be assessed for developmental dysplasia of the hip. Teratologic clubfoot is associated with a neuromuscular disorder, such as myelomeningocele, arthrogryposis, or other syndromes. Positional clubfoot is a normal foot that was held in the deformed position in utero.
The diagnosis is seldom confused with other disorders (Fig. 201-1). The presence of clubfoot should prompt a careful search for other abnormalities. The infant will have hindfoot equinus and varus, forefoot adduction, and varying degrees of rigidity. All are secondary to the abnormalities of the talonavicular joint. Calf atrophy and foot shortening are more noticeable in older children.
In infants, radiographs and advanced imaging are rarely necessary for assessment because their tarsals have incomplete ossification. The navicular ossifies at about 3 years of age for girls and 4 years for boys. As children age, radiographs can be used to follow the tibial calcaneal and lateral talocalcaneal angles and to assess navicular positioning.
0 to 6 years Poorly fitting shoes Fracture Puncture wound Foreign body Osteomyelitis Cellulitis Juvenile idiopathic arthritis Hair tourniquet Leukemia 6 to 12 years Poorly fitting shoes Trauma (fracture, sprain) Juvenile idiopathic arthritis Puncture wound Sever disease Accessory tarsal navicular Hypermobile flatfoot Oncologic (Ewing sarcoma, leukemia) 12 to 18 years Poorly fitting shoes Stress fracture Trauma (fracture, sprain) Foreign body Ingrown toenail Metatarsalgia Plantar fasciitis Achilles tendinopathy Accessory ossicles (navicular, os trigonum) Tarsal coalition Avascular necrosis of metatarsal (Freiberg infarction) or navicular (Kohler disease) Plantar warts
FIGURE 201-1 Clinical picture demonstrating clubfoot deformity. (From Kliegman RM, Behrman, RE, Jenson HB, et al: Nelson’s Textbook of Pediatrics, ed 18, Philadelphia, 2007, Saunders, p 2778.)
The goal of treatment is to correct the deformity and preserve mobility. Nonoperative treatment involves the Ponseti method of serial casting. The Ponseti method also relies on a percutaneous tenotomy of the Achilles tendon to help correct the equinus deformity.
FIGURE 201-2 Clinical picture of metatarsus adductus with a nor-mal foot on opposite side. (From Kliegman RM, Behrman, RE, Jenson HB, et al: Nelson’s Textbook of Pediatrics, ed 18, Philadelphia, 2007, Saunders, p 2777.)
About 20% of patients will require an anterior tibialis tendon transfer in early childhood. Rarely, more aggressive surgical procedures may need to be done. Complications of untreated clubfoot include severe disability. Complications of treated clubfoot include recurrence and stiffness.
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In-Toeing, Out-Toeing, and Toe-Walking