Common Childhood Foot Deformities

Congenital Clubfoot

This 3-month-old boy has an untreated right clubfoot deformity. The foot is stiff and uncorrectable. The vertical midfoot crease indicates significant deformity (A). An anteroposterior (AP) simulated weight-bearing radiograph shows parallelism of the long axis of the talus and calcaneus; this indicates varus alignment of the hindfoot (B). There is also forefoot adduction.

This is a typical case of congenital talipes equinovarus—or clubfoot—the most obvious of all childhood foot deformities, and one of the most common. It is easily diagnosed at birth by its characteristic appearance and soft tissue contractures. The incidence is 1 per 1000 live births; the condition is bilateral in about half of cases. The right side is involved more often than the left, and boys are affected twice as often as girls. Genetic factors are apparently involved, since the risk of a second child having this deformity in a family is about 5%.1 If a parent has a clubfoot, the risk per child will be approximately 25%.
Muscle and soft tissue biopsies and electromyographic studies show abnormalities that suggest a possible neuromuscular cause.2-6 This partially explains the foot-size discrepancy, calf hypoplasia, and mild lower extremity length discrepancy.

Physical examination. As its name suggests, the characteristic position of the foot resembles that of the head of a golf club; deformities include ankle equinus, hindfoot inversion (or varus), forefoot adduction, and variable rigidity. Positional clubfoot, in which the foot is flexible and its positioning is correctable, represents an in utero positional variation. It does not have the causative factors associated with a congenital clubfoot. Any child with a true congenital clubfoot requires a careful musculoskeletal and neurologic evaluation, since this deformity can be part of a more encompassing syndrome, such as arthrogryposis multiplex congenita.

Radiographic evaluation. Radiographs are not necessary for the diagnosis of clubfoot, but they are obtained as a baseline for assessing response to treatment. These include AP and lateral weight-bearing radiographs or simulated weight-bearing radiographs and a lateral film in which the foot is in maximum dorsiflexion (see B). The characteristic radiographic features of untreated clubfoot include ankle equinus, parallelism of the long axes of the talus and calcaneus (hindfoot varus), and forefoot varus and adduction.

Ultrasonography can help visualize the unossified cartilaginous tarsal bones of the foot, but it is not commonly used.7,8 In a clubfoot, the navicular, which does not ossify until 3 to 4 years of age, is subluxated medially on the head of the talus. Ultrasonography has also been used to diagnose clubfoot antenatally.8 This has led to consideration of treatment before delivery.

Management. Initial treatment consists of weekly manipulation and casting.9,10 This begins as soon after birth as possible. An affected infant should be referred to an orthopaedic surgeon before discharge from the newborn nursery. Initially, manipulation is directed at the foot deformity rather than the ankle plantar flexion (equinus). After each manipulation, the foot is immobilized in a long leg cast in the maximally corrected position. Weekly manipulation and casting continue until the foot is correct, both clinically and radiographically. The equinus is corrected last by stretching the Achilles tendon and posterior ankle structures.
The goal is to have the foot corrected clinically and radiographically by 3 months of age. The success rate has increased to 90% to 95% with the currently popular Ponseti technique.

Feet that correct with serial casting are managed with continued casting, an orthosis, or a Denis Browne splint. The last uses plates attached to the soles of
an infant’s shoes with a crossbar between them to hold the foot in the desired
position.10

Clubfoot that is not completely corrected by age 3 months is best managed by surgical intervention when the child is between 6 and 12 months of age. Postoperatively, the foot is immobilized for 6 to 12 weeks. The child is allowed to walk on the foot immediately following removal of the last cast. An orthosis, corrective shoe, or Denis Browne splint may be used until he or she is walking well.10 The results of surgery are satisfactory in approximately 85% to 90% of children.11-13 However, all children with clubfoot need to be followed throughout growth and development, since residual muscle imbalance can lead to partial recurrence or additional deformities.

REFERENCES:
1. Cowell HR, Wein BK. Current concepts review: genetic aspects of clubfoot. J Bone Joint Surg. 1980;62A:1381-1384.
2. Feldbrin Z, Gilal AN, Ezra E, et al. Muscle imbalance in the aetiology of idiopathic clubfoot. J Bone Joint Surg. 1995;77B:596-601.
3. Khan AM, Ryan MG, Gruber MM, et al. Connec-tive structure in clubfoot: a morphologic study. J Pediatr Orthop. 2001;21:708-712.
4. Karol LA, Concha MC, Johnston CE II. Gait analysis and muscle strength in children with surgically treated clubfeet. J Pediatr Orthop. 1997;17:790-795.
5. Loren GJ, Karpinski NC, Mubarak SJ. Clinical implications of clubfoot histopathology. J Pediatr Orthop. 1998;18:765-769.
6. Sano H, Uhthoff HK, Jarvis JG, et al. Pathogenesis of soft-tissue contracture in clubfoot. J Bone Joint Surg. 1998;80B:641-644.
7. Chami M, Daoud A, Maestro M, et al. Ultrasound contribution in the analysis of the newborn and infant normal and clubfoot: a preliminary study. Pediatr Radiol. 1996;26:298-302.
8. Tillett RL, Fisk NM, Murphy K, Hunt DM. Clinical outcome of congenital talipes equinovarus diagnosed antenatally by ultrasound. J Bone Joint Surg.2000;82B:876-880.
9. Ponseti IV. Current concepts review: treatment of congenital clubfoot. J Bone Joint Surg. 1992;74A:448-453.
10. 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.
11. Haasbeek JF, Wright JG. A comparison of the long-term results of posterior and comprehensive release in the treatment of clubfoot. J Pediatr Orthop. 1997;17:29-35.
12. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot: a thirty-year follow-up note. J Bone Joint Surg. 1995;77A:1477-1489.
13. Huang YT, Lei W, Zhoa L, Wang J. The treatment of congenital clubfoot by operation to correct
deformity and achieve dynamic muscle balance. J Bone Joint Surg. 1999;81B:858-862.

Metatarsus Adductus

This 1-year-old boy has a mild, flexible metatarsus adductus deformity of the right foot. The left foot is normal.

Metatarsus adductus, one of the most common childhood foot deformities, describes a medial deviation (adduction) of the forefoot.1 The lateral border of the foot is convex and the base of the fifth metatarsal has increased prominence. The medial aspect of the foot is concave. There may be a slight separation between the great and second toe. Metatarsus adductus occurs in 1 per 1000 live births, affects boys and girls equally, and is bilateral in approximately 50% of affected children. The condition is believed to be secondary to normal in utero positioning.1 It is more common in firstborn children because of the greater molding effect of the primigravid uterus and abdominal wall. The hips are typically flexed, abducted, and externally rotated while the knees are flexed and the lower legs are inwardly rotated. This allows the medial border of both feet to wrap around the posterolateral aspect of the thighs—which is thought to produce forefoot adduction.

Physical examination. Metatarsus adductus is usually diagnosed at or shortly after birth. The condition has been classified into 3 categories, based on forefoot flexibility.1

•Type I deformity (as seen in this case): the forefoot is flexible and corrects past neutral both actively and passively.
•Type II deformity: there is partial flexibility in the forefoot, which corrects passively past neutral but actively only to neutral.
•Type III deformity: the forefoot is rigid and does not correct to neutral, even with passive stretching.

These categories provide a useful way to assess deformity. The range of motion of the ankle, hindfoot, and midfoot is normal in all 3 types.

Radiographic evaluation. AP and lateral weight-bearing radiographs or simulated weight-bearing radiographs are necessary in any child with rigid metatarsus adductus. These images can distinguish a more severe skewfoot deformity from metatarsus adductus. However, radiographs in children with flexible metatarsus adductus are usually of no value because they do not demonstrate flexibility of the forefoot. In metatarsus adductus, the alignment of the hindfoot and midfoot is normal, but there is medial deviation of the forefoot (metatarsals).

Management. Metatarsus adductus tends to resolve spontaneously by 3 years of age. Children with types I and II metatarsus adductus need only observation2; occasionally, a corrective shoe or commercial orthosis can hasten correction.

A type III deformity is best managed by manipulation and serial casting.1,3 For best results, this should be performed before an infant reaches 8 months of age. The forefoot is manipulated into the correct position while the hindfoot is supported in the neutral position and a short leg cast is applied. The cast is changed at 1- to 2-week intervals until complete correction has been achieved. Most feet will correct in 6 to 8 weeks. After casting, the foot is maintained in a corrective shoe or an orthosis until the child is walking well. Dynamic adduction of the great toe (sometimes called a “searching” great toe) may be observed after satisfactory correction, but this will resolve within 1 to 2 years.

Children with metatarsus adductus rarely require surgical correction.2 It is a relatively benign deformity that has been shown to produce minimal disability as an adult. However, if a significant forefoot adduction is present in a child up to 6 years of age, a medial release followed by serial casting can be considered.4 After 6 years of age, tarsal or metatarsal osteotomies are necessary.

REFERENCES:

1. Crawford AH, Gabriel KR. Foot and ankle problems. Orthop Clin North Am. 1987;18:649-666.
2. Farsetti P, Weinstein SL, Ponseti IV. The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. J Bone Joint Surg. 1994;76A:257-265.
3. Bleck EE. Metatarsus adductus: classification and relationship to outcome of treatment. J Pediatr Orthop. 1983;3:2-9.
4. Asirvatham R, Stevens PM. Idiopathic forefoot-adduction deformity: medial capsulotomy and abductor hallucis lengthening for resistant and severe deformities. J Pediatr Orthop. 1997;17:496-500.

Skewfoot

Figure A depicts bilateral skewfoot in a 7-year-old boy. The deformities were rigid in this child, and there was no improvement with growth.

Physical examination. Skewfoot has the same general clinical appearance as metatarsus adductus, but there is hindfoot eversion (valgus) and more rigidity.1 The condition is associated with forefoot adduction, a flattened medial longitudinal arch, and hindfoot valgus. The Achilles tendon may be contracted.

Skewfoot may result from metatarsus varus, in which there is not only adduction but also supination of the forefoot. With ambulation, the forefoot supination resolves, but at the expense of creating hindfoot valgus. Thus, a skewfoot may be a developmental deformity.

Radiographic evaluation. Radiographs are necessary to distinguish between skewfoot and metatarsus adductus. In skewfoot deformity, forefoot adduction and valgusalignment of the hindfoot are characterized radiographically by an increase in the AP and lateral talocalcaneal angles. The foot has a typical Z appearance in the AP projection (B).

Management. Serial casting can be attempted in children with skewfoot, although only limited success has been reported.1,2 While the forefoot is manipulated into the corrected position, the hindfoot is brought into a varus position so that both components of the deformity can be addressed simultaneously. Children with skewfoot are usually immobilized in a long leg cast to maintain correction.

Surgical intervention may be required for skewfoot deformities that are resistant to serial casting. These deformities are more rigid and may become painful with shoe wear later in childhood. Surgery is complex; it typically consists of lengthening the neck of the calcaneus to correct the hindfoot valgus, performing an opening wedge osteotomy of the medial cuneiform to correct forefoot adduction, and lengthening the Achilles tendon.2

REFERENCES:

1. Peterson HA. Skewfoot (forefoot adduction and heel valgus). J Pediatr Orthop. 1986;6:24-30.
2. Mosca VS. Instructional course lectures: flexible flatfoot and skewfoot. J Bone Joint Surg. 1995;77A:1937-1945.

Flatfoot

The collapse of the medial longitudinal arch, increased hindfoot valgus (eversion), and forefoot abduction in the foot of this 12-year-old girl (when weight bearing) are all typical features of a flexible flatfoot deformity. The foot may also appear externally rotated in relation to the leg.

Pes planus, or flatfoot, has a variety of causes—congenital, developmental, neuromuscular, inflammatory, and infectious. Fortunately, the vast majority of children with flatfoot have hypermobile or flexible flatfoot; this is a manifestation of generalized ligamentous laxity, which is an autosomal dominant trait. Flexible flatfoot is usual in infants, common in children, and within normal limits in adults.1,2

Physical examination. In flexible flatfoot, the ankle, subtalar, and transverse tarsal joints usually demonstrate full range of motion. The medial longitudinal arch returns in the non–weight-bearing position or when the child stands on his or her toes. There may be some callus formation over the medial aspect of the talonavicular joint from collapse of the medial longitudinal arch and increased pressure with shoe wear. Fortunately, this is rarely symptomatic.

In painful or rigid flatfoot, there is usually decreased subtalar and midfoot motion. In the non–weight-bearing position, and when standing on the toes, the medial longitudinal arch will not reform.3

Radiographic evaluation. In children with rigid flatfoot, it is important to perform a more extensive evaluation to determine the exact cause. AP and lateral weight-bearing radiographs of the feet are required for radiographic evaluation of symptomatic flatfoot.1,2 In the lateral view, there is an increased lateral talocalcaneal angle, a talonavicular sag, and parallel alignment of the metatarsals. Additional views may also be necessary, depending on the suspected diagnosis. In tarsal coalition, an oblique view of the foot will reveal a calcaneonavicular coalition. If a middle facet talocalcaneal coalition is suspected, CT will be diagnostic.

Management. In the vast majority of children, flatfoot can be managed by observation. The indication for treatment with an orthosis is typically pain or abnormal shoe wear. Severely flat or pronated feet may cause abnormal medial shoe wear. When this happens, the use of an orthosis that restores the medial longitudinal arch may be beneficial in relieving symptoms and improving shoe longevity. This can be accomplished with athletic shoes with built-in arch supports, commercially available inserts or, in some cases, a custom-made orthosis. The last is only occasionally indicated because of its expense. Moreover, an orthosis will not permanently correct a pes planus deformity.4,5 The foot will still have a flat or pronated appearance.

Operative treatment of hypermobile flatfoot is rarely indicated. However, in certain children, lengthening of the neck of the calcaneus and plication of the talonavicular joint capsule may be beneficial.3 Midfoot fusions have also been reported to produce satisfactory long-term results.6 However, these fusions restrict motion and produce added stress on the remaining mobile joints. Subtalar joint arthroplasties are contraindicated.7
In children with tarsal coalitions, such as a calcaneonavicular or middle facet talocalcaneal coalition, resection and soft tissue interposition may help restore motion and relieve symptoms.

REFERENCES:

1. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999;7:44-53.
2. Staheli LT, Chew DE, Corbett M. The longitudinal arch: a survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg. 1987;69A:426-428.
3. Mosca VS. Instructional course lectures: flexible flatfoot and skewfoot. J Bone Joint Surg. 1999;81B:858-862.
4. Staheli LT. Footwear for children. Instr Course Lect. 1994;43:193-197.
5. Wenger DR, Maudlin D, Speck G, et al. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg. 1989;
71A:800-810.
6. Fraser RK, Menelaus MB, Williams PF, Cole WG. The Miller procedure for mobile flat feet. J Bone Joint Surg. 1995;77B:396-399.
7. Black PR, Betts RP, Duckworth T, Smith TW. The Viladot implant in flatfooted children. Foot Ankle Int. 2000;21:478-481.

Congenital Vertical Talus

The left foot of this 4-month-old boy has a convex sole with a rocker-bottom appearance, hindfoot equinus, and midfoot and forefoot dorsiflexion. This is the typical appearance of congenital vertical talus. This deformity is usually rigid; the midfoot cannot be brought into proper alignment with the hindfoot. The entire foot appears to be in a pronated or valgus position. The head of the talus may be prominent and can be palpated on the medial and plantar aspects of the foot.

Congenital vertical talus is relatively uncommon, with an incidence of approximately 1 in 10,000 live births. It occurs with equal frequency in both sexes and is bilateral in approximately 50% of cases. Although idiopathic deformities occur, most are associated with an underlying disorder, such as trisomies 13 through 15 and 18 syndromes, arthrogryposis multiplex congenita, or myelodysplasia.1 Thus, a very careful musculoskeletal and neurologic evaluation is necessary in all infants and children with this deformity.

Physical examination. It is important to distinguish congenital vertical talus from the more common calcaneovalgus of the newborn and from idiopathic flatfoot.

Radiographic evaluation. Obtain AP and lateral weight-bearing radiographs or simulated weight-bearing radiographs of the foot, as well as a lateral view with the foot in maximum plantar flexion. The hindfoot equinus and vertically oriented talus are recognizable in the lateral view. The plantar flexion lateral view can demonstrate the inability of realigning the midfoot (navicular) with the hindfoot (talus). (The long axis of the talus and first metatarsal are parallel in a normal foot.) However, keep in mind that the navicular is not seen on radiographs in infants and young children, because it does not ossify until age 3 or 4 years.

Management. All infants with congenital vertical talus require a trial of serial manipulation and casting.1 The midfoot and forefoot may be cast in a plantar-flexed position in an attempt to reduce the dislocated navicular onto the head of the talus; however, this is rarely successful. Improvement must be confirmed radiographically.

The majority of children with this deformity require surgery to achieve satisfactory alignment. This entails an extensive one-stage soft tissue release.2-5 In some children, tendon transfers may be necessary to achieve muscle balance.5 The results of surgical intervention are relatively good, although some children may require an orthosis to maintain proper alignment during the early phase of growth and development.

REFERENCES:

1. Drennan JC. Congenital vertical talus. The American Academy of Orthopaedic Surgeons Instructional Course Lecture. J Bone Joint Surg. 1995;77A:1916-1923.
2. Kodros SA, Dias LS. Single-stage surgical correction of congenital vertical talus. J Pediatr Orthop. 1999;19:42-48.
3. Duncan DR, Fixsen JA. Congenital convex pes valgus. J Bone Joint Surg. 1999;81B:250-254.
4. Stricker SJ, Rosen E. Early one-stage reconstruction of congenital vertical talus. Foot Ankle Int. 1997;18:535-543.
5. Mazzoca AD, Thompson JF, DeLuca PA, Romness MJ. Comparison of the posterior approach versus the dorsal approach in the treatment of congenital vertical talus. J Pediatr Orthop. 2001;21:212-217.

Calcaneovalgus Foot

This 4-month-old infant has calcaneovalgus foot—a relatively common finding in newborns. The foot has excessive dorsiflexion that allows its dorsum to come into contact with the anterior aspect of the lower leg. The forefoot has an abducted appearance.

Physical examination. Calcaneovalgus foot occurs secondary to a normal variation in the in utero position.1 The plantar surface of the foot is against the wall of the uterus, which forces it into a hyperdorsiflexed and everted position. This fetal position also produces external tibial torsion (in fact, external tibial torsion of 30 to 50 degrees is a finding commonly associated with calcaneovalgus foot). Plantar flexion usually remains normal or almost normal. Calcaneovalgus foot is typically a unilateral deformity, but may occasionally be bilateral.

It is important to rule out 3 other conditions with a similar appearance:

•Congenital vertical talus.
•Posteromedial bow of the tibia.
•A neuromuscular disorder, such as paralysis of the gastrocnemius muscle.

Radiographic evaluation. AP and lateral simulated weight-bearing radiographs of the foot may be necessary to differentiate between calcaneovalgus foot and congenital vertical talus. In a calcaneovalgus foot, the radiographs either appear normal or reveal a mild increase in forefoot abduction and hindfoot valgus. In congenital vertical talus, the lateral view demonstrates a vertical orientation at the talus and dorsal subluxation at the midfoot. AP and lateral radiographs of the tibia and fibula are necessary if there is bowing of the lower leg.

Management. No treatment is necessary for the typical calcaneovalgus foot. The problem usually resolves by the time the child begins to stand and walk independently. The external tibial torsion may persist, however, and follows the same natural history as internal tibial torsion. This usually resolves by 2 years of age.

REFERENCE:

1. Thompson GH. Gait disturbances. In: Kliegman RM, ed. Practical Strategies in Pediatric Diagnosis and Therapy. Philadelphia: WB Saunders Company; 1996:757-778.