CLUBFOOT
Andrew Darmahkasih, MD PGY-2
UCI-CHOC Pe diatric Re side ncy Program
Introduction
• Also known as talipe s e quinovarus
• A de ve lopme ntal de formity of the foot in which one or both fe e t are
e xce ssive ly plantar fle xe d, with the fore foot swung me dially and the
sole facing inward
• An e asy way to re me mbe r the de formity is the mne monic CAVE
– Cavus (plantarfle xion of the first ray)
– Adductus (of the fore foot/midfoot)
– Varus (of the hindfoot) - foot is maintaine d in fixe d inve rsion
– Equinus (of the hindfoot) - foot is place d in plantar fle xion
Introduction
• Can be cate gorize d as conge nital, syndromic, or positional
– Conge nital: affe cts bone s, muscle s, te ndons, and blood ve sse ls of one or both
fe e t
– Syndromic: with associate d anatomic malformations and/or chromosomal or
ge ne tic abnormalitie s
– Positional: due to the baby's position in the ute rus, like ly due to re strictive
ute rine e nvironme nt (oligohydramnios, ute rine anomalie s)
• Positional clubfoot is flexible , rathe r than rigid, and can be
positione d into a ne utral position e asily by hand
INTRINSIC EXTRINSIC
Chromosomal Muscular Amniotic bands or synechiae
Trisomy 18 Myopathy Early amniocentesis
Deletions of chromosomes 18q, 4p, 7q, 9q, 13q Myotonic dystrophy Intrauterine crowding
Connective tissue Skeletal dysplasia Fibroids
Arthrogryposis Campomelic dysplasia Multiple gestation
Collagen defects Chondrodysplasia punctata Oligohydramnios
Joint synostosis Diastrophic dysplasia Potter sequence
Neurologic Ellis-van Creveld Malposition
Anencephaly Syndromes Breech
Anterior motor horn cell deficiency Escobar syndrome
Hydrancephaly Hecht syndrome
Holoprosencephaly Larsen syndrome
Myelomeningocele Meckel-Gruber syndrome
Spina bifida Multiple pterygium
Pena Shokeir
Smith-Lemli-Opitz
Zellweger syndrome
Congenital Clubfoot
• Conge nital clubfoot is se e n in approximate ly 1 in 10 0 0 live births,
most like ly from multifactorial polyge nic inhe ritance
• Risk is 1 in 4 whe n both a pare nt and a sibling have clubfe e t
• 50 % unilate ral, 50 % bilate ral
• Involve s abnormal tarsal morphology (plantar and me dial de viation
of the he ad and ne ck of the talus), abnormal re lationship be twe e n
the tarsal bone s in all thre e plane s, and the associate d contracture
of soft tissue s on the plantar and me dial aspe cts of the foot
• May also have conge nital abse nce of ce rtain te ndinous structure s in
some instance s
Congenital Clubfoot
• Should be diffe re ntiate d from othe r foot de formitie s (e .g., those due
to ne urological issue s, spinal cord te the ring, or isolate d me tatarsus
adductus, a common cause of intoe ing among infants)
• Transvaginal US can some time s de te ct the abnormality as e arly as
12-13 we e ks of ge station
– Now up to 80 % are de te cte d pre natally
– Can find associate d anomalie s in at le ast 10 % of patie nts with clubfoot
• Upon de live ry, pe rform a comple te physical e xamination to rule out
coe xisting ne urological and musculoske le tal issue s
– De gre e of fle xibility
– Atrophy
Congenital Clubfoot
• While XR is not ne e de d to be pe rforme d routine ly for idiopathic
clubfoot, it may be he lpful if suspicious for syndromic fe ature s
• Typical finding on XR is “paralle lism” be twe e n line s drawn through
the axis of the talus and the calcane us on late ral radiograph
Management
• Should be starte d as soon as possible afte r birth
• Ponse ti te chnique has large ly re place d e xte nsive
surge ry, which was pre viously the standard of
care manage me nt
– Te chnique for manipulation and se rial casting
– Orde r of corre ction follows CAVE mne monic
– We e kly cast change s pe rforme d x 6 we e ks, the n
pe rcutane ous te notomy of Achille s te ndon (e ithe r in
office or in OR), the n anothe r se t of casts for 3-4 we e ks
– The n child we ars Ponse ti shoe s and brace (bar be twe e n
the shoe s) for 3 months, and the n at nighttime only for 3
ye ars
– Compliance is ve ry important
Management
• Re sult has be e n e xce lle nt, up to
40 ye ars of follow up
• De spite casting, childre n do not
have much dysfunction or de lay
in achie ving normal motor
function
• Surge ry re se rve d for the
minority of case s that faile d
nonope rative or minimally
invasive me thods
References
• Klie gman RM, St Ge me JW, Blum NJ, Shah SS, Taske r RC, Wilson
KM. Nelson Textbook of Pediatrics. Else vie r He alth Scie nce s. 20 20 ,
21st e d.
• Magriple s U. Pre natal diagnosis of talipe s e quinovarus (clubfoot).
UpToDate. 20 20 . Acce sse d April 13, 20 20 .
• McKe e -Garre tt TM. Lowe r e xtre mity positional de formations.
UpToDate. 20 20 . Acce sse d April 13, 20 20 .
• Zite lli BJ, McIntire SC, Nowalk AJ. Zitelli and Davis’ Atlas of Pediatric
Physical Diagnosis. Else vie r He alth Scie nce s. 20 18, 7th e d.
