CTEV (Club-Foot)

BY: UJJWALA SINGH

Introduction
• CTEV is a common developmental disorder of the
lower limb where one or both of the feet are twisted
out of there normal position
• It is caused due to the abnormal relationship of the
joints, tendons and ligaments of the feet.
What is CTEV ?
• Rotatory subluxation of Talocalcaneonavicular
joint with Talus in plantar flexion and subtalar
complex in medial rotation and inversion.
Congenital Talipes Equino Varus

From “Tali”- Talus Equinus- Heel

Birth “Pes”- Foot Plantarflexion Inversion
(Talus acts as (Hindfoot- (Subtalar
foot) ankle joint) joint)
Deformities (C A V E)
• Cavus- exaggerated medial longitudinal arch
at midfoot
• Adductus – Forefoot in adduction at
Tarsometatarsal junction
• Varus- Hindfoot rotated inwards at
Talonavicular joint.
• Equinus-Foot fixed in plantar flexion at ankle
joint
Epidemiology in numbers
• Incidence: 1-2 per 1000 live birth
• Incidence in first degree relation- 2%
• Incidence in second degree relation- 0.6%
• Male: Female- 2.5:1
• Laterality- >50% cases bilateral
• In unilateral cases- Right>Left
Etiology
• Most Commonly cause is Idiopathic.
• Other than Idiopathic is Secondary CTEV
which is associated with underlying causes
Idiopathic ctev Theories
• Arrested fetal development
• Musculoligamentous fibrosis
• Vasular hypothesis
• Mechanical factor in utero
• Hereditary
Seconday ctev
1. Associated with neuromuscular or syndromic
etiologies:
-Streeter syndrome
-Freeman sheldon syndrome
-Mobius syndrome
-Nail patella syndrome
-Diastrophic dysplasia
Anthrogyroposis multipex congenital
2. Associated with paralytic disorder:
-Poliomyelitis
-Spina bifida
-Myelodysplasia
-Freidrichs ataxia
3. Genetic causes:
-N acetylation genes NAT1 AND NAT 2
-Xenobiotic metabolism genes CYP1A1
-Limb and muscle morphogenesis gene HOXA,
HOXD and IGF BP3
 HINDFOOT MIDFOOT

ANKLE JOINT MIDTARSAL

SUBTALAR JOINT
JOINT

Adduction
(Tibialis post,
Equinus (Tendo Varus (Tibialis Abductur
achilles) Posterior) Hallucis

Cavus
(Plantar Fascia)
Skin Changes
• Deep crease on medial side
• Dimples in lateral aspect of ankle and mid foot.
• Callosities and bursa on lateral side of foot
• Shortening on medial side
Vascular Changes
• Hypoplasia and absence of Dorsalis pedis and
anterior tibial artery

Joint capsule and Fascia

• Contractures seen in Plantar fascia
• Contractures seen in subtalar capsule, Talonavicular
joint capsule, Calcaneocuboid joint capsule.
 Diagnosis
• Generally prenatal diagnosis can be done by
ultrasound at 20 weeks of gestation
• At birth diagnosis can be done by physical
examination of the foot and Xray helps in
further examinining the relation of bones
Dorsiflexion Test for ctev
Kites Angle: <25 degrees
 Clinical features
• Calf is smaller
• Clubfoot is smaller than normal foot
• Metatarsal 1 is more plantar flexed than rest
of metatarsal
• Foot deformities: Forefoot- adduction
Hindfoot- equinus and varus
midfoot- cavus
Management
• AIM: to get plantigrade, active,functional and
a cosmetically acceptable foot in shortest
possible time with minimal distress to child
and family.

• Principle: soft tissue contracture release or

stretching to restore normal tarsal
relationship. Then braces/ orthosis till tarsal
bones remolds stable articular surface.
Historical Aspect

• Early evidence in Egyptian paintings

• Hippocrates- 400 BC gave first medical explnation
• Kite 1930: treatment with several manipulation and
plaster application
• Dennis Brown (1934): spliint for maintainace of
correction
• Ignacio ponseti (1950):
Ponseti method
Treatment phase:
• Begins as early as possible
• Simultaneous correction: C-A-V-E
• Talus head used as fulcrum
• Manipulation---Casting---Tenotomy
CAVUS CORRECTION:
• Elevation of first metatarsal and supination of the
forefoot

ADDUCTION AND VARUS CORRECTION:

• Correction of Cavus brings metatarsal, cuneiform,
navicular and cuboid in same plane of supination.
• Corrected simultaneously by abducting the foot
while counter pressure is applied laterally over talar
head
EQUINUS CORRECTION
• Should be attempted when hindfoot is neutral to
slight valgus and foot is abducted 70 degrees relative
to the leg.
• Correction by progressive dorsiflexion of foot by
applying pressure under entire sole after V-E
correction.
• Tendon is felt and blade enters parallel to medial
tendoachilles 0.5 to 1 cm above insertion at
calcaneum.
• Blade is pushed medial to tendon and rotated 90
degrees underneath it.
• Tendon is cut from medial to lateral direction.
• POP is felt- further dorsiflexion upto 15-20
degrees.
• No stitches, sterile cotton cast padding- cast in
max dorsiflexion with abduction upto 70
degrees
• Immobilisation 3 to 6 weeks.
Foot Abduction orthosis
DENNIS BROWN SPLINT

•Worn 24 hrs 3-4

months
•Worn at nap and
night times 2-4 yrs
CTEV SHOES
Follow Up Protocol:

• 2 weeks: to trouble shoot compliance issues

• 3 months: to graduate to nights and naps protocol
• Every 4 months: until age 3 to monitor compliance
and check for relapses
• Every 6 months: until age 4
• Every 1to 2 yrs: until skeletal maturity
 Complications of Non operative
Management
• Rocker Bottom foot
• Bean shaped foot
• Fractures
• Pressure sores
• Flat top Talus
• Failure of corrections
 Surgical Treatment
• 1-3 yrs: Soft Tissue Release
• 4-11yrs: Soft Tissue Release+ Osteotomies
according to Deformities
• >11yrs: Salvage procedures (Triple arthodesis
Talectomy)