Clubfoot 4

Clubfoot5
Approach to Clubfeet – Initial Assessment

Do a thorough birth/pregnancy/delivery history
Family history
Look for associative disorders: oligohydramnios, arthrogryposis, diastrophic dysplasia, Larsen�s, spinal dysraphism, Goldenhar�s syndrome, Pierre Robin syndrome, Streeter�s dysplasia (congenital constriction bands)

Consider the pathoanatomy

Hindfoot
– talar body is externally rotated (somewhat controversial) but the neck and head are medially and plantarly rotated (ie – there is some intra-talar deformity). The external rotation of the body leads to an externally rotated bimalleolar axis.
– the calcaneus is equinus and varus, so that it is parallel rather than divergent with the talus. The posterolateral capsular structures including the subtalar capsule, ankle capsule, calcaneofibular ligament, and posterior talofibular ligaments are contracted.
– the tendoachilles is contracted

Midfoot – Forefoot
– the talo-navicular joint subluxes, with the navicular riding medially and dorsally on the talar head, coming almost to lie adjacent to the medial malleolus; gives rise to the crease on the medial aspect of the foot.
– the calcaneocuboid joint similarly subluxes medially, with the cuboid riding medially and somewhat plantarly on the calcaneus – into a cavus type deformity
– the whole midfoot/forefoot complex is adducted and supinated, although the forefoot may actually be relatively pronated with respect to the midfoot (according to Ponsetti)

Then, all the soft tissues that cross the hindfoot and midfoot get contracted
– long and short plantar ligaments contracted – maintain the arch normally, but sustain the cavus in clubfoot
– tib post, FDL, FHL are all contracted – enforce the varus and cavus
– spring ligament contracted
– plantar fascia contracted

So on Physical Examination
– obviously, do a thorough physical exam: other joints involved? Hip? Knee? Arthrogryposis? Neurological? Look at back, neck, hands. Look for dysmorphic features.
– Look: posterior crease, medial crease, curvature of lateral border
– Feel: space between medial malleolus and navicular, the prominent lateral tarsal head (uncovered by subluxation of the cuboid), emptiness of the heel (calcaneus in equinus) and interval between fibula and Achilles (calcaneus is pulled up into equinus and the posterolateral capsular structures are tight)
– Move: how much ankle DF is there (ie. how rigid is the equinus?), how rigid is the midfoot adductus? And how tight are the long toe flexors.

Then on x-rays
– look at Kite angle (talocalcaneal angle) on the AP: should be 20-40
– look at talocalcaneal angle on lateral: should again be about 20-45

Begin treatment of the newborn with above knee casting, even if arthrogrypotic (anticipate that you�ll fix these later on)

– first, try to correct the midfoot/forefoot deformity by reducing the navicular back onto the talus and cuboid back to calcaneuos. Do not try to achieve correction of the equinus all in one shot – because the temptation is to push up on the foot to correct the equinus, and you simply break through the midfoot or create a flat-topped talus. Take it in steps. Correct the midfoot/forefoot first, and then gradually get the foot out of equinus.

– in the end, if you can get a plantigrade foot with closed reductions and castings, that may be the best result possible.

– plan on trying successive manipulations and casting for at least 3 months.
– they then go into an AFO for a year.