Common Pediatric MSK Concerns

Infant foot deformities

Infant foot deformities are generally noted at birth. They may be unilateral or bilateral. Some feet are flexible requiring only minimal treatment (often parental stretching or only one or two casts). These are sometimes termed 'positional'. More severe, increasingly rigid deformity indicates a more complex process that requires early referral. A thorough physical examination is important to identify any other abnormalities such as developmental dysplasia of the hip (DDH), spinal abnormalities or genetic syndromes. Family history should be explored to identify any relatives with similar conditions.The names of common foot deformities are usually descriptive. For example:

Forefoot adductus (a.k.a. metatarsus adductus or varus)

This was discussed along with other causes of 'intoeing' earlier in the module.

Calcaneovalgus foot

Some authors have called this the most common infant foot deformity noting it to some degree in 30% of babies. The foot is held in a dorsiflexed position, often with the dorsum of the foot touching the anterior shin. The heel is in valgus. This deformity is flexible and resolves quickly with time. Stretching may be used; casting is rarely needed. It is important to differentiate this benign condition due to intra-uterine positioning from a more severe and rigid deformity: vertical talus. In the latter condition, the talonavicular joint is dorsally dislocated and the talar head is palpable as a firm prominence in the instep of the foot. The foot is rigid and not correctable. This condition requires surgical correction and a genetic consultation is indicated because of many associated syndromes.


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Note the forefoot adductus, heel varus and hindfoot equinus in this newborn baby with idiopathic congenital clubfoot prior to any intervention. Credit: L. Davidson Bilateral long leg casts applied after 'Ponseti' method manipulation. This is repeated weekly with gradual, gentle correction of deformity. In experienced hands, this treatment is effective in >80% of patients. Credit: L. Davidson 

This deformity is seen in 1-2:1000 births. It is bilateral approximately 50% of the time and is more common in families where there is a positive history of clubfoot. The deformity is complex involving the forefoot (metatarsus adductus) and hindfoot (hindfoot varus and equinus). Clubfoot is most commonly an isolated abnormality, however in some cases it is associated with a specific genetic diagnosis or syndrome. Developmental dysplasia of the hip has been associated with bilateral foot deformities (also forefoot adductus) therefore some authors recommend ultrasound screening of the hips in these patients. Serial casting as described by Ponseti is successful in 80-90% of cases. Some children require surgical releases after 6 months of age, however this should be avoided if possible as it may increase the stiffness of the foot.