Clubfoot deformity in Children The most common congenital disorder of
the lower extremities in children, clubfoot,and or talipes, is marked primarily by a
deformed shortened Achilles tendon and talus, which give the foot a
characteristic clublike appearance. In talipes equinovarus, the foot
points downward (equinus) and turns inward (varus), and the front of
the foot curls toward the heel (forefoot adduction).Clubfoot, which has an incidence of about 1 per 1,000 live births,
usually occurs bilaterally and is twice as common in boys as it is in
girls. It may be associated with other birth defects, such as
myelomeningocele, spina bifida, and arthrogryposis. Clubfoot is
correctable with prompt treatment.


Causes
A combination of genetic and environmental factors in utero appears
to cause clubfoot. Heredity is a definite factor in some cases,
although the mechanism of transmission is undetermined. If a child is
born with clubfoot, his sibling has a 1 in 35 chance of being born with
the same anomaly. Children of a parent with clubfoot have 1 chance in
10.
In children without a family history of clubfoot, this anomaly
seems linked to arrested development during the 9th and 10th weeks of
embryonic life, when the feet are formed. Researchers also suspect
muscle abnormalities, leading to variations in length and tendon
insertions, as possible causes of clubfoot.
Signs and symptoms
Talipes equinovarus varies in severity. Deformity may be so extreme
that the toes touch the inside of the ankle, or it may be only vaguely
apparent.
In every case, the talus is deformed, the Achilles tendon
shortened, and the calcaneus somewhat shortened and flattened. Depending
on the degree of the varus deformity, the calf muscles are shortened
and underdeveloped, with soft-tissue contractures at the site of the
deformity. The foot is tight in its deformed position and resists
manual efforts to push it back into normal position.
Clubfoot is painless, except in older, arthritic patients. In older
children, clubfoot may be secondary to paralysis, poliomyelitis, or
cerebral palsy, in which case treatment must include management of the underlying disease.
Diagnosis
An early diagnosis of clubfoot is usually no problem because the
deformity is obvious. With subtle deformity, however, true clubfoot must
be distinguished from apparent clubfoot (metatarsus varus or pigeon
toe).
Apparent clubfoot results when a fetus maintains a position in
utero that gives his feet a clubfoot appearance at birth. This can
usually be corrected manually.
Another form of apparent clubfoot is inversion of the feet,
resulting from the peroneal type of progressive muscular atrophy and
progressive muscular dystrophy. With true clubfoot, X-rays show
superimposition of the talus and the calcaneus and a ladderlike
appearance of the metatarsals.

Treatment
Appropriate treatment for clubfoot is administered in three stages:

• correcting the deformity
  
• maintaining the correction until the foot regains normal muscle balance
  
• observing the foot closely for several years to prevent the deformity from recurring.
  

In neonates, corrective treatment for true clubfoot should begin
immediately. An infant’s foot contains large amounts of cartilage; the
muscles, ligaments, and tendons are supple. The ideal time to begin
treatment is during the first few days and weeks of life—when the foot
is most malleable.
Sequential correction
Clubfoot deformities are usually corrected in sequential order:
forefoot adduction first, then varus (or inversion), then equinus (or
plantar flexion). Trying to correct all three deformities at once only
results in a misshapen, rocker-bottomed foot.
Forefoot adduction is corrected by uncurling the front of the foot
away from the heel (forefoot abduction); the varus deformity is
corrected by turning the foot so the sole faces outward (eversion); and
finally, equinus is corrected by casting the foot with the toes
pointing up (dorsiflexion). This last correction may have to be
supplemented with a subcutaneous tenotomy of the Achilles tendon and
posterior capsulotomy of the ankle joint.
Treatment methods
Several therapeutic methods have been tested and found effective in
correcting clubfoot. The first is simple manipulation and casting,
whereby the foot is gently manipulated into a partially corrected
position, then held there in a cast for several days or weeks. (The
skin should be painted with a nonirritating adhesive liquid beforehand
to prevent the cast from slipping.)
After the cast is removed, the foot is manipulated into an even
better position and casted again. This procedure is repeated as many
times as necessary. In some cases, the shape of the cast can be
transformed through a series of wedging maneuvers, instead of changing
the cast each time.
After correction of clubfoot, proper foot alignment should be
maintained through exercise, night splints, and orthopedic shoes. With
manipulating and casting, correction usually takes about 3 months. The
Denis Browne splint—a device that consists of two padded, metal foot
plates connected by a flat, horizontal bar—is sometimes used as a
follow-up measure to help promote bilateral correction and strengthen
the foot muscles.
Resistant clubfoot may require surgery. Older children, for example, with recurrent or neglected clubfoot usually need surgery.
Tenotomy, tendon transfer, stripping of the plantar fascia, and
capsulotomy are surgical procedures that may be used. With severe cases,
bone surgery (wedge resections, osteotomy, or astragalectomy) may be
appropriate. After surgery, a cast is applied to preserve the
correction.
Whenever clubfoot is severe enough to require surgery, it’s rarely
totally correctable. However, surgery can usually ameliorate the
deformity.
Special considerations

• Look for any exaggerated attitudes in an infant’s feet. Make sure
  you can recognize the difference between true clubfoot and apparent
  clubfoot. Don’t use excessive force in trying to manipulate a clubfoot.
  The foot with apparent clubfoot moves easily.
  
• Stress to the parents the importance of prompt treatment. Make sure they understand that clubfoot demands immediate therapy and orthopedic supervision until growth is completed.
  
• After casting, elevate the child’s feet with pillows. Check the
  toes every 1 to 2 hours for temperature, color, sensation, motion, and
  capillary refill time; watch for edema. Before a child in a clubfoot
  cast is discharged, teach parents to recognize circulatory impairment.
  
• Insert plastic petals over the top edges of a new cast while it’s
  still wet to keep urine from soaking and softening the cast. When the
  cast is dry, “petal” the edges with adhesive tape to keep out plaster
  crumbs and prevent skin irritation.
  
• Perform skin care under the cast edges every 4 hours, washing and
  drying the skin thoroughly. (Don’t use oils or powders; they tend to
  macerate the skin.)
  
• Warn parents of an older child not to let the foot part of the cast
  get soft and thin from wear. If it does, much of the correction may be
  lost.
  
• If the wedging method is being used, frequently check circulatory
  status; it may be impaired because of increased pressure on tissues and
  blood vessels. The equinus correction especially places considerable
  strain on ligaments, blood vessels, and tendons.
  
• After surgery, elevate the child’s feet with pillows to decrease
  swelling and pain. Watch for signs of discomfort or pain. Try to locate
  the source of pain—it may result from cast pressure, not the incision.
  If bleeding occurs under the cast, circle the location and mark the
  time on the cast. Watch for indications that the bleeding is spreading.
  
• Explain to the older child and his parents that surgery can improve
  clubfoot with good function but can’t totally correct it; the affected
  calf muscle will remain slightly underdeveloped.
  
• Emphasize the need for long-term orthopedic care to maintain
  correction. Teach the parents the prescribed exercises that their child
  can do at home.
  
• Urge the parents to be sure their child wears corrective shoes, as ordered, and splints during naps and at night.