A common reason for referral to a pediatric orthopedist is for foot deformities that may or may not be symptomatic. Conditions range from benign, self-resolving, perceived abnormalities involving the forefoot and toes, to more severe congenital and neuropathic deformities including clubfoot, congenital vertical talus, and cavus foot. Frequently, differentiation between a benign, resolving condition and a more severe pathologic deformity can be made by clinical examination and level of suspicion. A review of the common disorders, both benign and pathologic, will be presented to assist in the clinical evaluation of pediatric foot conditions.
CONGENITAL POSITIONAL FOOT DEFORMITIES
Metatarsus adductus is the medial deviation of the forefoot on the hindfoot (Fig. 210-1). It is thought to be secondary to intrauterine positioning, with the foot medially rotated across the fetal torso. The deformity is classified as either flexible or stiff. When viewed from the plantar surface, the lateral border of the foot is curved and appears “bean shaped” (Fig. 210-1B). The degree of severity is classified using the heel-bisector line. In this method, a line is drawn through the center of the heel and extended up through the toes. In a normal foot, the line extends to the interspace between the second and third toes (Fig. 210-2). Treatment of metatarsus adductus varies from observation to casting in more severe presentations. If the forefoot can be passively manipulated into a corrected position, then the parents can be instructed in passive stretching, and the “deformity” can be observed. Full resolution can be expected in most cases by the time the child reaches 3 years of age. If the forefoot is stiff, serial long-leg casting or a short period of casting may be warranted. Surgical correction is reserved for the rare patient with a fixed adductus and is controversial. Orthopedic consensus is that, even with moderately fixed residual adductus, adult function is still normal.
A: Dorsal view of bilateral metatarsus adductus. Note the medial deviation of all toes. B: Plantar view. The lateral border of the foot is curved and “bean shaped.” (Reproduced with permission from Herring JA: Tachdjian’s Pediatric Orthopaedics, 4th ed. Philadelphia: Elsevier; 2007.)
Illustration of heel-bisector line in normal foot and in metatarsus adductus. (Printed with permission from Texas Children’s Hospital.)
Calcaneovalgus foot is a postural deformity of infancy characterized by a sometimes dramatic hyperdorsiflexion position, in which the dorsum of the foot is plastered to the anterior surface of the tibia (Fig. 210-3). Plantarflexion is limited, and the foot may also be deviated laterally, the ...