Lower Extremity Disorders in Children and Adolescents

Brian G. Smith

doi:10.1542/pir.30-8-287

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Brian G. Smith, MD*

^*Associate Professor, Department of Orthopaedics, Yale University, New Haven, CT

Objectives

After completing this article, readers should be able to:

Recognize and distinguish congenital clubfoot from metatarsus adductus.
Understand treatments and approaches to pes planovalgus or flatfoot.
Describe the natural history of torsional lower extremity deformities in children.
Discuss the differential diagnosis of idiopathic toe walking in children.

Clubfoot

Congenital talipes equinovarus or clubfoot is one of the oldest known congenital deformities, and its diagnosis and treatment date back to the time of Hippocrates.

With a personal experience of clubfoot treatment over the past 50 years, Ignacio Ponseti from the University of Iowa has maintained that careful serial manipulation and casting followed by a percutaneous heel cord release yields better outcomes than the more extensive posteromedial release performed commonly in the past 2 decades.

Epidemiology

Clubfoot occurs in about 1 in 1,000 live births and is more common in certain races or ethnic groups. For example, among South Pacific natives, the incidence of clubfoot is 7 per 1,000. Involvement is bilateral in about 50% of patients, and there is a male predominance of 2:1.

Pathogenesis

The precise pathogenesis of congenital clubfoot remains unclear. This complex disorder possibly involves genetic, neurologic, muscular, and intrauterine compression influences. A genetic predisposition exists, but a specific genetic cause has not been identified at this time.

Physical Findings and Presentation

Clubfoot may be identified by prenatal ultrasonography as early as 12 weeks of gestational age. Definitive diagnosis is by clinical examination after birth and is characterized by the four components of clubfoot: equinus positioning, cavus positioning, metatarsus adductus, and hindfoot varus (Fig. 1).

Figure 1.

Congenital club foot, demonstrating equinus (A) and cavus positioning (B), metatarsus adductus (C), and hindfoot varus (D).

On physical examination, the foot is resistant to passive correction of the fixed hindfoot varus and typically maintains a rigid equinus position. The hindfoot involvement separates clubfoot from metatarsus adductus. Also in …