Clubfoot

1. Epidemiology
   1. Often Bilateral
   2. Hereditary
   3. Incidence: 1-2 per 1000 live births
   4. More common in hispanic patients
2. Signs (4 components): Foot is down and in
   1. Images
      1. 
   2. Heel inversion (varus) with internal rotation
      1. Medial malleoli are further from each other
   3. Forefoot inverted and adducted (soles face each other)
      1. Medial foot concave
      2. Lateral foot convex (Kidney shape)
      3. Foot inverted
   4. Plantar flexion with inability to dorsiflex
      1. Equinus of Ankle and forefoot
      2. Very tight heel cord
   5. Leg internal rotation
3. Associated deformity
   1. Congenital dislocation of Hip
   2. Spina bifida
   3. Myotonic Dystrophy
   4. Arthrogryposis
4. Types
   1. Extrinsic Clubfoot (Mild, Supple form)
      1. Secondary to intrauterine compression
   2. Intrinsic Clubfoot (Severe, Rigid form)
      1. Anatomic deformity (e.g. abnormal talus)
5. Differential Diagnosis
   1. Metatarsus Adductus (foot not in equinus)
6. Management
   1. Refer immediately for serial casts
   2. Serial Casting
      1. Start in first week of life
      2. Serial Casts weekly for 6-8 weeks
      3. Take advantage of neonatal ligamentous laxity
      4. Manipulate foot before and between casts
         1. Stretches contracted soft tissues
      5. Casting is most effective in extrinsic Clubfoot
      6. Dennis-Browne Splines
      7. Goal is a flat, platform-like base for ambulation
   3. Severe Clubfoot requires surgery
      1. Posteromedial release of heel cords
      2. Major surgery in 50-75% cases
7. Patient Resources
   1. Hughston Sports Medicine Foundation
      1. http://www.hughston.com/hha/a_13_4_1.htm
8. References
   1. Hoppenfeld (1976) Exam. Spine Extremities, p.159-60,223
   2. Churgay (1993) Am Fam Physician 47(4):883
   3. Gore (2004) Am Fam Physician 69(4):865-72
   4. Hoffinger (1996) Pediatr Clin North Am 43:1091-111