Clubfoot

Clubfoot, or talipes equinovarus, affects one in 1000 live births and is often diagnosed in utero. The condition is characterized by a smaller foot on the affected side, rigidity to plantar flexion, adductus of the forefoot, and inward angulation of the hindfoot (Figure 23-1). Half of cases are bilateral. Although many cases are idiopathic, maternal smoking, certain ethnic backgrounds, and genes affecting both the musculoskeletal and nervous systems have been identified as risk factors. Some believe that disordered development of the talus in utero causes the disorder.

Figure 23-1 Congenital clubfoot.

Management of clubfoot has trended away from immediate surgical reconstruction because of the need for multiple corrective procedures, which can result in muscle weakness or stiffening. Currently, patients with the disorder are treated by progressive treatments that include more specific surgical repair if indicated to prepare for normal ambulation. The Ponseti method is typically used, which begins with tenotomy in most cases and is followed by serial casting and manipulation procedures. The less common French method involves daily physical therapy and binding over the first 2 months of life. Both methods are started early in the neonatal period, so early referral to a pediatric orthopedist is necessary. This visit may be arranged prenatally if the diagnosis is known. Clubfeet that do not respond to these conservative measures necessitate operative management.

In-toeing

In-toeing is expected in children until the lower limbs laterally rotate with time; adult walking patterns are not observed until about 7 or 8 years of age. The cause of in-toeing varies by age, often caused by metatarsus adductus in infants, internal tibial torsion in toddlers, and excessive femoral anteversion in preschool-aged children.

Internal Tibial Torsion

Internal tibial torsion is the most common cause of in-toeing and can be associated with metatarsus adductus. It is usually noted in toddlerhood when children begin to walk. It affects boys and girls equally and is bilateral in about two-thirds of cases. On examination, the knee remains in neutral position while the foot is medially rotated (Figure 23-2). Most cases self-resolve as children begin to walk independently, with normal alignment noted as early as 4 years or as late as 10 years of age.

Figure 23-2 Internal tibial torsion.

Bowlegs

Bowlegs, or genu varum, are noted when children begin walking and can be considered normal until about 3 years of age. Past this age group, however, bowing of the legs is pathologic, and other causes must be considered to establish proper treatment plans.