Problems of the Feet

Toe Walking

The tiptoe gait characteristic of beginning toddlers should give way to an adult-like pattern by 2 years of age. Neuromuscular conditions such as cerebral palsy or spinal cord lesions such as spina bifida, tethered cord, and diastematomyelia can produce foot deformity, which can be appropriately evaluated diagnostically or referral made if toe walking persists beyond age 2.

Clubfoot

Talipes equinovarus (clubfoot), which occurs in approximately 1/1000 births,9 is characterized by talar plantar flexion, hindfoot varus, forefoot adduction, and soft tissue contractures, resulting in a cavus foot deformity (Fig. 7.4).10 It is thought to be secondary to intrauterine position in a genetically predisposed fetus but is also associated with congenital hip dislocation, myelomeningocele, and arthrogryposis. The major deformity of clubfoot is in the subtalar complex, with shortening and medial deviation of the talus with displacement of the navicular medially.11 Radiographs confirm the severity of deformity, allow comparisons over time, and are essential for judging the type of surgical correction needed.

Treatment by an experienced orthopedic surgeon is an acquired skill that is becoming a lost art. Proper intervention involves reduction of the displaced navicular on the head of the talus and mobilization of tight capsules and tendons through manipulation followed by placement in a series of carefully molded corrective casts. The need for extensive surgery is reduced if casting is early and effective with 30% to 50% correction obtained.12 Operative intervention is indicated if complete correction cannot be obtained or maintained. Recognition and treatment of clubfoot deformity should be initiated in the newborn nursery; therefore, recognition and referral of this entity are imperative. Parents should be reassured it is normal for the affected foot and calf to be smaller throughout the child's life.

Cavus Foot

Pes cavus, or cavus foot, is a fixed equinus and pronation deformity of the forefoot in relation to the hindfoot, usually resulting from an

A) NORMAL B) METATARSUS VARUS C) CLUB FOOT

Fig. 7.4. Bone alignment. (A) Normal foot. (B) Metatarsus adduc-tus (varus). (C) Clubfoot, demonstrating Kite's angle. Note Kite's angle is increased in metatarsus varus and decreased in club foot.

underlying neuromuscular condition: spinal dysraphism (spina bifida, lipoma, tethered cord, diastematomyelia), Charcot-Marie-Tooth disease, Friedreich's ataxia, or cord tumor. Occasionally, cases are familial or idiopathic. When unilateral, a spinal disorder is almost always the cause. All cavus feet demonstrate excessive plantar flexion of the first ray with pronation of the forefoot in relation to the hindfoot. The workup includes family and neurological history and exam, weight-bearing radiographs of the feet, and strong consideration of a referral to the orthopedist. Corrective shoes and inserts are not effective for treating cavus feet. Surgical management, best undertaken after age 4 or 5 years, is directed toward medial and plantar release (plantar fascia, short flexors, adductor hallucis) followed by weekly cast changes to gain full correction.13

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