Pediatric Clubbed Foot

Clubfoot, also known as talipes equinovarus, is a congenital (present at birth) foot deformity. It affects the bones, muscles, tendons and blood vessels and can affect one or both feet. The foot is usually short and broad in appearance and the heel points downward while the front half of the foot (forefoot) turns inward. The heel cord (Achilles tendon) is tight. The heel can appear narrow and the muscles in the calf are smaller compared to a normal lower leg.

Clubfoot occurs in approximately one to three of every 1,000 births, with boys outnumbering girls two to one. One or both feet may be affected.

Clubfoot is considered a "multifactorial trait." Multifactorial inheritance means there are many factors involved in causing a birth defect. The factors are usually both genetic and environmental.

Often one gender (either male or female) is affected more frequently than the other in multifactorial traits. There appears to be a different "threshold of expression," which means that one gender is more likely to show the problem than the other gender. For example, clubfoot is twice as common in males as it is in females.

Once a child has been born with clubfoot, the chance for it to happen again depends on several factors. If a parent and child are affected, the recurrence may be as high as 25%. If a parent does not have club foot, than recurrence risk is based on gender of first born — 2% recurrence risk with male child and 5% for a female child. 

Risk factors may include:

• Family history of clubfoot
• Multiple gestations (twins or triplets)
• Position of the baby in the uterus
• Increased occurrences in those children with neuromuscular disorders, such as cerebral palsy (CP) and spina bifida
• Oligohydramnios (decreased amount of amniotic fluid surrounding the fetus in the uterus) during pregnancy

Babies born with clubfoot may also be at increased risk of having an associated hip condition, known as developmental dysplasia of the hip (DDH). DDH is a condition of the hip joint in which the top of the thigh bone (femur) slips in and out of its socket because the socket is too shallow to keep the joint intact.

Your child's doctor makes the diagnosis of clubfoot at birth with a physical examination. During the examination, your child's doctor obtains a complete prenatal and birth history of the child and asks if other family members are known to have clubfoot. If the diagnosis of clubfoot is made in an older infant or child, your child's doctor will also ask about developmental milestones since clubfoot can be associated with other neuromuscular disorders. Developmental delays may require further medical follow up to evaluate for underlying problems.

Diagnostic procedures of the foot may include:

• X-ray. A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones and organs onto film.

Specific treatment for clubfoot will be determined by your child's doctor based on:

• Your child's age, overall health and medical history
• The extent of the condition
• Your child's tolerance for specific medications, procedures or therapies
• Expectations for the course of the condition
• Your opinion or preference

The goal of treatment is to straighten the foot so that it can grow and develop normally. Treatment options for infants include:

• Nonsurgical treatment. There are various methods of nonsurgical treatment for infants with clubfoot. These methods include serial manipulation and casting, taping, physical therapy and splinting, and use of a machine that provides continuous passive motion. A nonsurgical treatment should be the first type of treatment for clubfoot, regardless of how severe the deformity is.
  
  According to the American Academy of Orthopaedic Surgeons (AAOS), the Ponseti method, which uses manipulation and casting, is the most frequently used method in the U.S. to treat clubfoot. Most cases of clubfoot in infants can be corrected within 2 to 3 months using this method. It is recommended that Ponseti method treatment be started as soon as clubfoot has been diagnosed, even as soon as 1 week of age. The AAOS states that infants with clubfoot occasionally have a deformity severe enough that manipulation and casting will not be effective. Because clubfoot may recur, braces are worn for several years to prevent relapse. Initially, the braces are worn for 23 hours a day for up to 3 months, then at night for 2 to 4 years.
• Surgery. Surgical treatment for clubfoot may be required in these situations: when nonsurgical treatment fails to correct the deformity, or when the deformity recurs and does not respond to nonsurgical treatment. The specific surgical procedure and extent of surgery will depend on the type and extent of the deformity. Postoperatively, surgical wires, pins and/or a cast may be used to maintain the corrected foot position until it has healed. Splints may also be needed for several months up to a few years after surgery.

Long leg casts are applied from the upper thigh to the foot. These casts are commonly used in the treatment of clubfoot. They can also be used with knee dislocations or after surgery on the leg or knee area.

Cast Care Instructions

• Keep your child's cast clean and dry
• Check for cracks or breaks in the cast
• Rough edges can be padded to protect the skin from scratches
• Do not scratch the skin under the cast by inserting objects inside the cast
• Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.
• Do not put powders or lotion inside the cast
• Cover the cast while your child is eating to prevent food spills from entering the cast
• Elevate the cast above the level of the heart to decrease swelling
• Prevent small toys or objects from being put inside the cast

Contact your doctor if your child develops one or more of the following symptoms:

• Fever greater than 101°F (38.3°C)
• Increased pain
• Increased swelling above or below the cast
• Complaints of numbness or tingling
• Cool or cold toes
• Drainage or foul odor from the cast

Most infants with clubfoot can be corrected with serial manipulation and casting. Some infants may require surgery to help correct the position of the foot. Additional surgeries may be necessary since the deformity may come back as the child grows and develops.