Let’s switch gears from DDH and start talking a little bit about clubfeet. The real name for clubfeet
is talipes equinovarus. But I’m going to call it clubfoot for short. This is a congenital complex
fixed foot deformity. Basically, the mid and forefoot are adducted. There is equinovarus of the hind foot.
This results in a high foot arch. Let me show you what I’m talking about. It’s generally idiopathic.
It may be associated with other problems such as developmental dysplasia of the hip or arthrogryposis.
There is a strong familial tendency even in distant relatives. We don’t know why but if great grandma
has a clubfoot, her child, her great grandchild may as well. So, here’s a picture of a child with a clubfoot.
As you can see, this child will have thin calf muscles from underuse. The forefoot is adducted.
There is a shortened foot. The entire foot is inverted and supinated with the heel rotated inwards
which is varus and the ankle in plantar flexion which is quinus. Here is a photo to show you
what I’m talking about. It’s a shortened foot. It’s bent in and up, supinated as it were.
Basically, with a child who has a clubfoot, it’s noticed usually right at birth. Those children should be
referred to the pediatric orthopedist. Left untreated, this child will start to learn to walk
on the side or top of the foot and it will result in a lifelong limp. Initial treatment is usually with a variety
of splinting and casting, a serial and gradual remanipulation of the foot into a correct position.
In some cases however, surgery is absolutely required. Usually around 6-12 months old
after the patient starts a splinting and casting regimen, the child may eventually go to surgery.
If the child has a poor response to both splinting and casting and surgery, they may have further
surgical correction at 5-6 years of age to continue to try and improve the function of that foot.
Let’s switch gears one more time to metatarsus adductus. This is also called metatarsus varus.
This is a deformity of the foot where the foot is turned inward as you can see in this picture.
This is the most common foot deformity in infants. About half the time, it’s bilateral. There is often
a family history. It’s also associated with torticollis or developmental dysplasia of the hip, in other words,
a tight uterine environment. The child has perhaps less hydramnios, oligohydramnios and that cramped
uterine environment has caused this feet to become this way. So, what you will note on exam
when you’re looking from the bottom of the patient is a medial deviation of the forefoot
but a normal hindfoot. The forefoot can be possibly stretched into a neutral position.
Ankle flexion and extension is normal. Therapy is through passive stretching or you can do
no therapy at all. This often will self-correct on its own by one to two years of age.
We do refer to orthopedics if it’s a fixed deformity, if it’s painful, or if the child is having difficulty
finding shoes that work for that child. Let’s look now at intoeing in children, reasons why children
tend to have their feet pointing in. This is a common complaint among parents coming to their
primary care provider. There are a couple of different reasons why this happens.
One possibility is tibial torsion. The femurs and knees are facing forward but the tibiae have torsed inward.
This often occurs in toddlers and may be associated with bowed legs which is also called tibia varus.
Usually in children with intoeing, no therapy is needed. Just let the families know
this will likely resolve in time. Patients may also develop femoral anteversion as a cause of intoeing.
Here, the knees are inwardly rotated because the problem is actually at the femoral insertion
into the pelvis. The femurs themselves are anteverted or turned in. We see this commonly in children
who like to sit in this sort of W position. Children sitting in this W position have an easy time
internally rotating their femurs. Sometimes this is associated with joint hypermobility
as in patients with Ehlers–Danlos syndrome. The good news is just like in tibial anteversion,
this problem self-corrects. Usually it self-corrects by around eight years of age. So, that's a brief summary
of the most common problems with the development of the legs in children. Thanks for your attention.