8. Pes equinovarus

Essay 8- Pes equinovarus (clubfoot)

Definition

• Congenital disorder characterized by deformities of the foot, including cavus midfoot arch, adduction of the forefoot, hindfoot varus, and equinus
• Also called clubfoot

Etiology

• Exact etiology is not clearly known
• Most likely genetic and environmental factors play a role in its manifestation:
• Maternal smoking
• Maternal diabetes
• Maternal alcohol consumption
• 24.4% of cases have an associated family history

What are the main deformities?

• Midfoot cavus
• Forefoot adductus
• Heel/hindfoot varus
• Hindfoot equinus

Pathophysiology

• Deformity predominantly exists in the tarsal bones, which are often in a position of maximal flexion and adduction!
• Presentations vary from mild, postural forms to severe, rigid deformity
• The talus is characteristically medially deviated and in plantarflexion
• The calcaneus is in varus and is rotated medially around the talus
• The navicular and the cuboid are displaced medially

Clinical features

• Often identifiable during routine intrauterine ultrasound of the fetus during the antenatal period!
• Clinically this deformation displays the typical trio of components:
• Equinus (ankle joint lacks flexibility and dorsiflexion)
• Shows a permanent frontal subluxatio of the foot at the ankle joint
• Supination
• Shows a lifting of the inner edge of the foot and lowering of the outer one
• Adduction
• Medial dislocation of the front of the foot
• After the child starts walking all 3 components (equinism, supination and adduction) aggravate fast due to body weight
• Patients step on the outer edge of the foot
• Soles are badly supinated and adducted

Diagnosis

• Prenatal ultrasound
• Clinical evaluation at birth
• X-ray imaging:
• AP films may show parallelism of the talus and calcaneus, with a talocalcaneal angle of fewer than 20 degree

Treatment

• Conservative treatment should begin as early as possible, even straight after birth
• First task is to manage adduction and supination followed by correction of the foot equinus
• Done by using plaster bands, step-by-step redressing or plaster bandages
• Bracing is the second phase of treatment, which maintains the correction achieved!
• Patient should wear the brace should be worn 24 hours per day for the first three months, reducing to 12 hours at night with 2 to 4 hours during the day up to 4 years of age
• Surgical intervention may be required those with residual deformities or recurrent relapses
• Ponseti method- manual reduction and immobilisation up to the age of 3-4 months