Definition
Congenital Talipes Equinovarus
Congenital abnormality of the foot characterised by
- hindfoot equinus & varus
- midfoot supination
- forefoot adduction
Types
Idiopathic
Syndromic - Arthrogryposis
Neurogenic - Spina bifida / Cerebral palsy / Muscular dystrophy / spinal muscular atrophy
Epidemiology Idiopathic
1:1000
Boys 2:1
Bilateral 30-50%
Genetic predisposition
- 35% in identical twins
- familial history - siblings / parents
Pathology
| Bony deformities | Soft tissue | Other |
|---|---|---|
|
Talus - equinus - head medially deviated - body externally rotated |
Plantar fascia - contracted - cavus |
Vessels deficient - dorsalis pedis - +/- posterior tibial - +/- peroneal |
|
Calcaneum - equinus - medial roation |
Tendons - Tendoachilles / Tibialis posterior / FHL / FDL - all shortened / contracted |
Muscles atrophied |
| Navicular - medially subluxed |
Ligaments - deltoid / spring / CFL / PTFL - all shortened / contracted |
|
| Cuboid - medially subluxed / adducted |
Joint capsule contractures - posterior ankle / posterior subtalar - TNJ / CCJ |
|
| Metatarsus adductus |
Clinical
CAVES deformity
- Cavus midfoot - relative pronation of forefoot compared to hindfoot
- Adduction forefoot
- Varus heel
- Equinus - heel
- Supination - midfoot
| Look | Feel | Move |
|---|---|---|
|
CAVES |
Empty heel |
Dorsiflexion |
|
Medial crease |
Palpable talus anterior to lateral malleolus | Eversion |
| Posterior crease | Navicular fixed to medial malleolus | |
| Curved lateral border of foot | Os calcis fixed to the lateral malleolus | |
| Calf atrophy |
Classification
| Postural | Rigid | Teratogenic |
|---|---|---|
|
Normal heel Normal foot size No transverse medial skin crease |
Small foot Atrophic calf Medial skin crease |
Spina bifida Arthrogryposis |
| Passively correctable | No correctable | Worse prognosis |
| No treatment | Ponseti casting |
Pirani scoring system
Six clinical signs of contracture
- each scored 0, 0.5, or 1 based upon severity
- 0 (no deformity), 0.5 (moderate deformity), 1 (severe deformity)
- Final score: 0 (corrected clubfoot), 6 (severe deformity)
| Look (3) | Feel (2) | Move (1) |
|---|---|---|
| Posterior hindfoot crease | Lateral head of talus | Dorsiflexion range / fixed equinus |
| Medial midfoot crease | Empty heel | |
| Lateral curvature of foot |
X-ray
Usually not indicated
- calcaneal & talus ossification centres are present at birth
- cuboid appearing by 6 months
- navicular will not appear until 2-4 years
Angles
Talo-1st metatarsal angle on AP xray
- long axis of talus to long axis of 1st metatarsal
- normal 5-15° abduction
- clubfoot 0° to adduction