Discussion in 'Spot Diagnosis' started by neo_star, Dec 27, 2012.
Hint: Most common congenital abnormality of foot
congenital talipes equinovarus
Ans : Metatarsus adductus
In patients with this condition, the front part of the foot (the forefoot) is turned inward as a result of adduction of the metatarsi at the tarsometatarsal joints associated with normal alignment of the hindfoot and midfoot. Most cases are mild and flexible, with the foot easily dorsiflexed and the lateral aspect easily straightened by passive stretching. A simple test to determine if the kidney-shaped curvature is within normal limits is to draw a line that bisects the heel. When extended, this line normally falls between the second and third toe space. If it falls more laterally, metatarsus adductus is present. In utero positioning is the suspected cause of the condition.
It is seen more frequently in first-born children, presumably because primigravida mothers have stronger muscle tone in the uterine and abdominal walls.
[TD="class: PA"]If the foot can be passively abducted beyond neutral, the prognosis is excellent for a spontaneous correction without any therapeutic intervention. In those feet that are stiffer, a program of passive stretching is in order. The parents are taught to hold the heel in a neutral position and manually abduct the forefoot using their thumb placed over the cuboid as a fulcrum. This exaggerated position should be held for a few seconds and the stretching repeated 10 times each session. These sessions should occur with bathing and diaper changing.
[TD="class: H9, width: 100%"]How do congenital metatarsus adductus and congenital metatarsus varus differ?
[TD="class: H9, width: 100"][Broken External Image]:http://forum.facmedicine.images/button_ansshow.gif
[TD="class: PA, width: 100%, bgcolor: #ffffff"]Both deformities are types of kidney-shaped feet in which the forefoot becomes adducted as a result of varying degrees of intrauterine compression. In metatarsus adductus, there is no bone abnormality, and the curvature can be readily corrected by passive stretch. In metatarsus varus, there is subluxation of the tarsometatarsal joints when the foot is dorsiflexed. Physical examination usually reveals a deep medial cleft, prominence of the base of the fifth metatarsal, and an inability to correct the forefoot passively to align with the heel. Making the distinction is important, because metatarsus adductus usually resolves spontaneously, whereas metatarsus varus gradually worsens without treatment.
[TD="class: PA, width: 100%, bgcolor: #ffffff"]Craig CL, Goldberg MJ: Foot and leg problems. Pediatr Rev 14:395-400, 1993.
Related Self Assessment Question
The fig shows the clinical photograph of a 3-month-old infant with a foot deformity that has been nonprogressive since birth.
Examination reveals that the deformity corrects actively and with passive manipulation. There is no associated equinus. Management should consist of
1. serial casting.
2. UCBL orthoses.
3. abductor hallucis lengthening.
4. observation and parental reassurance.
5. corrective shoes.
PREFERRED RESPONSE: 4
DISCUSSION: The patient has bilateral metatarsus adductus deformities. In a long-term follow-up study by Farsetti and associates, deformities that were passively correctable spontaneously resolved and no treatment was required. More rigid deformities were successfully treated with serial manipulation, with good results in 90%. There were no poor results. Therefore, observation is the management of choice for passively correctable deformities. In feet that are more rigid, serial manipulation and casting is the management of choice.
Farsetti P, Weinstein SL, Ponseti IV: The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265.
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