What is clubfoot?
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.
It occurs in about one in every 1,000 live births and affects boys twice as often as girls. Fifty percent of the cases of clubfoot affect both feet.
What causes clubfoot?
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 in a male or female child is about 4 percent overall. In other words, there is a 96 percent chance that another child would not be born with clubfoot.
What are the risk factors for clubfoot?
Risk factors may include:
- Family history of clubfoot
- 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.
How is clubfoot diagnosed?
Your child's physician makes the diagnosis of clubfoot at birth with a physical examination. During the examination, your child's physician 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 physician 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.
- Computed tomography scan (also called a CT or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called "slices"), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
The affected foot may be flexible, known as a "positional clubfoot." This flexible type of clubfoot is caused by the baby's position in the uterus. Positional clubfoot can easily be positioned into a neutral (not curved) position by hand. A true clubfoot is stiff, or rigid, and very hard to manipulate.
The symptoms of clubfoot may resemble other medical conditions of the foot. Always consult your child's physician for a diagnosis.
Treatment for clubfoot:
Specific treatment for clubfoot will be determined by your child's physician 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:
- Serial manipulation and casting - Treatment begins immediately after diagnosis by a pediatric orthopedic surgeon. The first type of treatment is serial manipulation and casting. Your child's physician will stretch the foot by hand. The position of the foot is then held in place with plaster casts. Casts are used to help stretch the soft tissues of the foot. Your child's physician will change the plaster casts every week for the first month, then every two weeks until the foot is straight. The foot usually responds to this type of treatment within the first few months. If the position of the foot does not respond to serial manipulation and casting, then surgery may be considered. Only about one-third of clubfeet are able to be managed with serial manipulation and casting alone.
- Surgery - Ideally, surgery is performed within six weeks to one year of diagnosis. The foot is aligned in a more normal position. A pin is placed in the foot to hold the bones in place while they heal. The pin can be seen between the big and second toes. Following surgery, long leg plaster casts are applied to hold the foot in place as it heals. The long leg cast and pin are removed usually three to four weeks after surgery by your child's physician. Short leg casts will continue to be used for at least three more months to continue to hold the foot in place and allow the tissues and bones to heal.
What are long leg casts?
Long leg casts are applied from the upper thigh to the foot. These casts are used for thigh, knee, or lower leg fractures. They can also be used with knee dislocations or after surgery on the leg or knee area.
What are short leg casts?
A short leg cast is applied to the area below the knee to the foot. This type of leg cast is used for leg fractures and severe ankle sprains/strains or fractures. A short leg cast may also be used to hold the leg or foot muscles and tendon in place after surgery to allow healing.
Cast care instructions:
- Keep the 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
- Prevent small toys or objects from being put inside the cast
- Elevate the cast above the level of the heart to decrease swelling
When to call your child's physician:
Contact your physician if your child develops one or more of the following symptoms:
- Fever greater than 101° F
- Increased pain
- Increased swelling above or below the cast
- Complaints of numbness or tingling
- Drainage or foul odor from the cast
- Cool or cold toes
Long-term outlook for a child with clubfoot:
Some infants with clubfoot will be corrected with serial manipulation and casting. Other 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.