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Metatarsus adductus clinic guidelines

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Updated by: Allison Duey-Holtz
Updated on: August 2, 2017 

Definition

An adduction or medial deviation of the forefoot that is recognized as a contracture at the tarsometatarsal joints

Diagnosis/Symptom

Signs and symptoms

  • Deformity usually present at birth but may not present until the first year of life (3)
  • Incidence estimated to be as high as 1 in 100 births (4)

Causes

  • Spontaneous resolution to normal in 83%(1) to 95% (4) of cases by age one
  • Pathogeneis is unknown but is believed to result from intrauterine crowding or positioning (4)

Referring provider’s initial evaluation and management:

Differential Diagnosis

  • Dynamic hallux varus
  • Internal rotation of the foot 
  • Metatarsus primus varus
  • Skewfoot
  • Tibial torsion
  • Clubfoot

Diagnostic Tests

  • Radiographs- not needed unless child has failed casting
  • Xerox of feet

Treatment Options

  • Mild/moderate flexible & approximately 7 months of age:
  • No intervention passively correctible deformity will spontaneously correct on its own by age 1 (3,4)
  • Educate families that the deformity should not interfere with normal development and that the child will have no restrictions or limitations in any sports or activities (4).
  • Offer casting which works best in children under 8 months of age
    Moderate/severe inflexible serial casting:
  • Inflexible: Initiate treatment immediately
  • If present at 8 months may initiate serial casting as the percentage of favorable outcomes decreases if treatment was initiated after the patient was more than 8 months of age (1)
  • If flexible, partially flexible at 8 months may cast
  • Follow-up post casting to ensure no recurrence

When to initiate referral/ consider refer to Orthopedic Clinic:

Parental or provider concern.

What can referring provider send to Orthopedic Clinic?

1. Using Epic

  • Please complete the external referral order In order to help triage our patients and maximize the visit, the following information would be helpful to include with your referral order:
  • Urgency of the referral
  • What is the key question you would like answered?
    Note: Our office will call to schedule the appointment with the patient. 

2. Not using Epic external referral order:

  • In order to help triage our patients maximize the visit time, please fax the above information to (414-607-5288)
  • It would also be helpful to include:
  • Chief complaint, onset, frequency
  • Recent progress notes
  • Labs and imaging results
  • Other Diagnoses
  • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient’s problems

Specialist’s workup will likely include:

After referral to Orthopedic Clinic:

  • Comprehensive birth history
  • Family history
  • HPI
  • Neuromuscular exam
  • Gait evaluation
  • Evaluate for hip dysplasia (9)
  • Complete rotational profile (internal and external hip rotation, thigh-foot axis, transmalleolar axis, heel bisector angle, foot progression angle) (1,3,4)
  • Neuromuscular exam
  • Assessment of the foot, assess for degree of flexibility (4)
  • Evaluate for hip dysplasia or other congenital orthopedic conditions(4)
  • Evaluate heel bisector line (1)
  • Identify: flexible, partially flexible, inflexible

Follow up Recommendations

If flexible & less than 7 months

  • f/u as needed at 7 months
  • Bi-weekly for 6-8 weeks if treating with plaster casts (2)

Follow-up with surgeon:

  • Over age 2years old
  • Rigid/Inflexible after casting
  • Operative treatment is not needed or desirable in patients who have mild or moderate deformities past age 2yo(3)

Evidenced Based Literature Review

Bleck, E.E. (1983). Metatarsus adductus: Classification and relationship to outcomes of treatment. Journal of Pediatric Orthopedics. 3, 2-9.

Farsetti, P., Weinstein, S.L., & Ponseti, I.V. (1994). The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. Journal of Bone & Joint Surgery. 76, 257-265.

Hart, E.S., Grottkau, B.E., Rebello, G.N., & Albright, M.B. (2005). The newborn foot: Diagnosis and management of common conditions. Orthopaedic Nursing. 24(5), 313-321.

Herring, J. A. (2008). Disorders of the foot. In M.O. Tachdjian & J.A. Herring (Eds), Tachdjian’s Pediatric Orthopedics (4th Ed) (pp.1035-1186). Philadelphia: Saunders Elsevier

Katz, K., David, R., & Soudry, M. (1999). Below-knee plaster cast for the treatment of metatarsus adductus. Journal of Pediatric Orthopedics. 19(1), 49-50.

Ponseti, I.V. & Becker, J.R. (1966). Congenial metatarsus adductus: The results of treatment. The Journal of Bone & Joint Surgery. 48, 702-711.

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