Module 45, Pediatric Orthopaedist Level

A 2 year old boy was seen for evaluation of intoeing. He had been previously diagnosed with bilateral metatarsus adductus at another institution. His prior treatment consisted of serial casting for eight weeks which began shortly after birth, this was followed by corrective shoes until 12 months of age. His parents felt that the metatarsus adductus had improved since birth, however they still had concerns over the residual deformity. They denied that their child had any functional problems. There was a positive maternal family history of "intoeing" which was treated with a Dennis Browne bar and corrective shoes. Examination revealed a well-appearing child. He had bilateral mild internal tibial torsion, however the major component of his intoeing appeared to be secondary to bilateral metatarsus adductus deformities which were supple and flexible and they were both able to be corrected to neutral position. The patient returned for follow-up at the age of 5 years and 1 month. His mother stated that he still had residual intoeing, and he appeared more clumsy with gait than other children his age. She was concerned that his metatarsus adductus had not corrected, and she wanted to know if anything more could be done. The patient still had not had any functional problems, nor had he any shoe wear problems. Examination revealed bilateral flexible metatarsus adductus deformities. There was no evidence of any skin breakdown or callous formation. He did have a noticeable valgus right heel with a less obvious left heel valgus deformity. His subtalar motion was maintained.

Question 45A

Now, by age 5 years this child definitely has a skewfoot.

Question 45B

In planning the treatment it is important to determine if the child has skewfoot or metatarsus adductus.

Question 45C

Most children with skewfoot are born with the deformity, however it only becomes noticeable as the bones in the foot ossify and the foot becomes more stiff.

Question 45D

Patients never have spontaneous correction of the skewfoot with time.

Question 45E

Now at age five, this boy should plan to have a surgical correction of the hindfoot valgus by subtalar fusion and a closing wedge calcaneocuboid fusion.