Clubfoot is a pathological deformity that causes the leg and its appended foot to resemble a clubbing instrument. Two varieties of clubfoot have been identified. The more severe talipes equinovarus is a condition in which the heel and forefoot are inverted, the forefoot is adducted, and the entire foot is plantar flexed. Figure 183-3 shows bilateral clubfoot in a newborn; Figure 183-4 shows an untreated right clubfoot. Talipes calcaneovalgus is characterized by eversion of the heel and forefoot, abduction of the forefoot, and dorsiflexion of the entire foot (Figure 183-5). Both forms occur in approximately 1 of every 200 live births, are bilateral in 50% of the cases, and affect boys almost twice as frequently as girls.

In the newborn period, functional deformities of the feet secondary to in utero positioning will often mimic both varieties of clubfoot. These functional deformities can be differentiated readily from clubfoot based on flexibility of the foot. The functionally deformed foot can be brought easily to a neutral position and even overcorrected, which is not possible when pathological deformities are present.

Figure 183-3 Bilateral talipes equinovarus in a newborn. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-4 Untreated talipes equinovarus in a 3-year-old child. (Tachdjian MO. Pediatric Orthopaedics. 2nd ed. Philadelphia, PA: WB Saunders; 1990. Copyright © 1990, Elsevier, with permission.)

Figure 183-5 Bilateral talipes calcaneovalgus. The left foot is held dorsiflexed and the right plantar flexed to show the range of ankle movement. (Sharrard WJW. Paediatric Orthopaedics and Fractures. 2nd ed. Oxford, NY: Blackwell Scientific; 1979. Reprinted by permission of Blackwell Publishing Ltd.)

Although many theories have been offered about the etiology of clubfoot, none has been proved. Most cases are idiopathic and occur in an otherwise-normal infant. If a family has a child with clubfoot, then the incidence in subsequent siblings is 3% to 4%. If 1 parent and a child have clubfoot, then subsequent children have a 25% chance of having clubfoot.

Clubfoot is characterized by 4 distinct components: (1) plantar flexion (equinus) of the ankle, (2) adduction (varus) of the heel (hindfoot), (3) high arch (cavus) at the midfoot, and (4) adduction of the forefoot.

When clubfoot is present, associated neurologic, muscular, or other skeletal anomalies should be sought. Neuromuscular clubfoot is a deformity associated with disorders such as arthrogryposis, meningomyelocele, and congenital constriction band syndrome.

Radiographic examination is required at the time of diagnosis and periodically during treatment to delineate the pathological finding and to guide management.

Treatment is with casting immediately on initial diagnosis; 2 to 4 months of manipulation and casting is usually required for correction. Recurrence is common after correction by manipulation alone; therefore prolonged casting is usually required. Recurrence after casting is most common within the first 2 to 3 years but may still happen up to age 5 to 7 years. Surgical correction (tenotomies, muscle transplants, and arthrodeses) may be required in severe cases, when conservative management fails or as a result of recurrence when the child is older. Recurrence is much less likely after surgical correction. Even with successful treatment the affected foot will be smaller and less mobile than a normal foot. Early initiation of therapy will increase the success rate of manipulative or conservative management and will therefore decrease the need for surgical intervention. Functional deformities are self-correcting and require no treatment.