9
Orthopaedic Nursing September/October 2005 Volume 24 Number 5 313 The Newborn Foot Diagnosis and Management of Common Conditions Erin S. Hart Brian E. Grottkau Gleeson N. Rebello Maurice B. Albright and infant physical examination. By detecting these com- mon deformities early, corrective treatment can be given and a successful outcome can often be reached. The phys- ical examination should include assessment of the vascu- lar, dermatologic, and neurologic status, as well as obser- vation, palpation, and evaluation of joint range of motion in both feet (Gore & Spencer, 2004). Often, simple obser- vation alone will reveal an obvious deformity of the foot. Although potentially challenging, the accurate diagnosis and assessment of these congenital deformities is vitally important to the prognosis and ultimate outcome. An assessment of the foot should be a part of every newborn physical examination. The newborn foot, although complex in structure, can be examined quickly in any office setting. Many foot deformities are diagnosed immediately after birth, allow- ing for earlier and often more successful treatment. A neonate with a foot deformity can be a source of anxiety to parents. Adequate knowledge of commonly encountered neonatal foot problems enables the nurse to give appropriate anticipa- tory guidance to the parents. Foot abnormalities usually occur as isolated findings in an otherwise healthy newborn. However, these deformities can also be seen in newborns with underlying neuromuscular dis- orders and syndromic conditions. Common newborn foot ab- normalities include equinovarus deformity (clubfoot), metatar- sus adductus, calcaneovalgus, congenital vertical talus, polydactyly (supernumerary digits), and syndactyly (webbed toes). These common foot disorders, their treatment, and their prognosis are discussed. This article also discusses fundamen- tal nursing implications needed to care for these young patients and their families. C ongenital deformities of the foot are relatively com- mon in newborns, but are frequently overlooked dur- ing routine physical examinations. Deformities in a neonatal foot encompass a clinical spectrum ranging from an isolated intrauterine positioning deformity to a nonfunctional foot with progressive deformity. Distin- guishing between a temporary positional deformity and a more serious structural malformation of the foot is challenging and requires a thorough understanding of anatomy, embryologic development, and the effect of environmental and intrauterine factors (Furdon & Donlon, 2002). A newborn foot is a small and complex structure. The foot consists of 26 bones, although most are cartilaginous and unossified at birth. The foot can be divided into three anatomic regions: the hindfoot (talus and calcaneus), the midfoot (navicular, cuboid, and three cuneiform bones), and the forefoot (metatarsals and phalanges). Both feet should be evaluated as a routine part of every neonatal Erin S. Hart, MS, RN, CPNP, RNFA, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. Brian E. Grottkau, MD, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. Gleeson N. Rebello, MD, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. Maurice B. Albright, MD, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. Although potentially challenging, the accurate diagnosis and assessment of these congenital deformities is vitally important to the prognosis and ultimate outcome. For simplicity and to facilitate identification, congeni- tal deformities in the foot can be classified into the follow- ing groups: 1. Toes pointing downward and/or inward: clubfoot, metatarsus adductus. 2. Toes pointing upward and/or outward: calcaneoval- gus, congenital vertical talus. 3. Too many toes (polydactyly), toes stuck together (syndactyly). 3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 313

Newborn Foot

Embed Size (px)

DESCRIPTION

7 of 7 journals assigned readings from Dr. Pascual (Ortho lect on June 3, 2008)

Citation preview

Page 1: Newborn Foot

Orthopaedic Nursing September/October 2005 Volume 24 Number 5 313

The Newborn FootDiagnosis and Management of Common Conditions

Erin S. Hart ▼ Brian E. Grottkau ▼ Gleeson N. Rebello ▼ Maurice B. Albright

and infant physical examination. By detecting these com-mon deformities early, corrective treatment can be givenand a successful outcome can often be reached. The phys-ical examination should include assessment of the vascu-lar, dermatologic, and neurologic status, as well as obser-vation, palpation, and evaluation of joint range of motionin both feet (Gore & Spencer, 2004). Often, simple obser-vation alone will reveal an obvious deformity of the foot.Although potentially challenging, the accurate diagnosisand assessment of these congenital deformities is vitallyimportant to the prognosis and ultimate outcome.

An assessment of the foot should be a part of every newbornphysical examination. The newborn foot, although complex instructure, can be examined quickly in any office setting. Manyfoot deformities are diagnosed immediately after birth, allow-ing for earlier and often more successful treatment. A neonatewith a foot deformity can be a source of anxiety to parents.Adequate knowledge of commonly encountered neonatalfoot problems enables the nurse to give appropriate anticipa-tory guidance to the parents.

Foot abnormalities usually occur as isolated findings in anotherwise healthy newborn. However, these deformities canalso be seen in newborns with underlying neuromuscular dis-orders and syndromic conditions. Common newborn foot ab-normalities include equinovarus deformity (clubfoot), metatar-sus adductus, calcaneovalgus, congenital vertical talus,polydactyly (supernumerary digits), and syndactyly (webbedtoes). These common foot disorders, their treatment, and theirprognosis are discussed. This article also discusses fundamen-tal nursing implications needed to care for these young patients and their families.

Congenital deformities of the foot are relatively com-mon in newborns, but are frequently overlooked dur-

ing routine physical examinations. Deformities in aneonatal foot encompass a clinical spectrum rangingfrom an isolated intrauterine positioning deformity to anonfunctional foot with progressive deformity. Distin-guishing between a temporary positional deformity anda more serious structural malformation of the foot ischallenging and requires a thorough understanding ofanatomy, embryologic development, and the effect ofenvironmental and intrauterine factors (Furdon &Donlon, 2002).

A newborn foot is a small and complex structure. Thefoot consists of 26 bones, although most are cartilaginousand unossified at birth. The foot can be divided into threeanatomic regions: the hindfoot (talus and calcaneus), themidfoot (navicular, cuboid, and three cuneiform bones),and the forefoot (metatarsals and phalanges). Both feetshould be evaluated as a routine part of every neonatal

▼ Erin S. Hart, MS, RN, CPNP, RNFA, Department of OrthopaedicSurgery, Yawkey Center for Outpatient Care, Mass General Hospital forChildren, Boston.

▼ Brian E. Grottkau, MD, Department of Orthopaedic Surgery, YawkeyCenter for Outpatient Care, Mass General Hospital for Children, Boston.

▼ Gleeson N. Rebello, MD, Department of Orthopaedic Surgery, YawkeyCenter for Outpatient Care, Mass General Hospital for Children, Boston.

▼ Maurice B. Albright, MD, Department of Orthopaedic Surgery, YawkeyCenter for Outpatient Care, Mass General Hospital for Children, Boston.

Although potentially challenging, theaccurate diagnosis and assessment ofthese congenital deformities is vitallyimportant to the prognosis and ultimateoutcome.

For simplicity and to facilitate identification, congeni-tal deformities in the foot can be classified into the follow-ing groups:

1. Toes pointing downward and/or inward: clubfoot,metatarsus adductus.

2. Toes pointing upward and/or outward: calcaneoval-gus, congenital vertical talus.

3. Too many toes (polydactyly), toes stuck together(syndactyly).

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 313

Page 2: Newborn Foot

314 Orthopaedic Nursing September/October 2005 Volume 24 Number 5

There are some key developmental stages that should benoted in the immature foot. Rapid growth of the foot oc-curs from approximately 4 weeks’ gestation when thelimb bud forms until approximately 18 months of agewhen the foot is approximately half of its adult size. Inaddition, neonatal and infant feet have a much greaterrange of motion than the adult foot, and joint laxity isquite common. The longitudinal arch of the foot is notpresent in the neonatal and infant foot. The longitudinalarch develops with growth and is often not clearly de-fined until age 4–5 years. The foot of a newborn shouldnormally appear flat, as there is a greater amount of sub-cutaneous fat in the neonatal foot (Figure 1) (Alexander& Kuo, 1997).

Metatarsus AdductusMetatarsus adductus is a common neonatal foot problemin which the forefoot is adducted and the lateral borderof the foot is convex (curved). Metatarsus adductus dif-fers from a clubfoot in that the heel or hindfoot is not inequinus. The incidence is estimated to be as high as 1 in100 births in the United States (Widhe, Aaro, & Elmstadt,1988). The pathogenesis is unknown but is believed to re-sult from intrauterine crowding or positioning. The charac-teristic features of metatarsus adductus are a lateral curvedborder of the foot, a “bean-shaped” sole of the foot, and ad-ductus or turning in of the forefoot (Figures 2A and B).

FIGURE 1. Normal newborn foot.

FIGURE 2(A) and (B). Metatarsus adductus of the foot. Notecurved lateral border of the foot.

A

B

The characteristic features of metatarsusadductus are a lateral curved border ofthe foot, a “bean-shaped” sole of thefoot, and adductus or turning in of theforefoot.

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 314

Page 3: Newborn Foot

Orthopaedic Nursing September/October 2005 Volume 24 Number 5 315

The foot with metatarsus adductus should be assessedfor the degree of flexibility. If the deformity is flexible andthe foot corrects to a normal position, treatment is rarelyneeded. Parents can be instructed to perform stretchingexercises several times a day; however, the overwhelmingmajority of these feet (approximately 95%) will sponta-neously resolve regardless of treatment (Weinstein, 2000).The stretching exercises consist of stabilizing the heeland gently pulling the forefoot into the corrected posi-tion. It must also be noted that metatarsus adductus hasan approximately 5% association with developmental hipdysplasia; therefore, these patients should always have acareful hip examination (Staheli, 2001).

If the forefoot deformity is severe and rigid (does notcorrect to normal with stretching), serial manipulationand casting may be necessary. Neonates and infants witha stiff metatarsus adductus should be referred to a pediatricorthopaedic surgeon early, because the treatment is mostsuccessful when casting is started at less than 6 monthsof age. When casting is needed in feet with a stiff defor-mity, 4–6 serial casts will be applied at weekly intervals.The feet are then placed in straight-last shoes or night-time bivalved casts to maintain the correction.

Surgical intervention is rarely indicated for metatarsusadductus and is only recommended in children older than3 years with a rigid deformity that has not responded tomanipulation and casting (Weinstein, 2000). Oftentimes,the difficulty in treating newborns and infants with meta-tarsus adductus is not in treating the actual foot defor-mity. It is often more difficult to convince parents andgrandparents that flexible metatarsus adductus will spon-taneously resolve. Nurses can have a key role in reinforc-ing the natural history and high percentage of sponta-neous resolution of metatarsus adductus. Parents shouldbe reassured that the deformity should not interfere withnormal development and that the child will have no restric-tions or limitations in any sports or activities (Ryan, 2001).

resolve on its own. A clubfoot can easily be differentiatedfrom metatarsus adductus by the hindfoot equinus.

All neonates and infants with suspected clubfoot shouldbe fully undressed for the physical examination and shouldbe assessed for possible anomalies of the head, neck, chest,hips, and spine. On examination, there is pronouncedtightness of the Achilles tendon, with an inability to dorsi-flex the foot or get the foot flat on the ground when theinfant is placed in a standing position (Figure 3A). Themedial border of the foot is concave in a clubfoot, andthere is often a deep medial skin crease seen in the foot.The heel, or calcaneus, is drawn up and inverted, and adeep skin crease is also seen on the posterior aspect ofthe ankle joint (Figure 3B). Regardless of any treatment

Nurses can have a key role inreinforcing the natural history and highpercentage of spontaneous resolution ofmetatarsus adductus. Parents should bereassured that the deformity should notinterfere with normal development andthat the child will have no restrictions orlimitations in any sports or activities.

ClubfootClubfoot, also known as talipes equinovarus, is a congen-ital deformity of the foot that occurs in approximately1–2 in 1,000 births in the United States. The clubfoot hasa typical appearance of pointing downward and twistinginward. The four main components of clubfoot are inver-sion and adduction of the forefoot, inversion of the heeland hindfoot, equinus of the heel, and internal or medialrotation of the lower extremity (Gore & Spencer, 2004).The deformity is not passively correctible and does not

A

B

FIGURE 3. (A) Congenital clubfoot deformity. (B) Severe bilat-eral clubfoot deformity. Note severe equinovarus.

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 315

Page 4: Newborn Foot

316 Orthopaedic Nursing September/October 2005 Volume 24 Number 5

given, the calf of the affected lower extremity is smaller incircumference, and the foot is slightly smaller and stifferthan an uninvolved foot (Dietz, 2002). Research hasshown that there is a male to female prevalence of ap-proximately 2.5:1, and approximately 50% of all casesoccur bilaterally.

There is still a great deal of controversy surroundingclubfoot, including its etiology, pathologic anatomy, andtreatment (Heilig, Matern, Rosenzweig, & Bennett, 2003).Clubfoot represents a spectrum of congenital deformitythat ranges from the mild “postural” clubfoot to the severeneuromuscular clubfoot that is associated with conditionssuch as arthrogryposis and myelomeningocele (spina bi-fida). Clubfoot is often termed idiopathic; however, it canalso be seen with extrinsic factors (congenital constrictionbands), Mendelian disorders (craniocarpotarsal dyspla-sia, Larsen syndrome, Pierre Robin sequence, and distalarthrogryposis), chromosomal abnormalities, and neuro-muscular disorders (amyoplasia and myelomeningocele)(Dietz, 2002). Although the etiology of clubfoot remainsunknown, there is dysplasia of all osseous, muscular, tendi-nous, cartilaginous, skin, and neurovascular structuresdistal to the knee in the affected limb. Clubfoot is a com-plex multifactorial deformity; both genetic and environ-mental factors are believed to play a role.

There are several different methods of classificationused in the diagnosis of congenital clubfoot. The mostcommon system used today is the etiologic classification,where the clubfoot is termed positional, idiopathic, or ter-atologic. Positional clubfoot is believed to be caused byintrauterine positioning late in pregnancy. These feet areflexible and usually resolve quickly with serial casting.Idiopathic clubfoot includes the multifactorial classic formwith an intermediate degree of stiffness. The teratologicclubfoot is associated with neuromuscular or syndromicdisorders, such as arthrogryposis. These feet are the mostdifficult to manage, because they are stiff and do not re-spond as well to nonoperative treatment.

The improvements in obstetric ultrasound in the UnitedStates have led to a significant increase in the prenatal di-agnosis of clubfoot. The 16- to 20-week ultrasound oftenshows the classical features of a clubfoot, allowing forearly prenatal counseling (Treadwell, Stanitski, & King,1999). Researchers have started to investigate the sensi-tivity and specificity for the prenatal diagnosis of club-foot made via routine ultrasound. One study done atBrigham and Women’s Hospital, Boston, investigated theoutcome of fetuses with clubfeet diagnosed by prenatalsonography. From 1989 to 2002, a total of 121 fetuses hada prenatal diagnosis of clubfoot; 48% had unilateral club-foot, whereas 52% had bilateral clubfoot on sonography.The false-positive rate was significantly higher with unilat-eral clubfoot (29%) than with bilateral clubfoot (7%). It wasalso noted that there was a much higher association ofother musculoskeletal anomalies, neural tube defects, andcardiovascular anomalies in the fetuses with bilateral club-foot (Mammen & Benson, 2004).

Prenatal diagnosis of clubfoot is extremely helpful inproviding expectant parents with time to learn about thediagnosis and current management of congenital club-foot. At the authors’ facility, a prenatal visit is scheduledto review the diagnosis of clubfoot and an educationalhandout is distributed that reviews expectations and thecurrent treatment algorithm. This visit is tremendouslyhelpful in easing parental anxiety, and it also assists in es-tablishing a long-term relationship with the family.

TreatmentAll suspected clubfoot deformities should be referred to apediatric orthopaedic surgeon for definitive diagnosisand treatment immediately after birth. Most orthopaedicsurgeons agree that the initial treatment of all clubfootdeformities should be nonsurgical. There is also general-ized consensus that the earlier treatment of clubfoot has ahigher success rate in the nonoperative treatment of club-foot. Many facilities prefer to initiate treatment in thenewborn nursery or neonatal intensive care unit withinthe first 24–28 hours of delivery. The objective of manag-ing all clubfeet is to correct the deformity and obtain aplantigrade (foot flat on the ground) foot with a normalload-bearing area.

Current Treatment AlgorithmThe majority of pediatric orthopaedic surgeons will initi-ate treatment on all clubfeet as soon as the diagnosis ismade. There has been a recent shift away from extensive

Clubfoot represents a spectrum ofcongenital deformity that ranges fromthe mild “postural” clubfoot to thesevere neuromuscular clubfoot that isassociated with conditions such asarthrogryposis and myelomeningocele(spina bifida).

The anatomic deformities seen in a clubfoot are nu-merous and complex. This has been an ongoing topic ofcontroversy among researchers. The most notable abnor-malities include a hypoplasia of the tarsal bones, with re-duced size and shortening of the talus. The talus is short-ened and deviated in a medial and plantar direction. Thereis also medial subluxation of the navicular bone on thetalar head so that it abuts the medial malleolus. The talusand calcaneus therefore become more parallel in all threeplanes (Staheli, 2001). In addition, there is thickening ofthe ligaments and muscular hypoplasia. This results in ageneralized hypoplasia of the limb, with shortening of thefoot and a smaller calf size. Parents should be informedthat a child with a unilateral clubfoot will often wear twodifferent shoe sizes. The degree of hypoplasia and theamount of foot shortening parallels the severity of theclubfoot deformity (Staheli, 2001). It should also be notedthat clubfoot can be associated with other anomalies orpart of a generalized syndrome. The overall incidence ofthese associated anomalies varies widely from 14% to67% (Crawford & Durrani, 2002). The presence of clubfootshould therefore prompt providers to perform a multi-system physical examination.

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 316

Page 5: Newborn Foot

Orthopaedic Nursing September/October 2005 Volume 24 Number 5 317

and hindfoot varus are corrected before starting any cor-rection of the heel cord equinus. Correction of equinus isnot attempted until the foot can be fully abducted on thetalus past neutral (Ponseti, 1996). The correction of theheel cord equinus frequently involves a percutaneous heelcord tenotomy (small procedure where the Achilles ten-don is transected at its insertion into the calcaneus). Thisis done under either local sedation in the office setting orlight anesthesia in the operating room. The tenotomy isdone in approximately 85–90% of all patients with club-foot. After the tenotomy, the foot is placed into a long legcast for another 3 weeks. When this cast is removed, thepatient is then placed into a Denis Browne splint withstraight-last shoes (Figure 5A).

Ponseti’s nonoperative approach to clubfoot proposesto gradually correct the deformity without producing thescar tissue that is commonly seen in feet that have had ex-tensive reconstructive surgery (Ponseti, 1996). After cor-rection of the clubfoot, splinting is essential in preventinga recurrence of the deformity. The infant must wear theDenis Browne splint full-time for 2–3 months and thenfor nighttime/naps only for an approximate 3-year period.Parents should be informed of the importance in followingthis bracing regimen to achieve the desired long-termsuccessful outcome (Figure 5B).

An untreated clubfoot deformity will continue to worsenover time with secondary bony changes developing. An

surgical reconstruction of the clubfoot, with more em-phasis placed on early nonoperative correction. The threemain goals of nonsurgical treatment are to provide ma-nipulative correction, restore movement, and maintainthe correction (Crawford & Durrani, 2002). The currenttreatment regimen involves early manipulation (stretch-ing) and serial casting. The treatment of clubfoot shouldideally begin in the first few days of life to take advantageof the neonate’s favorable fibroelastic connective tissue(Heilig et al., 2003). The foot is stretched, and a slow cor-rection is obtained with each cast. The long leg casts arechanged weekly (because of the rapid growth of the new-born) for a total of approximately 6–8 weeks. Clubfootcasts must be placed above the knee to control rotation ofthe lower extremity and to decrease the likelihood of thecasts falling off.

The three main goals of nonsurgicaltreatment are to provide manipulativecorrection, restore movement, andmaintain the correction.

FIGURE 4. Ponseti long leg plaster cast.

Many surgeons are currently using the soft fiberglassmaterial for the casts, although there has been a recenttrend in using the traditional plaster of paris. A slightlydifferent approach, developed by Dr. Ignatio Ponseti atthe University of Iowa, has become more widely used inthe management of clubfoot. A survey that was given to541 pediatric orthopaedic surgeons in 2003 revealed thatnearly 65% stated that they used the Ponseti casting tech-nique (Heilig et al., 2003). Dr. Ponseti has made tremen-dous contributions throughout his entire career to gainunderstanding and insight in the management of congen-ital clubfoot. Ponseti’s approach to clubfoot involves earlymanipulation and long leg casting. These casts are madefrom plaster of paris and are applied at weekly intervalsfor 5- to 6-week course (Herzenberg, 2002) (Figure 4).

In the Ponseti approach, there is a defined sequence inhow the correction is obtained. The forefoot adduction

A

FIGURE 5(A) and (B). Six-month-old patient with DenisBrowne splint.

B

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 317

Page 6: Newborn Foot

318 Orthopaedic Nursing September/October 2005 Volume 24 Number 5

Calcaneovalgus must be differentiated from congenitalvertical talus. This is easily done by viewing the hindfoot,which is in severe equinus in a foot with congenital verticaltalus. A neonate with a congenital vertical talus will alsodemonstrate a “rocker bottom” appearance or convexityof the sole. Any deformity that is suspected to be a congen-ital vertical talus should always be referred to a pediatricorthopaedic surgeon for evaluation and treatment.

The prognosis for complete spontaneous resolution inneonates with a calcaneovalgus deformity is excellent inthe majority of cases. Parents must be counseled that thedeformity is not fixed and that it will resolve on its ownwithout treatment. Although they are often encouragedto stretch the foot, parents probably benefit more fromthe treatment, because the deformity resolves on its ownby approximately 3–6 months of age without residual se-quelae (Sullivan, 1999). Occasionally, in the most severecases, serial casting of the foot in plantarflexion and in-version can be done to facilitate correction.

Congenital Vertical TalusCongenital vertical talus, also known as rocker-bottomfoot, is a rare deformity that results in reversal of the nor-

uncorrected clubfoot in the older child/adult is disabling.The abnormal development of the foot will cause the pa-tient to walk on the outside of his or her foot. This part ofthe foot is not designed for weight bearing, and signifi-cant calluses and pain are frequent problems in these pa-tients. Correction of the older child/adult with congenitalclubfoot is challenging and often involves extensive surgi-cal reconstruction.

The role of nursing in the treatment of clubfoot shouldnot be understated. It is the nurse who supports the fam-ily through the initial diagnosis, the frequent initial visitsto the orthopaedic surgeon for casting, and the long-termfollow-up care. Parents must learn to cope with the birthof a child with a congenital deformity, as well as the often-arduous initial treatment plan that is usually initiatedshortly after birth (McCullough & Pellino, 1994). Nursescan improve compliance and outcomes through frequentreinforcement of the treatment protocol and parental en-couragement (Luther & Faulks, 2005). To ease parentalanxiety, nurses should remember to emphasize that thetreatment of clubfoot is successful and that these chil-dren go on to live normal, happy, and healthy lives. Thereare no limitations that should be enforced. Many eliteathletes, in fact, were born with clubfeet. Although wecertainly do not understand the precise etiology orpathophysiology behind clubfoot, the methods of treat-ment have improved significantly during the last several

FIGURE 6(A) and (B). Corrected clubfoot deformity. Note fulldorsiflexion of foot.

To ease parental anxiety, nurses shouldremember to emphasize that thetreatment of clubfoot is successful andthat these children go on to live normal,happy, and healthy lives.

A

B

years, and the overall prognosis in this deformity is excel-lent (Figures 6A and B).

CalcaneovalgusCalcaneovalgus is believed to be a postural deformity sec-ondary to intrauterine positioning in which the dorsumof the foot is directly opposed to the anterior aspect of theleg (Figures 7A and B). The deformity is flexible, and thereare no tarsal dislocations or subluxations. It has also beendescribed as a neonatal flexible flatfoot. In the calcaneo-valgus foot, the hindfoot is in the dorsiflexed position(calcaneus position) so that the plantar aspect of the fore-foot is collinear with it. Newborns with a calcaneovalgusfoot will often dorsiflex the foot all the way up to the tibia(Alexander & Kuo, 1997). The estimated incidence of cal-caneovalgus is 0.4–1 in 1000 live births (Nunes & Dutra,1986), although some believe that a mild form of thispostural deformity is seen in approximately 30–40% ofall newborns. It also is more common in females and inbreech deliveries. Neonates with a calcaneovalgus footmay have a slightly higher incidence of developmentalhip dysplasia. Therefore, a thorough hip examination iswarranted in all of these patients.

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 318

Page 7: Newborn Foot

Orthopaedic Nursing September/October 2005 Volume 24 Number 5 319

mal longitudinal arch. This foot deformity is distinguishedby the rocker-bottom or convex appearance of the solecombined with severe heel cord equinus (Figure 8). It isuncommon and is considered the most severe and seriouspathologic flatfoot (Staheli, 2001). The foot is stiff, withcontractures of both the dorsiflexors and plantarflexors.The etiology of congenital vertical talus is unknown. Someresearchers believe that the deformity may result frommuscle imbalance. Both sexes are affected equally, andcongenital vertical talus is bilateral in approximately 50%of cases. Similar to clubfoot, congenital vertical talus can

The treatment of congenital vertical talus often involvessurgical correction between the ages of 6 and 12 months.Conservative therapies, such as manipulation and serialcasting, are often unsuccessful in this deformity. Currently,most surgeons believe that casting can be used to gradu-ally stretch the soft tissues but that surgical reconstructionis necessary in nearly all cases. Because congenital verticaltalus is such a rare deformity, there are not nearly as manylong-term studies when compared to other neonatal footdeformities. Most surgeons are currently using a single-stage surgery to obtain the necessary correction (Drennan,1995; Stricker & Rosen, 1997).

The best results are usually obtained when surgical cor-rection is done before 2 years of age (Jackson & Stricker,2003). The procedure most commonly done is a heel cordlengthening, posterolateral release, elevation of the plan-

FIGURE 7. (A) Typical appearance of a calcaneovalgus foot. (B)Note dorsiflexion of foot to tibia.

Congenital vertical talus, also known asrocker-bottom foot, is a rare deformitythat results in reversal of the normallongitudinal arch. This foot deformity isdistinguished by the rocker-bottom orconvex appearance of the sole combinedwith severe heel cord equinus.

A

B

FIGURE 8. Congenital vertical talus foot with typical “rocker-bottom” appearance.

The treatment of congenital verticaltalus often involves surgical correctionbetween the ages of 6 and 12 months.Conservative therapies, such asmanipulation and serial casting, areoften unsuccessful in this deformity.

be classified into two groups: idiopathic and teratologic.Approximately 50% of vertical tali are idiopathic, but theremainder are associated with various syndromes andneuromuscular conditions, such as arthrogryposis, myelo-meningocele, and chromosomal abnormalities (Jackson& Stricker, 2003). Therefore, all patients with congenitalvertical talus should have a careful evaluation for an un-derlying cause or associated disorder.

The typical radiographic evaluation of congenital ver-tical talus includes an anterior-posterior (AP) and a lat-eral view of the foot, as well as lateral views of the foot indorsiflexion and maximum plantarflexion. The dorsiflex-ion view shows the fixed equinus of the hindfoot, and theplantarflexion view confirms the dislocation of the talon-avicular joint (Jackson & Striker, 2003).

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 319

Page 8: Newborn Foot

320 Orthopaedic Nursing September/October 2005 Volume 24 Number 5

Unlike syndactyly of the hand, whichrequires surgical separation, webbing ofthe toes will not cause any functionalproblem or limitations.

including the tendons, ligaments, vascular structures,and nail bed. Radiographs should be taken to define theanatomy of the metatarsal and phalanx of the duplicateddigit. Most neonates and infants with polydactyly will re-quire surgical removal of the duplicated structures. In themajority of cases, the outer toes are usually amputated inpreaxial and postaxial polydactyly, unless those toes areclearly better developed than the inner duplicated toes.The surgery is generally done when the infant is between9 and 12 months of age. Surgical correction will improvecosmesis and will also facilitate normal shoe wear. Long-term follow-up studies have shown that 75% of patientswith untreated polydactyly will experience serious shoe-fitting problems (usually resulting from excessive fore-foot width) and approximately 25% will have persistentpain (Stevens, 1992).

SyndactylyCongenital webbing of the toes is also a common defor-mity of the foot. Syndactyly can also be classified as simpleor complex and varies in the degree of severity from incom-plete webbing of the skin of two digits to complete unionof digits and fusion of the bones and nails. Syndactyly ismost often simple or incomplete, with only proximal skinwebbing. Similar to polydactyly, syndactyly is bilateral in approximately 50% of patients. The most commonsite in the foot is between the second and third toes(Herring, 2002). Syndactyly in the foot does not cause anyfunctional problems, and treatment is therefore not usu-ally recommended. Unlike syndactyly of the hand, whichrequires surgical separation, webbing of the toes will notcause any functional problem or limitations. Parentsshould be counseled that surgical separation or release of

FIGURE 9. Twelve-month-old s/p surgical correction of con-genital vertical talus.

tar flexed talar head, and fixation with a single longitudi-nal transcutaneous K-wire (Figure 9) (Staheli, 2001). Thegoal of surgery, similar to other foot deformities, is toachieve a painless plantigrade (flat on the ground) footthat permits normal gait and shoe wear.

Congenital Toe Deformities: Syndactyly and Polydactyly

PolydactylyPolydactyly, or supernumerary digit, is a common con-genital foot deformity. It occurs in approximately 2–3 new-borns out of 1,000 live births, with a slightly higher inci-dence in African American newborns (Herring, 2002).Both polydactyly and syndactyly usually occur as isolatedidiopathic anomalies. However, they can also be associ-ated with a variety of syndromes, skeletal and visceralproblems, and skin dysplasias (Sullivan, 1996). A positivefamily history is found in approximately 30% of cases,and the deformity is bilateral approximately 50% of thetime (Phelps & Grogan, 1985). The extra digit or duplica-tion is seen laterally at the fifth toe in approximately 80%of all cases. This is known as postaxial polydactyly andusually involves duplication of the proximal phalanx witha block metatarsal or wide metatarsal head. There mayalso be preaxial polydactyly, which occurs when there isduplication of the great toe.

Polydactyly is often classified as complex or simple,and the duplication may range from a well-formed articu-lated digit to a tiny rudimentary digit. On occasion, the tinyrudimentary extra soft tissue can be removed with sutureligation when the neonate is still in the nursery. More often,however, the polydactyly is more complex and involves thedistal or proximal phalanx of the toe. The supernumerarydigit may also include duplications of the entire digit,

the syndactyly will often require skin grafts and will re-place the webbed toes with a scar.

Syndactyly may also be present in combination withpolydactyly. This is known as polysyndactyly and can beseen in Figure 10. Because of the problems with shoewear and subsequent pain, patients with polysyndactylyusually undergo surgical amputation of the extra digit be-tween 9 and 12 months of age. Often, the skin from theexcised toe can be used to cover the remaining toe.

ConclusionNurses are in a key position to educate parents, as well ashealthcare providers, about common neonatal foot defor-mities. A thorough assessment of the foot should be part ofevery newborn examination. Although some congenital footdeformities are being diagnosed prenatally via ultrasound,most are diagnosed by routine physical examination in thenursery or during scheduled well-child visits. The accu-rate diagnosis and assessment of various neonatal foot

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 320

Page 9: Newborn Foot

Orthopaedic Nursing September/October 2005 Volume 24 Number 5 321

FIGURE 10. Polysyndactyly of the foot.

disorders is vitally important to the overall prognosis andoutcome.

REFERENCESAlexander, M., & Kuo, K. N. (1997). Musculoskeletal assess-

ment of the newborn. Orthopaedic Nursing, 16(1), 21–32.Alexander, M., Ackman, J. D., & Kuo, K. N. (1999). Congenital

idiopathic clubfoot. Orthopaedic Nursing, 18(4), 47–55.Crawford, A., & Durrani, A. (2002). Clubfoot. In P. D.

Sponseller (Ed.), Orthopaedic knowledge update: Pediatrics(pp. 203–213). Rosemont, IL: American Academy of Ortho-paedic Surgeons.

Davidson, R. S. (2002). Miscellaneous foot disorders. In P. D.Sponseller (Ed.), Orthopaedic knowledge update: Pediatrics.(pp. 223–229). Rosemont, IL: American Academy of Ortho-paedic Surgeons.

Dietz, F. (2002). The genetics of idiopathic clubfoot. Journalof Pediatric Orthopaedics, 1, 39–48.

Drennan, J. C. (1992). The Child’s Foot and Ankle. New York:Raven Press.

Drennan, J. C. (1995). Congenital vertical talus. Journal ofBone and Joint Surgery, 77A, 1916–1823.

Furdon, S. A., & Donlon, C. R. (2002). Examination of thenewborn foot: positional and structural abnormalities.Advance Neonatal Care, 2, 248–258.

Gore, A. I., & Spencer, J. P. (2004). The newborn foot.American Family Physician, 69, 865–872.

Heilig, M. R., Matern, R. V., Rosenzweig, S. D., & Bennett,J. T. (2003). Current management of idiopathic clubfootquestionnaire: A multicentric study. Journal of PediatricOrthopaedics, 23, 780–787.

Herring, J. A. (2002). Disorders of the foot. In Tachdjian’sPediatric Orthopaedics (pp. 891–1037). Philadelphia: W. B.Saunders Company.

Herzenberg, J. E., Radler, C., & Bor, N. (2002). Ponseti ver-sus traditional methods of casting for idiopathic clubfoot.Journal of Pediatric Orthopaedics, 22, 517–521.

Jackson, J. F., & Stricker, S. J. (2003). Pediatric foot notes: Areview of common congenital foot deformities. Interna-tional Pediatrics, 18, 133–140.

Luther, B., & Faulks, S. (2005). Changing paradigm for thetreatment of clubfeet. Orthopaedic Nursing, 24, 25–30.

Mammen, L., & Benson, C. B. (2004). Outcome of fetuseswith clubfeet diagnosed by prenatal sonography. Journalof Ultrasound Medicine, 23, 497–500.

McCullough, L. M., & Pellino, T. A. (1994). Congenital anddevelopmental disorders. In Maher, A., Salmond, S., &Pellino, T. (Eds.), Orthopaedic Nursing (pp. 617–700).Philadelphia: W. B. Saunders Company.

Nunes, D., & Dutra, M. G. (1986). Epidemiological study ofcongenital talipes calcaneovalgus. Brazilian Journal ofMedicine and Biological Research, 19, 59–62.

Phelps, D. A., & Grogan, D. P. (1985). Polydactyly of the foot.Journal of Pediatric Orthopaedics, 5, 446–451.

Ponseti, I. V. (1996). Congenital Clubfoot: Fundamentals ofTreatment. Oxford: Oxford University Press.

Ponseti, I. V. (1992). Current concepts review: Treatment ofcongenital clubfoot. Journal of Bone and Joint Surgery,74A, 448–454.

Ryan, D. J. (2001). Intoeing: A developmental norm. Ortho-paedic Nursing, 20, 13–18.

Treadwell, M. C., Stanitski, C. L., & King, M. (1999). Prenatalsonographic diagnosis of clubfoot: Implications for patientcounseling. Journal of Pediatric Orthopaedics, 19, 8–10.

Staheli, L. T. (2001). Practice of pediatric orthopaedics.Philadelphia: Lippincott Williams & Wilkins.

Stevens, P. M. (1992). Toe deformities. In J. C. Drennan (Ed.),The Child’s Foot and Ankle (pp. 183–203). New York: RavenPress.

Sullivan, J. A. (1996). The child’s foot. In Lovell and Winter’sPediatric Orthopaedics (4th ed.) (pp. 1077–1135). Philadel-phia: Lippincott-Raven.

Sullivan, J. A. (1999). Pediatric flatfoot: evaluation and man-agement. Journal of American Orthopaedic Surgery, 7, 44–53.

Stricker, S. J., & Rosen, E. (1997). Early one-stage recon-struction of congenital vertical talus. Foot Ankle Interna-tional, 18, 535–543.

Weinstein, S. L. (2000). Long-term follow-up of pediatric or-thopaedic conditions: Natural history and outcomes oftreatment. Journal of Bone and Joint Surgery, 82, 980–990.

Widhe, T., Aaro, S. E., & Elmstedt, E. (1988). Foot deformi-ties in the newborn—incidence and prognosis. Acta Ortho-paedica Scand, 59, 176–179.

3120-03a_ON2405-Hart.qxd 9/16/05 2:36 PM Page 321