Approach

Diagnosis is rarely difficult and in some cases may have been made by antenatal ultrasound.[19][20][21]

The diagnosis is based on the physical examination, demonstrating the hindfoot in equinus and varus, with an adducted forefoot.[21] However, other foot deformities are seen in neonates that may resemble the various components of clubfoot. A careful history and examination is paramount to help identify associated conditions that may alter treatment and help predict the outcome.

All patients should be referred to an orthopaedic surgeon for further management.[21]

History

When assessing an infant with a foot deformity, it is important to obtain a thorough history. This should include a family history of foot deformities and other neurological conditions. Depending on the child's age, a full developmental history is needed, with milestones such as the age at which the child sat up, crawled, and walked.

It is sometimes helpful to determine whether other family members had or have foot deformities, and to find out how they were treated, because their expectations may be different from accepted current treatment.

Physical examination

The physical examination should include examination of the extremities, hips, and spine.[21] The hips should be examined, and imaging tests ordered as indicated (dynamic ultrasound or radiographs), because developmental dysplasia of the hip may be more common in infants with clubfoot. The British Society for Children’s Orthopaedic Surgery (BSCOS) Clubfoot Consensus Group has recommended that all babies with a clubfoot deformity should receive a screening ultrasound scan of their hips.[22] However, evidence regarding the association between clubfoot and developmental dysplasia of the hip is equivocal.[23][24][25]

The spine is assessed to identify any evidence of signs such as dimpling or hairy patches, which may lead to concern of an underlying spinal abnormality. Finally, the feet are assessed for deformities. A true clubfoot has fixed equinus, dorsiflexion is not possible, and the heel is in varus with the forefoot adducted resulting in a medial crease. This combination needs to be distinguished from other foot deformities such as metatarsus adductus, calcaneovalgus, and congenital vertical talus.

Tests

X-rays are occasionally ordered at the discretion of the treating orthopaedic surgeon, but are not routine.[21][26] If x-rays are ordered, anteroposterior and lateral views are required. The lateral view should be taken in maximum dorsiflexion. These views demonstrate parallelism between the talus and the calcaneus when lines are drawn through their longest axis.

Pelvic x-rays may be taken to rule out hip dysplasia, but dynamic ultrasound of the hips can show subluxation, allowing early treatment.[27][28] Imaging studies are still routinely performed at many centres, despite uncertainty regarding the association between hip dysplasia and clubfeet.[23][24][25]

CT scans are performed in older children and adolescents for preoperative planning, as non-operative methods of treatment (Ponseti) are usually used on children aged 2 years or younger.

Ultrasound of the abdomen and possibly a CT of the spine can be ordered to further investigate spinal abnormalities.

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