Distinguishing Orthopedic Deformities in Kids

Among its comprehensive review articles on spinal deformities, fractures, and other pediatric orthopedic conditions, the December 2013 issue of Surgery includes a concise and interesting article on the many foot problems orthopedic surgeons may encounter in children.

The article provides information about the known etiology, incidence, diagnosis, and management of 6 orthopedic conditions: clubfoot, metatarsus adductus, vertical talus, tarsal coalition, pes cavus, and flatfoot.

Although clubfoot occurs in boys twice as often as girls, the condition also appears to have a genetic predisposition, as children born into affected families are 30 times more likely to be born with clubfoot. Obstetricians often discover the defect in prenatal ultrasounds, and nonsurgical manipulation with casting is the preferred treatment approach.

Metatarsus adductus occurs in one out of every 1,000 live births and may be related to in utero positioning, specifically a breech presentation. The condition occurs in both feet in roughly half of affected children. Although the back of the foot and the ankles appear normal, the front of the foot is bent toward the middle. However, this condition often resolves with age or casting.

Congenital vertical talus presents as a rigid flatfoot with a rocker-bottom appearance and occurs in one out of every 15,000 live births. While muscle imbalance, intrauterine compression, and growth arrest during fetal development may cause the condition, its definitive etiologies have not yet been identified. Still, congenital vertical talus may be comorbid with conditions like myelomeningocele and arthrogryposis. If manipulation and serial casting fail, then surgery involving soft tissue release is needed.

Though tarsal coalition occurs in less than 1% of children, this abnormal connection between bones in the feet can be painful, so the goal of treatment is to reduce pain and increase foot flexibility. Nonsurgical treatments like insoles, orthotics, and casting may help, but if they do not, then surgery to excise the coalitions is needed.

Pes cavus is a high longitudinal arch that can cause claw toes and hindfoot deformities. Children with this condition frequently have underlying neurologic conditions and suffer from muscle imbalance. Pain and ankle instability are common, and surgery is the preferred treatment.

Unlike the other conditions described in this review, flexible or rigid flatfoot runs in families and requires no treatment in children.