General principles
Paediatric foot deformity should be described by:
- age at presentation
- flexible versus rigid
- unilateral versus bilateral
- neurological status
- progression
- pain and functional impact
Many flexible deformities are developmental variants and do not require surgery.
Clubfoot
Idiopathic congenital talipes equinovarus combines:
- cavus
- forefoot adductus
- hindfoot varus
- equinus
Treatment
The Ponseti method is standard first-line treatment:
- serial manipulation and casting
- percutaneous Achilles tenotomy in most complete corrections
- prolonged foot-abduction bracing to reduce relapse
Relapse is often associated with inadequate brace use. Recurrent deformity is assessed for flexibility and may need recasting, repeat tenotomy or tendon transfer in selected older children.
Flexible flatfoot
A flexible flatfoot has an arch when non-weight-bearing or during heel rise, with restoration of hindfoot varus on tiptoe.
Most painless flexible flatfeet require reassurance only. Treat symptoms rather than appearance.
Investigate when there is:
- pain
- rigidity
- asymmetry
- progressive deformity
- neurological abnormality
Flexible pes planovalgus is common in children. Typical features:
- arch reconstitutes when non-weight-bearing or on tiptoe
- hindfoot valgus corrects on heel rise
- subtalar motion is preserved
Asymptomatic flexible flatfoot usually needs reassurance rather than surgery.
Painful flatfoot requires assessment for:
- Achilles/gastrocnemius tightness
- accessory navicular
- coalition
- inflammatory disease
- neurological conditions
- rigid deformity
Tarsal coalition
A rigid painful flatfoot in an older child or adolescent should raise suspicion. CT or MRI confirms anatomy when radiographs are inconclusive.
Cavus
Paediatric cavus is neurological until proven otherwise. Examine spine, reflexes, sensation, muscle balance and family history. The Coleman block test helps identify whether hindfoot varus is driven by the first ray.
Goal of surgery
When surgery is needed, the goal is a plantigrade, painless, stable and shoeable foot while preserving motion whenever feasible.
General paediatric principles
A paediatric foot deformity must be assessed in the context of:
- age
- neurological status
- flexibility
- symmetry
- developmental stage
- pain and function
Many normal developmental variants improve with growth and should not be overtreated.
Congenital talipes equinovarus
Clubfoot includes:
- cavus
- adductus
- varus
- equinus
Modern treatment is based on serial manipulation and casting using the Ponseti method, usually followed by percutaneous Achilles tenotomy when required and then prolonged abduction bracing to reduce recurrence.
The order of correction matters: cavus and forefoot alignment are corrected before abduction of the foot and finally equinus.
Relapse commonly relates to brace non-adherence but may also reflect underlying muscle imbalance.
Metatarsus adductus
This is medial deviation of the forefoot relative to the hindfoot. Most flexible cases improve spontaneously. Severity and flexibility guide observation versus casting or rare operative correction.
Vertical talus
Congenital vertical talus is a rigid rocker-bottom deformity with dorsal dislocation of the navicular on the talus. It should be distinguished from flexible flatfoot.
Early treatment uses manipulation/casting strategies followed by limited surgery in many modern protocols.
Tarsal coalition in children
Coalition may present in later childhood with a painful rigid flatfoot and recurrent sprains as the bridge ossifies.
Neuromuscular foot
Always consider neurological causes when deformity is:
- progressive
- asymmetric
- associated with weakness
- cavovarus
- accompanied by abnormal reflexes or sensation
FRCS synthesis
The first division is flexible versus rigid. The second is developmental/idiopathic versus neurological or structural. Management follows from those two decisions.