HPI: The patient is a happy, healthy 16 month old male who presents because his grandmother is concerned that he does not walk well, and is concerned about his feet “pointing in.” The patient is nonverbal, but appears in no apparent distress...

 

feet

To view the full article, and the accompanying radiographs, follow this link: Residency Insight 49 - Case Study: Congenital Deformity in a Pediatric Patient.


Considering the history, physical exam, and radiographs and image presented, how would you proceed with this case?

  • Comments (3)
  • The Ponseti Method is a very effective technique in treating pediatric deformity. The more malleable the osseous structures, the easier it is to achieve correction. Therefore, early identification and implementation of treatment is key.

     

     

     

  • This statement has always rung apathy in most circumstances when dealing with pediatric deformities, but may ring true when talking about metatarsus adductus.  A 1994 article in JBJS entitled  "The Long-Term Functional and Radiographic Outcomes of Untreated and Non-Operatively Treated Metatarsus Adductus" by Farsetti and Ponsetti followed 31 patients (45 feet) for an average of 32 years.  They noted that of 16 feet that were passively correctable all resolved spontaneously.  For the 29 feet that were semirigid to rigid, 90 percent resolved well with serial manual manipulation and toe-to-groin holding casts.


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    Clinically, this patient has bilateral congenital hallux varus deformities, in addition to the pronounced metatarsus adductus component. Juvenile Hallux Varus can be address with an Abductor Hallucis release.

     

    Given the patient's age and osseous naivety, Ponseti serial casting will be of benefit. Alternatively, the patient may be fitted with a Wheaton Brace AFO. Long-term maintenance would be with UCBL orthosis with medial flange extending past the MTPJ. A Ganley splint or Dennis-Brown bar are other options.

     

    Should conservative care fail, surgical options would include soft tissue release such as the Heyman, Herndon, Strong procedure or osseous correction in the form of a Lepird procedure.

     

    Serial-weight-bearing radiographs should be obtained throughout development and treatment.