Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Washington Hospital Center
Washington, DC |
n a previous installment of Residency Insight, a case of a pediatric patient with congenital metatarsus adductus was presented. We received a lot of excellent responses from YOU in the E-talk section of PRESENT Podiatry regarding the management of this challenging patient. In this installment, the conclusion of that case will be presented.
TREATMENT PLAN:
Following the initial assessment of this pediatric patient, it was determined, through clinical observation and stress radiographs, that the patient’s deformity was reducible and therefore amenable to conservative serial casting. Ganley and Ganley demonstrated that the “flexibility test” was a good prognostic indicator for the success of treatment. In this classification system, a foot that was easily reducible with gentle manipulation is considered a mild deformity, and is associated with improved overall outcomes.1 Outcomes are noted to decrease as flexibility decreases. In this case, the patient was completely reducible with gentle manipulation bilaterally.
When casting the pediatric patient to reduce metatarsus adductus, it is important to maintain appropriate hand position to reduce the risk of iatrogenic complications. The rearfoot is held in neutral or slight varus, with the tarsal bones are stabilized at the level of the cuboid, and the forefoot is gently abducted. (Fig 1-3)
The patient will be casted until correction of the deformity is obtained, which is usually between three to six weeks.2 (Fig. 4)
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Figure 1: The extremity is prepared prior to cast placement. In this instance, stockinet was utilized as the initial contact layer. Skin adherent can be utilized to help hold padding in place in particularly active patients. |
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Figure 2: 2-inch cast padding is utilized to pad the boney prominences and the cast is extending above the knee. If too much cast padding is utilized, there will be less force applied to the bone, and therefore less powerful correction. |
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Figure 3: The rearfoot is held in neutral or slight varus position, while supporting the tarsals at the cuboid, and the forefoot is abducted. It is important to stabilize the tarsus to avoid the development subsequent foot deformity. |
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Figure 4: After one week of serial casting, the adduction deformity of of the foot was noted to be reducing. |
DISCUSSION:
Metatarsus adductus is a transverse plane congenital deformity with adduction of the forefoot at the tarsometatarsal joint, and is the most common congenital foot deformity. Metatarsus adductus is bilateral in approximately 50% of cases, and in 10-15% of cases, metatarsus adductus is associated with other congential deformities, such as hip displasia. Therefore, a thorough evaluation should be performed to rule out these concomitant conditions. In the literature, there is a reported incidence of one per 1,000 live births.1 Some authors, however, have suggested that this number may reflect only the moderate to severe cases, and that the true overall incidence may be higher.3
Commonly this condition is flexible, and can be managed successfully via conservative means. In young patients serial casting can be utilized, as has been described in the above case presentation. As patient age increases, flexible metatarsus adductus can be managed utilizing a combination of bracing and splinting, such as the ganley splint or the wheaton brace.3,4 In recalcitrant cases, surgical correction may be necessary. Often this correction includes tarsometatarsal capsulotomies with or without the addition of abductive metatarsal osteotomies. Osseous correction is usually delayed until after five years of age.
References:
- Ganley JV, Ganley TJ. Metatsus Adductus Deformity. In McGlamery ED, Banks AS, Downey MS, eds. Comprehensive textbook of Foot Surgery, 2nd ed. Baltimore: Williams & Wilkins. 1992:829-852
- Ponseti I, Becker J. Congenital Metatarsus Adductus: The results of treatment, J Bone Joint Surg 48-A, 4, 702-711, 1966.
- Farsetti P, Weinstein S, Ponseti I. The Long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. J Bone Joint Surg 76-A, 2, 257-265, 1994.
- Hunziker UA, Largo RH, Duc G. Neonatal metatarsus adductus, joint mobility, axis and rotation of the lower extremity in preterm and term children 0-5 years of age. Eur J Pediatr, 148(1): 19-23, Oct 1988.
| WHAT DO YOU THINK? |
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The E-talk discussion thread for this topic remains open, and the community would love to hear from you regarding your thoughts on this, and other topics.
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We at PRESENT love hearing from you. The E-talk function is an excellent way for you to share your interesting cases and general observations regarding podiatric medicine and surgery. The E-talk function on PRESENT Podiatry provides the clinician a significant resource to improve communication regarding challenging cases, provide treatment pearls, and to help broaden the overall body of knowledge between Residency programs across the country. If you have not already done so, I encourage each of you to take a moment a view the current threads and to share your observations and experiences with the rest of our online community.
We'll see you next week. Best wishes!
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