<aside> 📋
Congenital talipes equinovarus (CTEV), often known as ‘club-foot’, is defined as fixation of the foot in adduction, in supination and in varus, i.e. inclined inwards, axially rotated outwards and pointing downwards.
https://doi.org/10.1046/j.1469-7580.2003.00147.x
</aside>
Introduction:
CLUB FOOT Pathoanatomy Made Easy - The Young Orthopod
https://www.youtube.com/watch?v=BUxpO1BrhB0
https://www.youtube.com/watch?v=PabItKvmk-E
CAVE deformities:
Forefoot cavus, midfoot adductus, hindfoot varus and ankle equinus
Illustration of the four components of CTEV that are easily remembered using the acronym CAVE. (A) Pronation of the forefoot (cavus). (B) Adduction of the midfoot (adductus). (C) Inversion of the subtalar joint or hindfoot (varus). (D) Plantar flexion of the talus in the ankle (equinus).
Adham, Peixoto JB, Miyahara LK, et al. Clubfoot: Congenital Talipes Equinovarus. Radiographics. 2024;44(7). doi:https://doi.org/10.1148/rg.230178
Clinical photograph of CTEV child showing cavus (a), adductus (b), inversion (c) & equinus (d)
Drawn from Pirani S. Naddumba E. In: Staheli’s Ponseti club foot management. Teaching manual for healthcare providers. 2008;1:1-48
Pirani clubfoot score:
Pirani, S., et al. "A reliable method of clinically evaluating a virgin clubfoot evaluation." 21st SICOT congress. Vol. 29. 1999.
Pirani clubfoot- score. legend: this is a 6-item scale, in which every point has a 0 to 1 score (0 if normal, 0.5 if moderate-mild deformity is present, 1 with a severe malformation); the higher the score is, the worst is the deformity
Dibello, D., Di Carlo, V., Colin, G. et al. What a paediatrician should know about congenital clubfoot. Ital J Pediatr 46, 78 (2020). https://doi.org/10.1186/s13052-020-00842-3
Assessment of a child with congenital talipes equinovarus (CTEV) must include a thorough general examination, plus an upper limb, spine and hip examination. The feet (a, d) are methodically assessed for every component of the deformity: forefoot adduction, midfoot cavus, hindfoot equinus and varus (e).
The Pirani score has been widely adopted to provide a valid indicator of deformity and to monitor progression through treatment (see below). It uses six clinical signs, located in the midfoot (MF) and hindfoot (HF). The maximal score is 6 for the severest CTEV and 0 is a normal foot. A Pirani score of zero at initial assessment indicates a postural foot and essentially rules out a diagnosis of CTEV. An easy way to remember the components is to ‘look for 3, feel for 2 and move 1’. Midfoot signs include the medial crease, a curved lateral border and coverage of the lateral head of talus. The hindfoot components are the depth of the posterior crease and equinus. The empty heel refers to how easily the calcaneus is palpable and dorsiflexion measures the degree of rigid equinus. (b, c)
Plain radiographs of a child foot are not normally required but should be obtained if the feet are behaving atypical or in an unexpected manor. (b) AP and lateral radiographs of difficult-to-treat talipes taken at 3 months (AP) and 1 year (lateral). The ongoing CTEV deformity is visible in contrast to the normal foot (c) of a 4 month old who had radiographs performed for an injury to the ankle. On the AP view (a), the talo-calcaneal angle (light - dark blue) is 15° and talar-first metatarsal (light blue- purple) 50°. Normal angles are approximately 25° and 0° respectively. On the lateral view the talo-calcaneal is approximately 10° (normally 45°).
Dimeglio classification system:
https://journals.lww.com/jpo-b/abstract/1995/04020/classification_of_clubfoot.2.aspx
Categorizes CTEV into four grades to predict the outcome with the use of a 20-point scale.
| Grade | Score | Description |
|---|---|---|
| Grade I | 1–5 | Benign, ‘soft–soft’ or postural feet. They can be completely reduced. |
| Grade II | 6–10 | Moderate, ‘soft >stiff feet’. They are reducible but partly resistant. |
| Grade III | 11–15 | Severe, ‘stiff >soft feet’. They are resistant but partly reducible. |
| Grade IV | 16–20 | Very severe, ‘stiff–stiff feet’. Reducibility is very limited and may require surgery if Ponseti treatment fails.19 |