A 10-month-old boy is brought to the clinic due to abnormal feet and gait. The patient was recently adopted from overseas, and the adoptive parents state that he just began pulling himself up to stand a few weeks ago. However, he appears clumsy when trying to take steps. Height and weight are at the 25th percentile. Head circumference is at the 50th percentile. Vital signs are normal. The patient is alert while sitting in the parent's lap. The head appears normal, and the anterior fontanelle is open and flat. Examination of the chest is unremarkable, and the abdomen is soft and nontender. The back appears normal. Examination of the feet shows bilateral plantar flexion with adduction and inversion. The feet resist range-of-motion assessment. The knees and hips have normal range of motion. After pulling himself up to stand, the patient puts weight on the lateral sides of both feet. As he attempts to take a step, he falls. The parents ask about the prognosis of his condition. Which of the following is the most appropriate response?

Question

A 10-month-old boy is brought to the clinic due to abnormal feet and gait.  The patient was recently adopted from overseas, and the adoptive parents state that he just began pulling himself up to stand a few weeks ago.  However, he appears clumsy when trying to take steps.  Height and weight are at the 25th percentile.  Head circumference is at the 50th percentile.  Vital signs are normal.  The patient is alert while sitting in the parent's lap.  The head appears normal, and the anterior fontanelle is open and flat.  Examination of the chest is unremarkable, and the abdomen is soft and nontender.  The back appears normal.  Examination of the feet shows bilateral plantar flexion with adduction and inversion.  The feet resist range-of-motion assessment.  The knees and hips have normal range of motion.  After pulling himself up to stand, the patient puts weight on the lateral sides of both feet.  As he attempts to take a step, he falls.  The parents ask about the prognosis of his condition.  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ab_6123_8f63_41e47c4645db_MD0005_00 This patient with plantar flexed, adducted, and inverted feet has bilateral congenital clubfoot (talipes equinovarus), a developmental deformity of the talus bone. talus bone In congenital clubfoot, the tissues surrounding the talus are underdeveloped and the muscles are shortened and contracted, resulting in an internally rotated foot. In contrast to positional clubfoot (due to in utero crowding), in which the foot is flexible and can be easily manipulated to midline, congenital clubfoot is fixed and resists range-of-motion testing, as seen in this patient. The ipsilateral calf may also be less muscular and, in unilateral cases, shortened leg length is apparent on the affected side. If untreated, the child will attempt to bear weight on the lateral aspect of the inverted foot, as seen in this patient, and the ability to stand and walk will be affected, particularly with bilateral deformities. Initial treatment of congenital clubfoot is nonsurgical and involves stretching and serial casting. Although treatment is ideally started in the first few weeks of life when the anatomy is most supple, serial casting remains effective at correcting the majority of clubfoot in older infants and toddlers. After treatment is complete, bracing is usually required for a few years to prevent recurrence. If the response to casting is inadequate or if clubfoot recurs, surgical intervention may be considered (Choice D). (Choice A) Although certain progressive neuromuscular disorders such as congenital myotonic dystrophy are associated with an increased incidence of clubfoot, other findings such as muscle weakness and hypotonia would be present. This infant's ability to sit and pull to stand suggests normal tone, and clubfoot is a nonprogressive, congenital deformity. (Choice B) Rickets due to vitamin D deficiency causes pathologic genu varum (bowlegs) and is treated with vitamin replacement. Rickets is not associated with clubfoot. (Choice E) Physiologic genu varum is a normal lower-extremity angulation of the knees that is often most noticeable when children begin ambulating; it self-resolves by age 2. This patient has a fixed, plantar flexed foot consistent with clubfoot, and it will persist without intervention. Physiologic genu varum Educational objective: Congenital clubfoot is a deformity of the talus bone, resulting in a fixed, plantar flexed, adducted, and inverted foot. Nonsurgical treatment with serial casting is effective in most infants. References: Ponseti method in management of clubfoot under 2 years of age: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28632733) Expanded age indication for Ponseti method for correction of congenital idiopathic talipes equinovarus: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/29268899)

A 10-Month-Old Boy Is Brought to the Clinic Due to Abnormal