Congenital Abnormalities/Deformities of the Lower Limb

Congenital
Abnormalities/Deformities of the
Lower Limb
Gordon F Watt. FCPodMed
Lecturer in Podopaediatrics
Glasgow Caledonian University

Overview
• Genetic Factors
• Environmental Factors
• Mixture of both
• 1 in 50 born with severe malformation
• More common in premature babies and possibly
mothers with diabetes
• Genetic counselling
• Total correction may not be possible – residual
deformity and handicap – ongoing
podiatric/orthopaedic management

International Classification
• Failure of formation of parts
• Failure of differentiation of parts
• Duplication
• Undergrowth
• Overgrowth
• Congenital constriction band syndrome
• Generalised skeletal abnormalities

Failure of Formation of Parts

Failure of Differentiation of Parts

Duplication

Undergrowth

Overgrowth

Congenital Constriction Band
Syndrome (1)

Generalised Skeletal Abnormalities
• Achondroplasia
• Turners Syndrome
• Apert’s syndrome (Acrocephalosyndactyly,
craniosynostosis)

Achondroplasia

Turner’s Syndrome

Apert’s syndrome
(Acrocephalosyndactyly,
craniosynostosis) (1)

Apert’s syndrome
(Acrocephalosyndactyly,
craniosynostosis) (2)

Apert’s syndrome
(Acrocephalosyndactyly,
craniosynostosis) (3)

Common Congenital Conditions (1)
• Hammer toe
• Mallet toe
• Hallux – 3 phalanges
• Fifth toe – 2 phalanges
• Congenital curly or varus toe (curly toe
syndrome)
• Digiti quinti minimi varus (congenital
overlying fifth toe)

Hammer Toe

Mallet Toe

Claw Toe

Curly Toe Syndrome

Management

Digiti Quinti Minimi Varus
(Congenital Overlying Fifth Toe)

Congenital Curly or Varus Toe
(Curly Toe Syndrome)

Common Congenital Conditions (2)
• Congenital hallux varus
• Primary
• 2 nd type
• 3 rd • 3 type rd type
• Congenital Hallux Abducto Abducto-Valgus Valgus
• Polydactyly
• Pre-axial Pre axial
• Post Post-axial axial
• Central

Congenital Hallux Varus

Congenital Hallux Varus
• Primary – No other associated congenital
abnormalities. Supernummery digit on
medial side of foot undergoes
developmental arrest. Becomes tight
fibrous or cartlaginous band and
progressively pulls the toe to the midline.

Congenital Hallux Varus
• 2nd Type – Associated with other deformities of
the forefoot. Hallux varus with primarily
adductedfirst metatarsaland hallux varus with
congenital marked shortening and broadening of
the first metatarsal.
• 3 rd
rd Type – Associated with developmental
afflictions of the skeleton. e.g. diastrophic
dwarfism.

Congenital Hallux Varus

Congenital Hallux Abducto Abducto-Valgus Valgus

Polydactyly
• Pre-axial Pre axial – on side of hallux
• Post Post-axial axial – on side of 5 th toe (most
common)
• Central – duplication of one of the middle
toes

Polydactyly
• Duplication may be of the distal phalanx, the
distal and middle phalanx or whole toe.
• The metatarsal may be partially or totally
duplicated.
• Duplicated digits may share a common
metatarsal.
• May be accompanied by syndactyly and/or
macrodactyly/microdactyly.
• May occur alone or be associated with
supernummery digits on the hands

Polydactyly

Polydactyly

Polydactyly With Congenital
Overlying 5 th Toe

Common Congenital Conditions (3)
• Syndactyly
• Oligodactyly
• Divergent or Convergent toes
• Macrodactyly
• Microdactyly

Syndactyly
• Usually 2/3 – may be partial or total.
• May be associated with curly mallet or
hammer toe.
• May affecy any or all toes to a lesser or
greater extent.
• Treatment not usually required.
Occasional exception being 1/2

Syndactyly

Syndactyly

Syndactyly

Syndactyly

Syndactyly

Oligodactyly & Macrodactyly

Macrodactyly & Microdactyly

Macrodactyly & Microdactyly

Macrodactyly & Microdactyly

Common Congenital Conditions (4)
• Congenital constriction band syndrome

Congenital constriction band
syndrome
• May result in congenital loss of parts.
• Floating strands of amnion wrap around
affected part. Early foetal life –
amputation. Later foetal life – deep or
shallow concentric bands.
• Deep bands affect venous and lymphatic
drainage causing distal portion to enlarge.

Congenital Constriction Band
Syndrome (1)

Congenital Constriction Band
Syndrome (2)

Common Congenital Conditions (5)
• Lobster claw foot/cleft foot/partial
adactyly

Lobster claw foot/cleft foot/partial
adactyly
• Variably missing middle toes and
metatarsals with overloading of other
plantar structures and alteration to gait.

Common Congenital Conditions (6)
• Congenital vertical talus
• Congenital pes cavus
• Club Foot
• Talipes equino equino-varus varus
• Talipes calcaneo calcaneo-valgus valgus
• Talipes calcaneo calcaneo-varus varus
• Talipes equino valgus
• Congenital metatarsus adductus

Congenital Vertical Talus – Rocker
Bottom Foot

Congenital Vertical Talus – Rocker
Bottom Foot

Congenital Pes Cavus
• Retracted toes.
• Increased angulation of metatarsals.
• Backward tilting of calcaneum.
• “Humping” or hog’s back tarsus,
• Trigger hallux.
• Tight and shortened plantar fascia and
tendo tendo-achilles. achilles.

Congenital Pes Cavus

Club Foot
• Loose term used to describe any
abnormality in the shape of the foot.
• Latin synonym for club foot is talipes and
the descriptive nomenclature for a club
foot combines this term with the latin
description of the deformity.

Talipes - Nomenclature

Club Foot
• If the foot is inverted and adducted at the mid-
tarsal joint so that it cannot be fully everted the
deformity is classed as varus. The opposite is
true of valgus.
• If the foot is fixed in a position of plantar flexion
and cannot be fully dorsi dorsi-flexed flexed the deformity is
described as equinus. The opposite is describes
as calcaneus.

Talipes

Talipes Equino Equino-Varus Varus

Talipes Equino Equino-Varus Varus
• Incidence – 2-4 4 times in every 1000 births.
Males affected twice as often as females. In half
of affected children both feet are deformed.
• Unless very slight the diagnosis is obvious with
the heel being drawn up, the foot inverted and
the hindfoot adducted.
• In a small minority the deformity is postural and
easily corrected by manipulation to neutral and
beyond.
• The majority have rigidly deformed feet.

Talipes Equino Equino-Varus Varus – Aetiology
(1)
• “It has been suggested that raised intra intra-uterine uterine pressure
forces the lower limbs limbs of the the foetus against the walls of
the uterus so as to mould the feet into the position of
deformity. The presence of lesions of the skin over the
convex aspect of the foot in talipes equino equino-varus equino equino-varus varus (TEV)
which very much resemble healed pressure sores, lends
support to this belief. It has alternatively been suggested
that the primary disturbance is in the muscles of the calf
where some form of contracture possibly ischaemicin
nature, has been visualised as drawing the foot into a
position of deformity

Talipes Equino Equino-Varus Varus – Aetiology
(2)
• Neither of these postulated aetiological
mechanisms have received widspread support
and the most commonly held view isthat the
primary disturbance is a developmental defect of
the soft tissues of the leg affecting particularly
the ligaments on the concave side of the curve,
or possibly, in the case of TEV, the development
of the neck of the talus. Congenital club foot
may be paralytic and secondary to
myelodysplasia.”
Bailey Bailey and and Love’s Love’s Short Short Practice Practice of of surgery surgery

Talipes Equino Equino-Varus Varus -
Management
• Conservative – Correction obtained and maintained by Dennis
Brown splint. The splint is progressively bent to hold a greater
element of correction over 77-14
14 days until an over over-corrected corrected
position is reached and the child is sent home in splints. Continued
with manipulation over over-correction correction and reapplication of splints every
2 weeks until child starts to stand at end of first year.
• Alternative strategies – strappings and the use of PoP.
• Once walking – splints discarded. Appropriate footwear with outer
raise on heel and continued manipulation with night splints.
• Management gradually abandoned with progression to normal
footwear.
• However, the limb may be shorter, the foot smaller and stiffer than
usual and the lower tibial region may look wasted.

Talipes Equino Equino-Varus Varus -
Management
• Surgical – Soft tissue release to the medial and
posterior aspects of the foot and ankle. The
ligaments on the medial side of the ankle, talo-
navicular and navicular navicular-cunieform navicular navicular-cunieform cunieform joints are
divided, The tendond of Tib. Ant., Tib. Post.,
FHL & FDL are divided and elongated by Z-
plasty.
• In severe cases bony correction will be
necessary.

Talipes Equino Equino-Varus Varus

Talipes Equino Equino-Varus Varus

Talipes Equino Equino-varus varus -
Management

Talipes Equino Equino-varus varus -
Management

Talipes Equino Equino-Varus Varus

Talipes Calcaneo Calcaneo-Valgus Valgus

Talipes Calcaneo Calcaneo-Valgus Valgus
• The opposite deformity to that of TEV.
• Excellent prognosis being treated by daily
manipulation.

Metatarsus Adductus

Metatarsus Adductus

Nail Conditions
• Anonychia
• Onychauxis/onychgryphosis
• Onychocryptosis
• Involution
• Macro Macro-onychia onychia
• Micro Micro-onychia onychia
• Claw Claw-like like 5 th toe nails
• Additional/Accessory nails

Anonychia

Onychauxis/Onychgryphosis

Onychauxis/Onychgryphosis

Onychocryptosis – In In-Growing Growing Toe
Nail

Onychocryptosis - In In-Growing Growing Toe
Nail

Involution

The End