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)







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)


• 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


• 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




• 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.


Syndrome (1)


Syndrome (2)


• 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.


• 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 - 

Management

Talipes Equino Equino-varus varus - 

Management


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

Congenital Abnormalities/Deformities of the Lower Limb

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