Ans. c. CTEV (Ref: Apley's 9/e p291, 591-594; Turek's 6/e p658-661; Campbell's 11/e p1474-1475)The most probable diagnosis in a newborn child with inverted foot in whom the dorsum of the foot cannot touch the anterior tibia is CTEV.Congenital Talipes EquinoVarus (CTEV):Congenital deformity involving one foot or both.Affected foot appears rotated internally at the ankle.As heels are rotated internally patient is not able to touch tibia by dorsum of his foot.Congenital Vertical Talus (CVT):It is irreducible dorsal dislocation of the navicular on the talus with a fixed talo-navieular complex.CVT is a common cause of rigid flat foot, which can be isolated, or can occur with chromosomal abnormalities, myeloarthropathies (myelomeningocele) and neurologic disorders.Clinically talar head is prominent medially, sole is convex, forefoot is abducted and dorsiflexed, and the hind foot is equinovalgusSole of foot has a rocker-bottom (convex) deformityPatients demonstrate peg-leg gait (awkward gait with limited forefoot push off)Arthrogryposis Multiplex Congenita:Rare congenital disorder that is characterized by multiple joint contractures and can include muscle weakness and fibrosis.It is a non-progressive disease.The disease derives its name from Greek, literally meaning 'curved or hooked joints'.Cerebral Palsy:Includes the group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement.Divided into four major classifications to describe different movement impairments; also reflect the areas of the brain that are damaged.The four major classifications are:Spastic: MC type (70-80%)Ataxic: Caused by damage to the cerebellum (10%)Athetoid/dyskinetic: Mixed muscle tone, trouble holding in an upright, steady position for sitting or walking; often show involuntary motions.Hypotonic: Patients have musculature that is limp, and can move only a little or not at all.Congenital Talipes EquinoVarus (CTEV)/Club FootCongenital deformity involving one foot or both.Affected foot appears rotated internally at the ankle.As heels are rotated internally patient is not able to touch tibia by dorsum of his foot.CTE-V is classified into 2 groups: Postural TEV and Structural TEV.Incidence: 1 in 1,000 live births: More common in malesEtiology and Associated Anomalies:Idiopathic (MC)Q; Secondary club footSecondary club foot* Neurological disorders and neural tube defectsQ (myelomeningocele and spinal dysraphism)* Paralytic disorder (due to muscular imbalance) as polio. spina bifidaQ, myelodysplasia, and Freidreich's ataxia* Arthrogryposis multiplexaQ* Larsen syndrome* Freeman-Sheldon (Mobius) syndrome* Diasirophic dwarfism* Sacral agenesis, tibial deficiency, constriction rings and amniotic bands* Fetal alcohol syndrome* Down's syndrome Deformities affecting joints of the foot in CTEV* Inversion at subtalar jointQ* Adduction at talonavicular jointQ* Equinus at ankle jointQ"InAdEquate" for Inversion, Adduction and EquinusQ.Screening Methods:The foot of a newborn child normally can be dorsiflexed until the dorsal surface of foot touches the anterior aspect of shin of tibiaQ.It is a useful screening method for detecting the milder cases of CTEV, in which the foot cannot touch anterior tibia.Clinical Presentation:Classical appearance of CTEV is small size foot and small heel with characteristic CAVE deformity (Cavus, Adduction, Varus, Equinus) i.e. heel in equinuis with foot inverted on end of tibia giving the foot an upside down club appearance.Inability to bring the foot in opposite directions to deformity.Deep skin creases on medial side of foot and back of heel.Outer side of foot is convex and contains bony prominences (e.g. head of talus) and dimples.Prognosis:Prognosis of non-idiopathic syndromic club foot is generally worse than that for an idiopathic club foot, although there are certain exceptions like Down's syndrome or Larsen's syndrome: in which because of significant ligamentous laxity underlying the syndrome itself, correction may be achieved with non-operative treatment.Management of CTEVConservative managementOperative management* Clubfoot always requires treatment, which should begin at birthQ.* Manipulation should be frequently repeated, and after manipulation some form of splint or cast must be usedQ.* In the first month of life, manipulation should be repeated 6 times at each nappy change and adhesive strapping which maintains the correctionQ.* In place of strapping, splintage (Dennis Brown Splint) and even casting usually at one-week interval in the first month of lifeQ can also be used.* In infants >1 month, corrective manipulations and above knee cast (from toe to groin) is applied for 2 weeks.* Delaying surgery is suitable for severe, rigid deformities; for less severe cases it may be preferable to operate at around 6 months of ageQ.* Posteromedial soft tissue release is best done at 6 months-3 yearsQ.* Triple arthrodesis is necessary for recurrent or persistent club foot deformity in older children (chronic cases)Q. It is best done at 10-12 years of age when foot growth is completeQ. Pseudoarthrosis (most commonly of talonavicular joint) is commonest complicationQ.Kite's MethodPonseti Method (Method of choice)6 months-3 yearsPosteromedial soft tissue releaseOrder of correction of deformity:* Adduction of forefoot* Inversion (varus) of heel / hind foot and inversion (supination) of fore /mid foot* Equinus (plantar flexion) of ankleOrder of correction of deformity:* Cavus* Adductus* Varus* Equinus4-10 yearsRevision of soft tissue release together with shortening of lateral side of foot by:* Lichtblau's Procedure (<6 years)* Even-Dillwyn Procedure (>6 years)>10-12 yearsTriple arthrodesisQ