Clubfoot — Rapid | Doctor’s Passport

Synopsis

Distinguish rigid congenital talipes equinovarus from positional foot posture and deliver the Ponseti correction and prolonged bracing sequence that prevents avoidable relapse.

True clubfoot combines cavus, forefoot adduction, hindfoot varus and ankle equinus and is rigid compared with positional talipes.
First-line assessment is clinical at birth, including foot flexibility, perfusion, movement, hips, spine and features of arthrogryposis or neurological disease.
First-line treatment is the Ponseti method begun early: gentle weekly manipulation followed by toe-to-groin casts in a precise correction sequence.
Correct cavus first by supinating the forefoot, then abduct the whole foot around the talar head to correct adduction and heel varus.
Correct equinus last; most infants need a percutaneous Achilles tenotomy followed by a final cast while the tendon heals.
After correction, use a boots-and-bar foot-abduction brace about 23 hours daily for three months, then during sleep until roughly four or five years.
Brace adherence is the major modifiable relapse factor; the bar maintains abduction and must not be replaced by ordinary straight shoes.
Treat early relapse with repeat Ponseti casting and renewed bracing; dynamic supination in an older corrected child can require tibialis-anterior transfer.

Key red flags

A stiff small foot with deep medial or posterior creases and fixed cavus, adduction, hindfoot varus and equinus is true clubfoot rather than packaging.

A convex rocker-bottom sole and dorsiflexed hindfoot suggests congenital vertical talus, which requires a different manipulation sequence.

Weak movement, abnormal reflexes, spinal skin markers, arthrogryposis or other anomalies suggests syndromic or neuromuscular clubfoot and a broader assessment.

Toe colour change, swelling or a cast that slips requires urgent review because skin and neurovascular injury can develop rapidly.

Persistent empty heel or equinus after the forefoot corrects needs trained reassessment, commonly including Achilles tenotomy rather than forced dorsiflexion.

Reappearance of heel varus, forefoot adduction, loss of dorsiflexion or dynamic supination is relapse and should return promptly to the Ponseti team.

Investigation priorities

First-line structured clinical examinationFirst stepFirst line

Confirm CAVE deformity, flexibility and idiopathic versus syndromic features and establish a severity baseline.

Management branches

NewbornConfirm and refer early

A newborn foot has fixed cavus, adduction, varus and equinus.

Examine flexibility, skin, perfusion, movement, hips, spine and other contractures and document a severity score.
Differentiate positional talipes and vertical talus and refer true clubfoot directly to a trained Ponseti service.
Explain that treatment is gentle serial correction and was not caused by parental action.
Begin casting in the early weeks once medically appropriate and arrange transport and family support.

Key medicines

Local anaesthetic for Achilles tenotomyUse the specialist infant protocol with weight-appropriate local anaesthetic concentration and maximum dose, documenting total milligrams and adding oral or general anaesthesia only according to age and service practice.Calculate maximum dose carefully, monitor for local-anaesthetic toxicity and maintain sterile technique; analgesia does not substitute for trained tendon identification.

Paracetamol after casting or tenotomyPrescribe the current BNFC age- and weight-based dose with exact milligrams, formulation volume, interval and maximum for the infant.Check all products and liquid strengths; persistent distress, swollen or discoloured toes or absent movement requires cast review, not repeated dosing.

Open full textbook →Answer 2 questions