Metatarsus adductus is a subject of wide discussion, even for those who do not see many pediatric patients. The reality is that metatarsus adductus can cause devastating long-term sequelae if one does not identify and treat it correctly.
Early detection is also something that seems to be lacking in the pediatric population as children are not very good historians when it comes to complaints of pain and rarely will notice that they have a deformity unless it impedes them from doing what they want to do.
Many complaints in the pediatric population have to do with parents bringing in a child for “in-toeing” or saying that their child seems to trip a lot. Lately, I have encountered this when a child presents and the child’s mother mentions that the child was a big baby. It is important in the evaluation of the pediatric patient to ask the parent or legal guardian if he or she is familiar with the child’s birthing history. Be advised that a “tight” intrauterine position with the foot pushed against the uterine wall is the most common cause of metatarsus adductus.
Also ask whether the child reached all the growth milestones within a certain timeframe and if there were any abnormalities in this regard.
As the evaluation of the child proceeds, it is most important, particularly with this potential pathology, that you spend a significant amount of time watching the child stand and ambulate. There are many potential causes of in-toeing and it is vitally important to rule out any extra pedal causes of this apparent pathology.
Watch a child stand in a normal stance position rather than the military stance you get when you ask a child to stand up straight. Ask him or her first to ambulate normally, and then at a full run if you have the room. This can give you a much better idea if the in-toeing is occurring exclusively in the foot or if it originates in the tibial segment, the femoral segment, or if you can trace the occurrence to tight hip ligaments. The in-toeing can also present in a myriad of combinations as well.
In the state I practice, the previously mentioned morphology of in-toeing and its treatment is out of my scope of practice. Therefore, it is important to know when we can take advantage of our skills or if a referral to a friendly pediatric orthopedist is in order.
After determining that this in-toeing is indeed pedal in origin, the next decision is determining what course of treatment is most appropriate. This is ultimately based on the patient’s age and ambulatory status. Although it is possible to cast an ambulatory child, the likelihood of adherence on the child’s part is slim. Some children will cut off their own casts. Children may also maintain such a high level of activity while they are in the cast that the cast either breaks, falls off or the child develops skin lesions from the friction of the cast on their skin.
Ideally, examining a child and initiating treatment should occur as soon as a deformity is evident either to the parents or the child’s pediatricians. It has been my experience that the sooner treatment begins, the better the long-term results. It is for this reason that I would ideally love to be able to examine each child at the newborn wards at our area hospitals. I firmly believe that many pediatric deformities are not identified nearly early enough and that many teenagers and adults suffer painful foot deformities throughout their lives due to the lack of early detection.
In my eyes, the truly ideal situation includes detection before ambulation and cast immobilization with serial cast repositioning. In next month’s blog, I will discuss casting techniques, pearls and what do to if the child is just past the age where casting is reasonable.