In last month’s blog (see http://www.podiatrytoday.com/blogged/current-insights-detecting-metatar… ), I discussed the identification of metatarsus adductus in the pediatric patient. Early identification and intervention is crucial in preventing the potential long-term sequela of a debilitating foot deformity. Ideally, identifying this condition pre-ambulation would help in establishing a treatment protocol which the patient would best respond to and, more importantly, help him or her to develop normally.
When identifying a treatment protocol with children, as I have mentioned in previous blogs, it is vitally important to have the child’s parents or guardians on board with the treatment and the steps required to achieve the best results. One of the accepted standard treatment protocols in the pre-ambulatory treatment of metatarsus adductus is that of serial cast immobilization. Even though this can have a tremendous impact on the patient’s treatment, it is not always the easiest to accomplish.
First, you have to have a willing family and patient. It is not easy psychologically for parents to see their beautiful young child in bilateral foot casts and have to explain this to every relative and friend they see. I have even been told by parents that they do not want this treatment since they are afraid that Social Services will be called for an abuse situation as someone might think their child broke both of his or her legs.
Another issue that can occur is when parents of these patients actually soak off the cast before they come in for a new cast application. The rationale is that cast cutters are very noisy and children that age are easily scared by such loud noises, particularly when the loud noise is approaching them.
The other major limiting factor to the success of the treatment protocol with casting is provider related. If you have never put a cast on a young child, you may not be prepared to deal with this. Putting a hard plaster of Paris cast on a young child or baby is a very messy affair. Not only is it messy but you also have to have a firm but gentle approach to cast application as well. You need to be gentle enough not to hurt the child but firm enough to make sure you can hold the cast in a position of correction long enough for the cast to dry. It takes practice and not everyone is up to it.
The casting technique is also not very intuitive. It requires practice and skill. As with any lower extremity cast, it is important to avoid casting in a position of equinus (unless you are casting the Ponseti technique for talipes equinovarus) and one should ensure neutral position of the subtalar joint.
The next technique pearl is to cup the foot at the fifth metatarsal base with your thenar eminence and hold your thumb on the plantar foot and index finger on the dorsum of the foot as parallel to one another as possible. With this position of one hand, you then use the thumb of your contralateral hand and push gently on the first MPJ laterally in order to realign the foot.
One would do this technique in stages. When there is a young patient with a malleable foot, this technique generally requires six to eight weeks of serial casting, keeping the foot in the ultimately corrected position for several weeks after manipulation and repositioning. You can do this bilaterally as well.
Sadly, it seems that these types of casting techniques are becoming a lost art. Not many residencies teach their residents these techniques. Much to my dismay, many of my efforts to initiate casting workshops for this have fallen on deaf ears. Even though there is much interest in casting techniques, particularly with the Ponseti technique, regular practice is needed to truly maintain proficiency. For those who do not see these pathologies very often, it is hard to keep up the skills.
Next month, I will review the techniques for the ambulating child, the “grey area” by age and some techniques for surgical correction. As always, if you have any questions or comments please e-mail me at firstname.lastname@example.org