Updated: 6/14/2021

Metatarsus Adductus

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https://upload.orthobullets.com/topic/4061/images/Rigid metatarsus adductus - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4061/images/16_moved.JPG
https://upload.orthobullets.com/topic/4061/images/Flexible metatarsus adductus_moved.png
https://upload.orthobullets.com/topic/4061/images/Hamen procedure - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4061/images/heel foot bisector 2_moved.jpg
  • summary
    • Metatarsus Adductus is a common congenital condition in infants that is thought to be caused by intra-uterine positioning that lead to abnormal adduction of the forefoot at the tarsometatarsal joint.
    • Diagnosis is made clinically with medial deviation of the forefoot with normal alignment of the hindfoot.
    • Treatment is generally nonoperative with stretching if the deformity can be passively corrected, and with casting if the deformity is rigid. Surgical management is indicated for patients with progressive deformities who fail nonoperative management. 
  • Epidemiology
    • Incidence
      • occurs in approximately 1 in 1,000 births
      • equal frequency in males and females
      • bilateral approximately 50% of cases
    • Increased incidence in
      • late pregnancy
      • first pregnancies
      • twin pregnancies
      • oligohydramnios
    • Associated conditions
      • DDH (15-20%)
      • torticollis
  • Etiology
    • Mechanism
      • thought to be related to packaging disorder caused by intra-uterine positioning
  • Presentation
    • Symptoms
      • parents complain of intoeing, usually in first year of life
    • Physical exam
      • tickling to foot can allow evaluation of active correction
      • evaluation for intoeing
        • metatarsus adductus
          • forefoot is adducted
          • lateral foot border is convex instead of straight
          • a medial soft-tissue crease indicates a more rigid deformity
          • normal hindfoot and subtalar motion
        • femoral anteversion
          • hip motion shows >70° internal rotation (normal is 30-60°) and decreased external rotation
          • patella internally rotated
        • tibial torsion
          • observe foot-thigh angle in prone position
          • > 10° of internal rotation is indicative of tibial torsion (normal is 0-20° of external rotation)
  • Classification
    • Bleck classification by heel bisector method (Beck, JPO 1983)
      • Bleck classification
      • heel bisector method
      • Normal
      • Heel bisector line through 2nd and 3rd toe webspace
      • Mild
      • Heel bisector line through 3rd toe
      • Moderate
      • Heel bisector through 3rd and 4th toe webspace
      • Severe
      • Heel bisector through 4th and 5th toe webspace
    • Berg classification
      • Berg Classification
      • Simple MTA
      • MTA
      • Complex MTA
      • MTA, lateral shift of midfoot
      • Skew foot
      • MTA, valgus hindfoot
      • Complex skew foot (serpentine foot)
      • MTA, lateral shift, valgus hindfoot
  • Imaging
    • Radiographs
      • only indicated in older children
  • Differential
      • Causes of Intoeing
      • Condition
      • Key findings
      • Metatarsus Adductus
      • Medial deviation of the forefoot with normal alignment of the hindfoot
      • Internal Tibial Torsion
      • Thigh-foot angle > 10 degrees internal
      • Femoral Anteversion
      • Internal rotation >70 degrees and < 20 degrees of external rotation (tested in prone position)
    • In-toeing associated with the following necessitates further work-up
      • pain
      • limb length discrepancy
      • progressive deformity
      • family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses
      • limb rotational profiles 2 standard deviations outside of normal
    • Foot deformities
      • clubfoot
      • atavistic great toe (congenital hallux varus)
      • skewfoot
      • serpentine Foot (complex skew foot)
        • a condition that can be considered on the axis of severity of metatarsus adductus
        • residual tarsometatarsal adductus, talonavicular lateral subluxation, and hindfoot valgus
        • different from metatarsus adductus in that nonoperative treatment and casting are ineffective at correcting deformity
  • Treatment
    • Nonoperative
      • a benign condition that resolves spontaneously in 90% of cases by age 4
      • another 5% resolve in the early walking years (age 1-4 years)
        • Nonoperative treatment modalities
        • Condition
        • Nonoperative Treatment
        • Flexible deformities that can actively be corrected to midline
        • No treatment required
        • Flexible deformities that can passively be corrected to midline
        • Serial stretching by parents at home
        • Rigid deformity with medial crease
        • Serial casting with the goal of obtaining a straight lateral border of foot
    • Operative
      • metatarsus adductus
        • tarsometatarsal capsulotomies
          • indications
            • aged 2-4yr with failed nonop management
        • lateral column shortening and medial column opening osteotomies, multiple metatarsal osteotomies
          • indications
            • age > 5yrs (as the deformity may correct with growth until this age)
            • resistant cases that fail nonoperative treatment (usually with medial skin crease)
            • severe deformity produces difficulty with shoeware and pain
          • technique
            • lateral column shortening done with cuboid closing wedge osteotomy
            • medial column lengthening includes a cuneiform opening wedge osteotomy with medial capsular release and abductor hallucis longus recession (for atavistic first toe)
      • serpentine foot
        • opening wedge and closing wedge osteotomies
          • indications
            • indicated if serpentine deformity is symptomatic and significantly limits function
            • operative treatment is difficult and often times deformity is accepted and observed
          • technique
            • calcaneal osteotomy for hindfoot valgus
            • possible midfoot osteotomies to correct midfoot and forefoot deformities
            • multiple metatarsal osteotomies with forefoot pinning and tarsometatarsal capsular release (Hamen procedure)
  • Prognosis
    • Long-term studies show that residual metatarsus adductus is not related to pain or decreased foot function
    • Associated with late medial cuneiform obliquity (not hallux valgus)

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Flashcards (3)
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Questions (2)
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(SBQ04PE.33) A newborn child is born with the condition seen in Figure A. The bilateral feet correct passively with manipulation but also actively on observation. The ankle has full supple range of motion in plantarflexion and dorsiflexion. Which of the following is the next best step in management?

QID: 2218
FIGURES:
1

Serial manipulations and casting

10%

(163/1580)

2

Tarsometatarsal capsulotomies and achilles lengthening

0%

(4/1580)

3

Ponseti method casting and Achilles tenotomy

4%

(69/1580)

4

Parental manipulation and stretching

18%

(285/1580)

5

Parental reassurance and observation

67%

(1051/1580)

L 3 D

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