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The Newborn Foot
Diagnosis and Management of Common Conditions
Erin S. Hart ▼ Brian E. Grottkau ▼ Gleeson N. Rebello ▼ Maurice B. Albright

An assessment of the foot should be a part of every newborn physical examination. The newborn foot, although complex in structure, can be examined quickly in any office setting. Many foot deformities are diagnosed immediately after birth, allowing for earlier and often more successful treatment. A neonate with a foot deformity can be a source of anxiety to parents. Adequate knowledge of commonly encountered neonatal foot problems enables the nurse to give appropriate anticipatory guidance to the parents. Foot abnormalities usually occur as isolated findings in an otherwise healthy newborn. However, these deformities can also be seen in newborns with underlying neuromuscular disorders and syndromic conditions. Common newborn foot abnormalities include equinovarus deformity (clubfoot), metatarsus adductus, calcaneovalgus, congenital vertical talus, polydactyly (supernumerary digits), and syndactyly (webbed toes). These common foot disorders, their treatment, and their prognosis are discussed. This article also discusses fundamental nursing implications needed to care for these young patients and their families.

and infant physical examination. By detecting these common deformities early, corrective treatment can be given and a successful outcome can often be reached. The physical examination should include assessment of the vascular, dermatologic, and neurologic status, as well as observation, palpation, and evaluation of joint range of motion in both feet (Gore & Spencer, 2004). Often, simple observation alone will reveal an obvious deformity of the foot. Although potentially challenging, the accurate diagnosis and assessment of these congenital deformities is vitally important to the prognosis and ultimate outcome.

Although potentially challenging, the accurate diagnosis and assessment of these congenital deformities is vitally important to the prognosis and ultimate outcome.

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ongenital deformities of the foot are relatively common in newborns, but are frequently overlooked during routine physical examinations. Deformities in a neonatal foot encompass a clinical spectrum ranging from an isolated intrauterine positioning deformity to a nonfunctional foot with progressive deformity. Distinguishing between a temporary positional deformity and a more serious structural malformation of the foot is challenging and requires a thorough understanding of anatomy, embryologic development, and the effect of environmental and intrauterine factors (Furdon & Donlon, 2002). A newborn foot is a small and complex structure. The foot consists of 26 bones, although most are cartilaginous and unossified at birth. The foot can be divided into three anatomic regions: the hindfoot (talus and calcaneus), the midfoot (navicular, cuboid, and three cuneiform bones), and the forefoot (metatarsals and phalanges). Both feet should be evaluated as a routine part of every neonatal

For simplicity and to facilitate identification, congenital deformities in the foot can be classified into the following groups: 1. Toes pointing downward and/or inward: clubfoot, metatarsus adductus. 2. Toes pointing upward and/or outward: calcaneovalgus, congenital vertical talus. 3. Too many toes (polydactyly), toes stuck together (syndactyly).
▼ Erin S. Hart, MS, RN, CPNP, RNFA, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. ▼ Brian E. Grottkau, MD, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. ▼ Gleeson N. Rebello, MD, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston. ▼ Maurice B. Albright, MD, Department of Orthopaedic Surgery, Yawkey Center for Outpatient Care, Mass General Hospital for Children, Boston.
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FIGURE 1. Normal newborn foot.

There are some key developmental stages that should be noted in the immature foot. Rapid growth of the foot occurs from approximately 4 weeks’ gestation when the limb bud forms until approximately 18 months of age when the foot is approximately half of its adult size. In addition, neonatal and infant feet have a much greater range of motion than the adult foot, and joint laxity is quite common. The longitudinal arch of the foot is not present in the neonatal and infant foot. The longitudinal arch develops with growth and is often not clearly defined until age 4–5 years. The foot of a newborn should normally appear flat, as there is a greater amount of subcutaneous fat in the neonatal foot (Figure 1) (Alexander & Kuo, 1997).

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Metatarsus Adductus
Metatarsus adductus is a common neonatal foot problem in which the forefoot is adducted and the lateral border of the foot is convex (curved). Metatarsus adductus differs from a clubfoot in that the heel or hindfoot is not in equinus. The incidence is estimated to be as high as 1 in 100 births in the United States (Widhe, Aaro, & Elmstadt, 1988). The pathogenesis is unknown but is believed to result from intrauterine crowding or positioning. The characteristic features of metatarsus adductus are a lateral curved border of the foot, a “bean-shaped” sole of the foot, and adductus or turning in of the forefoot (Figures 2A and B).

The characteristic features of metatarsus adductus are a lateral curved border of the foot, a “bean-shaped” sole of the foot, and adductus or turning in of the forefoot.

B FIGURE 2(A) and (B). Metatarsus adductus of the foot. Note
curved lateral border of the foot.

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The foot with metatarsus adductus should be assessed for the degree of flexibility. If the deformity is flexible and the foot corrects to a normal position, treatment is rarely needed. Parents can be instructed to perform stretching exercises several times a day; however, the overwhelming majority of these feet (approximately 95%) will spontaneously resolve regardless of treatment (Weinstein, 2000). The stretching exercises consist of stabilizing the heel and gently pulling the forefoot into the corrected position. It must also be noted that metatarsus adductus has an approximately 5% association with developmental hip dysplasia; therefore, these patients should always have a careful hip examination (Staheli, 2001). If the forefoot deformity is severe and rigid (does not correct to normal with stretching), serial manipulation and casting may be necessary. Neonates and infants with a stiff metatarsus adductus should be referred to a pediatric orthopaedic surgeon early, because the treatment is most successful when casting is started at less than 6 months of age. When casting is needed in feet with a stiff deformity, 4–6 serial casts will be applied at weekly intervals. The feet are then placed in straight-last shoes or nighttime bivalved casts to maintain the correction. Surgical intervention is rarely indicated for metatarsus adductus and is only recommended in children older than 3 years with a rigid deformity that has not responded to manipulation and casting (Weinstein, 2000). Oftentimes, the difficulty in treating newborns and infants with metatarsus adductus is not in treating the actual foot deformity. It is often more difficult to convince parents and grandparents that flexible metatarsus adductus will spontaneously resolve. Nurses can have a key role in reinforcing the natural history and high percentage of spontaneous resolution of metatarsus adductus. Parents should be reassured that the deformity should not interfere with normal development and that the child will have no restrictions or limitations in any sports or activities (Ryan, 2001).

resolve on its own. A clubfoot can easily be differentiated from metatarsus adductus by the hindfoot equinus. All neonates and infants with suspected clubfoot should be fully undressed for the physical examination and should be assessed for possible anomalies of the head, neck, chest, hips, and spine. On examination, there is pronounced tightness of the Achilles tendon, with an inability to dorsiflex the foot or get the foot flat on the ground when the infant is placed in a standing position (Figure 3A). The medial border of the foot is concave in a clubfoot, and there is often a deep medial skin crease seen in the foot. The heel, or calcaneus, is drawn up and inverted, and a deep skin crease is also seen on the posterior aspect of the ankle joint (Figure 3B). Regardless of any treatment

Nurses can have a key role in reinforcing the natural history and high percentage of spontaneous resolution of metatarsus adductus. Parents should be reassured that the deformity should not interfere with normal development and that the child will have no restrictions or limitations in any sports or activities.

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Clubfoot
Clubfoot, also known as talipes equinovarus, is a congenital deformity of the foot that occurs in approximately 1–2 in 1,000 births in the United States. The clubfoot has a typical appearance of pointing downward and twisting inward. The four main components of clubfoot are inversion and adduction of the forefoot, inversion of the heel and hindfoot, equinus of the heel, and internal or medial rotation of the lower extremity (Gore & Spencer, 2004). The deformity is not passively correctible and does not

B FIGURE 3. (A) Congenital clubfoot deformity. (B) Severe bilateral clubfoot deformity. Note severe equinovarus.
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given, the calf of the affected lower extremity is smaller in circumference, and the foot is slightly smaller and stiffer than an uninvolved foot (Dietz, 2002). Research has shown that there is a male to female prevalence of approximately 2.5:1, and approximately 50% of all cases occur bilaterally. There is still a great deal of controversy surrounding clubfoot, including its etiology, pathologic anatomy, and treatment (Heilig, Matern, Rosenzweig, & Bennett, 2003). Clubfoot represents a spectrum of congenital deformity that ranges from the mild “postural” clubfoot to the severe neuromuscular clubfoot that is associated with conditions such as arthrogryposis and myelomeningocele (spina bifida). Clubfoot is often termed idiopathic; however, it can also be seen with extrinsic factors (congenital constriction bands), Mendelian disorders (craniocarpotarsal dysplasia, Larsen syndrome, Pierre Robin sequence, and distal arthrogryposis), chromosomal abnormalities, and neuromuscular disorders (amyoplasia and myelomeningocele) (Dietz, 2002). Although the etiology of clubfoot remains unknown, there is dysplasia of all osseous, muscular, tendinous, cartilaginous, skin, and neurovascular structures distal to the knee in the affected limb. Clubfoot is a complex multifactorial deformity; both genetic and environmental factors are believed to play a role.

Clubfoot represents a spectrum of congenital deformity that ranges from the mild “postural” clubfoot to the severe neuromuscular clubfoot that is associated with conditions such as arthrogryposis and myelomeningocele (spina bifida).

The anatomic deformities seen in a clubfoot are numerous and complex. This has been an ongoing topic of controversy among researchers. The most notable abnormalities include a hypoplasia of the tarsal bones, with reduced size and shortening of the talus. The talus is shortened and deviated in a medial and plantar direction. There is also medial subluxation of the navicular bone on the talar head so that it abuts the medial malleolus. The talus and calcaneus therefore become more parallel in all three planes (Staheli, 2001). In addition, there is thickening of the ligaments and muscular hypoplasia. This results in a generalized hypoplasia of the limb, with shortening of the foot and a smaller calf size. Parents should be informed that a child with a unilateral clubfoot will often wear two different shoe sizes. The degree of hypoplasia and the amount of foot shortening parallels the severity of the clubfoot deformity (Staheli, 2001). It should also be noted that clubfoot can be associated with other anomalies or part of a generalized syndrome. The overall incidence of these associated anomalies varies widely from 14% to 67% (Crawford & Durrani, 2002). The presence of clubfoot should therefore prompt providers to perform a multisystem physical examination. 316
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There are several different methods of classification used in the diagnosis of congenital clubfoot. The most common system used today is the etiologic classification, where the clubfoot is termed positional, idiopathic, or teratologic. Positional clubfoot is believed to be caused by intrauterine positioning late in pregnancy. These feet are flexible and usually resolve quickly with serial casting. Idiopathic clubfoot includes the multifactorial classic form with an intermediate degree of stiffness. The teratologic clubfoot is associated with neuromuscular or syndromic disorders, such as arthrogryposis. These feet are the most difficult to manage, because they are stiff and do not respond as well to nonoperative treatment. The improvements in obstetric ultrasound in the United States have led to a significant increase in the prenatal diagnosis of clubfoot. The 16- to 20-week ultrasound often shows the classical features of a clubfoot, allowing for early prenatal counseling (Treadwell, Stanitski, & King, 1999). Researchers have started to investigate the sensitivity and specificity for the prenatal diagnosis of clubfoot made via routine ultrasound. One study done at Brigham and Women’s Hospital, Boston, investigated the outcome of fetuses with clubfeet diagnosed by prenatal sonography. From 1989 to 2002, a total of 121 fetuses had a prenatal diagnosis of clubfoot; 48% had unilateral clubfoot, whereas 52% had bilateral clubfoot on sonography. The false-positive rate was significantly higher with unilateral clubfoot (29%) than with bilateral clubfoot (7%). It was also noted that there was a much higher association of other musculoskeletal anomalies, neural tube defects, and cardiovascular anomalies in the fetuses with bilateral clubfoot (Mammen & Benson, 2004). Prenatal diagnosis of clubfoot is extremely helpful in providing expectant parents with time to learn about the diagnosis and current management of congenital clubfoot. At the authors’ facility, a prenatal visit is scheduled to review the diagnosis of clubfoot and an educational handout is distributed that reviews expectations and the current treatment algorithm. This visit is tremendously helpful in easing parental anxiety, and it also assists in establishing a long-term relationship with the family.

Treatment
All suspected clubfoot deformities should be referred to a pediatric orthopaedic surgeon for definitive diagnosis and treatment immediately after birth. Most orthopaedic surgeons agree that the initial treatment of all clubfoot deformities should be nonsurgical. There is also generalized consensus that the earlier treatment of clubfoot has a higher success rate in the nonoperative treatment of clubfoot. Many facilities prefer to initiate treatment in the newborn nursery or neonatal intensive care unit within the first 24–28 hours of delivery. The objective of managing all clubfeet is to correct the deformity and obtain a plantigrade (foot flat on the ground) foot with a normal load-bearing area.

Current Treatment Algorithm
The majority of pediatric orthopaedic surgeons will initiate treatment on all clubfeet as soon as the diagnosis is made. There has been a recent shift away from extensive
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surgical reconstruction of the clubfoot, with more emphasis placed on early nonoperative correction. The three main goals of nonsurgical treatment are to provide manipulative correction, restore movement, and maintain the correction (Crawford & Durrani, 2002). The current treatment regimen involves early manipulation (stretching) and serial casting. The treatment of clubfoot should ideally begin in the first few days of life to take advantage of the neonate’s favorable fibroelastic connective tissue (Heilig et al., 2003). The foot is stretched, and a slow correction is obtained with each cast. The long leg casts are changed weekly (because of the rapid growth of the newborn) for a total of approximately 6–8 weeks. Clubfoot casts must be placed above the knee to control rotation of the lower extremity and to decrease the likelihood of the casts falling off.

The three main goals of nonsurgical treatment are to provide manipulative correction, restore movement, and maintain the correction.

Many surgeons are currently using the soft fiberglass material for the casts, although there has been a recent trend in using the traditional plaster of paris. A slightly different approach, developed by Dr. Ignatio Ponseti at the University of Iowa, has become more widely used in the management of clubfoot. A survey that was given to 541 pediatric orthopaedic surgeons in 2003 revealed that nearly 65% stated that they used the Ponseti casting technique (Heilig et al., 2003). Dr. Ponseti has made tremendous contributions throughout his entire career to gain understanding and insight in the management of congenital clubfoot. Ponseti’s approach to clubfoot involves early manipulation and long leg casting. These casts are made from plaster of paris and are applied at weekly intervals for 5- to 6-week course (Herzenberg, 2002) (Figure 4). In the Ponseti approach, there is a defined sequence in how the correction is obtained. The forefoot adduction

and hindfoot varus are corrected before starting any correction of the heel cord equinus. Correction of equinus is not attempted until the foot can be fully abducted on the talus past neutral (Ponseti, 1996). The correction of the heel cord equinus frequently involves a percutaneous heel cord tenotomy (small procedure where the Achilles tendon is transected at its insertion into the calcaneus). This is done under either local sedation in the office setting or light anesthesia in the operating room. The tenotomy is done in approximately 85–90% of all patients with clubfoot. After the tenotomy, the foot is placed into a long leg cast for another 3 weeks. When this cast is removed, the patient is then placed into a Denis Browne splint with straight-last shoes (Figure 5A). Ponseti’s nonoperative approach to clubfoot proposes to gradually correct the deformity without producing the scar tissue that is commonly seen in feet that have had extensive reconstructive surgery (Ponseti, 1996). After correction of the clubfoot, splinting is essential in preventing a recurrence of the deformity. The infant must wear the Denis Browne splint full-time for 2–3 months and then for nighttime/naps only for an approximate 3-year period. Parents should be informed of the importance in following this bracing regimen to achieve the desired long-term successful outcome (Figure 5B). An untreated clubfoot deformity will continue to worsen over time with secondary bony changes developing. An

A

B FIGURE 5(A) and (B). Six-month-old patient with Denis FIGURE 4. Ponseti long leg plaster cast.
Browne splint.
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uncorrected clubfoot in the older child/adult is disabling. The abnormal development of the foot will cause the patient to walk on the outside of his or her foot. This part of the foot is not designed for weight bearing, and significant calluses and pain are frequent problems in these patients. Correction of the older child/adult with congenital clubfoot is challenging and often involves extensive surgical reconstruction. The role of nursing in the treatment of clubfoot should not be understated. It is the nurse who supports the family through the initial diagnosis, the frequent initial visits to the orthopaedic surgeon for casting, and the long-term follow-up care. Parents must learn to cope with the birth of a child with a congenital deformity, as well as the oftenarduous initial treatment plan that is usually initiated shortly after birth (McCullough & Pellino, 1994). Nurses can improve compliance and outcomes through frequent reinforcement of the treatment protocol and parental encouragement (Luther & Faulks, 2005). To ease parental anxiety, nurses should remember to emphasize that the treatment of clubfoot is successful and that these children go on to live normal, happy, and healthy lives. There are no limitations that should be enforced. Many elite athletes, in fact, were born with clubfeet. Although we certainly do not understand the precise etiology or pathophysiology behind clubfoot, the methods of treatment have improved significantly during the last several

A

To ease parental anxiety, nurses should remember to emphasize that the treatment of clubfoot is successful and that these children go on to live normal, happy, and healthy lives.

B FIGURE 6(A) and (B). Corrected clubfoot deformity. Note full
dorsiflexion of foot.

years, and the overall prognosis in this deformity is excellent (Figures 6A and B).

Calcaneovalgus
Calcaneovalgus is believed to be a postural deformity secondary to intrauterine positioning in which the dorsum of the foot is directly opposed to the anterior aspect of the leg (Figures 7A and B). The deformity is flexible, and there are no tarsal dislocations or subluxations. It has also been described as a neonatal flexible flatfoot. In the calcaneovalgus foot, the hindfoot is in the dorsiflexed position (calcaneus position) so that the plantar aspect of the forefoot is collinear with it. Newborns with a calcaneovalgus foot will often dorsiflex the foot all the way up to the tibia (Alexander & Kuo, 1997). The estimated incidence of calcaneovalgus is 0.4–1 in 1000 live births (Nunes & Dutra, 1986), although some believe that a mild form of this postural deformity is seen in approximately 30–40% of all newborns. It also is more common in females and in breech deliveries. Neonates with a calcaneovalgus foot may have a slightly higher incidence of developmental hip dysplasia. Therefore, a thorough hip examination is warranted in all of these patients. 318
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Calcaneovalgus must be differentiated from congenital vertical talus. This is easily done by viewing the hindfoot, which is in severe equinus in a foot with congenital vertical talus. A neonate with a congenital vertical talus will also demonstrate a “rocker bottom” appearance or convexity of the sole. Any deformity that is suspected to be a congenital vertical talus should always be referred to a pediatric orthopaedic surgeon for evaluation and treatment. The prognosis for complete spontaneous resolution in neonates with a calcaneovalgus deformity is excellent in the majority of cases. Parents must be counseled that the deformity is not fixed and that it will resolve on its own without treatment. Although they are often encouraged to stretch the foot, parents probably benefit more from the treatment, because the deformity resolves on its own by approximately 3–6 months of age without residual sequelae (Sullivan, 1999). Occasionally, in the most severe cases, serial casting of the foot in plantarflexion and inversion can be done to facilitate correction.

Congenital Vertical Talus
Congenital vertical talus, also known as rocker-bottom foot, is a rare deformity that results in reversal of the norNumber 5

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A FIGURE 8. Congenital vertical talus foot with typical “rockerbottom” appearance.

B FIGURE 7. (A) Typical appearance of a calcaneovalgus foot. (B)
Note dorsiflexion of foot to tibia.

be classified into two groups: idiopathic and teratologic. Approximately 50% of vertical tali are idiopathic, but the remainder are associated with various syndromes and neuromuscular conditions, such as arthrogryposis, myelomeningocele, and chromosomal abnormalities (Jackson & Stricker, 2003). Therefore, all patients with congenital vertical talus should have a careful evaluation for an underlying cause or associated disorder. The typical radiographic evaluation of congenital vertical talus includes an anterior-posterior (AP) and a lateral view of the foot, as well as lateral views of the foot in dorsiflexion and maximum plantarflexion. The dorsiflexion view shows the fixed equinus of the hindfoot, and the plantarflexion view confirms the dislocation of the talonavicular joint (Jackson & Striker, 2003).

mal longitudinal arch. This foot deformity is distinguished by the rocker-bottom or convex appearance of the sole combined with severe heel cord equinus (Figure 8). It is uncommon and is considered the most severe and serious pathologic flatfoot (Staheli, 2001). The foot is stiff, with contractures of both the dorsiflexors and plantarflexors. The etiology of congenital vertical talus is unknown. Some researchers believe that the deformity may result from muscle imbalance. Both sexes are affected equally, and congenital vertical talus is bilateral in approximately 50% of cases. Similar to clubfoot, congenital vertical talus can

The treatment of congenital vertical talus often involves surgical correction between the ages of 6 and 12 months. Conservative therapies, such as manipulation and serial casting, are often unsuccessful in this deformity.

Congenital vertical talus, also known as rocker-bottom foot, is a rare deformity that results in reversal of the normal longitudinal arch. This foot deformity is distinguished by the rocker-bottom or convex appearance of the sole combined with severe heel cord equinus.

The treatment of congenital vertical talus often involves surgical correction between the ages of 6 and 12 months. Conservative therapies, such as manipulation and serial casting, are often unsuccessful in this deformity. Currently, most surgeons believe that casting can be used to gradually stretch the soft tissues but that surgical reconstruction is necessary in nearly all cases. Because congenital vertical talus is such a rare deformity, there are not nearly as many long-term studies when compared to other neonatal foot deformities. Most surgeons are currently using a singlestage surgery to obtain the necessary correction (Drennan, 1995; Stricker & Rosen, 1997). The best results are usually obtained when surgical correction is done before 2 years of age (Jackson & Stricker, 2003). The procedure most commonly done is a heel cord lengthening, posterolateral release, elevation of the planSeptember/October 2005 Volume 24 Number 5

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including the tendons, ligaments, vascular structures, and nail bed. Radiographs should be taken to define the anatomy of the metatarsal and phalanx of the duplicated digit. Most neonates and infants with polydactyly will require surgical removal of the duplicated structures. In the majority of cases, the outer toes are usually amputated in preaxial and postaxial polydactyly, unless those toes are clearly better developed than the inner duplicated toes. The surgery is generally done when the infant is between 9 and 12 months of age. Surgical correction will improve cosmesis and will also facilitate normal shoe wear. Longterm follow-up studies have shown that 75% of patients with untreated polydactyly will experience serious shoefitting problems (usually resulting from excessive forefoot width) and approximately 25% will have persistent pain (Stevens, 1992).

Syndactyly
Congenital webbing of the toes is also a common deformity of the foot. Syndactyly can also be classified as simple or complex and varies in the degree of severity from incomplete webbing of the skin of two digits to complete union of digits and fusion of the bones and nails. Syndactyly is most often simple or incomplete, with only proximal skin webbing. Similar to polydactyly, syndactyly is bilateral in approximately 50% of patients. The most common site in the foot is between the second and third toes (Herring, 2002). Syndactyly in the foot does not cause any functional problems, and treatment is therefore not usually recommended. Unlike syndactyly of the hand, which requires surgical separation, webbing of the toes will not cause any functional problem or limitations. Parents should be counseled that surgical separation or release of

FIGURE 9. Twelve-month-old s/p surgical correction of congenital vertical talus.

tar flexed talar head, and fixation with a single longitudinal transcutaneous K-wire (Figure 9) (Staheli, 2001). The goal of surgery, similar to other foot deformities, is to achieve a painless plantigrade (flat on the ground) foot that permits normal gait and shoe wear.

Congenital Toe Deformities: Syndactyly and Polydactyly
Polydactyly
Polydactyly, or supernumerary digit, is a common congenital foot deformity. It occurs in approximately 2–3 newborns out of 1,000 live births, with a slightly higher incidence in African American newborns (Herring, 2002). Both polydactyly and syndactyly usually occur as isolated idiopathic anomalies. However, they can also be associated with a variety of syndromes, skeletal and visceral problems, and skin dysplasias (Sullivan, 1996). A positive family history is found in approximately 30% of cases, and the deformity is bilateral approximately 50% of the time (Phelps & Grogan, 1985). The extra digit or duplication is seen laterally at the fifth toe in approximately 80% of all cases. This is known as postaxial polydactyly and usually involves duplication of the proximal phalanx with a block metatarsal or wide metatarsal head. There may also be preaxial polydactyly, which occurs when there is duplication of the great toe. Polydactyly is often classified as complex or simple, and the duplication may range from a well-formed articulated digit to a tiny rudimentary digit. On occasion, the tiny rudimentary extra soft tissue can be removed with suture ligation when the neonate is still in the nursery. More often, however, the polydactyly is more complex and involves the distal or proximal phalanx of the toe. The supernumerary digit may also include duplications of the entire digit, 320
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Unlike syndactyly of the hand, which requires surgical separation, webbing of the toes will not cause any functional problem or limitations.

the syndactyly will often require skin grafts and will replace the webbed toes with a scar. Syndactyly may also be present in combination with polydactyly. This is known as polysyndactyly and can be seen in Figure 10. Because of the problems with shoe wear and subsequent pain, patients with polysyndactyly usually undergo surgical amputation of the extra digit between 9 and 12 months of age. Often, the skin from the excised toe can be used to cover the remaining toe.

Conclusion
Nurses are in a key position to educate parents, as well as healthcare providers, about common neonatal foot deformities. A thorough assessment of the foot should be part of every newborn examination. Although some congenital foot deformities are being diagnosed prenatally via ultrasound, most are diagnosed by routine physical examination in the nursery or during scheduled well-child visits. The accurate diagnosis and assessment of various neonatal foot
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FIGURE 10. Polysyndactyly of the foot.

disorders is vitally important to the overall prognosis and outcome.

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Orthopaedic Nursing

September/October 2005

Volume 24

Number 5

321

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