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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, allow-
ing 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 anticipa-
tory 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 dis-
orders and syndromic conditions. Common newborn foot ab-
normalities include equinovarus deformity (clubfoot), metatar-
sus 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 fundamen-
tal nursing implications needed to care for these young
patients and their families.
C ongenital deformities of the foot are relatively com-
mon in newborns, but are frequently overlooked dur-
ing 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. Distin-
guishing 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
Orthopaedic Nursing
and infant physical examination. By detecting these com-
mon deformities early, corrective treatment can be given
and a successful outcome can often be reached. The phys-
ical examination should include assessment of the vascu-
lar, dermatologic, and neurologic status, as well as obser-
vation, palpation, and evaluation of joint range of motion
in both feet (Gore & Spencer, 2004). Often, simple obser-
vation 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.
For simplicity and to facilitate identification, congeni-
tal deformities in the foot can be classified into the follow-
ing groups:
1. Toes pointing downward and/or inward: clubfoot,
metatarsus adductus.
2. Toes pointing upward and/or outward: calcaneoval-
gus, 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 oc-
curs from approximately 4 weeks’ gestation when the
limb bud forms until approximately 18 months of age
A
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 de-
fined until age 4–5 years. The foot of a newborn should
normally appear flat, as there is a greater amount of sub-
cutaneous fat in the neonatal foot (Figure 1) (Alexander
& Kuo, 1997).

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 dif-
fers 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 re-
sult from intrauterine crowding or positioning. The charac-
teristic features of metatarsus adductus are a lateral curved
border of the foot, a “bean-shaped” sole of the foot, and ad-
ductus 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 B

forefoot. 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 resolve on its own. A clubfoot can easily be differentiated
for the degree of flexibility. If the deformity is flexible and from metatarsus adductus by the hindfoot equinus.
the foot corrects to a normal position, treatment is rarely All neonates and infants with suspected clubfoot should
needed. Parents can be instructed to perform stretching be fully undressed for the physical examination and should
exercises several times a day; however, the overwhelming be assessed for possible anomalies of the head, neck, chest,
majority of these feet (approximately 95%) will sponta- hips, and spine. On examination, there is pronounced
neously resolve regardless of treatment (Weinstein, 2000). tightness of the Achilles tendon, with an inability to dorsi-
The stretching exercises consist of stabilizing the heel flex the foot or get the foot flat on the ground when the
and gently pulling the forefoot into the corrected posi- infant is placed in a standing position (Figure 3A). The
tion. It must also be noted that metatarsus adductus has medial border of the foot is concave in a clubfoot, and
an approximately 5% association with developmental hip there is often a deep medial skin crease seen in the foot.
dysplasia; therefore, these patients should always have a The heel, or calcaneus, is drawn up and inverted, and a
careful hip examination (Staheli, 2001). deep skin crease is also seen on the posterior aspect of
If the forefoot deformity is severe and rigid (does not the ankle joint (Figure 3B). Regardless of any treatment
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 defor-
mity, 4–6 serial casts will be applied at weekly intervals.
The feet are then placed in straight-last shoes or night-
time 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 meta-
tarsus adductus is not in treating the actual foot defor-
mity. It is often more difficult to convince parents and
grandparents that flexible metatarsus adductus will spon-
taneously resolve. Nurses can have a key role in reinforc-
ing the natural history and high percentage of sponta-
neous resolution of metatarsus adductus. Parents should
be reassured that the deformity should not interfere with
normal development and that the child will have no restric-
tions or limitations in any sports or activities (Ryan, 2001).

Nurses can have a key role in

reinforcing the natural history and high
A
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.

Clubfoot
Clubfoot, also known as talipes equinovarus, is a congen-
ital 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 inver-
sion and adduction of the forefoot, inversion of the heel B
and hindfoot, equinus of the heel, and internal or medial
rotation of the lower extremity (Gore & Spencer, 2004). FIGURE 3. (A) Congenital clubfoot deformity. (B) Severe bilat-
The deformity is not passively correctible and does not eral 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 ap-
proximately 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 bi-
fida). Clubfoot is often termed idiopathic; however, it can
also be seen with extrinsic factors (congenital constriction
bands), Mendelian disorders (craniocarpotarsal dyspla-
sia, Larsen syndrome, Pierre Robin sequence, and distal
arthrogryposis), chromosomal abnormalities, and neuro-
muscular disorders (amyoplasia and myelomeningocele)
(Dietz, 2002). Although the etiology of clubfoot remains
unknown, there is dysplasia of all osseous, muscular, tendi-
nous, cartilaginous, skin, and neurovascular structures
distal to the knee in the affected limb. Clubfoot is a com-
plex multifactorial deformity; both genetic and environ-
mental 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 nu-
merous and complex. This has been an ongoing topic of
controversy among researchers. The most notable abnor-
malities include a hypoplasia of the tarsal bones, with re-
duced size and shortening of the talus. The talus is short-
ened 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 multi-
system physical examination.
316 Orthopaedic Nursing September/October 2005 Volume 24
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 ter-
atologic. 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 re-
spond as well to nonoperative treatment.
The improvements in obstetric ultrasound in the United
States have led to a significant increase in the prenatal di-
agnosis 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 sensi-
tivity and specificity for the prenatal diagnosis of club-
foot 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 club-
foot, whereas 52% had bilateral clubfoot on sonography.
The false-positive rate was significantly higher with unilat-
eral 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 club-
foot (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 club-
foot. 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 es-
tablishing 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 general-
ized consensus that the earlier treatment of clubfoot has a
higher success rate in the nonoperative treatment of club-
foot. 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 manag-
ing 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 initi-
ate 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 em-
phasis placed on early nonoperative correction. The three
main goals of nonsurgical treatment are to provide ma-
nipulative correction, restore movement, and maintain
the correction (Crawford & Durrani, 2002). The current
treatment regimen involves early manipulation (stretch-
ing) 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 cor-
rection is obtained with each cast. The long leg casts are
changed weekly (because of the rapid growth of the new-
born) 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 tech-
nique (Heilig et al., 2003). Dr. Ponseti has made tremen-
dous contributions throughout his entire career to gain
understanding and insight in the management of congen-
ital 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
FIGURE 4. Ponseti long leg plaster cast.
Orthopaedic Nursing
and hindfoot varus are corrected before starting any cor-
rection 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 ten-
don 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 club-
foot. 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 ex-
tensive reconstructive surgery (Ponseti, 1996). After cor-
rection 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
FIGURE 5(A) and (B). Six-month-old patient with Denis
Browne splint.
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uncorrected clubfoot in the older child/adult is disabling.

The abnormal development of the foot will cause the pa-
tient to walk on the outside of his or her foot. This part of
the foot is not designed for weight bearing, and signifi-
cant calluses and pain are frequent problems in these pa-
tients. Correction of the older child/adult with congenital
clubfoot is challenging and often involves extensive surgi-
cal reconstruction.
The role of nursing in the treatment of clubfoot should
not be understated. It is the nurse who supports the fam-
ily 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 often-
arduous initial treatment plan that is usually initiated
shortly after birth (McCullough & Pellino, 1994). Nurses A
can improve compliance and outcomes through frequent
reinforcement of the treatment protocol and parental en-
couragement (Luther & Faulks, 2005). To ease parental
anxiety, nurses should remember to emphasize that the
treatment of clubfoot is successful and that these chil-
dren 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 treat-
ment have improved significantly during the last several

To ease parental anxiety, nurses should

remember to emphasize that the
treatment of clubfoot is successful and
B
that these children go on to live normal,
happy, and healthy lives. FIGURE 6(A) and (B). Corrected clubfoot deformity. Note full
dorsiflexion of foot.

years, and the overall prognosis in this deformity is excel-
lent (Figures 6A and B).
Calcaneovalgus
Calcaneovalgus is believed to be a postural deformity sec-
ondary 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 calcaneo-
valgus foot, the hindfoot is in the dorsiflexed position
(calcaneus position) so that the plantar aspect of the fore-
foot 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 cal-
caneovalgus 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.
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 congen-
ital 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 se-
quelae (Sullivan, 1999). Occasionally, in the most severe
cases, serial casting of the foot in plantarflexion and in-
version 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 nor-

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A
B
FIGURE 7. (A) Typical appearance of a calcaneovalgus foot. (B)
Note dorsiflexion of foot to tibia.
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
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.
Orthopaedic Nursing
FIGURE 8. Congenital vertical talus foot with typical “rocker-
bottom” appearance.
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, myelo-
meningocele, and chromosomal abnormalities (Jackson
& Stricker, 2003). Therefore, all patients with congenital
vertical talus should have a careful evaluation for an un-
derlying cause or associated disorder.
The typical radiographic evaluation of congenital ver-
tical talus includes an anterior-posterior (AP) and a lat-
eral view of the foot, as well as lateral views of the foot in
dorsiflexion and maximum plantarflexion. The dorsiflex-
ion view shows the fixed equinus of the hindfoot, and the
plantarflexion view confirms the dislocation of the talon-
avicular joint (Jackson & Striker, 2003).
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.
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 gradu-
ally 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 single-
stage surgery to obtain the necessary correction (Drennan,
1995; Stricker & Rosen, 1997).
The best results are usually obtained when surgical cor-
rection 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 plan-
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FIGURE 9. Twelve-month-old s/p surgical correction of con-
genital vertical talus.
tar flexed talar head, and fixation with a single longitudi-
nal 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 con-
genital foot deformity. It occurs in approximately 2–3 new-
borns out of 1,000 live births, with a slightly higher inci-
dence in African American newborns (Herring, 2002).
Both polydactyly and syndactyly usually occur as isolated
idiopathic anomalies. However, they can also be associ-
ated 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 duplica-
tion 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 articu-
lated 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 Orthopaedic Nursing September/October 2005 Volume 24
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 re-
quire 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. Long-
term follow-up studies have shown that 75% of patients
with untreated polydactyly will experience serious shoe-
fitting problems (usually resulting from excessive fore-
foot width) and approximately 25% will have persistent
pain (Stevens, 1992).
Syndactyly
Congenital webbing of the toes is also a common defor-
mity of the foot. Syndactyly can also be classified as simple
or complex and varies in the degree of severity from incom-
plete 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 usu-
ally 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
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 re-
place 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 be-
tween 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 defor-
mities. 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 accu-
rate 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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