Metatarsus adductus clinic guidelines

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Updated by: Allison Duey-Holtz
Updated on: August 2, 2017 

Definition

An adduction or medial deviation of the forefoot that is recognized as a contracture at the tarsometatarsal joints

Diagnosis/Symptom

Signs and symptoms

• Deformity usually present at birth but may not present until the first year of life (3)
• Incidence estimated to be as high as 1 in 100 births (4)

Causes

• Spontaneous resolution to normal in 83%(1) to 95% (4) of cases by age one
• Pathogeneis is unknown but is believed to result from intrauterine crowding or positioning (4)

Referring provider’s initial evaluation and management:

Differential Diagnosis

• Dynamic hallux varus
• Internal rotation of the foot 
• Metatarsus primus varus
• Skewfoot
• Tibial torsion
• Clubfoot

Diagnostic Tests

• Radiographs- not needed unless child has failed casting
• Xerox of feet

Treatment Options

• Mild/moderate flexible & approximately 7 months of age:
• No intervention passively correctible deformity will spontaneously correct on its own by age 1 (3,4)
• Educate families that the deformity should not interfere with normal development and that the child will have no restrictions or limitations in any sports or activities (4).
• Offer casting which works best in children under 8 months of age
  Moderate/severe inflexible serial casting:
• Inflexible: Initiate treatment immediately
• If present at 8 months may initiate serial casting as the percentage of favorable outcomes decreases if treatment was initiated after the patient was more than 8 months of age (1)
• If flexible, partially flexible at 8 months may cast
• Follow-up post casting to ensure no recurrence

When to initiate referral/ consider refer to Orthopedic Clinic:

Parental or provider concern.

What can referring provider send to Orthopedic Clinic?

1. Using Epic

• Please complete the external referral order In order to help triage our patients and maximize the visit, the following information would be helpful to include with your referral order:
• Urgency of the referral
• What is the key question you would like answered?
  Note: Our office will call to schedule the appointment with the patient. 

2. Not using Epic external referral order:

• In order to help triage our patients maximize the visit time, please fax the above information to (414-607-5288)
• It would also be helpful to include:
• Chief complaint, onset, frequency
• Recent progress notes
• Labs and imaging results
• Other Diagnoses
• Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient’s problems

Specialist’s workup will likely include:

After referral to Orthopedic Clinic:

• Comprehensive birth history
• Family history
• HPI
• Neuromuscular exam
• Gait evaluation
• Evaluate for hip dysplasia (9)
• Complete rotational profile (internal and external hip rotation, thigh-foot axis, transmalleolar axis, heel bisector angle, foot progression angle) (1,3,4)
• Neuromuscular exam
• Assessment of the foot, assess for degree of flexibility (4)
• Evaluate for hip dysplasia or other congenital orthopedic conditions(4)
• Evaluate heel bisector line (1)
• Identify: flexible, partially flexible, inflexible

Follow up Recommendations

If flexible & less than 7 months

• f/u as needed at 7 months
• Bi-weekly for 6-8 weeks if treating with plaster casts (2)

Follow-up with surgeon:

• Over age 2years old
• Rigid/Inflexible after casting
• Operative treatment is not needed or desirable in patients who have mild or moderate deformities past age 2yo(3)

Evidenced Based Literature Review

Bleck, E.E. (1983). Metatarsus adductus: Classification and relationship to outcomes of treatment. Journal of Pediatric Orthopedics. 3, 2-9.

Farsetti, P., Weinstein, S.L., & Ponseti, I.V. (1994). The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. Journal of Bone & Joint Surgery. 76, 257-265.

Hart, E.S., Grottkau, B.E., Rebello, G.N., & Albright, M.B. (2005). The newborn foot: Diagnosis and management of common conditions. Orthopaedic Nursing. 24(5), 313-321.

Herring, J. A. (2008). Disorders of the foot. In M.O. Tachdjian & J.A. Herring (Eds), Tachdjian’s Pediatric Orthopedics (4th Ed) (pp.1035-1186). Philadelphia: Saunders Elsevier

Katz, K., David, R., & Soudry, M. (1999). Below-knee plaster cast for the treatment of metatarsus adductus. Journal of Pediatric Orthopedics. 19(1), 49-50.

Ponseti, I.V. & Becker, J.R. (1966). Congenial metatarsus adductus: The results of treatment. The Journal of Bone & Joint Surgery. 48, 702-711.