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Note what signs you see.
I (W. Wertelecki, M.D.) see that this young girl has congenital severe “club feet” (equino-varus). This composite illustration brings forth the need to distinguish what is or are “malformations” vs “deformations”, isolated or multiple “contractures” of articulations (joints); embryonal or environmental mechanical impacts on limb development or represent components of a generalized, usually inherited, disorder. These points are critical to frame early interventions.
PERSPECTIVE: The “nosology” or classification of “club feet”, their pathogenesis (mechanisms of expression), their etiology (causes that trigger pathogenesis), diagnosis (synthesis of symptoms, signs, pathogenesis, and etiology), and prognosis are complex subject presented elsewhere. However, it is pertinent to point out that all of these mentioned factors must be compatible with the “natural history” of this particular patient concerning her ailment. Contradictions of the first with the rest nulifies hypothetical diagnoses.
The natural history of this young girl includes the following points: the family history is not informative regarding genetic or teratogenic risk factors; she is the product of the first gestation; the uterine cavity was reduced by several large uterine myomas; the birth weight was 4.3 kg and examinations were within norms, except for the feet; the growth and developmental patterns were within norms at and since birth. However, as illustrated in the composite image, the posture of her right hand suggests that the history may be incomplete – perhaps the right hand is not within norm (an example for clinicians to have “clinical eyes” open). The above must be facts and the following are interpretations.
The risk factors associated with “club feet” are different by their subcategories: equinovarus, equinovalgus, metatarsus varus (discussed in a companion diagnoses – syndromes). In this instance of equinovarus the risk factors noted include: uterine myomas (constrain on fetal motion); prima gravida (lesser uterine elasticity vs multiparas), female sex – the significance of the postural laxity remains unknown.
Note that Hippocrates already attributed crippling feet anomalies to uterine pressure.
More comments in the diagnoses – syndromes channel.
Source: JW archive 1-Club Feet