From the Guidelines
The best next step in management for this 6-day-old boy is reassurance (option B). The physical findings described - bilateral medial deviation of the forefoot relative to the hindfoot that is correctable with passive abduction past the midline - are consistent with metatarsus adductus, a common positional foot deformity in newborns. This condition is typically benign and self-resolving, especially when the deformity is flexible and passively correctable as described in this case. Most cases of flexible metatarsus adductus resolve spontaneously within the first few months of life without any intervention, as suggested by the natural history of developmental dysplasia of the hip and other congenital conditions 1. Parents can be instructed to perform gentle stretching exercises during diaper changes to help facilitate resolution. Imaging studies such as radiographs or ultrasounds are unnecessary for flexible deformities, and the American Academy of Pediatrics recommends selective screening based on physical examination findings or risk factors 1. More aggressive interventions like serial casting would only be indicated if the deformity were rigid or failed to improve with time and stretching. Regular follow-up during well-child visits is sufficient to monitor the progression and ensure resolution of this common condition. Key points to consider in management include:
- The deformity is flexible and passively correctable
- Most cases resolve spontaneously
- Gentle stretching exercises can facilitate resolution
- Imaging studies are not necessary for flexible deformities
- Regular follow-up is sufficient for monitoring progression.
From the Research
Diagnosis and Management
The patient's condition is described as bilateral medial deviation of the forefoot relative to the hindfoot, which is correctable with passive abduction of the forefoot past the midline. This suggests a flexible deformity, which is a common finding in infants.
Possible Conditions
- The condition described is consistent with metatarsus adductus, a common congenital foot deformity characterized by inward deviation of the forefoot.
- Another possible condition is flexible flatfoot, which is also common in infants and often corrects itself as the child grows.
Management Options
- Reassurance: Given the flexible nature of the deformity and the fact that it is correctable with passive abduction, reassurance is a reasonable next step in management, as the condition is likely to improve on its own 2, 3.
- Serial manipulation and casting: While this is a common treatment for clubfoot, it may not be necessary in this case, as the deformity is flexible and correctable 4, 5.
- Foot radiographs: While radiographs may be useful in evaluating the deformity, they are not necessarily indicated in this case, as the deformity is flexible and correctable, and radiographic measurements have been shown to have poor inter-rater reliability 6.
- Ultrasonography of the hips or sacral spine: These tests are not indicated in this case, as the deformity is localized to the foot and there is no suggestion of hip or spinal abnormalities.
Best Next Step
Based on the information provided, the best next step in management of this patient is B. Reassurance, as the deformity is flexible and correctable, and reassurance has been shown to be an effective therapy in patients with benign or non-existent medical disease 2, 3.