Possible viva qn on short case on ctev

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clubfoot AND treatment

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clubfoot CTEV Ponseti method clinical examination guideline

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https://posna.org/physician-education/study-guide/clubfoot

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Possible viva questions for a short case of CTEV / clubfoot

1. What is your diagnosis?

Congenital talipes equinovarus (CTEV), also called congenital clubfoot.
Describe side involved, whether unilateral/bilateral, severity, rigidity, and whether it is primary idiopathic or syndromic.

2. What are the components of deformity?

Use CAVE:

Cavus: high medial arch due to plantar-flexed first ray
Adductus: forefoot adduction
Varus: hindfoot inversion/varus
Equinus: ankle plantar-flexion

This is also the order in which deformities are corrected by the Ponseti method.

3. Why is the foot called “clubfoot”?

Because the foot is turned inward and downward, resembling the shape of a golf club.

4. Is CTEV a positional deformity?

No. True CTEV is a structural, fixed deformity involving soft tissues, joints, and bones. It must be distinguished from a flexible positional foot deformity, which can be passively corrected.

5. How will you examine the child?

Observe from front, side, and back.
Determine laterality and severity.
Look for CAVE components.
Assess rigidity and passive correctability.
Check calf wasting and foot size. The affected foot and calf are often smaller.
Examine skin creases, especially medial and posterior creases.
Assess dorsiflexion at ankle and hindfoot position.
Check neurovascular status.
Examine the spine for occult spinal dysraphism.
Perform a full neurological examination.
Look for associated anomalies, especially DDH and arthrogryposis.

6. What is the typical appearance in an untreated case?

Small foot, heel elevated
Forefoot adducted and supinated
Hindfoot in varus
Equinus at ankle
Deep medial and posterior creases
Prominent lateral border of foot
Smaller calf on affected side

7. What is the difference between CTEV and metatarsus adductus?

CTEV	Metatarsus adductus
Forefoot adduction with hindfoot varus and equinus	Forefoot adduction only
Rigid structural deformity	Often flexible
Heel is in varus	Heel is usually neutral
Ankle dorsiflexion limited due to equinus	Ankle dorsiflexion normal
Needs Ponseti casting if idiopathic clubfoot	Often observation/stretching

8. Differentiate CTEV from congenital vertical talus.

CTEV: hindfoot equinus and varus, forefoot adducted.
Vertical talus: rigid rocker-bottom foot, hindfoot equinus with valgus, forefoot dorsiflexed and abducted, and a prominent talar head on the plantar-medial aspect.

9. What scoring systems are used?

Pirani score: evaluates six clinical signs, each scored 0, 0.5, or 1. Total score is 0 to 6.
Dimeglio score: grades severity and reducibility.

Pirani scoring is useful for documenting severity and monitoring response to serial casting.

10. Are radiographs necessary initially?

Usually not in a typical newborn with idiopathic CTEV, because diagnosis is clinical and tarsal bones are incompletely ossified. Radiographs may be needed in atypical, resistant, recurrent, neglected, or syndromic cases. POSNA guidance notes that initial radiographs are not commonly used for a clearly isolated clubfoot.

11. What are the associated conditions?

CTEV may be:

Idiopathic, most common
Syndromic, for example arthrogryposis and Larsen syndrome
Neuromuscular, for example spina bifida or cerebral palsy
Associated with congenital constriction bands

Bilateral, atypical, or rigid deformity should prompt a careful neurological and syndromic evaluation.

12. What is the management?

The standard treatment is the Ponseti method, started as early as possible after birth:

Gentle manipulation
Weekly above-knee plaster casts
Correction in CAVE order
Percutaneous Achilles tenotomy for residual equinus in most feet
Foot-abduction brace to maintain correction

13. Explain the Ponseti sequence.

Correct cavus first by elevating the first metatarsal and supinating the forefoot.
Correct adduction and varus together by abducting the foot around the talar head.
Correct equinus last, often with percutaneous Achilles tenotomy.

Never pronate the forefoot during correction, as this can worsen cavus and impede correction.

14. Why is the cast above knee?

An above-knee cast prevents knee movement and rotation, helping maintain correction and preventing slippage.

15. When is Achilles tenotomy done?

After correction of cavus, adduction, and varus, if residual equinus remains and adequate foot abduction has been achieved. It is usually a percutaneous procedure followed by a final cast.

16. What brace is used after correction?

A foot-abduction brace, commonly the Denis Browne bar with shoes attached in external rotation.

Typical positioning:

Affected foot: about 60-70 degrees external rotation
Unaffected foot in unilateral CTEV: about 30-40 degrees external rotation
Both feet: around 60-70 degrees external rotation in bilateral disease

17. What is the brace protocol?

Commonly:

Full-time wear for about the first 3 months after final correction
Then during sleep and naps until approximately 4-5 years of age

Exact protocol can vary by treating unit.

18. What is the commonest cause of relapse?

Poor compliance with the foot-abduction brace. Parents must be counselled that casting achieves correction, but bracing maintains it. POSNA reports high initial correction rates with Ponseti treatment, while recurrence remains common if bracing is discontinued. POSNA clubfoot review

19. How does relapse present?

Recurrent equinus
Dynamic forefoot supination during walking
Recurrent adduction or heel varus
Difficulty wearing normal shoes

20. How do you manage relapse?

Depends on age and deformity:

Repeat Ponseti manipulation and casting for early relapse
Repeat Achilles tenotomy or lengthening if equinus persists
Tibialis anterior tendon transfer for dynamic supination in an ambulatory child, after obtaining a supple plantigrade foot
More extensive surgery only for resistant, rigid, or neglected cases

21. What is dynamic supination?

During gait, the forefoot supinates in swing phase and the child bears weight on the lateral border of the foot. It suggests overactivity of tibialis anterior and may require tibialis anterior tendon transfer after correction of fixed deformity.

22. What are the indications for surgery?

Surgery is reserved for:

Failure of properly performed Ponseti management
Rigid resistant deformity
Recurrent deformity not responding to recasting
Neglected clubfoot in older children
Selected syndromic or neuromuscular clubfoot

Extensive posteromedial release is generally avoided where possible because it can lead to a stiff, painful foot later.

23. What is the aim of treatment?

A painless, plantigrade, flexible, functional foot that can fit into normal footwear. The goal is not merely a cosmetically straight foot.

24. What should you tell the parents?

Treatment should start early.
Serial casting is highly effective.
Tenotomy is commonly required and is a small procedure.
Brace adherence is essential for years.
Relapse can occur, but early recognition and recasting often work well.
The affected foot and calf may remain smaller despite successful treatment.

High-yield closing statement for viva

“This child has CTEV characterized by CAVE deformity: cavus, forefoot adduction, hindfoot varus, and equinus. I will assess rigidity, Pirani score, associated neuromuscular or syndromic causes, and then manage with early Ponseti serial above-knee casting, correcting CAVE sequentially, followed by Achilles tenotomy for residual equinus and prolonged foot-abduction bracing to prevent relapse.”

Recent-evidence note: a 2024 network meta-analysis supports contemporary nonoperative Ponseti-based management for idiopathic clubfoot (PMID: 38015923).

Give me a rapid-fire CTEV viva quiz

Reading File

Rapid-fire mode: answer in one line or bullet points. I’ll correct and move on.

Q1. Define CTEV and expand the abbreviation.

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