How to examine document ctev case in orthopedic
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Examination of a CTEV (Congenital Talipes Equinovarus / Clubfoot) Case in Orthopedics
CTEV is a complex three-dimensional foot deformity combining four elements, remembered by the mnemonic CAVE: Cavus (high arch), Adduction of forefoot, Varus of hindfoot, Equinus of ankle. Here is a systematic approach to examining a CTEV case.
1. Definition and Deformity Components
CTEV consists of:
- Equinus - plantarflexion of the ankle (heel pointing down)
- Varus - inversion of the hindfoot (heel tilts inward)
- Adductus - forefoot adducted toward the midline
- Cavus - high medial arch (pronation of first ray)
The talonavicular joint is subluxed with the navicular displaced medially relative to the talar head.
2. History
- Age at presentation and whether treated previously
- Antenatal diagnosis (ultrasound)
- Family history (multifactorial inheritance)
- Birth history - associated conditions (spina bifida, arthrogryposis, amniotic band syndrome)
- Laterality (unilateral vs bilateral - 50% are bilateral)
- Sex (males twice as commonly affected)
- Any prior casting or surgery
3. General Observation (Before Touching)
Look at the child from a distance:
- Overall posture and gait (if walking age)
- Does the child walk on the outer border of the foot?
- Asymmetry of limbs
Look at the foot:
- The foot is plantarflexed, inverted, and adducted
- The sole faces medially/posteriorly (plantarflexion + inversion)
- There is a deep medial crease (from forefoot adduction) and a single deep posterior crease (from equinus)
- The lateral border of the foot is convex ("rocker-bottom" appearance in some)
- Small foot and calf - smaller foot size and calf hypoplasia compared to the opposite side
- The heel appears "empty" because the calcaneus is pulled up by the shortened tendo-Achilles
Distinguish from postural clubfoot:
- Postural clubfoot is flexible and corrects fully to neutral - by definition must normalize by 3 months
- True structural CTEV has fixed deformity that cannot be passively corrected to neutral
4. Inspection - Detailed
| Feature | Findings in CTEV |
|---|---|
| Foot posture | Plantarflexion + inversion + adduction |
| Medial crease | Deep medial skin crease (from adduction) |
| Posterior crease | Deep posterior crease (from equinus) |
| Heel | Empty, small, pulled upward |
| Calf | Hypoplastic, smaller than normal side |
| Skin | May have skin breakdown/calluses at lateral border if walking (neglected/older case) |
| Tibial shortening | May be apparent with growth |
5. Palpation
- Talar head - Palpate the head of talus on the dorsolateral aspect of the foot; it will be prominent laterally as the navicular is displaced medially off it
- Calcaneus - Small, in varus (inverted) and equinus position; the heel pad feels "empty" or underfilled
- Tendo-Achilles (TA) - Tight, prominent, shortened
- Tibialis posterior tendon - Tight on palpation
- Navicular - Displaced medially; may not be ossified in infants
- Skin creases - Feel the depth of medial and posterior creases
- Calf bulk - Measure calf circumference bilaterally and compare
6. Assessment of Flexibility / Passive Movements
This is the most critical part - determines postural vs structural CTEV and guides treatment.
Method:
- Fix the lower leg with one hand to stabilize the tibia
- Hold the heel with the other hand (not the forefoot)
- Attempt to passively correct each component:
| Movement | How to Test | Finding in CTEV |
|---|---|---|
| Dorsiflexion (equinus) | Hold leg, dorsiflex foot at ankle | Limited - cannot reach neutral (0°) |
| Eversion (varus) | Hold heel, evert the calcaneus | Limited - resistance felt medially |
| Abduction (adductus) | Hold heel with lower leg, abduct forefoot at midtarsal joint | Limited |
| Cavus | Assess plantar arch height | Fixed high arch |
- In postural clubfoot: all movements are correctable to normal
- In true CTEV: movements cannot be fully corrected passively
Simmons test / Heel bisector line:
- Normally the heel bisector line passes through the 2nd web space
- In CTEV it passes laterally (through 4th or 5th toe)
7. Severity Scoring Systems
Pirani Score (most widely used for Ponseti treatment)
Six clinical signs, each scored 0 (normal), 0.5 (moderate), or 1 (severe) - total 0-6:
Hindfoot score (3 signs):
- Posterior crease - depth and number
- Empty heel - degree of calcaneal elevation
- Rigid equinus - ability to dorsiflex
Midfoot score (3 signs):
4. Medial crease - depth
5. Talar head coverage - lateral prominence
6. Curvature of lateral border - convexity
Higher score = more severe, requires more casts
Dimeglio Classification (I-IV)
Based on reducibility of deformity in 4 planes - predicts casting difficulty. Both Pirani and Dimeglio must be assessed at maximal correction position (not at rest).
8. Neurological Examination
This is mandatory in every CTEV case:
- Muscle power - assess tibialis anterior, peroneals, gastrosoleus, toe extensors/flexors
- Sensation - check dermatomal distribution (L4/L5/S1)
- Reflexes - ankle jerk (S1), knee jerk (L3/L4)
- Weakness of evertor muscles (peroneals) is common even in idiopathic CTEV
Why important: CTEV may be secondary to:
- Spina bifida (myelomeningocele) - examine the spine for sacral dimple, hairy patch, midline defect
- Arthrogryposis - multiple joint contractures
- Poliomyelitis - asymmetric muscle weakness
9. Examination of Knee, Hip, and Spine
Always examine proximally:
- Spine - inspect for spinal dysraphism (hairy tuft, dimple, gibbus)
- Hip - DDH may co-exist; test Barlow/Ortolani in neonates
- Knee - assess for genu valgum, tibial torsion
- Leg length - tibial shortening may develop with growth
10. Radiological Assessment
Standard X-rays have limited value in infants due to unossified cartilage, but are used in older children and post-treatment:
| View | Finding in CTEV |
|---|---|
| AP (weight-bearing) | Talocalcaneal (Kite) angle < 20° (normal 20-40°); talus-1st metatarsal angle is negative (normal 0-20°); parallelism of calcaneus and talus |
| Lateral (Turco / dorsiflexion stress) | Talocalcaneal angle < 35° on dorsiflexion lateral view |
Key radiological sign: Parallelism of talus and calcaneus (normally they diverge). In CTEV both bones are parallel and pointing in the same direction.
11. Summary of Clinical Signs at a Glance
| Sign | Description |
|---|---|
| CAVE deformity | Cavus, Adductus, Varus, Equinus |
| Deep medial crease | From forefoot adduction |
| Deep posterior crease | From hindfoot equinus |
| Empty heel | Calcaneus pulled up |
| Calf hypoplasia | Smaller calf on affected side |
| Prominent talar head | Lateral prominence, navicular displaced medially |
| Rigid, non-correctable | Cannot passively reach neutral |
| Pirani score | 0-6 scale for severity |
Sources
- Bailey and Love's Short Practice of Surgery, 28th Edition, p. 647
- S Das - A Manual on Clinical Surgery, 13th Edition, p. 325
- Miller's Review of Orthopaedics, 9th Edition
- Campbell's Operative Orthopaedics, 15th Ed 2026
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