CTEV (Congenital Talipes Equinovarus / Clubfoot)

C = Cavus        → high medial arch / plantar-flexed first ray
A = Adductus     → forefoot deviated medially
V = Varus        → heel inverted
E = Equinus      → ankle plantar-flexed, heel cannot touch ground

Etiology

CTEV
  ↓
Multifactorial cause
  ├─ Genetic predisposition
  │   ├─ Positive family history
  │   └─ Occasionally familial autosomal-dominant pattern
  │
  ├─ Intrinsic developmental abnormalities
  │   ├─ Abnormal talus and tarsal alignment
  │   ├─ Medial displacement of navicular and calcaneus
  │   └─ Short/tight posteromedial muscles, tendons, ligaments and capsule
  │
  ├─ Neuromuscular / syndromic causes
  │   ├─ Myelomeningocele
  │   ├─ Arthrogryposis
  │   └─ Other neuromuscular disorders
  │
  └─ Environmental associations
      ├─ Maternal or paternal smoking
      ├─ Maternal obesity
      └─ Some antenatal exposures

Clinical features

At birth
  ↓
Foot is turned inward and downward
  ↓
Inspection
  ├─ Cavus: increased medial longitudinal arch
  ├─ Forefoot adduction: toes point medially
  ├─ Heel varus: heel inverted
  ├─ Equinus: plantar-flexed ankle
  ├─ Deep medial and posterior skin creases
  ├─ Small heel / underdeveloped calf
  └─ Internal tibial torsion may coexist
  ↓
Examination
  ├─ Deformity is rigid and not fully passively correctable
  ├─ Marked limitation or absence of ankle dorsiflexion
  ├─ Assess severity: Pirani score or Dimeglio score
  ├─ Assess hips, spine and neurologic status
  └─ Look for associated syndromes or neuromuscular disease

Typical appearance

                Forefoot adduction
                      ←
          toes  /-------\
                \       /
                 \_____/
                    ↓
              Hindfoot varus
                    ↓
             Equinus at ankle

Management flow chart

Newborn with suspected CTEV
          ↓
Confirm clinical diagnosis
          ↓
Assess:
- Flexible or rigid?
- Idiopathic or syndromic/neuromuscular?
- Severity: Pirani/Dimeglio score
- Spine, hips, neurological examination
          ↓
Refer early to paediatric orthopaedic service
          ↓
          ┌─────────────────────────────────┐
          │ Begin Ponseti treatment early    │
          │ preferably in first weeks of life│
          └─────────────────────────────────┘
          ↓
Weekly gentle manipulation + long-leg cast
          ↓
Correct in order: C → A → V → E
          ↓
After 4-8 casts, assess ankle dorsiflexion
          ↓
        Is equinus corrected?
        /                    \
      Yes                     No
       ↓                       ↓
Foot-abduction brace       Percutaneous Achilles
                           tendon tenotomy
                                  ↓
                           Final cast for about
                           3 weeks
                                  ↓
                         Foot-abduction brace

Ponseti method: correction sequence

1. CAVUS
   Elevate plantar-flexed first metatarsal
   and supinate forefoot

          ↓

2. ADDUCTUS + VARUS
   Gradually abduct foot while stabilizing
   the head of talus
   Do NOT pronate the forefoot

          ↓

3. EQUINUS
   Correct last
   Usually needs percutaneous Achilles tenotomy

Bracing protocol after correction

Corrected foot
      ↓
Foot-abduction brace
      ↓
23 hours/day for first 3 months
      ↓
During sleep and naps until 4-5 years of age
      ↓
Regular follow-up for relapse

Relapse management

Relapse detected
      ↓
Assess brace adherence and type of relapse
      ↓
Early, supple relapse
      → Repeat Ponseti manipulation and casts
      → Reinforce brace adherence
      ↓
Persistent dynamic supination in walking child
      → Tibialis anterior tendon transfer
        (usually after age 2.5-3 years, after full correction)
      ↓
Rigid residual or severe recurrent deformity
      → Limited soft-tissue procedure / osteotomy
      ↓
Neglected older child or severe salvage case
      → Corrective osteotomy, external fixation,
        or arthrodesis in selected mature patients

Key exam points

CTEV = CAVE deformity
Treatment = Ponseti method
Order of correction = Cavus → Adductus → Varus → Equinus
Equinus is corrected last
Achilles tenotomy is often required
Brace compliance prevents relapse
Extensive posteromedial release is not first-line treatment