A 2-day-old male newborn born to a 28-year-old primigravida is noted to have bilateral foot deformities on routine neonatal examination. Both feet are inverted, plantarflexed, and adducted. The feet cannot be passively dorsiflexed beyond midline. The mother reports no significant antenatal complications or family history of skeletal abnormalities. What is the most likely diagnosis?

## Diagnosis of Congenital Talipes Equinovarus ### Clinical Presentation **Key Point:** CTEV is the most common congenital foot deformity, occurring in approximately 1–2 per 1000 live births. The classic presentation includes the **four cardinal deformities**: equinus (plantarflexion), varus (inversion), adduction, and supination. ### Diagnostic Features in This Case - **Bilateral involvement** (present in ~50% of cases) - **Rigid deformity** at birth (cannot be passively corrected beyond midline) - **Inverted, plantarflexed, adducted feet** — the hallmark triad - **Neonatal presentation** — detected on routine newborn screening - **Absence of neuromuscular or syndromic features** — suggests idiopathic CTEV ### Mnemonic for CTEV Deformities **CAVE**: Cavus (high arch), Adduction, Varus, Equinus ### Pathoanatomy The deformity results from: 1. Medial deviation of the talar neck 2. Inversion of the calcaneus 3. Plantarflexion of the entire foot 4. Supination and adduction of the forefoot ### Clinical Pearl **High-Yield:** Bilateral CTEV (as in this case) is more common than unilateral and may be associated with neuromuscular conditions (cerebral palsy, spina bifida) or genetic syndromes (trisomy 18, trisomy 13). However, the majority of bilateral cases are idiopathic. ### Differential Diagnosis at a Glance | Feature | CTEV | Calcaneus | Metatarsus Adductus | Vertical Talus | |---------|------|-----------|--------------------|-----------------| | **Plantarflexion** | Yes (equinus) | No (dorsiflexed) | No | No | | **Inversion** | Yes (varus) | No (valgus) | No | No | | **Adduction** | Yes | No | Yes | No | | **Rigidity** | Rigid | Flexible | Flexible | Rigid | | **Talar position** | Medially deviated | Normal | Normal | Vertically oriented | | **Age of detection** | Neonatal | Neonatal | 3–6 months | Neonatal | ### Initial Management **Tip:** Ponseti casting is the gold standard first-line treatment, with >95% success rate when started within the first weeks of life. Serial manipulation and casting correct the deformity in 6–8 weeks, followed by a maintenance phase with an abduction brace. ## Why the Other Options Are Incorrect **Calcaneus deformity:** Presents with dorsiflexion (not plantarflexion) and valgus (not varus) alignment. Often associated with neuromuscular conditions. **Metatarsus adductus:** Primarily a forefoot adduction deformity without equinus or varus components. Usually flexible and detected later (3–6 months). Often resolves spontaneously. **Vertical talus:** A rigid rocker-bottom foot with dorsiflexion (not equinus). The talus is vertically oriented on imaging. Requires surgical intervention and has a poorer prognosis than CTEV.