A 2-day-old male neonate born to a 28-year-old primigravida is noted to have bilateral foot deformities at birth. On examination, both feet are in equinus and varus positions, with the sole facing medially. The feet cannot be passively dorsiflexed beyond neutral. There is no associated cleft palate, cardiac murmur, or other dysmorphic features. What is the most likely diagnosis?

Explanation

## Diagnosis: Congenital Talipes Equinovarus (CTEV) ### Clinical Presentation The neonate presents with the classic tetrad of CTEV: 1. **Equinus** — plantar flexion of the foot 2. **Varus** — inversion of the foot 3. **Adductus** — medial deviation of the forefoot 4. **Internal rotation** — medial twist of the entire foot The sole faces medially (inverted), and passive dorsiflexion is limited — hallmark findings. ### Key Diagnostic Features | Feature | CTEV | Calcaneovalgus | Metatarsus Adductus | |---------|------|-----------------|---------------------| | **Position** | Equinus + varus | Dorsiflexed + valgus | Forefoot adduction only | | **Sole orientation** | Faces medially | Faces laterally | Faces forward | | **Passive correction** | Difficult | Easy | Easy | | **Incidence** | 1–2 per 1000 | 1 per 1000 | 1–2 per 1000 | | **Prognosis** | Requires treatment | Self-limiting | Self-limiting | **Key Point:** CTEV is the most common congenital foot deformity and is **NOT self-correcting**. Bilateral presentation (as in this case) occurs in ~50% of CTEV cases. ### Pathophysiology The deformity arises from: - Shortened and tight medial soft tissues (tibialis posterior, flexor digitorum longus, posterior capsule) - Underdevelopment of lateral foot structures - Intrauterine positioning and genetic factors (autosomal dominant with incomplete penetrance) **High-Yield:** CTEV is associated with: - Neuromuscular conditions (cerebral palsy, spina bifida) - Chromosomal abnormalities (trisomy 18, trisomy 13) - Arthrogryposis multiplex congenita (but this patient has isolated foot deformity) - Family history (10% if one parent affected; 30% if both parents affected) ### Management Principles 1. **Early intervention** — start within first 2 weeks of life 2. **Conservative (Ponseti method)** — serial casting with weekly manipulation (success rate ~95%) 3. **Surgical** — if conservative fails (tibialis posterior tenotomy, soft tissue releases) **Clinical Pearl:** The Ponseti method involves sequential manipulation and casting in a specific sequence: correct adductus first, then varus, then equinus. Percutaneous tenotomy of the Achilles tendon is often needed after 5–6 casts.