import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Clubfoot Examination (Pirani Score) Clubfoot examination requires systematic assessment of the four deformity components (CAVE: Cavus, Adductus, Varus, Equinus) and scoring using the Pirani system. Examiners expect you to calculate the Pirani score accurately, understand the Ponseti method principles, and recognize syndromic versus idiopathic clubfoot. ## Quick Reference One-Pager ## Understanding Clubfoot **Congenital Talipes Equinovarus (CTEV):** A complex 3D deformity with four components (CAVE): | Component | Location | Description | |-----------|----------|-------------| | **C**avus | Forefoot | Increased medial arch, pronated forefoot | | **A**dductus | Forefoot/Midfoot | Forefoot points medially | | **V**arus | Hindfoot | Heel inverted/turned inward | | **E**quinus | Ankle | Fixed plantarflexion (Achilles tightness) | **Incidence:** 1 in 1,000 live births **M:F Ratio:** 2:1 **Bilateral:** 50% **The Talus is the Key:** In clubfoot, the talus is: - Fixed in the ankle mortise in equinus - The navicular is displaced medially on the talar head - The calcaneus is inverted (varus) under the talus Understanding this explains why correction follows CAVE order (supination before pronation/abduction). ## Clinical Examination ### Observation **With Baby Undressed:** - Bilateral or unilateral? - Severity of deformity - Deep skin creases (indicate severity and rigidity) - Calf muscle wasting (always present to some degree) **Syndromic Features (look for):** - Arthrogryposis (multiple joint contractures) - Myelomeningocele (examine spine!) - Constriction band syndrome - Other dysmorphic features **Family History:** - 25% have affected family member ### Deformity Assessment **1. Cavus (Forefoot):** - Deep plantar medial crease - Pronated first ray - Elevated medial arch **2. Adductus (Forefoot/Midfoot):** - Forefoot deviated medially relative to hindfoot - Curved lateral border of foot - Medial crease at midfoot **3. Varus (Hindfoot):** - Heel inverted (varus position) - Palpate calcaneus - points medially - Posterior crease over heel **4. Equinus (Ankle):** - Fixed plantarflexion - Assess passive dorsiflexion - "Empty heel" sign - heel feels empty/small - Rigid Achilles tendon ### Corrective Assessment **Key Question:** How much does the deformity correct with passive manipulation? **Technique:** - Gently attempt to correct each component - Note resistance and degree of correction - Never force - observe what happens naturally **Cavus:** - Does forefoot supinate to align with hindfoot? - Corrects first in Ponseti casting **Adductus/Varus:** - Can you abduct the forefoot? - Can the heel be corrected to neutral? - Counter-pressure on talar head (Ponseti technique) **Equinus:** - Assess with knee extended AND flexed - Most rigid component - often needs tenotomy - Tests Achilles contracture ## Pirani Scoring System **Purpose:** Quantify severity and guide treatment **Range:** 0 to 6 (higher = more severe) **Components:** 3 midfoot signs + 3 hindfoot signs **Each sign scored:** - 0 = Normal - 0.5 = Moderate abnormality - 1 = Severe abnormality ### Midfoot Score (0-3) ### Hindfoot Score (0-3) ## Pirani Score Interpretation **Using Pirani Score Clinically:** - **Initial assessment**: Quantify severity, predict number of casts - **Progress monitoring**: Score decreases with successful treatment - **Tenotomy decision**: If hindfoot score greater than 0.5 after midfoot score is 0, tenotomy indicated - **Recurrence detection**: Rising score indicates relapse ## Idiopathic vs Syndromic Clubfoot ## Associated Examinations **Always Examine:** 1. **Spine**: Dimple, hairy patch, scoliosis (spinal dysraphism) 2. **Hips**: DDH association (also has packaging abnormality) 3. **Other limbs**: For contractures (arthrogryposis) 4. **Neurological**: Tone, reflexes (neuromuscular cause?) 5. **Dysmorphic features**: Face, hands (syndromic clubfoot) ## Summary Presentation ## Examiner Tips