Figure A depicts bilateral skewfoot in a 7-year-old boy. The deformities were rigid in this child, and there was no improvement with growth.
Physical examination. Skewfoot has the same general clinical appearance as metatarsus adductus, but there is hindfoot eversion (valgus) and more rigidity.1 The condition is associated with forefoot adduction, a flattened medial longitudinal arch, and hindfoot valgus. The Achilles tendon may be contracted.
Skewfoot may result from metatarsus varus, in which there is not only adduction but also supination of the forefoot. With ambulation, the forefoot supination resolves, but at the expense of creating hindfoot valgus. Thus, a skewfoot may be a developmental deformity.
Radiographic evaluation. Radiographs are necessary to distinguish between skewfoot and metatarsus adductus. In skewfoot deformity, forefoot adduction and valgus alignment of the hindfoot are characterized radiographically by an increase in the AP and lateral talocalcaneal angles. The foot has a typical Z appearance in the AP projection (B).
Management. Serial casting can be attempted in children with skewfoot, although only limited success has been reported.1,2 While the forefoot is manipulated into the corrected position, the hindfoot is brought into a varus position so that both components of the deformity can be addressed simultaneously. Children with skewfoot are usually immobilized in a long leg cast to maintain correction.
Surgical intervention may be required for skewfoot deformities that are resistant to serial casting. These deformities are more rigid and may become painful with shoe wear later in childhood. Surgery is complex; it typically consists of lengthening the neck of the calcaneus to correct the hindfoot valgus, performing an opening wedge osteotomy of the medial cuneiform to correct forefoot adduction, and lengthening the Achilles tendon.2
1. Peterson HA. Skewfoot (forefoot adduction and heel valgus). J Pediatr Orthop. 1986;6:24-30.
2. Mosca VS. Instructional course lectures: flexible flatfoot and skewfoot. J Bone Joint Surg. 1995;77A:1937-1945.