Metatarsalgia in Metatarsus Adductus Patients: A Rational Approach

Metatarsus adductus (MA) is a congenital condition resulting in adduction of the forefoot at the tarsometatarsal joint, medial metatarsal deviation, supination of the hindfoot through the subtalar joint, and plantarflexed first ray. The exact underlying pathophysiology remains elusive. There is increasing evidence highlighting the importance of recognizing MA as an associated deformity that complicates management of hallux valgus (HV). Unfortunately, metatarsalgia and lesser toe pathology is also common in this population. We present a review regarding the epidemiology, pathomechanics, and a comprehensive surgical treatment algorithm to optimize the management of patients with MA, HV, lesser toe deformity, and metatarsalgia.

The incidence of common orthopaedic problems in newborn at Siriraj Hospital

BACKGROUND

The congenital orthopaedic anomalies in Thai population had a limited data and the previously studies are based on only hospital chart records.

OBJECTIVE

To determine the incidence of common congenital orthopedic problems by physical examination in newborn at Siriraj Hospital.

MATERIAL AND METHOD

A prospective study was conducted by physical examination of 3,396 newborns from June 2009 to September 2009. All orthopaedic abnormalities of newborns were recorded along with maternal age, obstetric history of mother, complications during pregnancy, complications in labour stage, mode of delivery and presentation. Sex of newborn, birth weight, body length and APGAR score were recorded.

RESULTS

Incidence of calcaneovalgus was found in 60:1,000 live births following by metatarsus adductus in 7.6:1,000, polydactyly or syndactyly in 2.6:1,000, talipes equninovarus in 2.4:1,000, brachial plexus injury in 1.5:1,000, developmental dysplasia of hip in 0.6:1,000, osteogenesis imperfecta in 0.6:1,000, skeketal dysplasia in 0.6:1,000, congenital vertical talus in 0.3: 1,000 and fracture clavicle at birth in 0.3: 1,000.

CONCLUSION

In the present study, the calcaneovalgus was the most common orthopaedic problem followed by metatasus adductus, polydactyly or syndactyly.

Foot ulceration in a secondary care diabetic clinic population: a 4-year prospective study

Diabetes guidelines recommend that feet are stratified into low-risk, increased-risk and high-risk. We examined prospective foot ulceration in our secondary care diabetes clinic. At 4-year follow-up, foot ulceration was present in 1/586 (0.17%) in the low-risk, 10/305 (3.3%) in those at increased-risk and 28/236 (11.9%) in the high-risk group.

[Prevalence of congenital split hand/split foot malformation in Chinese population]

OBJECTIVE

To study the epidemiological and clinical features of congenital split hand/split foot malformation (SHFM) in Chinese population.

METHODS

Data used in this study were provided by the Chinese Birth Defects Monitoring Network. The SHFM cases were categorized into two groups: isolated (SHFM only and SHFM with other limb defects) and syndromic (SHFM with non-limb defects). Prevalence rates were calculated by residential area (urban versus rural) and by gender. Further analyses were conducted to identify the characteristics of SHFM with related to gestational age, birth weight, perinatal outcome and affected limbs.

RESULTS

A total of 736 newborn babies were identified with SHFM among 4,489,692 births, with a prevalence of 1.64/10,000. The prevalence of isolated SHFM and syndromic SHFM were 0.64 and 1.00 per 10,000 births, respectively. The prevalence of SHFM in male and female babies were 1.79 and 1.25 per 10,000 births, respectively. The prevalence of SHFM in urban and rural areas were 1.51 and 1.86 per 10,000 births, respectively. Preterm birth and low birth weight accounted for 30.20% and 43.93% of the SHFM cases, respectively. The perinatal mortality for the SHFM, isolated SHFM, and syndromic SHFM were 50.27%, 24.74%, and 66.59%, respectively. SHFM occurred more often in upper limbs.

CONCLUSION

The prevalence of SHFM in Chinese population is greater than foreign populations. The high perinatal mortality rate of SHFM is associated with the severity of accompanied malformations.

Central ray deficiency with extensive syndactyly: a dilemma for classification

Split Hand Foot Malformation (SHFM) (cleft hand/foot, central ray deficiency) is a complex, highly variable anomaly involving the hands and/or feet. A clinical epidemiologic study of split hand/foot (central ray deficiency) of the Manitoba population identified a subset of patients who did not present with either typical or atypical split hand. Clinically, some patients presented with "mitten hand" syndactyly; the deficiency was not recognized before imaging. In this paper, we identify additional similarly affected literature cases, review existing classifications of split hand and syndactyly and attempt to classify these patients. This group presents a challenge for classification and genetic counseling. General classifications permit inclusion of patients with diverse phenotypes; however, details are overlooked. Osseous fusions and disorganization of osseous components complicate classification. Many of these patients had findings that overlapped different subtypes within existing classifications. This cohort highlights the importance of imaging patients with distal limb anomalies. An effective classification scheme should include relevant clinical and radiographic findings in order to assist clinicians following these patients.

Brachydactyly

Brachydactyly ("short digits") is a general term that refers to disproportionately short fingers and toes, and forms part of the group of limb malformations characterized by bone dysostosis. The various types of isolated brachydactyly are rare, except for types A3 and D. Brachydactyly can occur either as an isolated malformation or as a part of a complex malformation syndrome. To date, many different forms of brachydactyly have been identified. Some forms also result in short stature. In isolated brachydactyly, subtle changes elsewhere may be present. Brachydactyly may also be accompanied by other hand malformations, such as syndactyly, polydactyly, reduction defects, or symphalangism. For the majority of isolated brachydactylies and some syndromic forms of brachydactyly, the causative gene defect has been identified. In isolated brachydactyly, the inheritance is mostly autosomal dominant with variable expressivity and penetrtance. Diagnosis is clinical, anthropometric and radiological. Prenatal diagnosis is usually not indicated for isolated forms of brachydactyly, but may be appropriate in syndromic forms. Molecular studies of chorionic villus samples at 11 weeks of gestation and by amniocentesis after the 14th week of gestation can provide antenatal diagnosis if the causative mutation in the family is known. The nature of genetic counseling depends both on the pattern of inheritance of the type of brachydactyly present in the family and on the presence or absence of accompanying symptoms. There is no specific management or treatment that is applicable to all forms of brachydactyly. Plastic surgery is only indicated if the brachydactyly affects hand function or for cosmetic reasons, but is typically not needed. Physical therapy and ergotherapy may ameliorate hand function. Prognosis for the brachydactylies is strongly dependent on the nature of the brachydactyly, and may vary from excellent to severely influencing hand function. If brachydactyly forms part of a syndromic entity, prognosis often depends on the nature of the associated anomalies.

Relationship between foot type, foot deformity, and ulcer occurrence in the high-risk diabetic foot

We hypothesized an association between foot type, foot deformity, and foot ulceration and conducted an analysis of a well-characterized, high-risk diabetic population of 398 subjects. The average age was 62 years of age and 74% of the study population were males. Foot-type distributions were 19.5% pes cavus (high arch), 51.5% neutrally aligned (normal arch), and 29.0% pes planus (low arch). We quantified the presence of hallux valgus (23.9%), hammer/claw toes (46.7%), and hallux limitus (24.4%). A significant association was found between foot type and hallux valgus (p = 0.003); pes planus feet had the highest prevalence as compared with neutrally aligned feet (odds ratio [OR] = 2.43, p = 0.0006). Foot type was also significantly associated with fixed hammer/claw toes (p = 0.01); pes cavus feet had the highest prevalence as compared with neutrally aligned feet (OR = 3.89, p = 0.001). Foot type was also significantly associated with hallux limitus (p = 0.006) with pes planus feet having the highest prevalence as compared with neutrally aligned feet (OR = 2.19, p = 0.003). However, foot type was not significantly related to any ulcer outcome (p = 0.7). Fixed hammer/claw toes (OR = 3.91, p = 0.003) and hallux limitus (OR = 3.02, p = 0.006) were associated with increased risk of any ulcer occurrence. This study affirms that foot type and foot deformity are related and that foot deformities are associated with ulcer occurrence.

Prevalence and pathogenesis of congenital anomalies in cerebral palsy

BACKGROUND

It has been hypothesised that cerebral palsy (CP) and other congenital anomalies are attributable to feto-fetal transfusion problems in a monochorionic multiple gestation. Thus more than one organ could be compromised leading to the coexistence of two or more anomalies in a fetus. Such anomalies in a singleton birth may be attributable to early demise of the co-conceptus as a vanishing twin.

AIM

To determine whether the coexistence of congenital anomalies and CP is greater than a chance finding by comparing the prevalence of congenital anomalies in children with CP with that in the general population of children.

METHODS

A population-based register of children with CP born in 1966-1991 in the counties of Merseyside and Cheshire, UK, comprised the index population. Coexisting congenital anomalies were recorded. For comparison the population prevalence of congenital anomalies was obtained from eight congenital malformation registers in the UK.

RESULTS

Children with CP were found to have highly significant increases in risk for microcephaly, isolated hydrocephaly, congenital anomalies of the eye, congenital cardiac anomalies, cleft lip and/or palate and congenital dislocation of the hips and talipes (p<0.001) and atresias of the oesophagus (p<0.001) and intestines (p<0.01). The relative risks ranged from 3.1 (95% CI 1.9 to 4.8; p<0.001) for congenital malformations of the cardiac septa to 116.09 (95% CI 84.0 to 162.3; p<0.001) for microcephaly.

CONCLUSIONS

Congenital anomalies in children with CP are found much more frequently than expected by chance. A common pathogenic mechanism may account for the coexistence of disparate congenital anomalies. A hypothesis is proposed for such a common pathogenic mechanism.

Frequency of feet deformities in pupils attending junior grades of elementary school

The examination of feet by plantograph was performed in 552 pupils of first, second and fourth grades of elementary school "Harmani II" in Bihać. Examination revealed 201 children (36,42%) with satisfactory condition (pedes recti) while 351 pupils were diagnosed with certain form of feet deformity. Frequencies of feet deformities in girls are 60,00% in first, 65,19% in second and 66,30% in fourth grade. Average frequency of feet deformities in the examined girls is 64,90%. Pedes plani was found in 24,91% pupils. Frequencies of feet deformities in boys are 61,29% in first, 65,54% in second and 52,54% in fourth grade. Average frequency of feet deformities in the examined boys is 62,17%. Pedes plani is the most frequent deformity (23,83%).

Congenital myotonic dystrophy: prenatal ultrasound findings and pregnancy outcome

OBJECTIVE

The objective of this study was to assess the maternal and prenatal ultrasound findings and outcome in pregnancies complicated by congenital myotonic dystrophy Type 1 (DM1).

METHODS

A retrospective chart review of all patients with a diagnosis of DM1 and pregnancy presenting to the Oxford Radcliffe Hospital between 1990 and 2004 was undertaken. Obstetric case notes were reviewed and details of all pregnancies obtained. This included data on prenatal diagnostic tests and obstetric ultrasound scans performed as well as pregnancy complications and pregnancy outcome. Maternal and fetal CTG expansion size was also recorded where available. Maternal genetic case notes were reviewed for details of maternal grip myotonia.

RESULTS

Sixty pregnancies among 26 couples in which one of the parents was a carrier of DM1 were identified during the study period. These resulted in 36 (60%) pregnancies affected by congenital DM1 and 19 (31.7%) unaffected pregnancies. There were four miscarriages and one termination of pregnancy for non-medical reasons. Nineteen of the 36 affected pregnancies ended in termination following the antenatal diagnosis of congenital DM1 by either chorionic villus sampling (CVS) or amniocentesis. In the remaining 17 affected pregnancies (16 singleton and one twin) there was one miscarriage of an affected fetus with co-existing Down syndrome and eight perinatal deaths. The principal cause of perinatal death was respiratory failure in the early neonatal period. Antenatally noted clinical/sonographic abnormalities in these pregnancies included polyhydramnios (100%), talipes (26.6%) and borderline ventriculomegaly (13.3%). Uni- or bilateral talipes was noted at delivery in 10 of 16 (62.5%) neonates. Maternal grip myotonia was present in all but one of these cases.

CONCLUSION

The antenatal findings of polyhydramnios and talipes should prompt a search for maternal grip myotonia. If present, definitive testing for congenital DM1 should be considered.

Split-hand/split-foot malformation 3 (SHFM3) at 10q24, development of rapid diagnostic methods and gene expression from the region

Split-hand/split-foot malformation (SHFM, also called ectrodactyly) is a clinically variable and genetically heterogeneous group of limb malformations. Several SHFM loci have been mapped, including SHFM1 (7q21), SHFM2 (Xq26), SHFM3 (10q24), SHFM4 (3q27) and SHFM5 (2q31). To date, mutations in a gene (TP63) have only been identified for SHFM4. SHFM3 has been shown by pulsed-field gel electrophoresis to be caused by an approximately 500 kb DNA rearrangement at 10q24. This region contains a number of candidate genes for SHFM3, though which gene(s) is (are) involved in the pathogenesis of SHFM3 is not known. Our aim in this study was to improve the diagnosis of SHFM3, and to begin to understand which genes are involved in SHFM3. Here we show, using two different techniques, FISH and quantitative PCR that SHFM3 is caused by a minimal 325 kb duplication containing only two genes (BTRC and POLL). The data presented provide improved methods for diagnosis and begin to elucidate the pathogenic mechanism of SHFM3. Expression analysis of 13 candidate genes within and flanking the duplicated region shows that BTRC (present in three copies) and SUFU (present in two copies) are overexpressed in SHFM3 patients compared to controls. Our data suggest that SHFM3 may be caused by overexpression of BTRC and SUFU, both of which are involved in beta-catenin signalling.

Undiagnosed fracture in a common foot variant: the biphalangeal little toe

The biphalangeal little toe is an anatomical anomaly that has been previously well described in the early anatomical literature. But, as is the case with many anomalies, there is a lack of awareness of it amongst current clinicians. We report the case of a fracture through the distal phalanx of the little toe, with a delay in the diagnosis due to confusion over the X-ray findings. X-rays revealed a biphalangeal toe with a fracture through the distal phalanx, which mimicked the usual triphalangeal toe. This is the first reported case of clinical confusion over this anatomical variation. A review of 102 human skeletal feet at the Department of Anatomy, University of Melbourne, was performed to evaluate the frequency of the biphalangeal little toe variant, revealing an incidence of 26%.

Split hand foot malformation (SHFM)

The nomenclature describing the phenotype of missing central rays in the hand and/or foot in the genetics and surgical literature is heterogeneous and confusing. Split hand/foot malformation (SHFM) is the most common term for this phenotype in the genetics community; however, other names such as the offensive 'lobster-claw malformation' and the non-specific 'ectrodactyly' are still utilized to describe this malformation. In this article, we briefly review the nomenclature associated with SHFM and its classifications.

Clinical and epidemiological findings in patients with central ray deficiency: Split hand foot malformation (SHFM) in Manitoba, Canada

We conducted a clinical population study to examine the incidence and epidemiology of split hand foot-malformation (SHFM) in Manitoba from 1957 to 2003. The total number of births during this period was 850,742. Forty-three patients with SHFM were identified, resulting in an incidence of 1 in 19,784 births. Most patients were ascertained through referrals to the Section of Genetics and Metabolism at the Children's Hospital, Winnipeg, Manitoba. Overall, 22 (51.2%) of affected individuals were females and 21 (48.8%) were male. The left upper limb (LUL) was the most frequently affected, (in 46.5% of patients). The right hand was involved in 39.5%. In 4 patients (9.3%) all four limbs were affected. SHFM is classified as a failure of formation of parts according to the International Federation of Surgical Societies of the Hand (IFSSH) and has also been categorized as Typical or Atypical. Individuals in the Manitoba cohort were classified into two main categories: Typical (29 cases) and Atypical (3 cases). However, 11 patients were not easily placed into either group and comprised a distinct category termed "difficult to classify." Patients in the three groups were then further subdivided depending on whether or not they had additional congenital anomalies. These complex patients included those with single gene disorders in which SHFM has been reported (e.g., ectodermal dysplasia Ectrodactyly Clefting (EEC), tibial aplasia with SHFM, fibular aplasia with SHFM), as well as those with other recognized or unknown patterns of anomalies. Two had deletions involving 9q and 5p respectively. Unlike some other studies, we did not find an excess of males or right-sided defects and only two of the cases--two sisters--were related.

Management of congenital talipes equino varus in Scotland: a nationwide audit

The Scottish Talipes Register is a record of all newly diagnosed cases of idiopathic congenital talipes equinovarus (CTEV) in Scotland over a four.year period. Two hundred and sixteen children were entered into the register, which recorded initial management and all subsequent interventions, both non-operative and operative. The data, therefore, represent a record of the different management regimens used within Scotland highlighting the variations in duration of conservative management and variations in surgical intervention following different methods of conservative management.

Gait disorders and leg deformities in children

Gait disorders and leg deformities have become the most prevalent orthopedic problems in children in Japan. Usually, at the first visit to our outpatient clinics, there are many difficulties in fully determining the causes and prognoses of these problems. Several series of observations, carried out at intervals, will be required to ascertain whether these problems are really pathologic or whether they are actually within the normal range. In-toeing gait and bow-legged deformities were the most common complaints observed in each of the above problems. The conditions in the majority of such patients were observed to spontaneously improve with time. However, we must always focus on the patient's past history, beginning from infancy, and we must carry out some physical examinations so as not to overlook any actual disorders underlying the patient's present condition.

Early amniocentesis and congenital foot deformities

OBJECTIVE

Several studies have shown an increased risk of congenital foot derformities after early amniocentesis. These studies have comprised amniocenteses performed before 13 completed gestational weeks. In this study, the risk of foot deformities after amniocentesis performed at 12-14 completed gestational weeks was determined.

METHODS

3,469 genetic amniocenteses in singleton pregnancies performed before 15 completed gestational weeks were studied. The intention was to perform the amniocenteses at 12-14 weeks of gestation, but 32 amniocenteses were performed at the gestational age 11 weeks + 5 days or 11 weeks + 6 days. The pregnancies were followed up with regard to fetal loss and leakage of amniotic fluid. After birth, newborns with a diagnosis of foot deformity were identified from the Swedish Medical Birth Registry. The observed number of foot deformities was then compared with the expected number which was calculated stratified for delivery hospital, year of birth, and maternal age.

RESULTS

The observed number of foot deformities was significantly higher than the expected: exact odds ratio 1.74 (exact 95% confidence interval 1.06-2.69). The rate of spontaneous abortions after the procedure was 1.8%, and the rate of leakage of amniotic fluid was 1.9%. There was a significant trend for all complications to decrease with increasing gestational age at amniocentesis.

CONCLUSION

Women undergoing amniocentesis at 11+5 to 14+6 gestational weeks have an increased risk of giving birth to a child with a congenital foot deformity.

Association between congenital foot anomalies and gestational age at amniocentesis

OBJECTIVES

Our objectives were to confirm the reported association between early amniocentesis and congenital foot anomalies as well as to report, for the first time, on the outcome of amniocenteses performed during the 13th and 14th weeks of gestation.

METHODS

We conducted a triple cohort retrospective study of 4457 amniocenteses. Cohort definitions: early amniocentesis (EA), 11 weeks and 0/7 days to 12 weeks to 6/7 days; early midtrimester amniocentesis (EMA), 13 weeks and 0/7 days to 14 weeks and 6/7 days; and midtrimester amniocentesis (MA), 15 weeks and 0/7 days to 19 weeks and 6/7 days. Outcome measures were obtained by searching the Alberta Congenital Anomalies Surveillance System (ACASS) database for children born with foot anomalies represented by International Classification of Diseases version 9 (ICD-9) codes 754.5, 754.6 and 754.7.

RESULTS

Incidences of congenital foot anomalies were: EA 11/980 (1.1%), EMA 11/2515 (0.4%), and MA 1/962 (0.1%). There is a significant difference between the EA and EMA cohorts (p=0.019) and between the EA and MA cohorts (p=0.003); however, these data suggest there is no difference between EMA and MA cohorts (p=0.11).

CONCLUSIONS

Our incidence of congenital foot anomalies of 1.1% for women who underwent EA is similar to previously reported data, which further validates this association; however, our data also suggest that the foot anomaly risk may be limited to amniocenteses performed before the 13th week of gestation.

Limb deficiencies in newborn infants

OBJECTIVE

The prevalence rate of all types of limb reduction defects in general and those that potentially are caused by vascular disruption in particular is needed to provide a baseline for the evaluation of infants who are exposed in utero to teratogens that cause vascular disruption. The objective of this study was to determine this prevalence rate.

METHODS

All infants with any limb deficiency among 161 252 liveborn and stillborn infants and elective terminations were identified in a hospital-based Active Malformations Surveillance Program in Boston in the years 1972 to 1974 and 1979 to 1994. An extensive search was made to identify infants who were missed by the Surveillance Program; an additional 8 infants (7.3% of total) were identified. The limb reduction defects were classified in 3 ways: 1) by the anatomic location of the defect, that is longitudinal, terminal, intercalary, etc; 2) for infants with absence/hypoplasia of fingers or toes, a tabulation of which digit or digits were affected; and 3) by apparent cause.

RESULTS

The prevalence rate for all types of limb deficiency was 0.69/1000. The apparent causes included single mutant genes, familial occurrence, and known syndromes (24%); chromosome abnormalities (6%); teratogens (4%); vascular disruption (35%); and unknown cause (32%).

CONCLUSIONS

A hospital-based surveillance program can be used to establish the prevalence of limb reduction defects, if ascertainment is extended to include elective terminations for fetal abnormalities. An apparent cause can be established for most limb defects when the clinical findings are used rather than reliance only on the International Classification of Diseases, Ninth Revision, codes of the discharge diagnoses. The prevalence rate of limb reduction defects as a result of presumed vascular disruption was 0.22/1000.

Operative management of rigid congenital club feet in Bangladesh

We report the early results of the surgical treatment of 59 rigid congenital clubfeet in 42 patients. All the feet were operated on in the same hospital by using a one-stage posteromedial release in 41 patients. The patients were divided into two groups as 24 patients (32 feet) had come to the hospital from rural areas, whereas 18 patients (28 feet) all came from the local semi-urban area. After an average of 2 years and 3 months 44 feet were graded either excellent or good, 7 were fair, and 8 had not been adequately corrected. The best results were seen in children who were operated on between the ages of 1 and 3 years. Those from the semi-urban area and who received adequate long-term postoperative care were slightly better.

Tarsal coalition in adults

32 feet in 27 adults, seen at The Johns Hopkins Hospital Foot and Ankle Clinic from 1993-1998, with the diagnosis of tarsal coalition were retrospectively reviewed. There were 18 subtalar coalitions, 14 calcaneonavicular coalitions and 1 naviculocuneiform coalition. The average age was 40 years. Clinically, 22 feet had a neutral heel, 7 had a valgus heel with flattening of the longitudinal arch, 1 had a varus heel and 2 heels had an unknown position. Subtalar motion was decreased in 23 feet. Peroneal spasm was only seen in 2 patients. 11 feet were asymptomatic. Nonoperative treatment consisting of activity modification, nonsteroidal anti-inflammatory medications and casting was successful in the majority of patients. Subtalar fusion was performed in 4 feet and coalition resection in 1. The treatment of a symptomatic tarsal coalition in the adult is as in children but the clinical presentation may differ.

Musculoskeletal conditions in children attending two Togolese hospitals

OBJECTIVE

A retrospective study was conducted in order to point out the different kinds of musculoskeletal conditions observed in children attending two Togolese hospitals.

RESULTS

A total of 434 (242 females, 192 males) of the 29 620 children examined (1.5%) were suffering from these conditions. Probable joint and bone infections (187 patients, 43%), limb deformities (106 patients, 24%), osteochondrosis (60 patients, 14%) and vaso-occlusive crisis due to haemoglobinopathies (29 patients, 7%) were the main conditions observed. Osteomyelitis observed in 128 patients affected the humerus (25 patients), radius (10 patients), femur (68 patients), tibia (15 patients), fibula (five patients), and both tibia and fibula (five patients). Probably, infectious arthritis seen in 30 patients affected mainly the hip (11 patients) and the knee (13 patients). In the spine, infection affected the midthoracic and upper lumbar areas. Underdevelopment, sickle cell anaemia and sickle cell haemoglobin C disease were the main risk factors in determining susceptibility to infections. Vaso-occlusive crises were due to sickle cell anaemia (11 patients) and sickle cell haemoglobin C disease (18 patients). Osteochondrosis seen in 60 patients free from haemoglobinopathy involved the spine (Scheuermann's disease, 38 patients) and the hip (Legg-Calvé-Perthes disease, 22 patients). Limb deformities were observed in the knee (varus and valgus deformities in 64 patients) and the foot (talipes varus equin in 40 patients).

CONCLUSION

This study's findings, which require further confirmation, suggest some conclusions. Scheuermann's disease can explain in part the degenerative disc conditions observed in African adults. Valgus and varus deformities play an important role in the development of knee osteoarthritis in Black Africa. An African child with joint or bone pain should be investigated for sickle cell anaemia. In the future, improved lifestyle and better health care will be essential to reduce bone and joint infections, and allow refined diagnosis of connective tissue diseases now probably underestimated in African children.

Associated anomalies in individuals with polydactyly

An epidemiological analysis of the association of polydactyly with other congenital anomalies was performed in 5,927 consecutively born polydactyly cases. They were grouped into three categories: duplicated fifth digit, duplicated first digit, and rare polydactylies; also into isolated or associated groups, if other birth defects were or were not observed in the same infant. Associated cases were further subdivided into: combined, if the other defect was a limb defect; syndromic, if a non-limb defect constituted a recognized causal or pathogenetic entity; and MCA, if a non-limb defect did not constitute a recognized entity. In 14.6% of the 5,927 polydactyly cases studied, polydactyly was not the only congenital anomaly. This associated proportion was minimal for postaxial (11.8%), intermediate for preaxial-I (20.0%), and maximal for rare polydactyly (54.9%). Duplication of the fifth toe plus syndactyly of fourth and fifth toes, as well as other syndactylies adjacent to the duplicated digit is the most frequent type. Syndactyly of fourth and fifth toes was also combined with a duplicated fifth finger, suggesting the existence of an arrested or amputated in utero sixth toe. Polydactylies are rarely associated with other congenital anomalies except in recognizable syndromes. When syndromes are excluded, most of the significant positive associations disappear. Trisomy 13, Meckel, and Down syndrome explained 255 of the 338 syndromic polydactyly cases. Down syndrome is strongly associated with first-digit duplication, and negatively associated with postaxial polydactyly. The latter could not be explained by maternal age differences among Black and non-Black case sub-sets.

Minor physical anomalies in schizophrenic patients and their siblings

OBJECTIVE

The aim of this study was to assess the frequency and type of minor physical anomalies in schizophrenic patients and their normal siblings.

METHOD

Sixty adult patients with schizophrenia, 21 siblings of these patients, and 75 normal comparison subjects were assessed through use of an extended scale consisting of the Waldrop scale and 23 other minor physical anomalies.

RESULTS

Patients had significantly more minor physical anomalies than comparison subjects in all body areas tested and also more minor physical anomalies in total than their siblings. Hand, eye, and mouth minor physical anomalies best discriminated patients from comparison subjects. Siblings had significantly more minor physical anomalies than normal comparison subjects. Sixty percent of the patients and 38% of the siblings, but only 5% of the comparison subjects, had a higher rate of minor physical anomalies (i.e., six or more). With the exception of ear minor physical anomalies, no association was found between minor physical anomalies in the patient and sibling in the same family.

CONCLUSIONS

Higher levels of minor physical anomalies (especially in the eye, mouth, and hand/foot regions) characterize both schizophrenic patients and their normal siblings, but there is little similarity in these anomalies between patients and siblings in the same family. Thus, one or more genetic or shared environmental factors may increase the risk for development of both minor physical anomalies and schizophrenia in these families at large. Minor physical anomalies associated with schizophrenia are frequently found in, but are clearly not limited to, the head or facial region. The Waldrop scale identifies minor physical anomalies strongly associated with schizophrenia. Nevertheless, assessment of the new items clearly indicates that many additional minor physical anomalies are found in schizophrenic patients.

Os intermetatarseum: a heritable accessory bone of the human foot

The os intermetatarseum is a relatively common accessory bone of the human foot located at the tarsometatarsal border between the first and second metatarsals. It can occur as an independent ossicle or as an osseous spur projecting from the proximal ends of the first two metatarsals, or the distal end of the first cuneiform. To determine the frequency of this congenital defect in native North American groups and East Asians from Japan, the skeletons of 846 Native Americans and 125 modern Japanese and Ainu were examined for the presence of the os intermetatarseum. The North American skeletons are from archaeological sites in various parts of Canada and the United States, including the Arctic coast, the Subarctic, the Aleutian Islands, the Northern Plains, the Illinois River area, and the Southwest. Overall frequencies ranged from no occurrence among the Arctic samples to 8% of individuals from Pecos Pueblo. Second metatarsal spurs occurred in particularly high frequencies among American Indians, whereas the East Asians were only found to have os intermetatarseums associated with the first cuneiform. Because pedigrees have shown the os intermetatarseum to be an inherited defect, its high frequency among some Native Americans may be due, in part, to a higher degree of genetic relatedness among the individuals in the North American samples than among the relatively modern East Asians.

[Deformities and misalignment of feet in children--a field study of 345 students]

PURPOSE

purpose of this study was to evaluate paediatric feet and to document possible problems.

MATERIAL AND METHODS

In 345 high school pupils of the 5th and 6th class aged 10 to 13 the feet as well as leg alignment were evaluated with a standardised protocol.

RESULTS

Only 36.5% showed regular feet. In almost 2/3rd of the pupils malalignements or even deformities were present. The valgus foot showed the highest incidence with 39.4% followed by a flat foot with 19.1%. 17.1% of the children showed a hallux valgus. There was no correlation between body weight, body height, leg alignment and foot deformity. However, a significant correlation could we found between hallux valgus and splay foot.

CONCLUSION

The presented data underlines the necessity for paying attention on the problems of the paediatric feet. During sport lessons in school a special foot training for children should be performed.

Hand and foot postaxial polydactyly: two different traits

The aim of this work was to test whether postaxial hexadactyly had different clinical and epidemiological characteristics depending on hand or foot involvement. In the period 1967-1993, the Latin-American Collaborative Study of Congenital Malformations (ECLAMC) enrolled 1,582,289 births, and 2,271 cases with isolated (nonsyndromal) postaxial polydactyly (5th-digit hexadactyly). The prevalence was 14.3/10,000 births. Postaxial polydactyly (PP) of the hand (HPP) was the most frequent type (N:1,733; 76.3%; prevalence: 11.0/10,000), followed by foot PP (FPP=N:351; 15.5%; prevalence: 2.2), and hand and foot PP (BPP=N:187; 8.2%; prevalence: 1.2). Unlike HPP (55.0% bilateral; 77.2% left), FPP was less frequently bilateral (19.4%), with lower preference for the left side (55.5%). As expected, HPP was associated with African Black ethnicity, male sex, twinning, low maternal education, parental consanguinity, and there was frequent recurrence in 1st-degree relatives. Conversely, FPP was associated with Amerindian racial background, parental subfertility, and bleeding in the 1st trimester of pregnancy. BPP displayed the highest frequency of associated congenital defects (23.4%, vs HPP:6.6%, FPP: 15.4%). In its isolated form, BPP resembled HPP more than FPP with respect to left preference (90.9%), familial recurrence (11.0% of 1st degree relatives), and low maternal education. Although male sex preference and high frequency of twinning was observed in the 3 PP subtypes, statistical significance was present only in HPP. None of the 3 PP subtypes showed abnormal values for perinatal mortality, birth weight, length of gestation, parental ages, or parity. A logistic regression analysis showed Black race only to be associated with HPP, parental subfertility with FPP, parental consanguinity with BPP, and non-Black race with both FPP and BPP. The data presented here are the first indication that HPP and FPP are 2 different entities, with a larger genetic component in HPP than in FPP.

Minor malformations and physical measurements in autism: data from Nova Scotia

In the context of an epidemiological study of autism in Nova Scotia, subjects were evaluated for minor physical anomalies and physical measurements. Normal control children, children with autism and their siblings, and children with developmental disabilities and their siblings were compared. Posterior rotation of the external ears was found to be a characteristic related to autism specifically, rather than to developmental disabilities in general. Small feet and normal-to-large hands also were observed in the autism group. Children with autism had a significant reduction in interpupillary distance, but not intercanthic distance or head circumference. In contrast, children with other developmental disabilities were notable for general small stature, which affected the hands, feet, eyes, and head size, as well as height. Abnormal ear configuration was the minor malformation most characteristic of the developmental disability group, and the subset of Down syndrome children had single transverse creases of the palm and epicanthic folds that resulted in significantly increased rates of these anomalies in the developmentally disabled controls. Siblings of the two disabled groups were not significantly different from normal controls on any of the measures that characterized children with autism or other developmental disabilities. The results agree with those of several previous studies, which have suggested that abnormalities of the ears are the general category of minor anomalies most associated with autism. Recent evidence regarding the embryological origin of autism suggests that the ear effects may be an important marker of the initiating events that lead to the disorder.

Does periconceptional multivitamin use reduce the risk for limb deficiency in offspring?

There is accumulating evidence that periconceptional multivitamin use may prevent the occurrence of some birth defects other than neural tube defects. Using data from the population-based Atlanta Birth Defects Case-Control Study, we investigated the possible association between periconceptional multivitamin use and the occurrence of limb deficiency. We examined the periconceptional use of multivitamins among mothers of 117 babies with nonsyndromic limb deficiency who were liveborn or stillborn to residents of metropolitan Atlanta from 1968 to 1980 and among mothers of 3,029 control babies born without birth defects who were randomly selected through birth certificates. We found that children whose mothers were periconceptional multivitamin users had a lower risk of having a limb deficiency [odds ratio (OR) = 0.47; 95% confidence interval (CI) = 0.23-0.97]. This protective effect, however, was mostly seen for transverse limb deficiency (OR = 0.30; 95% CI = 0.07-1.32) and not for longitudinal deficiency (including preaxial and postaxial deficiencies; OR = 1.03; 95% CI = 0.17-4.30). Adjustment for potential confounding factors did not change these findings. We found a trend of decreasing risk for all transverse limb deficiencies with earlier vitamin use. These data indicate that mothers' periconceptional multivitamin use may reduce the risk for some types of limb deficiency among their offspring. In addition, because we did not find the protective effect for all types of limb deficiency, the data may also indicate causal heterogeneity of limb deficiencies.

Foot deformities at birth: a longitudinal prospective study over a 16-year period

In a prospective study of 2,401 newborns, the incidence of foot deformities was 4%, of which three fourths were various forms of adductus anomalies. At age 16 years, the children with a foot deformity and a random sample of those with normal feet as newborns were examined by dynamic foot pressure (EMED) and gait analysis (Vifor). The natural course of all congenital foot deformities, except clubfoot, was favorable. The importance of monitoring the children during the entire growth period is shown by the fact that at age 6 years, 87%, and at 16 years, 95% of the adductus deformities had resolved.

[Results of podoscope screening in 948 non-selected children, with special reference to cavus foot]

OBJECTIVE

To ascertain the prevalence of cavus foot in a non-selected pediatric population, the percentage of secondary forms and to establish criteria for remission to the specialist.

PATIENTS AND METHODS

A randomized study of 948 healthy children older than four years, in which the sole footprint was studied through podoscope, was performed.

RESULTS

Cavus foot of different grades was present in 16.3% of the children studied, with a statistically significant difference in favor of girls. There were family antecedents in 60%. Symptoms and/or exploratory abnormal signs were presented in 19.3%, mainly pain, limp and sole dermatitis. Of the diagnoses made, 7.7% were referred to the specialist, with the diagnosis confirmed in 75% and treatment implemented in 50%. There were no cases of secondary cavus foot.

CONCLUSIONS

Cavus foot is very frequent in healthy children, has a familiar character and only exceptionally obeys the rules of a neuromuscular cause. We propose four criteria for the selection of patients for referral to the specialist.

Macrodactyly: report of eight cases of a rare anomaly

Macrodactyly or megalodactyly is a rare anomaly of the extremities. Neural factors are involved in the etiology. Presented here are eight cases which comprise five macrodactylous toes and three fingers. The mean age at first referral was 6.8 years. Six patients underwent resection of the proximal phalanges together with bulk reduction of the soft tissue mass. Only soft tissue reduction was performed in the remaining two patients. Skin necrosis was observed in two cases, one of which necessitated amputation at the proximal interphalangeal joint level. The functional outcome was evaluated as poor with limited range of motion and stiffness in the joints. As far as functional results are concerned, macrodactylous toes had a better prognosis than that of fingers. It was concluded that none of the available methods as yet gives ideal functional and cosmetic results in macrodactyly.

Symphalangism (two phalanges) in the digits of the Japanese foot

We report here an investigation into the number of phalanges of the 2nd to 5th toes in a Japanese population. The number of phalanges in each of these toes is normally three, distal, middle and proximal. However, occasionally only two phalanges are observed. In this condition, known as symphalangism, the middle and distal phalanges are fused (synarthrosis of the distal interphalangeal joint). The incidence of symphalangism in the 488 feet was found to be 72.5% in the 5th toe, 11.9% in the 4th toe, 0.8% in the 3rd toe, and 0.0% in the 2nd toe. No left-to-right or sex differences were observed. The reported overall incidence of symphalangism in the 5th toe of the foot in the Japanese population (74.7%) is significantly higher than that in the European population (40.2%). In the present sample, the incidence of symphalangism of the 4th toe (11.9%) was significantly higher than that in Japanese population samples previously studied (4.2%).

Minor physical anomalies in schizophrenia

Using the Waldrop scale, minor physical anomalies were studied in 82 Caucasian subjects, including 41 schizophrenic and 8 bipolar adults, as well as 14 normal and 19 mentally retarded adults. An increased incidence of minor physical anomalies was found in the mentally retarded adults relative to the other groups. Consistent with previous studies, there was a trend for the total mean Waldrop score of the schizophrenic group to be higher than the mean score of the normal group. Minor physical anomalies (assessed by the Waldrop scale), however, appear to be of questionable utility in identifying "congenital" schizophrenia, at least as this putative subgroup of schizophrenia is currently conceptualized.

Familial spondyloepiphyseal dysplasia tarda, brachydactyly, and precocious osteoarthritis associated with an arginine 75-->cysteine mutation in the procollagen type II gene in a kindred of Chiloe Islanders. I. Clinical, radiographic, and pathologic findings

OBJECTIVE

To characterize a kindred of Chiloe Islanders with spondyloepiphyseal dysplasia tarda (SEDT), brachydactyly, precocious osteoarthritis (OA), and intraarticular calcification.

METHODS

Sixteen family members underwent a complete physical examination, anthropometric measurements, radiographic studies of the spine and peripheral joints, and analysis of the type II procollagen gene (COL2A1).

RESULTS

Seven family members presented with SEDT, brachydactyly, precocious OA, and periarticular calcification while 2 others had the same syndrome but without brachydactyly. The inheritance was autosomal dominant, and the disease cosegregated with a base substitution in the COL2A1 gene.

CONCLUSION

The syndrome o SEDT, precocious OA, and brachydactyly in a kindred of Chiloe Islanders is associated with a point mutation in 1 allele of the COL2A1 gene. The relationship of this type of SEDT to familial calcium pyrophosphate dihydrate deposition disease and idiopathic hip dysplasia, both endemic in Chiloe Islanders, needs to be further investigated.

The position of symbrachydactyly in the classification of congenital hand anomalies

The clinical features of 53 cases of intercalated hypoplasia and 113 cases of distal aplasia are reviewed and compared with each other and with 129 cases of syndactyly. Tri-, di- and mono-phalangeal symbrachydactyly, and adactyly with nubbin digits are consecutive anomalies. Transverse deficiency may result if the mesenchyme is damaged severely, and if damage is mild and formation has continued, intercalated transverse deficiency may occur. Webbing in symbrachydactyly may result from failure of the apical ectodermal ridge under the influence of damaged mesenchyme.

A morphological and family study on isolated terminal transverse type of congenital limb deficiency in Hungary, 1975-1984

A population-based and validated data set of 195 cases with isolated terminal transverse-type congenital limb deficiency was evaluated in Hungary, 1975-1984. Terminal transverse types of congenital limb deficiency are not usually associated with non-limb defects, and typically only one limb is affected. Upper limb is more frequently affected than lower (9:1) in monomelic cases. The left side and females are affected more often in upper limbs while lower limb defects are evenly distributed between right and left sides and both sexes. Familial occurrence was not found.

The correction of complex foot deformities using Ilizarov's distraction osteotomies

Twenty-five very complex foot deformities were treated by Ilizarov distraction osteotomies. The osteotomy types included supramalleolar, U, V, posterior calcaneal, talocalcaneal neck, midfoot, and metatarsal osteotomies. In addition, the leg was lengthened and widened in most cases. The mean treatment time was 6.4 months. There were 20 minor or major complications related to the foot osteotomies in 18 feet, including deep pin-tract infection in three, failure of osteotomy separation in nine, acute postoperative tarsal tunnel syndrome in two, toe contractures in three, wire breakage or cutout in two, and buckle fracture in one. Nineteen secondary procedures were required in 13 patients to treat these complications. The final result was a plantigrade foot in 22 in late follow-up evaluation. The three nonplantigrade feet were attributable to unrecognized heel varus in one, ball and socket ankle joint in one, and partial growth arrest progressive deformity in one. Gait was improved in all cases. Pain was eliminated in all but two patients. Based on these criteria, the results were judged to be satisfactory in 22 and unsatisfactory in three. The Ilizarov method can successfully correct complex foot deformities despite complications.

An epidemiological study of isolated split hand/foot in Hungary, 1975-1984

A population based and validated 10 year cohort of 94 cases with split hand/foot born in Hungary, 1975-1984 was evaluated. This type of congenital limb deficiency was relatively frequently (43%) associated with non-limb defects. Fifty-four cases with isolated split hand/foot are evaluated in this paper. A single limb was affected in 78% of cases. The upper limbs were 21 times more frequently affected in unimelic cases with a right sided predominance and male excess. Case-control analysis indicated intrauterine growth retardation and lower socioeconomic status of parents of cases. Family study showed six familial cases with autosomal dominant inheritance among 152 first and 452 second degree relatives. All familial cases were males.

Congenital defects of the limbs in stillbirths: data from a population-based study

We analyzed limb deficiencies occurring in stillbirths with congenital anomalies registered in the Health Surveillance Registry of British Columbia between the years 1964 and 1984. Thirty stillborn infants presenting with various defects of the limbs were found during this time, giving an incidence of 39.52 in 10,000 stillbirths (1:253). This incidence is significantly higher than the incidence among liveborn individuals in the Province (5.97 in 10,000 livebirths or 1:1,842). Most cases involved the upper limbs, and most frequently the radius. Additional anomalies were present in 77% of cases, compared to 48% in liveborns. The study of stillbirths with congenital anomalies provides important information regarding the spectrum of birth defects seen in this group. This may be of relevance because of improved survival possibilities due to advances in perinatal care.

Amniotic band sequence and limb defects: data from a population-based study

Cases with amniotic bands were analysed separately as part of an ongoing study of limb defects occurring among 1,213,913 liveborn infants in British Columbia during the years 1952 to 1984. A total of 24 cases with this specific condition was identified among 659 cases with limb defects. The calculated incidence for amniotic band sequence with significant limb involvement was 0.19 in 10,000 livebirths. This is a minimal incidence, as cases without defects of the limbs, but with constriction rings were not identified with this approach. Familial cases and cases with additional anomalies were found.

The prevalence of congenital orthopaedic anomalies in a rural community

A rural Indian population of 50,055 was studied for the detection of congenital orthopaedic anomalies by a door-to-door survey. An incidence of 2.25 cases per 1000 population was found. Club foot was the commonest anomaly at 0.9 per 1000, followed by polydactyly and syndactyly at 0.45 and 0.38 cases per 1000. The most common anomaly found in females was a congenital short 4th metatarsal (0.24 per 1000).

[Split hand/foot abnormalities: classification, pathogenesis, epidemiology]

Authors report on the genetic epidemiologic investigation of one of the sentinel anomalies made on purpose to define the birth prevalence of the different types of it, to calculate the mutation rate of autosomal dominant forms as well as to recognize the clinical features of Hungarian cases. 58% of all cases registered in the Hungarian Congenital Abnormality Registry in 1975-1984 proved to be atypical. The birth prevalence of autosomal dominant forms was 1.33/100.000 total birth. 71% of dominant forms was sporadic since 29% was familial. Thus the mutation rate was estimated 4.7 x 10(-6) +/- 1.22 x 10(-6).

Rotational deformities of the tibia and foot in preterm infants

Metatarsus adductus and medial tibial torsion are common in term infants. Our study shows that metatarsus adductus is rare, whereas medial tibial torsion does not occur in preterm infants with gestational ages of less than or equal to 30 weeks. These preterm infants have lateral rotation of the legs, external tibial rotation, and everted or normal feet at birth. This posture may explain the rarity of metatarsus adductus and medial tibial torsion in preterm infants.