Well Child Care - Toddler Foot

Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 14-month-old is brought into the clinic for a well-child visit. Born at 39.5 weeks gestation, he has been healthy and is up-to-date with immunizations. The child started to walk at age 12 months and the parents note that “his feet look a little crooked when he stands and sometimes he will trip when he is trying to run because they curve in.”  The NP notes a mild inward curvature of the front half of the foot bilaterally,  with an intoeing positioning when he stands. The feet are flexible and the child walks with ease without evidence of discomfort during ambulation or on exam. There is no joint redness, heat, or swelling. This most likely represents:
Pes planus.
Club foot.
Metatarsus adductus.
Idiopathic juvenile arthritis.
Where should you start? First, let's determine what kind of a question this is. Clearly, this is a diagnosis question, as we're given history and physical exam findings, and then we’re being asked what is the most likely causing what we see.
Some background information: When you're seeing a child of this age, remember that the body is still developing, and maturing, and the pediatric physical exam is quite different from what we see in the adult. Indeed, in particular, the orthopedic exam in kids around this age will find some things that wouldn’t be normal in the adult. For example, kids this age invariably have a lordotic posture. So in other words a curvature in the back and a bit of, I’ll put it this way because we all know what I’m talking about, a little bit of a potbelly, even in a child who is rather slender. That’s perfectly normal in the toddler and could be a concern in the adult. Flat feet in a kid this age, are absolutely perfectly normal but could problematic in an adult. Slightly bowlegged, we don’t give it a second thought in an early walker but would be of concern in the adult. The list goes on and on, and I think you’ve gotten the point by now,  but let’s get back to what the question is and I'll explain why the correct answer is the correct answer.
I’m going to do things a little bit differently with this question and rather than go into a deeper discussion on pediatric orthopedics, I’m going to incorporate my discussion into the question itself. Back to the question.
A 14-month-old is brought in for a well-child visit. Born at 39.5 weeks gestation, he has been healthy and is up-to-date with immunizations. The child started to walk at age 12 months and his parents noted that “his feet look a little crooked when he stands and sometimes he will trip when he is trying to run since they curve in.”  The NP notes a mild inward curvature of the front half of the foot bilaterally,  with an intoeing positioning when he stands. His feet are flexible and the child walks with ease, without evidence of discomfort during ambulation or examination. There is no joint redness, heat, or swelling. This most likely represents: Pes planus.
That’s incorrect. That’s the technical name for flat feet. And if we were told the child’s feet were flat bilaterally, which we were not, what we would automatically need to say is oh, kids this age have flat feet.  And why do kids of this age invariably have flat feet? It is in part due to ligamental laxity and neurological development. In other words, the neuro system is more immature than you would find in an older child or an adult. Indeed, many of the findings that are normal on the pediatric exam but would be of concern on the adult exam are explained by how ligaments and neuro system work together and are more immature in the child. By age 5-6, as the foot matures, nearly all children will have a notable arch in the foot. As a result, “watch and wait” is the treatment for flat feet in kids aged 5 years and younger. I will tell you if you have the privilege of working with children, and I do consider it a privilege, you will be asked about flat feet at every well-child visit in kids until they’re about 6 years old when they finally do have an arch in their foot. And what you do is reassurance of course is the intervention: Club foot.
This is also incorrect. Club foot would not first be noted when the child is a toddler, but would be a birth finding because it’s congenital in nature. In addition, club foot is usually unilateral, although on rare occasions it can be bilateral. As a matter of fact, one of the reassuring findings in this little squirt’s feet is that the findings are bilateral because that leans towards a normal variation on the exam. The child with clubfoot who made it to age 14 months having it uncorrected would likely be unable to walk with ease as is described. Intervention for clubfoot starts at birth and usually is done via stretching and serial casting in order for the child’s foot to be able to be straightened out and then the child usually that’s all taken care of by the time the child is old enough to walk: Metatarsus adductus.
Please note I’m saying “add” not “ab.” This is the correct answer.  In the younger child, typically aged 4-5 and under, this involves the metatarsal bones, a group of bones found in the midsection of the foot. Adductus, ad, adductus, refers to moving towards the body’s midline. The intoeing gait noted with metatarsus adductus is usually only really picked up once the child starts to stand or walk, but its been present since the child was born.  It’s considered to be a normal limit variant, and one of the reasons for it is thought might be due to some intrauterine crowding issues, but whether that’s actually true or not is still up for discussion. This is, as I said, a normal limit variant, it’s going to resolve without special intervention by the time the child is 4-5 years, if not significantly sooner. I have seen kids whose feet were really intoed quite significantly with this condition, they’re 14 months old, and they’ve been walking for a few months, I see them back at the 2-year visit,  and their feet are straight as arrows, so it oftentimes does resolve after a number of months of walking. On rare occasions, particularly if the feet are quite stiff and the condition persists, particularly beyond age 4-5 years, then ortho referral is indicated.  Parental reassurance is the intervention, and often the parents are concerned that the child trips because of the intoeing, and again reassurance that this will get better over time, would be most warranted. And in fact parents will often ask about that even for kids without intoeing gait, they’ll say, “The baby been walking for 6 weeks now, I think the baby falls too often.” Toddlers fall a lot. They do. And always take every parental/caregiver observation like that seriously, don’t be dismissive, but a good part of our job in pediatrics is reassuring families of what’s normative: Idiopathic juvenile arthritis
That’s incorrect because we’ve already chosen the correct answer.  When arthritis is noted in a very young child like this, usually the clinical presentation would include foot and joint swelling, redness, and heat, most likely bilateral, and the report that the child cries or demonstrates discomfort when attempting to walk or stand. Arthritis in a very young child is almost always autoimmune in nature and systemic. We would also see it in multiple joints. Systemic findings such as fever could be reported as well. In this question, we're told that the child has been well since birth, and doesn’t show any signs of discomfort when walking or on exam, and that should steer you away from choosing an option like a systemic inflammatory disease such as juvenile arthritis. You can also get an idea from this question that a clinical scenario in a kid can differ a lot than it can from an adult where children don’t develop single-joint arthritis like adults can. Seventy-year-old adults might have an arthritic left knee from osteoarthritis largely from a combination of genetics and wear and tear. Fourteen-month-old is not going to have that. The next step in a child with suspected idiopathic juvenile arthritis includes laboratory confirmation of the diagnosis and prompt subspecialty referral.
Key takeaway: In pediatrics,  as the child’s body grows, you will encounter clinical findings that would be abnormal in the adult. This is particularly true for the musculoskeletal exam. Knowledge of normative findings in a patient of any age is key to providing effective healthcare.
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