Cleft foot

In brief

Cleft foot is a rare congenital malformation in which one or more of the bones or toes in the central part of the foot are missing, creating a cleft between the remaining toes. It can look like a pincer or a lobster claw. Treatment is tailored to each child and aims to improve function, make wearing shoes easier and, when needed, correct the shape of the foot.

Typical age

From birth

Also known as

Split foot · Ectrodactyly of the foot · Lobster-claw foot

What is it?

Cleft foot is a congenital malformation in which the central elements of the foot are partly or completely absent. One or more toes and their metatarsals may be missing, creating a cleft of variable depth. In mild forms there may be only a toe abnormality; in more complex ones the separation may extend into the midfoot.

It is a very rare anomaly. Published estimates vary considerably, ranging roughly from one case in 90,000 to one in 120,000 births in some series. It arises during embryonic development and may occur on its own or as part of a genetic condition. Some families have an inherited predisposition, although it can also appear with no family history.

Cleft foot may affect one foot or both and is sometimes associated with a similar malformation of the hands. So when it is diagnosed, it is important to carry out a full examination and assess whether there are other congenital anomalies that need investigating.

The functional impact varies widely. Some children walk normally and wear ordinary shoes, while others have difficulty finding suitable shoes, discomfort when bearing weight, calluses or problems related to the stability and shape of the forefoot. The decision to treat depends on these circumstances and on the anatomy of each case.

Signs parents may notice

The most common signs are:

• A cleft in the central part of the foot: a visible gap between the remaining toes.
• One or more missing toes: sometimes with absent or incompletely developed metatarsals.
• A pincer or lobster-claw appearance: the toes on either side of the cleft may be spread apart.
• Differences between the two feet: the deformity may affect one foot or be of different severity on each side.
• Difficulty wearing ordinary shoes: the width or shape of the forefoot can make shoes hard to fit.
• Calluses or pressure areas: these may appear when weight is distributed unevenly.
• Walking problems: some children have discomfort when walking or functional difficulties, although others walk normally.

The absence of pain does not mean surgery is needed. The assessment must consider the anatomy, how the foot works and the child’s needs.

When to see a specialist

Cleft foot should be assessed by a paediatric orthopaedic surgeon from the time of diagnosis, even if the child has no pain.

A specialist assessment is advisable if:

• A cleft or missing toes are noticed at birth.
• It is hard to find comfortable shoes.
• Pain, calluses or weight-bearing problems appear.
• The child has difficulty when starting to walk.
• The deformity is associated with abnormalities of the hands or other parts of the body.
• There is a family history of similar malformations and genetic counselling is needed.

When is it urgent?

Congenital cleft foot is not usually an emergency in itself. However, a sudden change in colour, a cold foot, significant swelling, severe pain or an injury affecting the skin need urgent medical assessment.

How is it diagnosed?

The diagnosis is usually made by physical examination, which identifies the cleft and shows which toes and structures are present. The specialist also examines the shape of the foot, joint movement, stability, the condition of the skin and whether the hands are involved.

X-rays show the bone anatomy and determine which metatarsals and phalanges are present, which are incompletely developed and how the forefoot bones are arranged. This information is essential to classify the deformity and plan treatment.

In selected cases other imaging tests or a genetic assessment may be needed, especially if there are associated malformations or a family history. The work-up is tailored to each patient.

Treatment

Treatment is tailored to the type of cleft foot, the number of missing structures, the width of the cleft and the functional impact. Not every child needs surgery.

Conservative treatment

When the foot is stable, allows pain-free walking and fits shoes well, clinical monitoring may be enough.

Conservative measures may include:

• Adapted footwear: shoes of suitable width and shape to avoid pressure on the toes and the edges of the foot.
• Orthoses or insoles: may be used in selected cases to improve weight-bearing or relieve overloaded areas.
• Skin checks: it is important to spot rubbing, calluses or sores caused by shoes.
• Follow-up during growth: to see how walking develops and whether new functional needs arise.

These measures do not rebuild missing bones or toes, but they may be enough for some children to walk well and wear ordinary shoes.

Surgical treatment

Surgery may be considered when the cleft makes wearing shoes difficult, causes pain or calluses, affects stability or creates significant functional problems. The family’s concerns about appearance can also be taken into account, considering the features of the deformity, expectations and possible risks.

There is no single surgical technique that suits every cleft foot. Depending on the anatomy, different procedures may be combined:

• Closing the cleft: reduces the central gap and improves the shape of the forefoot using soft-tissue reconstruction techniques.
• Bone correction: osteotomies may be performed to change the position of the metatarsals and narrow the foot.
• Treatment of abnormal toes or bones: in some cases rudimentary structures that interfere with function need to be corrected or removed.
• Combined reconstruction: in more complex deformities, bone and soft-tissue procedures may be combined to improve alignment and make wearing shoes easier.

The operation is usually performed under general anaesthesia. It may require fixation wires, other stabilisation methods or a cast. The length of hospital stay and weight-bearing restrictions depend on the reconstruction performed.

Surgery can improve shape and function, but it also carries risks such as wound-healing problems, scarring, stiffness, alignment problems or the need for further operations. So planning must be carefully tailored to each child.

Outlook and recovery

Recovery depends on the complexity of the deformity and the techniques used.

• After an assessment without surgery: follow-up is adapted to the function of the foot, footwear and growth.
• After soft-tissue reconstruction: the operated area may need to be protected with a dressing or cast for several weeks.
• After bone correction: the period of immobilisation and weight-bearing restrictions depend on bone healing and the stability of the fixation.
• Return to school: usually possible before a return to sport, once pain is under control and the child can get around safely.
• Return to sport: should wait until the wounds have healed, the reconstructed structures have recovered sufficiently and the specialist confirms that loading is safe.

Check-ups monitor wound healing, bone position, shoe comfort and how walking develops. Some children may need several operations during growth, although not every case requires more than one.

Frequently asked questions

Can cleft foot correct itself with growth?

No. It is a congenital structural malformation that does not go away on its own. However, some children have good enough function not to need surgery.

Do all children need an operation?

No. If the foot allows pain-free walking and suitable footwear, monitoring and adapting shoes when needed may be enough.

Can cleft foot also affect the hands?

Yes. In some patients the malformation affects both the feet and the hands. The specialist will assess whether other associated conditions need to be investigated or a genetic assessment is needed.

Will my child be able to walk and play sport normally?

It depends on the degree of involvement and the structures present. Many children can walk and take part in physical activities, although some need adapted footwear or treatment to improve function.

Will surgery make the foot look normal?

The aim is to improve shape and function, but the result depends on the initial anatomy. A completely normal appearance is not always possible, and the benefits and risks must be weighed individually.

This page is for general information and does not replace an assessment by a specialist. If you are worried about your child's foot, talk to their paediatrician or book an appointment.