Kaissi et al Figure 2. Coronal reformatted CT scan showed a line drawn to the head of the talus and through the body of the talus, makes a Z shape. on the chin in the shape of an inverted V. Apparently, there is a major orofacial malformation which warrants specialised orthodontic intervention. The limbs are thin with poor mus- culature and mobility (especially the scapulohumeral joint and pronation-supination of the forearm) were present. Flexed ﬁngers (mostly over the metacarpophalangeal joints) associated with ulnar deviation (wind swept deformity) were notable. Examination of the foot revealed severe forefoot ad- duction, lateral subluxation (abduction) at the talonavicular joint and valgus of the heel. The deformity was extremely rigid. His vision, hearing and neurological examination were normal though his language skills were limited associated with defective social behaviour. The child had normal geni- talia. All other investigations including an abdominal ultra- J Clin Med Res • 2011;3(5):265-267 sound, karyotyping, and metabolic tests, which aimed to test calcium, phosphorus, and vitamin D metabolism, were normal. Family history showed ﬁrst degree cousins healthy parents. The mother had a history of multiple spontaneous abortions and the reason behind was unknown. Radiographic ﬁndings, lateral skull radiograph showed signiﬁcant hyperostosis of the skull base associated with to- tal sclerosis of the lambdoid sutures and partial sclerosis of the coronal sutures respectively. The anteroposterior length of both base and cranium are relatively shorter than that of the facial height (Fig. 1). Lateral view showed an increased talocalcaneal angle indicative of valgus of the hindfoot (there is dorsiﬂexion of the talonavicular joint (probably secondary to increased talar plantar ﬂexion) and plantar ﬂexion of the tarsometetarsal joints, another Z deformity (Fig. 2). Coronal reformatted CT scan showed a line drawn to the head of the talus and through the body of the talus, makes a Z shape (Fig. 3). Treatment Because of lack of criteria for deﬁnition of the deformity and its relative severity, early treatment of skew-foot is often based on a perception of need to treat the metatarsus adduc- tus. Thus, a more severe adductus that is not passively cor- rectable and is rigid as in our patient, this can be treated by stretching and serial casting. The cast technique must care- fully mold the hindfoot into varus to avoid exacerbating the existing valgus while correcting the forefoot. Therefore, we used redression casts in order to get the hindfoot into varus, and to avoid the exacerbating existing valgus deformity. Fur- thermore we aimed to give a counter pressure on the lateral side of the foot (cuboid bone) to avoid the lateral subluxation of the chopard joint. Figure 3. Lateral view showed an increased talocalcaneal angle indicative of valgus of the hindfoot ( there is dorsiﬂexion of the talonavicular joint probably secondary to increased talar plantar ﬂexion) and plantar ﬂexion of the tarsometatarsal joints, another Z deformity. 266 Articles © The authors | Journal compilation © J Clin Med Res and Elmer Press™ | www.jocmr.org