Clubfoot

Clubfoot I. Definition Clubfoot is a condition in which one or both feet are twisted into an abnormal position at birth. The condition is also known as talipes. It is a general term used to describe a range of unusual positions of the foot. This is present at birth and affects the foot and/or ankle. There is no known cause for clubfoot, and it is twice as common in male children as it is in female children. Most type of clubfoot is present at birth which can happen in one foot or in both feet. In almost half of affected infants, both feet are involved.Although clubfoot is painless in a baby, treatment should begin immediately. Clubfoot can cause significantly problems as the child grows, but with early treatment most children born with clubfoot are able to lead a normal life

II. A.K.A Giles Smith syndrome, Talipes equinovarus; Talipes

III. Incidences The frequency of congenital clubfoot is approximately 1 per 1,240 live births. In children there is a subtle imbalance in muscle forces in the lower leg resulting in the foot deformity. Often, the foot is ‘kidney- shaped”. About 50% of the time, both feet are affected with clubfoot. In USA, there are 1-2 cases for every 1000 live births. The ratio of males to females with clubfoot is 2.5 to 1.

IV. Risk/ Predisposing Factors

Risk factors may include: • • • •

Family history of clubfoot. Position of the baby in the uterus. Increased occurrences in those children with neuromuscular disorders, such as cerebral palsy (CP) and spina bifida. Oligohydramnios (decreased amount of amniotic fluid surrounding the fetus in the uterus) during pregnancy.

V. Manifestation Although there is no known cause of congenital clubfoot, some doctors believe the use of drugs or alcohol during pregnancy or the presence of other diseases can cause it. In some cases, clubfoot is just the result of the position of the baby while it is developing in the mother’s womb. Clubfoot is painless in a baby, but it can eventually cause discomfort and become a noticeable disability. Left untreated, clubfoot does not straighten itself out. The foot will remain twisted out of shaped, and the affected leg may be shorter and smaller than the other. These symptoms become more obvious and more of a problem as the child grows.  Fixed plantar Flexion (equinos) of the ankle, characterized by the drawn up position of the heel and inability to bring the foot to a plantigrade (flat) standing position. This is caused by a tight Achilles tendon.  Adduction (varus), or turning in of the heel or hindfoot.  Adduction (turning under), of the forefoot and midfoot giving the foot a kidneyshaped appearance.  Abnormal (slightly smaller) size of foot & calf muscles.  The heel cord (Achilles tendon) is tight causing the heel to be drawn up toward the leg.

VI. Type/ Stage/ Classification There are two categories of clubfoot/ talipes equinovarus(TEV). •

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Structural TEV is caused by: genetic factors, such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affect limb are also causes of Structural TEV. Genetic influences increase dramatically with family history. Postural TEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. However, this is countered by findings that TEV does not occur more frequently than usual when the intrauterine space is restricted.

VII. Pathophysiology

Theories of the pathogenesis of clubfeet are as follows: • • •

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Arrest of fetal development in the fibular stage Defective cartilaginous anlage of the talus Neurogenic factors: Histochemical abnormalities have been found in posteromedial and peroneal muscle groups of patients with clubfeet. This is postulated to be due to innervation changes in intrauterine life secondary to a neurologic event, such as a stroke leading to mild hemiparesis or paraparesis. This is further supported by a 35% incidence of varus and equinovarus deformity in spina bifida. Retracting fibrosis (or myofibrosis) secondary to increased fibrous tissue in muscles and ligaments: In fetal and cadaveric studies, Ponseti also found the collagen in all of the ligamentous and tendinous structures (except the Achilles tendon), and it was very loosely crimped and could be stretched. The Achilles tendon, on the other hand, was made up of tightly crimped collagen and was resistant to stretching. Zimny et al found myoblasts in medial fascia on electron microscopy and postulated that they cause medial contracture.1,2,9 Anomalous tendon insertions: Inclan proposed that anomalous tendon insertions result in clubfeet.10 However, other studies have not supported this. It is more likely that the distorted clubfoot anatomy can make it appear that tendon insertions are anomalous. Seasonal variations: Robertson noted seasonal variations to be a factor in his epidemiologic studies in developing countries.11 This coincided with a similar variation in the incidence of poliomyelitis in the children in the community. Clubfoot was therefore proposed to be a sequela of a prenatal poliolike condition. This theory is further supported by motor neuron changes in the anterior horn in the spinal cord of these babies.

VIII. Diagnostic Studies • •

Physical examination. Ultrasound o Ultrasound done while a fetus is developing can sometimes detect clubfoot. It is more common for your health professional to diagnose the condition after the infant is born, though, based on the appearance and mobility of the feet and legs. In some cases, especially if the clubfoot is due just to the position of the developing baby, the foot is flexible and can be moved into a normal or nearly normal position

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X-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called "slices"), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

IX. Management Treatment for clubfoot usually begins soon after birth, so the foot grows to be stable and positioned to bear weight for standing and moving comfortably. Nonsurgical treatment such as casting or splinting is usually tried first. The foot (or feet) is moved (manipulated) into the most normal position possible and held (immobilized) in that position until the next treatment.

2 common methods of manipulation and casting: •

Traditional

In traditional treatment, one position of the foot at a time is treated with manipulation and casting. Usually, the inward direction of the front of the foot is corrected first. If the foot is not responsive, major surgery is performed to further straighten the foot. •

Ponseti method

In this method, two problems w/ foot position (the front part of the foot being turned in and up) are corrected at once. Toward the end of the series of castings, if the whole foot is pointing down, children treated with this method still require a minor surgery to lengthen the tight Achilles tendon. This is usually an outpatient procedure. Recent research indicates that the Ponseti method is successful in most children clubfoot if treatment is started immediately and if the health professional’s instructions for bracing are followed after casting is finished. One study indicated that 94% of children treated with traditional casting will require major corrective surgery within the first year of life, while only35% of children treated with the Ponseti method will require this major surgery.

Other Methods  Casting- can be started on the day of birth or within several weeks after birth. In this procedure, the orthopedist pushes and twists the foot into an over corrected position and then cast is applied to ensure holding of foot in same manner. (kiting)  Dennis Brown Brace- used when long leg cast is removed after 3 weeks of treatment. The bar is fit shoulder width apart and worn full time for the 1st 2 months after the last cast is removed.

Pharmacologic Management: NSAIDs- used mainly for management of pain of low to moderate intensity. Example: Ibuprofen X. Nursing Diagnosis

1. Risk for disproportionate growth related to congenital disorders. 2. Impaired physical mobility related to musculoskeletal impairment. 3. Impaired skin integrity related to musculoskeletal impairment. 4. Disturbed body image related to developmental changes. 5. Social isolation related to alterations in physical appearance.

XI. Nursing Responsibilities • • • • •

Review the pathology, prognosis and future expectations to mothers to provide knowledge base from which parents can make informed choice. Discuss deformity and expected treatment in terms the parents can understand to rule out misconceptions and to provide information about the deformity. Encourage parents to hold and play with child and participate in care to promote bonding. Assess and teach parent to assess for signs of excessive pressure on skin, redness, excoriation because these signs require immediate evaluation and intervention. Elevate the extremity to promote venous return and prevents edema.

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Check the toes every 1-2 hours for temperature, color, sensation, motion, and capillary refill time. Stimulate movement of toes to promote circulation. Insert plastic petals over the top edges of a new cast while it is still wet to keep urine from soaking and softening the cast. Provide comfort measures such as soft music, pacifier, teething ring, or rocking to promote relaxation and may enhance patients coping abilities by refocusing attention. When the Kite casting method is being used, check circulatory status frequently. Circulation maybe impaired because of increased pressure on tissues and blood vessels. The equines correction specially places considerable strain on ligaments, blood vessels, and tendons. Discuss the importance of physical therapist to enhance mobility.

XII. Illustration

A photo of a newborn baby with a clubfoot.

A photo of a newborn baby in the NICU with a bilateral clubfoot deformity.

A two month old infant in a casts as treatment for his bilateral clubfoot deformity.

This is a photo of an infant in a Denis Browne bar (foot abduction brace) bar after undergoing months of casting using the Ponseti method as treatment for his bilateral clubfeet.

References: en.wikipedia.org

www.epodiatry.com www.mercksource.com www.nlm.nih.gov www.umm.edu http://healthline.com/ http://adam.about.com/