Clubfoot causes: There are two types of clubfoot.

The more severe type is usually associated with other abnormalities or problems such as spinal dysraphism, tethered cord, arthrogyrposis, etc The second type of clubfoot is less severe and is often called "idiopathic" as the cause is not known. The clubfoot appearance at birth does resemble the position the foot is in during early fetal development, so it is assumed that some unknown cause halts the normal change of foot position during fetal growth.

There are many treatments available for clubfoot and many different opinions exist concerning treatment regimes. The aim of the treatment regime should be: -

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Correct the deformity early. Correct the deformity fully Hold the correction until growth stops.

Below is the summary of some of the main conditions.

Casting CLUB FOOT (CONGENITAL TALIPES EQUINOVARUS) This may be begin from the 1 day of life to several weeks after birth. The foot is pushed and twisted into an over corrected position by the Orthopedist. The cast is then applied in order to hold the foot into that position. This may be uncomfortable for the child. Casts are usually changed every two weeks. Splints or braces may be used after a few years of casting the feet. The Ponseti method of casting and manipulation can also be effective. This method was pioneered in the 1940's by Dr Ignocio Ponseti and can be successful in certain cases. Please refer to your consultant for further information.
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INTRODUCTION

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Clubfoot is a congenital foot condition, which affects approximately 1 out of every 1000 births in the United Kingdom. However, prevalence of this condition is twice as common in males than females. The deformity can be mild or severe and it can affect one foot or both feet. As many as 50% of cases are bilateral (both feet are affected). Club Foot is sometimes confused with other congenital foot defects, such as Calcaneovalgus and Metatarsus adductus. These deformities are caused by the position of the foot in the womb and are usually corrected with minimal intervention. True clubfoot affects all the joints, tendons and ligaments in the foot and is often referred to as Congenital Talipes EquinoVarus. Another form of clubfoot is Congenital Vertical Talus, this is not as common as true clubfoot, the foot appears more rigid then a true club foot deformity. In most cases, clubfoot is idiopathic, which means that the cause is unknown and there is no genetic tendency. However it is associated with Spina Bifida and Hip Dysplasia. APPEARANCE High arched foot that may have a crease across the sole of the foot. The heel is drawn up. The toes are pointed down. The bottom of the foot (heel) is pointed away from the body. Thus, the foot is twisted in towards the other foot (please refer to photograph below) The foot and leg may be smaller in comparison to a comparatively normal child. The foot will lack motion and be noticeably stiff. The calf muscle may also be smaller. Surgery

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The above photograph is of a Clubfoot casting.

SYMPTOMS If left untreated the child will walk on the outer top surface of the foot. The patient may also experience corns, hard skin and in growing toenails. Clubfoot in adulthood can lead to difficulty in purchasing shoes and a gait abnormality (walking pattern).

There are many surgical procedures available for clubfoot. Surgery is usually recommended to a child of six months old. Below are the list of commonly used surgical procedures. For further information concerning these surgical procedures, please consult an Orthopedist. Perctuneous tenotomy. The Achilles tendon is cut to allow the foot to drop. Posterior release. Medial release. Subtarsal release. Complete tendon transfer.

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WHAT YOU SHOULD NOT DO DO NOT ignore this condition in a hope that it will spontaneously disappear.

Physiotherapy

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WHAT YOU SHOULD DO

This is primarily a non-surgical treatment that can begin when the child is three months old. It involves frequent visits by a physical therapist who tapes and/or manipulates the foot. This method has proved highly successful in some cases.

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Seek immediate advice from a pediatric consultant. Seek as many opinions as you can before you commence a treatment regime.

WHAT THE CHIROPODIST WILL DO

TREATMENTS

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Refer you to a pediatric consultant or a physical therapist. In adulthood, the chiropodist will treat any foot conditions that may arise due to clubfoot, i.e. Corns. The chiropodist may customize insoles or shoes for the patient.

1. SERIAL PLASTER CASTING: All treatment options should begin with casting. Treatment should be started right away. The initial treatment consists of manipulating the foot to get it to the best position possible, and then holding the correction in a cast. The cast is changed regularly (at first on a weekly basis), with manipulation before each casting, to obtain further correction. Casting should be the full-leg cast not just to the knees as was done in Evan's case. 2. SPLINTS/BRACES: Are used as a follow-up after serial casting, or after casts applied at surgery. Ponseti AFO - more information can be found here Denis Brown (DBB) type where boots or shoes are attached to a bar which can be adjusted gently daily, until eventually the feet are in the correct position, Ankle-foot orthoses (AFO's), which are a light-weight, plastic splint held on by velcro. These can be worn 24 hours a day, or at night only. They can be removed easily for bathing. Shoes that may be used after splints are straight last shoes where the medial border is straight.

CONDITIONS THAT RESEMBLE A CLUB FOOT Calcaneovalgus Metatarsus Adductus

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What is Clubfoot?

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Clubfoot or talipes is a congenital deformity of the foot that occurs in approximately 1:1000 births with half of them being bi-lateral (both feet) and it is twice as common in boys as in girls. The foot has a typical appearance of pointing downwards and twisted inwards. Since the condition starts in the first trimester of pregnancy, the deformity is quite established at birth, and is often very rigid. There are three main types of defects: Equinovarus - This is the most severe type. The foot is twisted inward and downward so that the child cannot place the sole flat on the ground but must walk on the ball, the side, or even the top of the foot. Calcaneus valgus - In this moderately severe form, the foot is angled upward and outward so that the child has to walk on the heel or the inner side of the foot. Metatarsus varus or adductus - The mildest form of defect does not involve the ankle but only the bones and connective tissues of the foot, causing the front part to turn inward.

3. Non-Surgical Treatment Options: The Ponseti method is rapidly becoming the universal standard in clubfoot treatment. I encourage parents to use this method even if you have to travel a very long way! We didn't know that any other options existed until many years after Evan's surgeries. How we would have loved to avoid surgery (and the stiffness of scar tissue) if possible and gain a better correction. There are two non-surgical methods of treatment: Ponseti non-surgical treatment (Dr. Ignacio Ponseti of Iowa) consists of a weekly series of gentle manipulations followed by placement of casts which extend from the toes to the upper thigh. Five to seven weekly casts are applied. Before applying the last cast, which is worn for three weeks, the heel-cord is cut in the clinic in order to complete the correction of the foot. By the time the cast is removed the heel-cord has healed. Following this two month program of casting, a denis-browne splint is worn full-time for 2-3 months and then is worn only at night for 2-4 years. The splint consists of two high-top open-toed shoes connected to a bar. The shoes maintain the foot or feet in the corrected position. To locate a Doctor qualified in the Ponseti method, check out this listing. French technique, consists of daily visits with the physical therapist. Gentle, painless stretching of the foot is performed. The foot is then taped to maintain the improved position and is held this way until just before the next day's visit. At night, the taped foot is placed into a continuous passive motion machine at home in order to maximize the amount of stretching. This is tolerated well by the infants. The tape is removed for two hours each day to allow for bathing, airing of the skin, and home exercises. Removable aquaplast splints are also used to reinforce the taped position. The one-hour physical therapy sessions are conducted five days each week for as long as three months (in very stiff feet). Taping is discontinued when the child starts to walk. Botox has also been used in conjunction with physical therapy and casting/splinting produced significant improvements in foot flexibility and in some cases surgery was not required. This method involves injecting calf muscles with a purified form of botulinum toxin (a deadly poison if injested). The Ilizarov technique has been used in the treatment of complex resistant clubfoot deformities. The Ilizarov technique involves placing tension wires through the bony structures of the clubfoot to realign the joint surfaces and foot anatomy. The Ilizarov external fixator also called the Ilizarov Aparatus is a very powerful tool that may also be used to stabilize fractures, regrow lost bone or correct deformities in the length rotation or angles of bones.

No one really knows what causes the deformity. There may be a positive family history. A postural clubfoot is caused by position of the fetus in utero and is usually mild responding quickly to serial casting. Sometimes a child born with clubfoot will also have other congenital deformities such as in Evan's case, amniotic band syndrome. In some instances a child born with myelomeningocele (spina bifida) or arthrogryposis may also have clubfeet. Beyond these observations, no actual cause is known. If your child has clubfoot, it is not due to anything you did or did not do during pregnancy. During development, the posterior and medial tendons and ligaments (in the back and inside) of the foot fail to keep pace with the development of the rest of the foot. As a result, these tendons and ligaments tether the posterior and medial parts of the foot down, causing the foot to point downwards and twist inwards. The bones of the feet are therefore held in that abnormal position. Over time, if uncorrected, the bones will become misshapen. Clubfoot does not cause pain in the infant. Because it is so obvious, it is usually discovered at birth. If left untreated, the deformity does not go away. It gets worse over time, with secondary bony changes developing over years. An uncorrected clubfoot in the older child or adult is very unsightly, and worse, very crippling. The patient walks on the outside of his foot which is not meant for weight-bearing. The skin breaks down, and develops chronic ulceration and infection. What are the Treatment Options? 1. 2. 3. Serial Plaster Casting Splints/Braces Non-Surgical Treatment Methods o Ponseti Method o French Physiotherapy Method o Botox - botulinum toxin o Ilizarov Technique Surgery

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4. SURGERY: The Last Resort Surgery, called posteromedial release, consists of releasing all the tight tendons and ligaments in the posterior

and medial aspects of the foot, and repairing them in the lengthened position. More recently, it has been recognized that some of the lateral ligaments have to be released as well, to allow a complete release. The incision used may vary. After surgery, the foot needs to be casted followed by the use of splints to hold the correction. The objective of clubfoot treatment is to obtain a plantigrade and flexible foot. "Plantigrade" means the child stands with the sole of the foot on the ground, not on his heels or the outside of his foot. "Flexible" means one can move the foot around freely without pain. When recurrence occurs, further surgery may be needed. In the younger child, soft tissue releases and lengthening may suffice. In the older child, because of bone changes, surgery involving osteotomy (cutting the bone) may be needed. Following treatment, children with clubfeet will go on to lead normal active lives. They will need to have regular assessment of their feet during childhood and adolescence until they reach maturity, to ensure that there is not a recurrence of the condition. Although their feet will be functional, some children with only one foot affected may require 2 different shoe sizes. It is normal that the calf muscle will be smaller and that there will be some degree of stiffness as scar-tissue builds up following surgery.

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Lateral cuneiform Cuboid Navicular Talus Calcaneus

Metatarsals form the sole and are composed of 5 bones. Phalanges form the toes and are composed of 14 bones. Each toe has 3 phalanges with the exception of the great toe having only 2. Ligaments connects bones. Tendons attaches bone to a muscle allowing movements or a specific amount of elasticity. Pathophysiology Etiology The exact cause of this deformity is unknown. But suggestions or hypotheses of its disease process are the following:

Definition Talipes deformity is a disorder of ankle and foot. It comes from the Latin words talus meaning ankle and pes meaning foot. Incidence Commonly called clubfoot, it is a congenital anomaly occurring at approximately 1 to 2 in every 1000 live births. Male-female incidence ratio is 2:1. Bilateral deformity involvement accounts 30%-50% of cases. True Talipes Disorder Talipes deformity could either be unilateral (affecting a single foot only) or bilateral (both feet are affected). Regardless of which extremity is affected, some newborns have developed a twisted foot appearance due to intrauterine position. However, with manipulation the foot can be brought into a straight position. This temporary abnormality is called a pseudo-talipes disorder. A true clubfoot cannot be aligned properly without further intervention. Skeletal Anatomy of the Foot Two essential functions of the foot: 1. 2. Reinforces body weight Allows the body to move forward when running or walking

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Genetic factor Abnormal tendon insertion

Anomalous tendons may affect the alignment of the foot.

Retracting fibrosis (myofibrosis)

Collagen found in all ligaments and tendons are coiled and could be stretched with the exception of Achilles tendon (made up of tightly coiled collagen and cannot be stretched). Thickening and scarring of fibrous tissue could cause the twisted foot appearance.

Neurogenic factors

Innervation changes during the prenatal period could be due to the presence of neurologic events or disorder such as, spina bifida. Studies show that 35% of children with clubfoot have neurologic impairment.

Oligohydramnios

Fluid leak during the prenatal period could cause restriction of fetal movements thereby, predisposing to a deformed foot.

Developmental arrest of fetal development

Facts about the foot bone: 1. The weight of the body is carried by the largest tarsal bones, calcaneus (heelbone) and talus (ankle bone). To create a strong arch of the foot it is arranged longitudinally (medial and lateral) and transverse.

Disruption of the medial rotation of the fetal foot could result to a clubfoot condition.

Diminished Vascular Circulation

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Disruption of the branches of the vascular supply of the lower extremity could contribute to misalignment of the foot. Types of True Talipes Deformity

Parts of the Foot Bone: Tarsus the posterior half of the foot composed of seven tarsal bones: 1. 2. Medial cuneiform Intermediate cuneiform

Ponseti Method Applies certain techniques to reduce and correct the deformity to promote normal foot mobility and position. Methods used are the following: 1. Manipulation - Slightly pivoting the bones and stretching the soft tissue Placement of above the knee cast

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Frequency of changing the cast is every 5-7 days to accommodate the rapid growth during the first year of life. In most cases, severing of Achilles tendon (tenotomy) is done before the final cast is applied. The reason for doing this is to loosen the foot. The procedure is usually done in a clinic where a local anesthetic is used. A small cut (about 3 mm) is made above the heel of the foot to lengthen the tendon. After the procedure final casting is done. Final cast is removed after 2-3 weeks when Achilles tendon is already healed. After the final cast is removed:

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Equinus (plantarflexion)

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Calcaneus (Dorsiflexion) Varus (foot turns inward) Valgus (foot turns outward) 1.

Some children with this deformity have a combination of the types listed. For example, a child who walks on the heel with the foot turning outwards has calcaneovalgus disorder while the child who tiptoes with the foot inverted has equinovarus deformity. Diagnostic Evaluation:

Denis Brown Splints (shoes or boots attached to a bar) are used 23 hours each day for 3 months to maintain the normal foot alignment. For the next 2-4 years the splint is fitted during naps and nighttime only. Passive foot exercises (full range-of-motion) are executed by the primary caregiver to further maintain the position.

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Post-tenotomy management Physical Examination Observe for the following:

Twisted foot appearance should be assessed and gently manipulated. If the straightened foot does not move to a normal position, true clubfoot is present.

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Drainage on the cast Foul smelling odor from inside the cast. Swelling, redness and irritation at the distal portion of the cast. High fever

Radiography

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Use of x-rays is definitive diagnosis for clubfoot as it determines abnormal bone anatomy and assesses the treatment efficiency.

Management Categories of treatment: 1. For mild cases: manipulation, cast and splint application (nonsurgical management) For severe cases: surgery

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Nonsurgical management

ilizarov frame Ilizarov Technique Method used for complex ankle-foot deformity. Ilizarov frames, the circular structure placed around the limb, are used in this technique which are attached to metal pins and are inserted through the bone. A frame is individually made for each patient and

denis browne splint

weighs approximately 7 lbs. Placement of the frame requires the administration of a general anesthetic and the procedure may last for several hours. Surgical Management Posteromedial Release The last option for a clubfoot is the release of all tight tendons and ligaments in the posterior and medial parts of the foot. The structures are then put back together in a lengthened position. Tendon Transplant Done at 4-7 years of age when other corrective measures have been ineffective. Complications

Medication

Acetaminophen (Tylenol) is an analgesic and antipyretic given for pain relief after traction or tenotomy. Do not use Tylenol with NSAIDs or salicylates. Combined use predisposes the child to experience adverse renal effects.

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Exercise

Execution of passive foot exercises several times a day for several months to maintain the corrected foot alignment. Never forcibly evert or pronate the foot during clubfoot casting. This can cause damage to the bones.

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Treatment

Rocker bottom Foot

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Cast application Physiotherapy Surgery (last option)

Vertical talus results from a forceful manipulation causing bone breakage. This then will give rise to a flat foot.

Recurrent deformity Health Teaching

The corrected foot may return to its deformed state if the parents or primary caregiver fails to apply the methods to further correct the position (e.g. passive foot exercises and Denis Brown splint). Nursing Interventions

Cast care:

Frequently change the infant s diaper to prevent soiling of the cast. Use dry cleanser in wiping the cast. 1. 2. Obtain a family and obstetric history for risk factors. Ongoing Assessment After delivery, assess the ankle and foot for a true talipes deformity by straightening the foot. Pseudo-talipes can be realigned to a normal position. Diet 3. For infants with cast assess for circulation, redness and swelling distal from the cast and foul odor. Monitor the infant s temperature (for those who underwent tenotomy or surgery). Fever is the first sign of infection. Cautiously evaluate crying. Infants cannot voice out pain. Crying may mean hunger, wet diapers, abdominal pain or tingling sensation from a tight cast. Keep the cast clean and dry by changing diapers frequently. Use a damp cloth and dry cleansers in wiping. Water and soap causes breakdown of cast particles.

Assess the circulation of casted foot.

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Spiritual

Breastfeeding for infants younger than 4-6 months. For older infants, introduction of solid foods must have the interval of 5-7 days.

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The mother or the primary caregiver is the significant person for the infant; therefore, she should be at the infant s side most of the time. Convey expression of parents towards the child s condition.

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7. Place a pillow or padding under the casted area to prevent cast damage and prevent sores from heel pressure. For children with traction, check and cleanse the pin sites frequently. Explain to the parents the importance of passive foot exercises after the final cast is removed.

Possible Nursing Diagnosis 1. Risk for Peripheral neurovascular dysfunction R/T mechanical compression (cast or brace) Risk for impaired skin integrity R/T cast application, traction or surgery Acute pain R/T muscular and tissue damage secondary to surgery Risk for Impaired Parenting R/T maladaptive coping strategies secondary to diagnosis of talipes deformity

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10. Maintaining the aligned position after the cast application is essential to prevent reoccurrence. 11. Administer analgesics as ordered for pain relief after a surgical correction. 12. Assess coping mechanisms of family and resources available for long-term treatment. Discharge Plan

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