CLUBFOOT

Clubfoot is used in connection with many foot deformities whether congenital or acquired. It is a condition in which the affected foot tends to be smaller than in normal with the heel pointing inward and downward and remains stuck in this position that resists realignment. Originally used to designate a foot deformity that causes the patient to walk on the ankle. 1 per 1000 live births Common in males Most common disorder of the legs and can range from mild and flexible to severe and rigid

4 cardinal position of the foot: 1. Varus or inversion 2. Valgus or eversion 3. Equinos or plantar flexion 4. Calcaneus or dorsiflexion

Alternative names: Talipes Talipes equinovarus Etiology: Talipes came from two Latin words Talus which means ankle, and Pes meaning foot

Causes Mainly idiopathic Theories that is being associated with clubfoot:

Common to individuals with Edwards syndrome. This is a condition resulting from a genetic abnormality in which an extra chromosome is present, specifically chromosome number 18 that has three instead of the usual two. The mother of a clubfoot baby used methylenedioxymethamphetamine (MDMA) or commonly known as ecstasy while having her baby in her womb. This can be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. Breech presentation. May be associated with neurogenic conditions such as spina bifida cystica, cerebral palsy and tethered cord

Anatomy and Physiology The foot composed of the tarsals, metatarsals and phalanges has two important functions. It supports our body weight and serves as a lever that allows us to propel our bodies forward when we walk and run. The tarsus forming the posterior half of the foot is composed of seven tarsal bones. Bodyweight is mostly carried by the two heel bones and the talus which lives between with tibia and the calcaneus. 5 metatarsals form the sole, and 14 phalanges form the toes. Like the fingers of the hand, each toe has three phalanges except the great toe which has two. The bones in the foot are arranged to form 3 strong arches: 2 longitudinal (medial and lateral) and one transverse. Ligaments which bind the foot bones together and tendons of the foot muscles help to hold the bones firmly in the arched position but still allow a certain amount of give or springs. Weak arches are referred to as fallen arches or flat feet .The forefoot includes the five metatarsal bones and the phalanges (the toes). The first metatarsal bone bears the most weight and plays the most important role in propulsion. It is the shortest and the thickest. It also provides attachment for several tendons. The second, third, and fourth metatarsal bones are the most stable of the metatarsals. They are well protected and have only minor tendon attachments and are not subjected to strong pulling forces. Never the head of the first metatarsal on the plantar surface of the foot are two sesamoid bones (a small, oval shaped bone which develops inside a tendon, where the tendon passes over a bony prominence). They are held in place by their tendons and are also supported by ligament. The mild foot includes 5 of the 7 tarsal bones (the navicular, cuboid and 3 cuneiform). The distal row contains the 3 cuneiforms and the cuboid. The midfoot meets the forefoot at the five tarso metatarsal (TMT) joints. There are multiple joints within the midfoot itself. Proximally the 3cuneiforms articulate with the navicular bone. The talus and the calcaneous make up the midfoot. The calcaneous is the largest tarsal

boneand forms the heel. The talus rests on top of it and forms the pivot of the ankle. Signs and Symptoms

High arched foot that may have a crease-cross of 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. 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.

Pathophysiology
Non-modifiable Factors: Genetics Sex Maternal illness Modifiable Factors: Maternal lifestyle Breech presentation

Arrest in fetal development of skeletal and soft tissue during 9-10 weeks gestation

Defective cartilage with ligaments laxity.

Shortening of medial cartilage

CLUBFOOT

Laboratory and Diagnostic Procedure

CT Scan X-Ray Physical Examination

Medical and Surgical Management 1. Serial casting Began immediately or shortly after birth. 2. Serial manipulation Repeated frequently every few weeks for 1-2 weeks then at 1-2 weeks interval to accommodate rapid growth of early infancy. Until usually 812 weeks but still depends on the severity of the case. 3. Denise Browne splint Brace for clubfoot. 4. Osteotomy A surgical operation to cut a bone into two parts, followed by realignment of the ends to allow healing. The operation is performed to reduce pain and disability in an arthritic joint, by changing the biomechanics of the joint, for cases in which conservative treatment hasfailed.

5. Open reduction surgical procedure at enables the surgeon to reduce (repair) the fractures under direct visualization open reduction internal fixation (ORIF) is done that includes pins, screws, nails, plates, wires and rods inserted through bone fragments or fixed to the side of the bone. 6. Ponseti method Daily or weekly manipulation and stitching of tissues of the affected extremity by the use of casts and simple exercises. Nursing Management and Intervention

Regular neurovascular checks on the affected toes. Observe toes for signs of circulatory impairment. Make sure toes are visible at the end of the cast.

Cast care:

Watch for signs of weakness and wear of the cast, especially if the child is allowed to walk on it. Ensure proper fitting and wearing off the cast and splints.Ensure the cast is not too tight nor too loose. Skin care to prevent formation of hot spots and ulcerations Prevent infection. Explain the importance of the procedure to the childs parents and relatives. Teach the parents all necessary care of emphasize the need for followup which may be prolonged.

For respiratory problem: hypostatic pneumonia Raise head if mattress rather than head to prevent flexion of the neck. Teach parents postural drainage and exercises for child by the use of blowing bubble to increase lung expansion. Encourage parents to seek immediate medical care.