Aira Madel Araba

Clubfoot
Definition
Clubfoot is a condition in which one or both feet are twisted into an abnormal position at
birth. The tendons on the inside of the leg of people with club foot are shortened, the bones have
an unusual shape and the Achilles tendon is tightened. If left untreated patients often appear to
walk on their ankles or on the sides of their feet. The condition is also known as Talipes. It is a
general term used to describe a range of unusual positions of the foot. It is also called Talipes
Equinovarus; Giles Smith Syndrome. This is present at birth and affects the foot and/or ankle.
Most type of clubfoot can happen in one foot or in both feet.
According to the National Institutes of Health (NIH), USA, approximately 1 in every
1,000 babies is born with club foot. Males are twice as likely to have the condition as females.
Classifications/types
There are 3 major classifications: A. Postural clubfoot (transitional, mild or postural):
occur primarily from intraunterine crowding and responds to simple stretching and casting. B.
Syndromic (teratologic): associated with other congenital anomalies such as myelomeningocele
and is a more severe form that is often resistant to treatment. C. Congenital clubfoot (idiopathic):
may occur in an otherwise normal child and has a wide range of rigidity and prognosis; true
clubfoot.
Different types are:
Talipes equinovarus: Plantar flexion and inversion
Talipes equinus: Plantar flexion, in which the toes are lower than the heel
Talipes calcaneovarus: Dorsiflexion and inversion
Talipes calcaneus: Dorsiflexion, in which the toes are higher than the heel
Talipes valgus: An eversion or a bending outward
Talipes cavus: normal arch is exaggerated
Talipes calcaneovalgus: Dorsiflexion and eversion
Talipes varus: inversion or a bending inward
Talipes equinovalgus: Plantar flexion and eversion

Risk factors
Risk factors are: Family history of clubfoot, Multiple gestations (twins or triplets),
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, and Smoking exposure in
utero.
Etiology/ Causes
Clubfoot is considered a "multifactorial trait." Multifactorial inheritance means there are
many factors involved in causing a birth defect. The factors are usually both genetic and
environmental. Often one gender (either male or female) is affected more frequently than the
other in multifactorial traits. There appears to be a different "threshold of expression," which
means that one gender is more likely to show the problem than the other gender. Once a child
has been born with clubfoot, the chance for it to happen again in a male or female child is about
4 percent overall. In other words, there is a 96 percent chance that another child would not be
born with clubfoot.
Signs and Symptoms
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 shape, 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. There are also
problems with fitting shoes and participating in normal play. Treatment that begins shortly after
birth can help overcome these problems.
Potential Complications
Clubfoot typically doesn't cause any problems until child starts to stand and walk. If the
clubfoot is treated, child will most likely walk fairly normally. Child is likely to develop arthritis.
Poor self-image -the unusual appearance of the foot may make the child's body image a concern
during the teen years. Inability to walk normally - the twist of the ankle may not allow the child
to walk on the soles of the feet. To compensate, he or she may walk on the balls of the feet, the
outside of the feet or even the top of the feet in severe cases. Muscle development problems -
these walking adjustments may prevent natural growth of the calf muscles, cause large sores or
calluses on the feet, and result in an awkward gait. Watch out for any complication such as
compartment syndrome and also chronic impairment (neglected clubfoot).
Diagnostic tests
1. Ultrasound a noninvasive procedure used to visualize and document fetal, placental,
and maternal structure. It is done while fetus is still developing so that the clubfoot is
early detected.
Nursing responsibilities:
Explain exam purpose and procedure; no radiation employed and test is painless
Offer encouragement to patient, because maintenance of a distended bladder may be
quite difficult
Remove or instruct patient to remove residual gel from skin. Instruct patient that she can
empty her bladder
Evaluate patient outcome
2. X-ray a diagnostic test that uses invisible electromagnetic energy beams to produce
images of internal tissues, bones, and organs onto film. Talus is superimposed and the
metatarsals is ladder-like.
Nursing responsibilities:
Explain exam procedure and purpose
Assess for test contraindication
Encourage patient to follow positional instructions if applicable
Evaluate patient outcomes
Nursing Diagnosis
Nursing diagnosis 1: Risk for altered peripheral tissue perfusion R/T pressure from cast.
Objective cues: A risk diagnosis is not evidenced by signs and symptoms as the problem has not
occurred; rather, nursing intervention s are directed at prevention.
Goal: prevent pressure from cast and promote circulation
Interventions:
Keep the casted extremity elevated to prevent edema.
Check circulation frequently (Every 15 min for the first 1 h, hourly for 24 h and 4 hourly thereafter.
Assess for color, warmth, presence of pedal pulses and sensations of numbness or tingling.
Signs of impaired neurovascular function are pain, pallor, pulselessness and parasthesia.
Edema that is not improved by elevation indicates also neurovascular impairment.
Nursing diagnosis 2: Risk for impaired tissue integrity R/T pressure from cast.
Objective cues: A risk diagnosis is not evidenced by signs and symptoms as the problem has not
occurred; rather, nursing intervention s are directed at prevention.
Goal: perform interventions identified to prevent wound or lesion.
Interventions:
When moving child in a wet cast, always use open palms to move the cast.
Pressing with fingers indent the cast and cause pressure points which can lead to an ulcer.
Turn the child every 2 h to allow the under surface of the cast to dry.
Do not use heaters or fans to dry the cast as it causes uneven drying.
When the cast is dry if the edges are not smooth or covered by a fold of stockinet smooth the adges by
applying adhesive tape strips (Petaling)
If casted area covers the genitalia cover the edges of the cast covering the genital area with a plastic or
waterproof material.
Keep the child in a semifowlers position.
Teach the child nothing to put between the cast and skin.
Nursing diagnosis 3: knowledge deficit related to condition and treatment
Objective cues: asks questions. Parental anxiety.
Goal: verbalize understanding of condition and treatment.
Interventions:
If the cast is for the lower extremity discuss how much weight bearing is allowed, and the use of
crutches if prescribed.
Reassure the parents that the child is comfortable with the cast.
Demonstrate how to move or position the child and allow return demonstrations.
If an abduction bar is used with the cast the parents should not use it as a handle to move or lift the
child.
Encourage providing touch stimulation to the remaining body parts.
If itching is a problem instruct them to apply a hand lotion or massage the area gently if it is reachable.
If not reachable blow cool air through the cast using a fan.
Instruct not to put anything inside to scratch.
Nursing diagnosis 4: impaired physical mobility related to musculoskeletal impairment
Objective cues: postural instability, abnormal position of foot and ankle
Goal: early detection and prevention of the impariment
Interventions:
Detection of club foot at birth
Early treatment
Application of cast to hold the foot in the corrected positions
Use of Denis Browne split, if less than one year
Shoes fixed with metal cross bars
Nursing diagnosis 5: Potential for physiologic injury, R/T failure to provide appropriate care.
Objective cues: A risk diagnosis is not evidenced by signs and symptoms as the problem has not
occurred; rather, nursing intervention s are directed at prevention.
Goal: provide appropriate care to prevent physiologic injury
Interventions:
The need to change the device as child grows
If the device is in effective, surgery may be performed
Support the foot after surgery with cast or club foot shoes
Additional nursing diagnosis:
1. Risk for disproportionate growth related to congenital disorders.
2. Disturbed body image related to developmental changes.
3. Social isolation related to alterations in physical appearance
Medical management
1. CASTS applied sequentially by first correcting the forefoot adduction, then the heal
inversion, and then the flexion of the ankle; usually changed at 1-2 week intervals to
allow infants foot to grow and manipulate the foot gradually
Nursing responsibilities:
Perform frequent neurovascular assessment
Palpate the cast for hot spots that may indicate the presence of underlying infection
Keep cast dry
Stimulate movements of toes to promote circulation
Elevate the childs feet 1-2 hours with pillow
Watch out for any complications such as compartment syndrome
Do not place any objects in the cast

2. BRACES - necessary for several years to prevent relapses. There are several different
braces that are commonly prescribed. All braces consist of a bar (the length of which is
the distance between the childs shoulders) with either shoes, sandals, or custom-made
orthoses attached at the end s of the bar in about 70 degrees of external rotation. The
braces is worn 23 hours a day for three months and then at night time for three to four
years.
Nursing responsibilities:
Urge the parents to make sure the child wears his corrective shoes (braces)
Check the childs feet several times a day after initiating the bracing to ensure no blisters
are developing
Pad the bar to protect the child from the metal bar
Never use lotion on any red spots on the skin
Pharmacologic Management: NSAIDs- used mainly for management of pain
of low to moderate intensity. Example: Ibuprofen
Surgical management
Surgery is done if there is failure to achieve satisfactory clinical and radiographic evidence of
deformity correction. Mostly done to children between 6 months to one year of age.
1. Achilles tenotomy cutting or clipping of Achilles tendon
Nursing responsibilities:
Confirm that all required consent forms are fully completed
Keep child NPO as ordered
Take and record vital signs
Elicit any family history of reaction to anaesthesia
Check lab values for any signs of systemic abnormality
Closely monitor all vial physiologic functions
Use aseptic technique to avoid complications
Monitor vital signs and IV
2. The Ponseti method - a specialist manipulates the baby's foot with their hands. The aim
is to correct the bend in the foot. Then a plaster cast is applied from the patient's toes to
their thigh to hold the foot in position. Each session is generally done once a week. The
manipulation and casting are done very gently and the patient should experience no
pain.At each session the plaster cast is changed, and each time the foot is corrected a tiny
bit more. The whole process may be done 4 to 10 times (4 to 10 new casts used). When
the foot is eventually corrected the patient has to wear special boots attached to a brace to
hold the foot (feet) in the best position. For two to three months the boots are worn 23
hours a day; eventually they are just worn at night and during daytime naps - until the
patient is about four years old.
3. The French functional method - consists of daily stretching, exercise, massage, and
immobilization of the foot with nonelastic tape to slowly move the foot to the correct
position. These therapy sessions are performed primarily by a physical therapist for the
first three months, when most of the improvement occurs, but parents receive training
during this time in order to perform some of the treatments at home. The taping and
splinting continues until the child is two years old. It is important to note that this method
is currently not available in many parts of the United States.

References
Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide. (12
th

Ed.). 2012.
Lippincott Williams & Wilkins. Lippincott Manual of Nursing Practice series Pathophysiology. 2007.
http://cirrie.buffalo.edu/encyclopedia/en/article/350/
http://umm.edu/programs/orthopaedics/services/pediatric/club-feet
http://www.medicalnewstoday.com/articles/183991.php
http://www.webmd.com/a-to-z-guides/clubfoot-topic-overview