Clubfoot (Talipes Equinovarus)

DEFINITION Congenital talipes equinovarus, commonly known asclub foot, is a foot deformity in which the foot is twisted inward with the toes pointing down. It affects approximately 1 in every 1,000 newborns in the US each year. It is more common in males. Club foot may affect one or both feet. In 30% to 50% of affected children, it involves both feet.This condition sometimes runs in families. If one child in the family has club foot, the likelihood of another child having this condition increases to 10%. Clubfoot can be classified as (1) postural or positional or (2) fixed or rigid. Postural or positional clubfeet are not true clubfeet. Fixed or rigid clubfeet are either flexible (ie, correctable without surgery) or resistant (ie, require surgical release, though this is not entirely true according to the Ponseti experience

CAUSES y The exact cause is unknown y Gene Variation A study funded by SPARKS, a children's medical research charity organization, and led by Zosia Miedzybrodska, geneticist, and Linda Sharp, epidemiologist, discovered, for the first time, that a variation in the gene that processes folate may be part of the cause of clubfeet. It was determined that those infants who possessed the less common variant of C677T variant, in the gene that is called MTHFR or methyltetrahydrofolate reductase, were more apt to be born with a clubfoot than infants who did not possess this variant.
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Environmental and Genetic Factors According to the March of Dimes, scientists believe environmental and genetic factors contribute to the development of clubfoot. Clubfoot, which develops by the second trimester of pregnancy, may be caused by drugs, cigarette smoking, infection or uterine exposure to other factors.

Malpositioning of Foot in Utero In the past, clubfoot was thought to be the result of the way the fetus' foot was positioned in the uterus. If the fetus' foot (or feet) was cramped or twisted during gestation this was believed to result in clubfoot. But scientists are now discovering other factors that may result in clubfoot. However, some foot abnormalities do result from malpositioning of the fetus' feet, according to the March of Dimes, including mild metatarsus adductus and calcaneovalgus, which self-correct after birth. Spina Bifida Link Most babies born with a clubfoot do not have any other defects; however, occasionally, another defect will pop up. Clubfoot does appear to be connected with birth defects, such as an open spine or spina bifida. Children with spina bifida may have clubfoot which, in the case of spina bifida, is caused by nerve damage to the spine, which has an effect on the development of the legs and feet. Sometimes when spina bifida is present, there is no evidence of a foot problem at birth but the foot or feet may become twisted later on, which can happen when there is a muscle or nerve disease.

Smoking during pregnancy.

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If a woman with a family history of clubfoot smokes during pregnancy, her baby's risk of the condition may be 20 times greater than average.

CLINICAL MANIFESTATIONS The key identifying features are:

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tightening of the Achilles tendon (heel cord) inward turning of the front of the foot downward-pointing toes resting of the foot on its outer border abnormal shape of the foot rigidity and other changes in the movements of the foot

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RELEVANT ANATOMY (based on clubfoot features) Bone Tibia: Slight shortening is possible. Fibula: Shortening is common Talus: In equinus in the ankle mortise, with the body of the talus being in external rotation, the body of the talus is extruded anterolaterally and is uncovered and can be palpated. The neck of the talus is medially deviated and plantar flexed. All relationships of the talus to the surrounding bones are abnormal. Os calcis: Medial rotation and an equinus and adduction deformity are present. Navicular: The navicular is medially subluxated over the talar head. Cuboid: The cuboid is medially subluxated over the calcaneal head. Forefoot: The forefoot is adducted and supinated; severe cases also have cavus with a dropped first metatarsal. Muscle Atrophy of the leg muscles, especially in the peroneal group, is seen in clubfeet. The number of fibers in the muscles is normal, but the fibers are smaller in size. The triceps surae, tibialis posterior, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) are contracted. The calf is of a smaller size and remains so throughout life, even following successful long-lasting correction of the feet. Tendon sheaths: Thickening frequently is present, especially of the tibialis posterior and peroneal sheaths. Joint capsules: Contractures of the posterior ankle capsule, subtalar capsule, and talonavicular and calcaneocuboid joint capsules commonly are seen. Ligaments: Contractures are seen in the calcaneofibular, talofibular, (ankle) deltoid, long and short plantar, spring, and bifurcate ligaments. Fascia: The plantar fascial contracture contributes to the cavus, as does contracture of fascial planes in the foot. TEST AND DIAGNOSIS Most commonly, a doctor recognizes clubfoot after birth just from looking at the shape and positioning of the newborn's feet. The doctor may request X-rays to fully understand the severity of the deformity.

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It's possible to clearly see some cases of clubfoot before birth during a baby's ultrasound examination. If clubfoot affects both feet, it's more likely to be apparent in an ultrasound. While nothing can be done before birth to solve the problem, knowing about the defect may give you time to learn more about clubfoot and get in touch with appropriate health experts, such as a genetic counselor or an orthopedic surgeon. TREATMENT AND MANAGEMENT Because the newborn's bones and joints are extremely flexible, treatment for clubfoot usually begins soon after birth. The goal of treatment is to restore the look and function of the foot before your child learns to walk, in hopes of preventing long-term disabilities. Treatment options include:
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Stretching and casting (Ponseti method). This treatment entails manipulating the foot into a correct position and then placing it in a cast to maintain that position. Repositioning and recasting occurs every week for several weeks. After the shape of the foot is realigned, it's maintained through stretching exercises, special shoes or splinting with braces at night for up to three years. For this method to work effectively, you'll need to apply your child's braces according to your doctor's specifications so that the foot doesn't return to its original position. Stretching and taping (French method). This approach involves daily manipulation of the foot, followed by the use of adhesive tape to maintain the correct position until the next day. After two months, treatments are reduced to three times each week until the baby is 6 months old. Once the foot's shape is corrected, parents continue to perform daily exercises and use night splints until their baby is walking age. This method requires commitment to very frequent appointments for six months. Some providers combine the French method and the Ponseti method. Surgery. In some cases, when clubfoot is severe or doesn't respond to nonsurgical treatments, your baby may need surgery. An orthopedic surgeon can lengthen tendons to help ease the foot into a more appropriate position. After surgery, your child will need to wear a brace for a year or so to prevent recurrence of the deformities. Parental education for Club Foot Parents need to understand the diagnosis The overall treatment program, the importance of regular cast changes, and the role they play in the longterm effectiveness of the therapy. Reinforce and clarify the orthopaedic surgeon s explanations and instructions Provide emotional support Teach parents about care of the cast or appliance (including vigilant observation for potential problems) Encourage parents to facilitate normal development within the limitations imposed by the deformity or therapy. Care of children with plaster cast Preparation for cast application Explain to the child what to expect with casting. Allow the parent to accompany the child to the cast room to hold their hand and talk to them during application. Stretch a tube stockinette over the area to be casted and place soft cotton sheets over the bony prominences. Inform the child the cast feels cool when it is applied wet but, will feel warm when it starts drying.

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Nursing care plans Nursing diagnosis 1: Risk for altered peripheral tissue perfusion R/T pressure from cast. 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 there after. 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. 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 semifowler s position. Teach the child nothing to put between the cast and skin. Nursing diagnosis 3: Parental health seeking behaviors R/T care of child with cast at home. 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 any thing inside to scratch. Teaching Plan- contents Physical care: 1. Maintain appropriate muscle tone 2. Provision of comfort 3. Traction/ Cast care 4. Prevention of urinary stasis and constipation 5. Promotion of skin integrity Parent teaching: How to apply devices such as Denis Brown splint. Explain the procedure Teaching of diversional therapy during application of traction/cast Caring of cast (wet, how to dry) Assess for circulatory and neurological disturbance