Clubfoot
Clubfoot: Excerpt from Professional Guide to Diseases (Eighth Edition)
Clubfoot, or talipes, is the most common congenital disorder of the lower extremities. It’s marked primarily by a deformed talus and shortened Achilles tendon, which give the foot a characteristic clublike appearance. In talipes equinovarus, the foot points downward (equinus) and turns inward (varus), whereas the front of the foot curls toward the heel (forefoot adduction).
Causes and incidence
A combination of genetic and environmental factors in utero appears to cause clubfoot. Heredity is a definite factor in some cases, although the mechanism of transmission is undetermined. In children without a family history of clubfoot, this anomaly seems linked to arrested development during the 9th and 10th weeks of embryonic life, when the feet are formed. Researchers also suspect muscle abnormalities, leading to variations in length and tendon insertions, as possible causes of clubfoot.
Clubfoot, which has an incidence of approximately 1 per 1,000 live births, usually occurs bilaterally and is twice as common in boys. It may be associated with other birth defects, such as myelomeningocele, spina bifida, and arthrogryposis.
Signs and symptoms
Talipes equinovarus varies greatly in severity. Deformity may be so extreme that the toes touch the inside of the ankle, or it may be only vaguely apparent. In every case, the talus is deformed, the Achilles tendon shortened, and the calcaneus somewhat shortened and flattened. Depending on the degree of the varus deformity, the calf muscles are shortened and underdeveloped, and soft-tissue contractures form at the site of the deformity. The foot is tight in its deformed position and resists manual efforts to push it into normal position. Clubfoot is painless, except in elderly, arthritic patients. In older children, clubfoot may be secondary to paralysis, polio-myelitis, or cerebral palsy, in which case treatment must include management of the underlying disease.
Diagnosis
Early diagnosis of clubfoot is usually possible because the deformity is obvious. In subtle deformity, however, true clubfoot must be distinguished from apparent clubfoot (metatarsus varus or pigeon toe). Apparent clubfoot results when a fetus maintains a position in utero that gives his feet a clubfoot appearance at birth. This can usually be corrected manually. Another form of apparent clubfoot is inversion of the feet, resulting from the peroneal type of progressive muscular atrophy and progressive muscular dystrophy. In true clubfoot, X-rays show superimposition of the talus and the calcaneus and a ladderlike appearance of the metatarsals. (See Recognizing clubfoot.)
Treatment
Clubfoot is correctable with prompt treatment, which is performed in three stages: correcting the deformity, maintaining the correction until the foot regains normal muscle balance, and observing the foot closely for several years to prevent the deformity from recurring. In neonates with true clubfoot, corrective treatment should begin at once. An infant’s foot contains large amounts of cartilage; the muscles, ligaments, and tendons are supple. The ideal time to begin treatment is during the first few days and weeks of life, when the foot is most malleable.
Clubfoot deformities are usually corrected in sequential order. Several therapeutic methods have been tested and found effective in correcting clubfoot. In all patients, the first procedure should be simple manipulation and casting, whereby the foot is gently manipulated into a partially corrected position and held in place by a cast for several days or weeks. (The skin should be painted with a nonirritating adhesive liquid beforehand to prevent the cast from slipping.) After the cast is removed, the foot is manipulated into an even better position and casted again. This procedure is repeated as many times as necessary. In some cases, the shape of the cast can be transformed through a series of wedging maneuvers instead of changing the cast each time.
After correction of clubfoot, proper foot alignment should be maintained through exercise, night splints, and orthopedic shoes. With manipulating and casting, correction usually takes about 3 months. The Denis Browne splint, a device that consists of two padded, metal footplates connected by a flat, horizontal bar, is sometimes used as a follow-up measure to help promote bilateral correction and strengthen the foot muscles.
Resistant clubfoot may require surgery. Older children, for example, with recurrent or neglected clubfoot usually need surgery. Tenotomy, tendon transfer, stripping of the plantar fascia, and capsulotomy are some of the surgical procedures that may be used. In severe cases, bone surgery (wedge resections, osteotomy, or astragalectomy) may be appropriate. After surgery, a cast is applied to preserve the correction. Clubfoot severe enough to require surgery is rarely totally correctable; however, surgery can usually ameliorate the deformity.
Special considerations
The primary concern is recognition of clubfoot as early as possible, preferably in neonates.
❑ Look for any exaggerated attitudes in an infant’s feet. Make sure you recognize the difference between true clubfoot and apparent clubfoot. Don’t use excessive force in trying to manipulate a clubfoot. The foot with apparent clubfoot moves easily.
❑ Stress to parents the importance of prompt treatment. Make sure they understand that clubfoot demands immediate therapy and orthopedic supervision until growth is completed.
❑ After casting, elevate the child’s feet with pillows. Check the toes every 1 to 2 hours for temperature, color, sensation, motion, and capillary refill time; watch for edema. Before a child in a clubfoot cast is discharged, teach parents to recognize circulatory impairment.
❑ Insert plastic petals over the top edges of a new cast while it’s still wet to keep urine from soaking and softening the cast. This is done as follows: Cut a plastic sheet into strips long enough to cover the outside of the cast, and tuck them about a finger length beneath the cast edges. Using overlapping strips of tape, tack the corner of each petal to the outside of the cast. When the cast is dry, petal the edges with adhesive tape to keep out plaster crumbs and prevent skin irritation. Perform good skin care under the cast edges every 4 hours, washing and carefully drying the skin. (Don’t rub the skin with alcohol, and don’t use oils or powders, which tend to macerate the skin.)
❑ If the child is old enough to walk, caution parents not to let the foot part of the cast get soft and thin from wear. If it does, much of the correction may be lost.
❑ When the wedging method of shaping the cast is being used, check circulatory status frequently; it may be impaired by increased pressure on tissues and blood vessels. The equinus (posterior release) correction especially places considerable strain on ligaments, blood vessels, and tendons.
❑ After surgery, elevate the child’s feet with pillows to decrease swelling and pain. Report any signs of discomfort or pain immediately. Try to locate the source of pain; it may result from cast pressure rather than from the incision. If bleeding occurs under the cast, circle the location and mark the time on the cast. If bleeding spreads, report it.
❑ Explain to the older child and his parents that surgery can improve clubfoot with good function but can’t totally correct it; the affected calf muscle will remain slightly underdeveloped.
❑ Emphasize the need for long-term orthopedic care to maintain correction. Teach parents the prescribed exercises that the child can do at home. Urge them to make the child wear the corrective shoes ordered and the splints during naps and at night. Make sure they understand that treatment for clubfoot continues during the entire growth period. Correcting this defect permanently takes time and patience.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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