CLUB FOOT

SYNONYM :
Giles Smith syndrome, Talipes equinovarus Talipes

INTRODUCTION
Clubfoot is a condition in which one or both feet are twisted into an abnormal position at birth.

This is present at birth and affects the foot and/or ankle. There is no known cause for clubfoot, and it is twice as common in male children as it is in female children.

There are two categories of clubfoot:

Structural TEV
is caused by: genetic factors, such as Edward Syndrome, a genetic defect with three copies of chromosome 18 Genetic influences increase dramatically with family history.

Postural TEV
could be caused by external influences in the final trimester such intrauterine compression from oligohydramnios or from amniotic band syndrome..

Appearance
high arched foot that may have a crease across the sole of the foot The heel is drawn up The toe 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 smaller in comparison to a comparatively normal child The foot will lack motion and be noticeably stiff The calf muscle may also be smaller

ANATOMY BONE
Forefoot The forefoot is adducted and supinated; severe cases also have cavus with a dropped first metatarsal. BoneTibia:

Slight shortening is possible.

Fibula:

Shortening is common.

Common characteristics of and difficulties associated with club foot include: Feet turning inwards Foot pain Ankle pain Leg pain Hip & knee pain

 PATHOPHYSIOLOGY
ETIOLOGY

The etiology of idiopathic clubfoot is unknown. The most widely accepted theory is that clubfoot is caused by a combination of genetic and environmental factors.
RISK FACTORS Family history of clubfoot. Position of the baby in the uterus. Increased occurrences in those children with neuromuscular disorders, such ascerebral palsy (CP) and spina bifida. Oligohydramnios (decreased amount of amniotic fluid surrounding the fetus inthe uterus) during pregnancy

SIGN AND SYMPTOMS

Heel inversion (varus) with internal rotation Forefoot inverted and adducted (soles face each other) Medial foot concave Lateral foot convex (Kidney shape) Foot inverted Plantar flexion with inability to dorsiflex Equinus of Ankle and forefoot Very tight heel cord Leg internal rotation

POSSIBLE COMPLICATION If left untreated can become a burden. arthritis The twist of the ankle may not allow your child to walk on the soles of the feet. hardening of the skin development of corns and ulcers over the outer border of the foot

 LABORATORY EXAM
Ultrasound
It can be done before birth to determine if the fetus has a club foot

 DIAGNOSTIC PROCEDURE
x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. computed tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

MEDICAL MANAGEMENT
Refer immediately for serial casts Serial Casting
Start in first week of life Serial Casts weekly for 6-8 weeks Take advantage of neonatal ligamentous laxity Manipulate foot before and between casts
Stretches contracted soft tissues

Casting is most effective in extrinsic Clubfoot Dennis-Browne Splines Goal is a flat, platform-like base for ambulation

Severe Clubfoot requires surgery

Posteromedial release of heel cords Major surgery in 50-75% cases

 Left: The Markell Abduction Brace Right: The Mitchell Abduction Brace

child in bilateral long leg plaster casts for clubfoot correction

DRUGS
Antidepressant Zoloft
If you took Zoloft while pregnant and your baby was born with clubfoot or other birth defects

Zoloft side effects included:

Nausea -- in up to 30 percent of people Insomnia -- up to 28 percent Ejaculation problems -- up to 19 percent Diarrhea or loose stools -- up to 24 percent Dizziness -- up to 17 percent

Dry mouth -- up to 16 percent Fatigue -- up to 16 percent Drowsiness -- up to 15 percent Indigestion -- up to 13 percent Shakiness (tremor) -- up to 11 percent Loss of appetite -- up to 11 percent Decreased sex drive (libido) -- up to 11 percent.

NURSING MANAGEMANT
Review the pathology, prognosis and future expectations to mothers to provide knowledge base from which parents can make informed choice.

Discuss deformity and expected treatment in terms the parents can understand to rule out misconceptions and to provide information about the deformity.
Encourage parents to hold and play with child and participate in care to promote bonding.

 Assess and teach parent to assess for signs of excessive pressure on skin,redness, excoriation because th ese signs require immediate evaluati on andintervention. Elevate the extremity to promote venous return and prevents edema.

 Check the toes every 1-2 hours for temperature, color, sensation, motion, and capillary refill time.

Stimulate movement of toes to promote circulation. Insert plastic petals over the top edges of a new cast while it is still wet to keep urine from soaking and softening the cast.
Discuss the importance of physical therapist to enhance mobilitY

 Provide comfort measures such as soft music, pacifier, teething ring, or rocking to promote relaxation and may enhance patients coping abilities by refocusing attention.
When the Kite casting method is being used, check circulatory status frequently. Circulation maybe impaired because of increased pressure on tissues and blood vessels. The equines correction specially places considerable strain onligaments, blood vessels, and tendons.

Congenital Hip Dislocation

INTRODUCTION
Congenital hip dislocation
The abnormal formation of the hip joint in which the ball at the top of the thighbone (the femoral head) is not stable within the socket (the acetabulum). The ligaments of the hip joint may also be loose and stretched.

Synonym:
Congenital Hip Dislocation Hip dislocation in the Newborn Developmental Dysplasia of the hip Congenital Hip dysplasia

ANATOMY The hip is a ball and socket joint between the head of the upper femur (thighbone) and the bony pelvis. The femoral head is the ball and the acetabulum of the pelvic bone is the socket. The hip joint is lined with cartilage.

 The hip bursae are fluid-filled areas in the soft tissues around the hip joint where tendons and muscles pass over bony prominences. These fluid-filled sacs serve as a cushion between tendons and bone and lubricate the region with synovial fluid. Cartilage is the smooth, gliding surface inside all joints. Joints are also lubricated with a substance known as synovial fluid.

PATHOPHYSIOLOGY
UNKNOWN
Risk Factors Breech Presentation Female gender Family History(positive in up to one third of cases) Firstborn Oligohydramnios

Sign and symptoms Palpable of an audible click when the hips are flexed and abducted Perineum bread and the buttocks flattered Swelling in the gluteal region Limping Shortening of the limb waiding

Femoral head dislocates from acetabulum

Results from Acetabular Dysplasia (shallow acetabulum)

Results in subluxed, dislocated or unstable hip

COMPLICATIONS Avascular necrosis of the hip Osteoarthritis Heterotopic calcification Recurrent dislocation Complications of immobilization (DVT, pulmonary embolus, decubiti, pneumonia) Sciatic nerve injury (posterior dislocation) Femoral nerve injury (anterior dislocation) Femoral artery injury (anterior dislocation) Ligamentous injury of the knee fractures

LABORATORY EXAM

Barlow's Test is used to describe the provoked dislocation of an unstable hip by gently adducting flexed hip while pushing posteriorly in line of shaft of femur

ORTOLANI MANEUVER
The examiner's thumb is placed over the patient s inner thigh, and the index finger is gently placed over the greater trochanter.

The hip is abducted, and gentle pressure is placed over the greater trochanter. In the presence of DDH, a clunk, similar to turning a light switch on or off, is felt when the hip is reduced.

 DIAGNOSTIC PROCEDURE
CT scan
A CT scan of the hip is very accurate in delineating the extent and nature of acetabular and hip fractures and dislocations.

MRI
the best imaging modality in detecting and assessing avascular necrosis of the hip and in detecting undisplaced stress fractures of the femoral neck.

Radionucleotide scanning
is a sensitive method for detecting early avascular necrosis.

MEDICAL MANAGEMENT
Step 1: Pavlik Harness A Pavlik harness is used in the treatment of hip dysplasia in infants. The Pavlik harness is fit to the baby and holds his or her hips in proper position. By flexing up the legs, and allowing the knees to fall outwards, the hips are held in proper position. By doing so, the hip joint is properly reduced, and the hips will form normally.

 Step 2: Closed Reduction and Casting

Closed reduction is the process of realigning broken bones through exterior means and without the use of surgery. In most cases, the doctor will apply force to the bone in a manner exactly opposite to that which originally injured it.

Step 3: Surgical Open reduction

Reduction of a fractured bone by manipulation after incision intoskin and muscle over the site of the fracture.

DRUGS
Analgesia is indicated if the patient's clinical status allows. Conscious sedation with agents that provide muscle relaxation, amnesia and analgesia are indicated for ED reductions. General anesthesia
may be required for patients with dislocations that are irreducible by closed means as well as those with significant associated fractures, central dislocations or associated neurovascular injury.

 NURSING MANAGEMENT
for Impaired physical mobility
Maintain the correct position of the hip. Explain the components and purposes of splint or cast. Enhance play and using the upper portion of the body. Teach walking with cast Support the casted limp and avoid pressure on heels

 For Potential for injury

1. Watch for signs of compression 2. Observe pedal pulse and ability to move fingers 3. Ask for tingling, numbness, pain, or burning sensation 4. Assess for tightness by inserting finger between cast and skin

 For Knowledge deficit of parent regarding home care: 1. Teach how to care of the child 2. Different treatment procedures 3. Involve parent in care of the child 4. Regular Follow up