Professional Documents
Culture Documents
(Clubfoot)
Anatomy/Terminology
3 main sections
1.Hindfoot talus,
calcaneus
2.Midfoot navicular,
cuboid, cuneiforms
3.Forefoot
metatarsals and
phalanges
Anatomy/Terminology
Important joints
Anatomy/Terminology
Varus/Valgus
Incidency
-Varies with race & sex
-Caucasians : 1,2/1000 , : = 2 : 1
-Hawaiians : 4,9/1000
-Maori : 6,5-7,0/1000
-Bilateral : 50%, 1/3 of cases
-Unilateral : right > left
Heredity
-Genetic factors : 10%, others sporadis
-Environmental factors :
Idelberger :
Identical (Monozygotic) twins 32,5%
Fraternal (Dizygotic) twins 2,9%
Etiology
- The exact cause : unknown
2. Neuromuscular Defect
- White, 1929 : A peroneal N. lesion caused by
pressure at the intrauterine stage
- Middleton, 1934 : Mal development of the
striated muscle
- Flinchum, 1953 : Muscle imbalance due to
dysplasia of the peroneals
- Ritsila : Concluded that primary soft tissue
changes
provoking skeletal deformities
Pathology
A. Bony Deformities
1. The Talus
- Medial & plantar deviation of the anterior end of
the talus
- declination angle : by the long axis of the
head & neck of the talus with the long axis of its
body
- Obliquity the neck of talus : medial tilting of the
anterior part of the talus (adult : 12-32 degrees,
fetus : 35-75 degrees, CTEV : 50-65 degrees)
2. The Calcaneus
- Much less deformed than the talus
- Rotated on its long axis inward &
downward
beneath the talus
- The sustentaculum tali usually
underdeveloped
& in close proximity to the medial
maleolus
B. Articular Malalignments
1. Relationship of talus to distal tibia & fibula
- The talus has no muscle attachments, it
is stabilized by the ankle mortis
4. Relationship of
Calcaneus to Cuboid
bone
- The cuboid is
displace medially in
relation to the
anterior end of the
calcaneus
C. Soft-Tissue Changes
Diagnosis
Clinical picture :
- Clublike appearance
- Deep creases at the posterior aspect of the
ankle joint
- Mid & forefoot are adducted, inverted &
equinus
- The navicular bone abuts the anterior & medial
margin of the medial maleolus, on palpation
cant insert a finger between the two bones
Radiographic Assessment
-The purpose is to define precisely the anatomic
relationship of talocalcaneonavicular, tibiotalar,
midtarsal & tarso-metatarso joint
-To assess the degree of subluxation of the
talocalcaneonavicular joint & the severity of the
deformity before treatment
- To provide an accurate guide to progress during the
course of closed non operative treatment
- To assess wether reduction of the talocalcaneonavicular
dislocation & normal articular alignment have been
achieved
Normal range of
roentgenographic angles
Talocalcaneal angle
Anteroposterior view: 30 to 55 degrees
Dorsiflexion lateral view : 25 to 50
degrees
Tibiocalcaneal angle
Stress lateral view : 10 to 40 degrees
Treatment
The objective :
1. To achieve reduction of the dislocation or
subluxation of the talocalcaneonavicular joint
2. To maintain the reduction
3. To restore normal articular alignment of the
tarsus & the ankle
4. To establish muscle balance between the evertors
& invertors, and the dorsiflexors & plantarflexors
5. To provide a mobile foot with normal function &
weight bearing
Advantage :
- A dynamic corrective
-
force is transmitted to
the foot
In expensive, applied
easily, reapplied at
frequent intervals
Relatively safe
Being least likely to
cause pressure sores
Lat X-ray
AP : The talocalcaneal angle should be
>20, the talo-first metatarsal angle <15
Lat : The talocalcaneal angle should be 3045
Retention of reduction
Treatment of resistant
clubfoot
Metatarsus adductus
>5yr : metatarsal osteotomy
Hindfoot varus
Equinus
Tendo calcaneus lengthening plus
posterior capsulotomy of subtalar joint,
ankle joint (mild to moderate deformity)
Lambrinudi procedure (severe deformity,
skeletal immaturity)