CLUB FOOT

• Clubfoot


  Also known as talipes equinovarus
• Clubfoot


  • Deformed talus and shortened Achilles tendon give the foot a characteristic club-like appearance
  • Most common congenital disorder of the lower extremities
  • Classified as postural/positional, which is not considered true clubfoot, or fixed/rigid, which requires the long-term use of casts or splints or surgery
• Clubfoot


  Fixed/rigid condition consisting of bone deformity and soft tissue contracture
• Clubfoot Involves several tissue abnormalities, including

  
  

  Involves several tissue abnormalities, including muscle and cartilage anomalies, bone primary germ plasm defects, and vascular abnormalities, such as hypoplasia or absence of the anterior tibial artery
• Causes of clubfoot


  • Idiopathic
  • Intrinsic (20% of cases): neurologic, muscular, vascular, or connective tissue disease or other birth defects like spina bifida, myelomeningocele, amniotic band sequence, congenital myotonic dystrophy, tethered spinal cord, or arthrogryposis
  • Genetics (single gene may be involved) - syndromes like diastrophic dwarfism, Freeman-Sheldon syndrome, Smith-Lemli-Opitz syndrome, chromosome 22q11.2 deletion syndrome, trisomy 18
  • Extrinsic: Intrauterine molding caused by movement restriction related to multiple gestation, malpresentation, uterine cavity abnormalities, breech position, or oligohydramnios
• Clubfoot occurs in 0.5 to 2 in every 1,000 live births in the United States
• Hawaiian and Maori ethnicities have a much higher prevalence of clubfoot, at 6.8 per 1,000 live births
• Clubfoot is bilateral about 50% of the time
• Clubfoot is twice as common in boys as it is in girls
• Complications of clubfoot


  • Abnormal gait and balance
  • Stress changes on the lateral side of the foot
  • Residual deformity
  • Wound infection (with surgery)
• Recognizing clubfoot


  • Deformed talus with a shortened Achilles tendon and somewhat shortened and flattened calcaneus
  • Heel initially soft to touch (similar to the feel of a cheek) and then becoming firmer (similar to the feel of the nose or chin)
  • Shortened, underdeveloped calf muscles, with soft tissue contractures at the site of the deformity
  • Hindfoot supinated with foot pronated
  • Foot tight in its deformed position and resistant to manual efforts to push it back into normal position
• Diagnostic tests for clubfoot

  1. Ultrasonography (transvaginal) can detect the abnormality as early as 12 to 13 weeks' gestation

  2. Radiography shows superimposition of the talus and the calcaneus and a ladderlike appearance of the metatarsals
• Ponseti method (gold standard treatment for clubfoot)

  1. Foot is moved into a correct position and then a cast is placed to hold it there (often performed by an orthopedic specialist)

  2. Foot is repositioned and recast once or twice a week for several months

  3. A minor surgical procedure (Achilles tenotomy) may be performed to lengthen the Achilles tendon toward the end of this process

  4. After realignment of foot shape, the family needs to maintain it by performing stretching exercises and ensuring the child wears special shoes and braces full time for 3 months and then at night for up to 3 years
• French method for fixed clubfoot

  1. Incorporates stretching, mobilization, and taping

  2. Directed by a physical therapist who has specialized training and experience

  3. Daily, the foot must be stretched and manipulated, then taped to maintain the range of motion gained by the manipulation. After taping, a plastic splint is put over the tape to maintain the improved range of motion

  4. Requires three visits to the physical therapist each week. The therapist teaches the parents how to correctly perform stretching and gentle mobilization at home

  5. After 3 months, most babies have significant improvement in foot position, and visits to the physical therapist are required less often

  6. Babies treated with the French method commonly require an Achilles tenotomy to improve dorsiflexion of the ankle (approximately 80%)

  7. To prevent clubfoot recurrence, the daily regimen of stretching, taping, and splinting must be continued by the family until the child is 2 to 3 years old
• Approximately 20% of cases require an anterior tibialis transfer
• Less-Extensive Surgery


  An orthopedic surgeon lengthens the tendons and joints that are contributing to the deformity, often the Achilles tendon or the anterior tibial tendon
• Major Reconstructive Surgery


  1. In severe cases, extensive release of multiple soft tissue structures of the foot is necessary

  2. After correction, the foot joints are stabilized with pins and a long leg cast while the soft tissue heals

  3. After 4 to 6 weeks, the surgeon removes the pins and cast and typically applies a short-leg cast, which the child must wear for 4 weeks

  4. The child must wear special shoes or braces for 1 year or more after removal of the last cast to try to prevent the foot muscles from returning to the clubfoot position
• Medications


  • Acetaminophen for postoperative pain
  • Prophylactic antibiotics
• Nursing Interventions


  • Administer prescribed medications and monitor their effect
  • Assist with serial manipulations and casting; for an infant, initial treatment is often initiated in the first week after birth
  • After casting, elevate the child's feet with pillows. Be sure to pad pressure points
  • Complete a pediatric fall risk assessment using an approved screening tool, and implement necessary precautions
  • Perform proper skin and cast care
  • Provide comfort measures to assist in managing pain, if indicated
  • Provide support to the child and family
  • Encourage the family to ask questions and ensure their understanding of the disease process. Actively listen and answer questions honestly
  • Encourage the family's participation in the child's care and decision making
  • Encourage the family to stay with the child
  • Prepare the child and family for possible surgery, including explanations of preoperative care, postoperative treatment, and the future use of orthotics and braces, as indicated
  • Consult with care management to ensure that all home-going needs are met prior to discharge
  • Consult with a child life specialist to provide age-appropriate distractions and support
  • Consult with social services to provide counseling, community resources, and support
• Monitoring


  • Neurovascular status of the affected extremity after casting or surgery
  • Proper foot alignment
  • Pain level and relief
  • Skin integrity
• Associated Nursing Procedures


  • Cast application, pediatric
  • Cast assessment and management, pediatric
  • Cast removal, assisting, pediatric
  • Fall prevention, pediatric
  • Pain assessment, pediatric
  • Pain management
  • Postoperative care
  • Preoperative care, pediatric
  • Pressure injury prevention, pediatric
  • Pulse assessment, pediatric
  • Skin assessment
  • Wound care, pediatric
• Patient and Family Teaching

  • Disease; diagnosis; treatment, including early initiation of serial manipulations and casting, beginning in the first week after birth and performed weekly; and prognosis
  • Prescribed medications, including drug names; dosages; indications for use; frequency, route, and duration of administration; expected results; potential adverse effects; and signs and symptoms of toxicity
  • Evaluation of neurovascular status of the affected extremity, including signs of circulatory impairment and the need to immediately notify the practitioner if any occur
  • Measures for proper skin care, especially to areas surrounding the casted area
  • Cast care using teach-back method, if indicated
  • Use of exercise, night splints, braces, and orthopedic shoes to maintain alignment
  • Reasons to call the practitioner, such as if toes swell, bleed, or change color under the cast; cast appears to be causing significant pain; toes disappear into the cast; cast slides off; or foot begins to turn in again after treatment
  • Importance of follow-up appointments
• Discharge Planning


  • Assess the child's (if appropriate) and the parents' or caregiver's understanding of the diagnosis, treatment regimen, need for follow-up care, and warning signs or potential problems that require medical attention
  • Explain the importance of scheduling and attending all follow-up appointments
  • Confirm transportation arrangements for initial follow-up appointments
  • Ensure that the parents or caregivers understand the treatment regimen, including the purpose and desired effect of each medication, the dosage and how to administer it, and potential adverse effects
  • Ensure that the parents or caregivers are able to obtain the prescribed medications. Ensure that the child (if appropriate) and the parents or caregivers have the name and contact information of someone to call if they encounter a problem