Club Foot

1LITERATURE READING – Orthopaedics – 17/03/2004

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Congenital talipes equinovarus (CTEV)

Talipes, literally "ankle-foot", refers to the talusEquinovarus refers to the position of the clubfoot, in equinus and varus or adductus

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Congenital deformity1 of 1000 babiesOne or both feetboy : girl = 2 : 11st trimester of pregnancyThe foot pointing downwards and twisted inwardsClub, "kidney shaped", with a prominent medial crease along the plantar aspect of the foot

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Clubfoot does not cause pain in the infantIt gets worse over time, with secondary bony changes developing over years

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An uncorrected clubfoot in the older child or adult is very unsightly, and worse, very cripplingThe patient walks on the outside of his foot which is not meant for weight-bearingThe skin breaks down, and develops chronic ulceration and infection

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Two variations: 1) positional deformities

caused by the position of the foot in the womb

2) structural malformations where bones, joints, muscles, and blood vessels are malformed

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Whether positional or structural, there are four common types of clubfoot

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• Clubfoot can be recognized in the infant by examination

• The foot is inturned, stiff and cannot be brought to a normal position

• Children with the condition should be referred to an orthopedic surgeon for complete evaluation and treatment of the deformity

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Treatment

very important to treat clubfoot as early as possible (i.e. shortly after birth) to prevent disability and problems with walking when the child gets older

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The first step is taping/casting of the footThe physician holds the foot in the proper position and then puts tape or cast on to hold it in place One-third of feet, usually the ones more mildly affected, will respond to this therapyDuring the immediate postnatal period, the cast or tapings are changed every day

CASTING

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child will be seen frequently by the pediatric orthopedic surgeon: every one to two weeksInitial treatment is provided by a series of casts to the affected foot

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Infants are placed in casts covering the entire limb(s)The severity of child's deformity will determine the number of casts requiredThe casts will need to be kept dry

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After multiple serial castings are completed (2-3 months), special shoes with or without a bar may be needed

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The Pediatric Orthopaedic Surgeon lengthens several of the tendons (structures which connect muscle to bone) which allows to foot to adopt a normal position

SURGERY

Achilles lengthening procedure

If cast treatment fails, surgery is necessaryThis is not performed until the child is between four and eight months of age

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The Operation

patient is anesthetizedpositioned pronea tourniquet applied to the proximal limbthe limb is surgically scrubbed and drapedreleases and reductionsone or two K-wires are inserted by drill, to hold the reduced and corrected position, to fixate the talonavicular and calcaneocuboid jointsthen are shortened and bent externallyThis makes for easy removal, and eliminates danger of migration

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Steri-strips and a dressing are applied and a plaster of Paris backslab long leg splint is appliedMost surgeons do not splint the foot in the completely corrected position initiallyThis is to allow for expected post-operative soft tissue swelling and to prevent ischemia of the footThe limb is then elevatedThe hospital stay is commonly just one nightPain and circulation status must be under control before discharge

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One week after surgeryunder general anesthetic or sedation,the splint is removedthe foot is examined

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a circumferential long leg cast is applied in the over-corrected position of heel dorsiflexion,pronation of the foot and external rotation of the ankleThe knee is placed at 90 degrees of flexion

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Sometimes orthotic fitting is done at this time for a knee-ankle-foot orthotic (KAFO) OR an ankle-foot orthotic (AFO)The device will be worn for months

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If a KAFO is used, it will eventually be replaced by an AFO to allow the baby to walk. These are worn inside shoes

Bilateral AFO orthotics

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Developmental Dysplasia of the Hip (DDH)

Introduction

• CDH

• 5 – 20 per 1000 live births

• Girls : boys = 7 : 1

• Left > right

• 1 in 5 cases, bilateral.

Etiology

• Genetic factors• Hormonal factors• Intrauterine

malposition• Postnatal factors

Pathology

Physical Exam Maneuvers

• A. Barlow Test– dislocates an unstable hip

– stabilize pelvis with one hand, then flex and adduct opposite hip with posterior pressure.

– dislocation is felt as a “clunk”

– release of posterior pressure spontaneously relocates femoral head.

Physical Exam Maneuvers (con’t.)

• B. Ortolani Test– reduces a recently dislocated hip– flex and abduct thigh to lift femoral head

into acetabulum– relocation “clunk”– most likely to be positive at 1-2 mos.

Physical Exam Maneuvers (con’t)

Clinical Manifestations

• In the newborn– limitation of hip abduction– assymetric number of thigh skinfolds– uneven knee levels– apparent shortening of an extremity

18 Months to 5 Years

Trendelenburg sign

X-RAY

• Acetabular angle shold be < 30°• Perkins’ line : ossification centre should

be inner lower quadrant• Shentons line : broken on dislocated side• ossification centre : smaller on

dislocated side

Ossification centre

Treatment

• Treatment is age specific• Neonate

– Goal: maintain hip in flexed and abducted position to maintain femoral head reduction and tighten ligamentous structures.

– Pavlik harness or Frejka splint for 1-2 mos.

Treatment

• 1-6 months– Pavlik harness for 3-4 weeks.– Closed surgical reduction if harness fails.

Treatment

• 6-18 mos.

– Closed or open surgical reduction

– Hip spica cast

Treatment

• 18 mos.-8 years– Open reduction with pelvic and/or femoral

osteotomy

Complication’s

• The most common complication of treatment of DDH is osteonecrosis of the femoral head

• Growth disturbance of proximal femoral physis

• Gait abnormality

Thank you