congenital skeletal malformations
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Congenital skeletal malformationsTRANSCRIPT
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Maria Carmela L. Domocmat, RN, MSN
Intructor
Northen Luzon Adventist College 1
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� a congenital deformity in which the foot is
twisted out of shape or position;
� Aka: clubfoot
Maria Carmela L. Domocmat, RN, MSN 2
Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
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� dorsiflexion - t. calca´neus
� plantar flexion - t. equi´nus
� abducted and everted -t.val´gus or flatfoot
abducted and inverted - t. va´rus� abducted and inverted - t. va´rus
� various combinations
� t. calcaneoval´gus
� t. calcaneova´rus
� t. equinoval´gus
� t. equinova´rus
Maria Carmela L. Domocmat, RN, MSN 3
Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
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� t. calcaneoval´gus� the foot is turned outwards with the toes pointing
upwards� t. calcaneova´rus
� the foot points inwards and up� the foot points inwards and up� t. equinoval´gus
� the foot points outwards and down� t. equinova´rus
� most common type
� foot is fixed in plantar flexion (downward) and deviated medially (inward)
Maria Carmela L. Domocmat, RN, MSN 4
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Maria Carmela L. Domocmat, RN, MSN 5
http://img.tfd.com/dorland/thumbs/talipes.jpg
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Maria Carmela L. Domocmat, RN, MSN 6
http://www.abdn.ac.uk/~gen155/graphics/clubfoot.jpeg
http://www.fpnotebook.com/_media/Ortho
PedsFootCF.jpg
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Maria Carmela L. Domocmat, RN, MSN 7
http://1.bp.blogspot.com/_IZV_l47MkXQ/TRpGEJogmHI/AAAAAAAAAGw/X1VQqO
DtJG4/s1600/child_foot_clubfoot_intro01.jpg
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o The true etiology of congenital clubfoot is
unknown
oExtrinsic associations include oExtrinsic associations include � Teratogenic agents (eg, sodium aminopterin)
� Oligohydramnios
� Congenital constriction rings
Maria Carmela L. Domocmat, RN, MSN 8
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oGenetic associations include
o mendelian inheritance (eg, diastrophic dwarfism;
o autosomal recessive pattern of clubfoot inheritance).o autosomal recessive pattern of clubfoot inheritance).
o Cytogenetic abnormalities (eg, congenital talipes
equinovarus [CTEV]) can be seen in syndromes
involving chromosomal deletion.
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oTalipes may be positional or structural. � Positional talipes is caused by abnormal pressures
compressing the foot while it's developing, as a result
of its position in the womb.
� Structural talipes is a more complex condition and
probably caused by a combination of factors, such as
a genetic predisposition
Maria Carmela L. Domocmat, RN, MSN 10
http://www.bbc.co.uk/health/physical_health/conditions/talipes2.shtml
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o deformity is readily apparent at birth
o can be detected antenatally during the routine
development ultrasound scan around 20 weeks.development ultrasound scan around 20 weeks.
o X-rays may be needed to confirm diagnosis.
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o treatment is most successful when started
early in infancy because delay causes muscles
and bones of legs to develop abnormally, and bones of legs to develop abnormally,
with shortening of tendons
Maria Carmela L. Domocmat, RN, MSN 12
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� gentle, manipulation of foot with casting
� done every few days for 1 to 2 weeks then at 1- to 2-week
intervals
� Ponseti’s Method of treatment� Ponseti’s Method of treatment
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Maria Carmela L. Domocmat, RN, MSN 14
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� involves serial manipulation and plaster casting of the clubfoot.
� The ligaments and tendons of the foot are gently stretched with weekly, gently manipulations. stretched with weekly, gently manipulations.
� A plaster cast is then applied after each weekly sessions to retain the degree of correction obtained and to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct alignment.
� Four to five long leg (from the toes to the hip) are applied with the knee at a right angle.
Maria Carmela L. Domocmat, RN, MSN 15
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LONG LEG CAST DENNIS BROWN SPLINT
Maria Carmela L. Domocmat, RN, MSN 16
http://www2.massgeneral.org/ORTHO/DennisBrownBrace.gifhttp://www2.massgeneral.org/ORTHO/BabyCast.gif
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� Making A Difference: Caring For Clubfoot at
the Sinai Hospital of Baltimore at
http://www.youtube.com/watch?v=Rmkrrvw
MH4A&feature=player_embedded#!MH4A&feature=player_embedded#!
Maria Carmela L. Domocmat, RN, MSN 18
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� done if nonsurgical treatment not effective � tight ligaments released� tendons lengthened or transplanted � Other surgical treatments � Other surgical treatments
- circumferential release: "cincinati incision"- Goldner four quadrant approach:
- medial release- posterior release- posteromedial release- tendon transfers
Maria Carmela L. Domocmat, RN, MSN 19
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� extended medical supervision is required
� bcoz there is a tendency for this deformity to recur
(considered cured when the child is able to wear
normal shoes and walk properly)normal shoes and walk properly)
� care emphasizes muscle reeducation (by
manipulation) and proper walking
Maria Carmela L. Domocmat, RN, MSN 20
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� heels and soles of braces or shoes
prescribed following correction must be
kept in repair
corrective shoes may have sole and heel lifts � corrective shoes may have sole and heel lifts
on lateral border to maintain proper
positioning
Maria Carmela L. Domocmat, RN, MSN 21
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• Approximately 50-60% of club feet in newborns
can be corrected non-operatively.
• About 20% of infants requiring surgery need • About 20% of infants requiring surgery need
further surgery at a later stage.
Maria Carmela L. Domocmat, RN, MSN 22
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Maria Carmela L. Domocmat, RN, MSN 23
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Maria Carmela L. Domocmat, RN, MSN 24
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• imperfect development of hip –can affect
femoral head, acetabulum, or both
• head of femur does not lie deep enough within • head of femur does not lie deep enough within
the acetabulum and slips out on movement
• occurs in females 7 times more often than males
Maria Carmela L. Domocmat, RN, MSN 25
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Maria Carmela L. Domocmat, RN, MSN 26
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o acetabular dysplasia� mildest form
� femoral head remains in acetabulum
o subluxation o subluxation � most common form
� femoral head partially displaced
o dislocation � femoral head not in contact with acetabulum
� displaced posteriorly and superiorly
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o limitation in abduction of leg on affected
side
o asymmetry of gluteal, popliteal, and thigh o asymmetry of gluteal, popliteal, and thigh
folds
o Waddling gait and lordosis when child
begins to walk
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Maria Carmela L. Domocmat, RN, MSN 29
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� With child in a supine position, the right knee on the side of the subluxation the subluxation appears lower than the left because of malposition of the femur head.
Maria Carmela L. Domocmat, RN, MSN 30
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� infant on a supine position.
� Doctor abducts the hips by moving the bent
hips and knees apart.
If the hip feels like it can be pushed out the � If the hip feels like it can be pushed out the
back of the socket, this is considered
abnormal.
� This is called a positive Barlow's Test and is a
sign of instability in the hip.
Maria Carmela L. Domocmat, RN, MSN 31
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� As the hip is abducted further, the doctor
might feel the ball portion (the femoral head)
slide forward as it slips back into the socket.
Or audible click when abducting and � Or audible click when abducting and
externally rotating hip on affected side:
Maria Carmela L. Domocmat, RN, MSN 32
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� directed toward enlarging and deepening the
acetabulum by placing the head of femur within the
acetabulum and applying constant pressure� proper positioning: legs slightly flexed and abducted � proper positioning: legs slightly flexed and abducted
� Surgical Ix
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o proper positioning: legs slightly flexed and
abducted � Pavlik harness� Pavlik harness
� Frejka pillow: a pillow splint that maintains
abduction of legs
� Bryant’s traction
� Spica cast
� Closed reduction
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� Hip abduction splint
� holds the hips in an
abduction position,
forcing the femur forcing the femur
head into the
acetabulum.
Maria Carmela L. Domocmat, RN, MSN 36
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Maria Carmela L. Domocmat, RN, MSN 38
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Maria Carmela L. Domocmat, RN, MSN 39
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� A hip abduction cast for correction of
subluxation of the hip.
Maria Carmela L. Domocmat, RN, MSN 41
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Maria Carmela L. Domocmat, RN, MSN 44
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� open reduction with casting
� derotational osteotomy
� Pelvic osteotomies� Pelvic osteotomies
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� femur is cut and rotated to make it easier to
keep the femoral head inside the acetabulum.
� When this procedure is done, the soft tissues
loosen up and the forces of the muscles tend to loosen up and the forces of the muscles tend to
keep the femoral head reduced.
� Once again, the child is put in a spica cast for
several months while the bone heals.
� A CT scan may be used to confirm successful
reduction before removing the cast.
Maria Carmela L. Domocmat, RN, MSN 46
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� for children older than 18 months which may require
additional surgery to change the acetabulum
(socket) in addition to the femur (thighbone)� The problem has been present longer and the anatomy has grown � The problem has been present longer and the anatomy has grown
more distorted over the longer period of time.
Maria Carmela L. Domocmat, RN, MSN 48
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� Several different types of osteotomies are used to
tilt the acetabulum in a more horizontal angle to the
floor. By doing this, the femoral head is less likely to
slide up and out of the socket with weightbearing. slide up and out of the socket with weightbearing.
� Types : Steele osteotomy; Salter osteotomy;
Pemberton osteotomy
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� This can stop the femoral head from sliding
up and out of the socket.
� Over time this shelf of bone above the
acetabulum remodels and forms a deeper acetabulum remodels and forms a deeper
acetabulum.
� the bone of the pelvis just above the
acetabulum is cut to allow the bone to slide
out and form a new roof over the hip joint.
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� uses a bone graft placed just above the hip
joint to create a new, wider roof, or shelf over
the acetabulum.
This keeps the femoral head from sliding up � This keeps the femoral head from sliding up
and out of the socket and, as it heals, makes a
larger weightbearing surface to spread out
the weight that needs to be transferred from
the femoral head to the acetabulum and
pelvis.
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� not as common
� the entire acetabulum is cut free of the pelvis
and moved or dialed at the best angle and
then allowed to heal in that position.then allowed to heal in that position.
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o Same with other clients with cast and
braces; pre- and post-op care
o Transportation and positioningo Transportation and positioning� use wagon or stroller with back flat or mechanic’s
creeper
� protect child from falling when positioned
� never pick up child by the bar between the legs of
cast (use two people to provide adequate body
support if necessary)
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� A patient's guide to developmental dysplasia of the hip in children retrieved on September 4, 2011 at http://www.orthopediatrics.com/docs/Guides/dysplasia.html
� Massachusets General Hospital. Pediatric orthopaedic ailments: Clubfoot. Retrieved on September 4, 2011 at http://www2.massgeneral.org/ORTHO/ClubFoot.htmSaxton, Nugent, and Pelikan. (2006). Mosby’s comprehensive http://www2.massgeneral.org/ORTHO/ClubFoot.htm
� Saxton, Nugent, and Pelikan. (2006). Mosby’s comprehensive review of nursing [18th ed]. St. Louis: Mosby
� Talipes Equinovarus. Retrieved on September 4, 2011 at http://www.patient.co.uk/doctor/Club-Foot.htm
� Wheeless’ Textbook of Orthopaedics. Talipes equinovarus/Clubfoot Retrieved on September 4, 2011 at http://www.wheelessonline.com/ortho/talipes_equinovarus_clubfoot
Maria Carmela L. Domocmat, RN, MSN 57