SEMINAR ON

ANOMALIES OF SKELETAL SYSTEM

TALIPES AND DEVELOPMENTAL

DYSPLASIA OF HIP

SUBMITTED TO SUBMITTED BY

Mrs.Deepa.P Ms.Sreekala.R

Asst.Professor 2nd year MSc Nursing Student

Govt.College Of Nursing Govt.College Of Nursing

Alappuha Alappuha

SUBMITTED ON

08/03/2016

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ANOMALIES OF SKELETAL SYSTEM

TALIPES AND DEVELOPMENTAL DYSPLASIA OF HIP

INTROUCTION:

Some skeletal defects may be diagnosed at birth or within days, weeks, or months after birth. In

other cases, the deviation may be difficult to detect without careful inspection. Therefore, it is

imperative that nurses become acquainted with signs of these defects and understand the

principles of therapy in order to direct others in the care and management of these children.

DEVELOPMENTAL DYSPLASIA OF THE HIP

The broad term developmental dysplasia of the hip (DDH) describes a spectrum of disorders

related to abnormal development of the hip that may occur at any time during fetal life, infancy,

or childhood. A change in terminology from congenital hip dysplasia and congenital dislocation

of the hip to DDH more properly reflects a variety of hip abnormalities in which there is a

shallow acetabulum, subluxation, or dislocation.

EPIDEMIOLOGY

o Incidence

most common orthopaedic disorder in newborns

dysplasia is 1:100

dislocation is 1:1000

o Location

most common in left hips in females

bilateral in 20%

o Demographics

more commonly seen in Native Americans and Laplanders

rarely seen in African Americans

o Risk factors

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first born

female (6:1 over males)

breech

family history

oligohydramnios

CLASSIFICATION

1. Acetabular dysplasia—This is the mildest form of DDH, in which there is neither

subluxation nor dislocation. There is a delay in acetabular development evidenced by

osseous hypoplasia of the acetabular roof that is oblique and shallow, although the

cartilaginous roof is comparatively intact. The femoral head remains in the acetabulum.

2. Subluxation—The largest percentage of DDH, subluxation, implies incomplete

dislocation of the hip and is sometimes regarded as an intermediate state in the

development from primary dysplasia to complete dislocation. The femoral head remains

in contact with the acetabulum, but a stretched capsule and ligamentum teres cause the

head of the femur to be partially displaced. Pressure on the cartilaginous roof inhibits

ossification and produces a flattening of the socket.

3. Dislocation—The femoral head loses contact with the acetabulum and is displaced

posteriorly and superiorly over the fibrocartilaginous rim. The ligamentum teres is

elongated and taut.

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PATHOPHYSIOLOGY

The cause of DDH is unknown, but certain factors such as gender, birth order, family history,

intrauterine position, delivery type, joint laxity, and postnatal positioning are believed to affect

the risk of DDH.

Predisposing factors associated with DDH may be divided into three broad categories:

(1) Physiologic factors, which include maternal hormone secretion and intrauterine positioning;

(2) mechanical factors, which involve breech presentation, multiple fetus, oligohydramnios, and

large infant size (other mechanical factors may include continued maintenance of the hips in

adduction and extension that will in time cause a dislocation); and

(3) Genetic factors, which entail a higher incidence of DDH in siblings of affected infants and

an even greater incidence of recurrence if a sibling and one parent were affected.

Some experts categorize DDH into two major groups:

(1) Idiopathic, in which the infant is neurologically intact, and

(2) Teratologic, which involves a neuromuscular defect such as arthrogryposis or

myelodysplasia. The teratologic forms usually occur in utero and are much less common.

CLINICAL MANIFESTATIONS

Infants

Shortening of limb on affected side (Galeazzi sign)

Restricted abduction of hip on affected side

Unequal gluteal folds (best visualized with infant prone)

Positive Ortolani test (hip is reduced by abduction)

Positive Barlow test (hip is dislocated by adduction)

Older Infants and Children

Affected leg appears shorter than the other

Telescoping or piston mobility of joint—Head of femur felt to move up and down in

buttock when extended thigh is pushed first toward child’s head and then pulled distally

Trendelenburg sign—When child stands first on one foot and then on the other (holding

onto a chair, rail, or someone’s hands) bearing weight on affected hip, pelvis tilts

downward on normal side instead of upward, as it would with normal stability

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Greater trochanter prominent and appearing above a line from anterosuperior iliac spine

to tuberosity of ischium

Marked lordosis and waddling gait (bilateral hip dislocation)

DIAGNOSTIC EVALUATION

Physical exam (< 3 months)

o mainstay of physical diagnosis is palpable hip subluxation/dislocation on exam 

Barlow 

dislocates a dislocatable hip by adduction and depression of the flexed femur

Ortolani   

reduces a dislocated hip by elevation and abduction of the flexed femur.

Galeazzi (Allis)   

apparent limb length discrepancy due to a unilateral dislocated hip with hip and knee

flexed at 90 degrees

femur appears shortened on dislocated side

hip clicks are nonspecific findings

Barlow and Ortolani a rarely positive after 3 months of age because of soft-tissue

contractures about the hip

Physical exam (> 3 months)

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limitations in hip abduction

most sensitive test once contractures have began to occur

occurs as laxity resolves and stiffness begins to occur

decreased symmetrically in bilateral dislocations

leg length discrepancy predominate

Physical exam (> 1 year - walking child)

pelvic obliquity

lumbar lordosis in response to hip contractures resulting from bilateral dislocations in a

child of walking age

Trendelenburg gait results from abductor insufficiency

toe walking compensate for relative shortening of affected side

IMAGING

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Radiograph

It becomes primary imaging modality at 4-6 month after the femoral head begins to ossify

HIP DISLOCATION

Hilgenreiner's line

It is a horizontal line through right and left triradiate cartilage ,femoral head ossification should

be inferior to this line

Perkin’s line

It is a perpendicular line to Hilgenreiner's through a point at lateral margin of acetabulum

femoral head ossification should be medial to this line

Shenton's line

It is an arc along inferior border of femoral neck and superior margin of obturator foramen ,arc

line should be continuous. delayed ossification of the femoral head is seen in cases of

dislocation

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HIP DYSPLASIA

Acetabular index (AI)

It is an angle formed by a line drawn from point on the lateral triradiate cartilage to point on

lateral margin of acetabulum and Hilgenreiners line. It should be less than 25° in patients older

than 6 months.

Center-Edge Angle (CEA) Of Wiberg

It is an angle formed by a vertical line from the center of the femoral head and a line from the

center of the femoral head to the lateral edge of the acetabulum ,less than 20° is considered

abnormal . It is reliable only in patients over the age of 5 years.

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•Ultrasound

It evaluates for acetabular dysplasia and/or the presence of a hip dislocation and is useful before

femoral head ossification (<4-6 mos). It may produce spurious results if performed before 4-6

weeks of age. It allows view of bony acetabular anatomy, femoral head, labrum, ligamentum

teres, hip capsule .

Alpha Angle

It is an angle created by lines along the bony acetabulum and the ilium. Norrmal is greater than

60. °

Beta Angle

It is an angle created by lines along the labrum and the ilium. Normal is less than 55°, femoral

head is normally bisected by a line drawn down from the ilium. It is used as an adjunct only in

patients at 3-4 weeks in patients who are considered high risk (family history and/or have an

equivocal physical exam). Normal ultrasound in patients with soft-tissue 'clicks' will have normal

acetabular development. It allows for monitoring of reduction during Pavlik harness treatment. It

is not cost effective for routine screening

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Arthrogram

It is used to confirm reduction after closed reduction under anesthesia. It helps to identify

possible blocks to reduction, inverted labrum, labrum enhances the depth of the acetabulum by

20% to 50% and contributes to the growth of the acetabular rim.In the older infant with DDH the

labrum may be inverted and may mechanically block concentric reduction of the hip, inverted

limbus. It represents a pathologic response of the acetabulum to abnormal pressures caused by

superior migration of the head, consists of fibrous tissue, transverse acetabular ligament, hip

capsule is constricted by iliopsoas tendon causing hour-glass deformity of the capsule, pulvinar,

ligamentum teres.

CT

CT study of choice to evaluate reduction after closed reduction and spica casting

MRI

It does not play significant role in primary diagnosis.

TREATMENT

• Nonoperative

Abduction Splinting/Bracing (Pavlik Harness)

Indications

DDH < 6 months of age and reducible hip

Pavlik harness treatment is contraindicated in teratologic hip dislocations

It is a dynamic splint that requires normal muscle function for successful outcomes

It is contraindicated in patients with spina bifida or spasticity

outcomes

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overall Pavlik harness has success rate of 90%

dependent upon age at initiation of treatment and time spent in the harness

abandon pavlik harness treatment if not successful after 3-4 weeks

If pavlik harness fails, convert to semi-rigid abduction brace with weekly ultrasounds for an

addition 3-4 weeks before considering further intervention.

Closed Reduction And Spica Casting

Indications

DDH in 6 - 18 months of age

failure of Pavlik treatment

OPERATIVE

open reduction and spica casting

Indications

DDH in patient >18 months of age

failure of closed reduction

open reduction and femoral osteotomy

Indications

DDH > 2 yr with residual hip dysplasia

anatomic changes on femoral side (e.g., femoral anteversion, coxa valga)

femoral head should be congruently reduced with satisfactory ROM, and reasonable

femoral sphericity

best in younger children (< 4 yr)

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after 4 yr, pelvic osteotomies are utilized

open reduction and pelvic osteotomy

Indications

DDH > 2 yr with residual hip dysplasia

severe dysplasia accompanied by significant radiographic changes on the acetabular side

(increased acetabular index)

used more commonly in older children (> 4 yr)

decreased potential for acetabular remodeling as child ages.

Abduction splinting/bracing (Pavlik harness)

Goals

Ttreatment is based on early concentric reduction in order to prevent future degeneration of

the hip.

Risk, complexity and complications are increased with delays in diagnosis

Position in bracing

goal is 90-100° flexion (controlled by anterior straps) and abduction of 50° (controlled by

posterior straps)

discontinue if hip is not reduced by 3-4 weeks to prevent Pavlik disease- erosion of the

pelvis superior to the acetabulum and prevention of the development of the posterior wall

of the acetabulum, worn for 23 hours/day for at least 6 weeks or until hip is stable

wean out of harness over 6-8 weeks after hip has stabilized until normal anatomy

develops.

confirm position with ultrasound or xray and monitor every 4-6 week

• Closed reduction and spica casting

o performed under general anesthesia

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o arthrogram used to confirm reduction

concentric reduction must be obtained with less than 5mm of contrast pooling medial to

femoral head and the limbus must not be interposed

the arthrogram will also help identify anatomic blocks to reduction:

spica casting

following reduction immobilize in a spica cast with hip flexion of 100 deg. and abduction

of 45 deg with neutral rotation for 3 months

'human position'

change cast at 6 weeks

adductor tenotomy performed if patient has an unstable safe zone

used if excessive abduction required to maintain the reduction

confirm reduction with CT scan in spica cast with selective cuts to minimize radiation to

the child

• Open reduction

o anterior approach (Smith-Peterson) most common to decrease risk to medial femoral

circumflex artery

capsulorrhaphy can be performed after reduction

used if patient is older than 12 months

o other possible approaches include

medial adductor approach, variation of Ludloff

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Pros

directly addresses block to reduction

can be used in patients under 12 months of age

less blood loss

Cons

unable to perform a capsulorrhaphy

higher association of AVN

anteromedial approach

posteromedial approach

o remove possible anatomic blocks to reduction

iliopsoas contracture, capsular constriction, inverted labrum, pulvinar, hypertrophied

ligamentum teres

o adductor tenotomy performed if patient has an unstable safe zone

if excessive abduction required to maintain the reduction

o immobilize in functional position of 15° of flexion, 15° of abduction and neutral rotation

• Femoral Osteotomy

o used to correct excessive femoral anteversion and/or valgus

o femoral osteotomy and shortening may be needed to prevent AVN

decrease tension produced by reduction of a previously dislocated hip

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• Pelvic Osteotomies

o increase anterior or anterolateral coverage

o used after reduction is confirmed on abduction-internal rotation views and satisfactory

ROM has been obtained.

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 Indication Technique

Salter Younger patients

typically with open

triradiate cartilage

Single cut above acetabulum through the ilium to sciatic

notch. Acetabulum hinges through the pubic symphysis.

The redirectional osteotomy can provide 20-25° lateral

and 10-15° anterior coverage (coverage limitations in

anterolateral head). May lengthen leg up to 1 cm.

Triple(Steele) Favored in older children

because their symphysis

pubis does not rotate

well. Performed when

open triradiate cartilages

are present

Salter osteotomy plus additional cuts through superior

and inferior pubic rami. Acetabular reorientation

procedure.

PAO (Ganz) Triradiate cartilage must

be closed in order to

perform

Involves multiple osteotomies in the pubis, ilium, and

ischium near the acetabulum. This allows improved three-

dimensional correction of the acetabulum configuration.

It is technically the most challenging. Posterior column

and pelvic ring remain intact and patients are allowed to

weight bear early 

Pemberton For moderate to severe

DDH; most versatile;

triradiate cartilage must

be open

Osteotomy starts approximately 10 to 15 mm above the

AIIS, proceeds posteriorly, and ends at the level of the

ilioischial limb of the triradiate cartilage (halfway

between the sciatic notch and the posterior acetabular

rim). Osteotomy hinges at the triradiate cartilage

posteriorly and the symphysis pubis anteriorly.  This

osteotomy does do not enter the sciatic notch and is

therefore stable and does not need internal

fixation. Reduces acetabular volume

Dega Favored in

neuromuscular

dislocations (CP) and

patients with posterior

acetabular deficiency; for

severe cases

Osteotomy from acetabular roof to triradiate cartilage

(incomplete cuts through pericapsular portion of the

innominate bone). The acetabular configuration changes

by hinging through the triradiate cartilage. This

osteotomy does do not enter sciatic notch and is therefore

stable and does not need internal fixation. Reduces the

acetabular volume

Dial Technically difficult and

rarely used

The dial or spherical osteotomy leaves the medial wall

or teardrop in its original position and, as a result, is intra-

articular.

Nursing Care Management

Nurses are in a unique position to detect DDH in early infancy. During the infant assessment

process and routine nurturing activities, the hips and extremities are inspected for any deviations

from normal. These observations are reported to the attending practitioner, and an ambulatory

child who displays a limp or an unusual gait should be referred for evaluation. This may indicate

an orthopedic or neurologic problem. Non ambulatory children with cerebral palsy should also

be assessed for evidence of hip problems. The major nursing problems in the care of an infant or

child in a cast or other device are related to maintenance of the device and adaptation of

nurturing activities to meet the patient’s needs. Generally, treatment and follow-up care of these

children are carried out in an outpatient setting.

The primary nursing goal is teaching parents to apply and maintain the reduction device.

The Pavlik harness allows for easy handling of the infant and usually produces less

apprehension in the parent than heavy braces and casts. Because of infants’ rapid growth,

the straps should be checked in the beginning of therapy and every 1 to 2 weeks for

adjustments .It is important that parents understand the correct use of the appliance,

which may or may not allow for its removal during bathing. Removing the harness is

determined individually on the basis of the provider’s recommendation, the family’s level

of understanding, and the degree of hip deformity. Parents are instructed to not adjust the

harness. The child should be examined by the practitioner before any adjustment is

attempted to make certain the hips are in correct placement.

Skin care is an important aspect of the care of an infant in a harness. The following instructions

for preventing skin breakdown are stressed:

• Always put an undershirt (or a shirt with extensions that close at the crotch) under the chest

straps and put knee socks under the foot and leg pieces to prevent the straps from rubbing the

skin.

• Check frequently (at least two or three times a day) for red areas under the straps and the

clothing.

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• Gently massage healthy skin under the straps once a day to stimulate circulation. In general,

avoid lotions and powders because they can cake and irritate the skin.

• Always place the diaper under the straps. Parents are encouraged to hold the infant with a

harness and continue care and nurturing activities. The nurse can assist by being available for

parents’ questions about the necessary adaptations to daily care to decrease the parents’ anxiety

and possible feelings about the child being hurt by routine caring. Casts and orthotic devices

(braces) offer more challenging nursing and caregiver problems because they cannot be removed

for routine care, although sometimes a brace may be removed for bathing. Care of an infant or

small child with a cast requires nursing innovation to reduce irritation and to maintain cleanliness

of both the child and the cast, particularly in the diaper area. It is important for nurses, parents,

and other caregivers to understand that children in corrective devices need to be involved in all

of the activities of any child in the same age group. Confinement in a cast or appliance should

not exclude children from family (or unit) activities. They can be held astride the lap for comfort

and transported to areas of activity. The child may be allowed to walk in a cast or orthotic

device. An adapted wheelchair, stroller, or scooter can offer mobility to an older infant or child.

Nursing Care plan for DDH

• Pain relief

• protect operated joint from further injury

• RICE therapy (Rest, Ice, Compression, Elevation)

• Immobilization

• Family support

• Making sure that the family understand the rehabilitation program

• Demonstrating the adaptation required for patients in cast

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• making sure that the family understand how to check for suture line infections and if

there are drainage or bad odor from the cast and the importance of reporting them immediately

Nursing diagnosis:

1. Impaired physical mobility R/T dislocation of hip, and presence of splint or cast

Interventions

1. Maintain the correct position of the hip.

2. Explain the components and purposes of splint or cast.

3. Enhance play and using the upper portion of the body.

4. Teach walking with cast

5. Support the casted limp and avoid pressure on heels

Nursing diagnosis:

2. Potential for injury, neurovascular impairment R/T compression by cast.

Interventions

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

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Nursing diagnosis:

3. Knowledge deficit of parent regarding home care:

Interventions

1. Teach how to care of the child

2. Different treatment procedures

3. Involve parent in care of the child

4. Regular Follow up.

COMPLICATIONS

Numerous possible complications can occur, including re dislocation, stiffness of the hip,

infection, blood loss, and, possibly the most devastating, avascular necrosis of the femoral head.

The rate of femoral head necrosis varies substantially; depending on the study, it may be

anywhere from 0% to 73%. Numerous studies demonstrate that extreme abduction, especially

when combined with extension and internal rotation, results in a higher rate of avascular

necrosis.

PROGNOSIS

Overall, the prognosis for children treated for hip dysplasia is very good, especially if the

dysplasia is managed with closed treatment. If closed treatment is unsuccessful and open

reduction is needed, the outcome may be less favorable, although the short-term outcome

appears to be satisfactory. If secondary procedures are needed to obtain reduction, then the

overall outcome is significantly worse.

Some authors believe that patients with bilateral hip dysplasia have a poorer prognosis because

of frequent delays in diagnosis and greater treatment requirements. In a study comparing the

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outcomes of walking-age children with bilateral hip dislocations who underwent open reduction

and pelvic osteotomy with or without femoral osteotomy with those of walking-age children with

unilateral dislocated hips who underwent the same set of procedures, the radiographic outcomes

were similar.

CLUB FOOT

Definition

Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot

supination, hindfoot varus, and ankle equinus. Deformities of the foot and ankle are described

according to the position of the ankle and foot. The more common positions involve the

following variations:

Talipes varus—An inversion, or bending inward

Talipes valgus—An eversion, or bending outward

Talipes equinus—Plantar flexion, in which the toes are lower than the heel

Talipes calcaneus—Dorsiflexion, in which the toes are higher than the heel

Talipes equinovarus—Toes lower than the heel and facing inward

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EPIDEMIOLOGY

The incidence of clubfoot is approximately 1 case per 1000 live births in the United States. The

incidence differs among ethnicities. For example, it is close to 75 cases per 1000 live births in

the Polynesian islands, particularly in Tonga.

The male-to-female ratio is 2:1. Bilateral involvement is found in 30-50% of cases. There is a

10% chance of a subsequent child being affected if the parents already have a child with a

clubfoot.

Parker et al pooled data from several birth defects surveillance programs (6139 cases of clubfoot)

to better estimate the prevalence of clubfoot and investigate its risk factors. The overall

prevalence of clubfoot was 1.29 per 1,000 livebirths, with 1.38 among non-Hispanic whites, 1.30

among Hispanics, and 1.14 among non-Hispanic blacks or African Americans. Maternal age,

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parity, education, and marital status were significantly associated with clubfoot, along with

maternal smoking and diabetes.

CLASSIFICATION

Clubfoot may be further divided into three categories:

(1) Positional clubfoot (also called transitional, mild, or postural clubfoot), which is believed to

occur primarily from intrauterine crowding and responds to simple stretching and casting;

(2) Syndromic (or teratologic) clubfoot, which is associated with other congenital anomalies

such as myelomeningocele or arthrogryposis and is a more severe form of clubfoot that is often

resistant to treatment;

(3) Congenital clubfoot, also referred to as idiopathic, which may occur in an otherwise normal

child and has a wide range of rigidity and prognosis. The mild, or postural, clubfoot may correct

spontaneously or may require passive exercise or serial casting. There is no bony abnormality,

but there may be tightness and shortening of the soft tissues medially and posteriorly. The

teratologic clubfoot usually requires surgical correction and has a high incidence of recurrence.

The congenital idiopathic clubfoot, or “true clubfoot,” almost always requires surgical

intervention because there is bony abnormality

ETIOLOGY

The true etiology of congenital clubfoot is unknown. Most infants who have clubfoot have no

identifiable genetic, syndromal, or extrinsic cause.

Extrinsic associations include teratogenic agents (eg, sodium aminopterin),oligohydramnios, and

congenital constriction rings. Genetic associations include mendelian inheritance (eg, diastrophic

dwarfism; autosomal recessive pattern of clubfoot inheritance).

Cytogenetic abnormalities (eg, congenital talipes equinovarus [CTEV]) can be seen in

syndromes involving chromosomal deletion. It has been proposed that idiopathic CTEV in

otherwise healthy infants is the result of a multifactorial system of inheritance. Evidence for this

is as follows:

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• Incidence in the general population is 1 per 1000 live births

• Incidence in first-degree relations is approximately 2%

• Incidence in second-degree relations is approximately 0.6%

• If one monozygotic twin has a CTEV, the second twin has only a 32% chance of having a

CTEV

Factors related to bone anatomy include the following:

Tibia - Slight shortening is possible

Fibula - Shortening is common

Talus - In equinus in the ankle mortise, with the body of the talus being in external rotation, the

body of the talus is extruded anterolaterally and is uncovered and can be palpated; the neck of

the talus is medially deviated and plantarflexed; all relations of the talus to the surrounding

bones are abnormal

Os calcis - Medial rotation and an equinus and adduction deformity are present

Navicular - The navicular is medially subluxated over the talar head

Cuboid - The cuboid is medially subluxated over the calcaneal head

Forefoot - The forefoot is adducted and supinated; severe cases also have cavus with a dropped

first metatarsal

Factors related to muscle anatomy include the following:

Atrophy of the leg muscles, especially in the peroneal group, is seen in clubfeet

The number of fibers in the muscles is normal, but the fibers are smaller

The triceps surae, tibialis posterior, flexor digitorum longus (FDL), and flexor hallucis longus

(FHL) are contracted

The calf is smaller and remains so throughout life, even after successful long-lasting correction

of the feet

Thickening of the tendon sheaths frequently is present, especially of the tibialis posterior and

peroneal sheaths. Contractures of the posterior ankle capsule, subtalar capsule, and talonavicular

and calcaneocuboid joint capsules commonly are seen. Contractures are seen in the

calcaneofibular, talofibular, (ankle) deltoid, long and short plantar, spring, and bifurcate

ligaments. The plantar fascial contracture contributes to the cavus, as does contracture of fascial

planes in the foot.

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PATHOPHYSIOLOGY

Various theories of the pathogenesis of clubfeet have been advanced, including the following:

Arrest of fetal development in the fibular stage

Defective cartilaginous anlage of the talus

Neurogenic factors

Retracting fibrosis

Anomalous tendon insertions

Seasonal variations

With respect to neurogenic factors, histochemical abnormalities have been found in

posteromedial and peroneal muscle groups of patients with clubfeet. This is postulated to be due

to innervation changes in intrauterine life secondary to a neurologic event, such as a stroke

leading to mild hemiparesis or paraparesis. This is further supported by a 35% incidence of varus

and equinovarus deformity in spina bifida.

Retracting fibrosis (or myofibrosis) may occur secondary to increased fibrous tissue in muscles

and ligaments. In fetal and cadaveric studies, Ponseti also found the collagen in all of the

ligamentous and tendinous structures (except the Achilles [calcaneal] tendon), and it was very

loosely crimped and could be stretched. The Achilles tendon, on the other hand, was made up of

tightly crimped collagen and was resistant to stretching. Zimny et al found myoblasts in medial

fascia on electron microscopy and postulated that they cause medial contracture.

Inclan proposed that anomalous tendon insertions result in clubfeet. However, other studies have

not supported this proposal. It is more likely that the distorted clubfoot anatomy can make it

appear that tendon insertions are anomalous.

Robertson noted seasonal variations to be a factor in his epidemiologic studies in developing

countries. This coincided with a similar variation in the incidence of poliomyelitis in the children

in the community. Clubfoot was therefore proposed to be a sequela of a prenatal poliolike

condition. This theory is further supported by motor neuron changes in the anterior horn in the

spinal cord of these babies.

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DIAGNOSTIC EVALUATION

Seek a detailed family history of clubfoot or neuromuscular disorders, and perform a general

examination to identify any other abnormalities. Examine the feet with the child prone, with the

plantar aspect of the feet visualized and supine to evaluate internal rotation and varus. If the child

can stand, determine whether the foot is plantigrade, whether the heel is bearing weight, and

whether it is in varus, valgus, or neutral.

Imaging Studies

Imaging studies generally are not required to understand the nature or the severity of the

deformity. Radiography, however, provides a useful baseline before and after surgical correction

of the feet, closed Achilles tenotomy, or a limited posterior release. Radiographs show the true

gain in foot (ankle) dorsiflexion and confirm the appearance of an iatrogenic rockerbottom foot

should one result. Occasionally, radiographs are necessary to diagnose clubfeet associated with

tibial hemimelias.

THERAPEUTIC MANAGEMENT

Medical Therapy

The aims of medical therapy for clubfoot are to correct the deformity early and fully and to

maintain the correction until growth stops.

Traditionally, two categories of clubfeet are identified, as follows:

• Easy or correctable clubfeet - These are readily corrected with manipulation, casting, and

splintage alone

• Resistant clubfeet - These respond poorly to splinting and relapse quickly after seemingly

successful manipulative treatment; they require early operative management and are said to be

associated with a thin calf and a small high heel.

The Pirani scoring system, devised by Shafiq Pirani, MD, of Vancouver, BC, consists of six

categories, three in the hindfoot and three in the midfoot, as follows:

• Curvature of the lateral border (CLB) of the foot

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• Medial crease (MC)

• Uncovering of the lateral head of the talus (LHT)

• Posterior crease (PC)

• Emptiness of the heel (EH)

• Degree of dorsiflexion (DF)

The first three (CLB, MC, and LHT) constitute the midfoot score, and the last three (PC, EH, and

DF) constitute the hindfoot score.Each category is scored as 0, 0.5, or 1. The lowest possible (ie,

best) total score for all categories combined is 0, and the highest possible (ie, worst) total score is

6. The Pirani scoring system can be used to identify the severity of the clubfoot and to monitor

the correction.

It is necessary to provide counsel and advice to parents. They should be reassured that they are in

no way responsible for the deformity and that it is unlikely to be reproduced in subsequent

pregnancies.

Traditional non operative treatment

With traditional non operative treatment, splintage begins at 2-3 days after birth. The order of

correction is as follows:

• Forefoot adduction

• Forefoot supination

• Equinus

Attempts to correct equinus first may break the foot, producing a rockerbottom foot . Force must

never be used. Merely bring the foot to the best position obtainable, and maintain this position

either by strapping every few days or by changing casting weekly until either full correction is

obtained or correction is halted by some irresistible force.

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The corrected position is maintained for several months. Surgery should be used as soon as it is

obvious that conservative treatment is failing (persisting deformity, rockerbottom deformity, or

rapid relapse after correction has stopped).

By 6 weeks, it is usually apparent whether the foot is easy or resistant; this is confirmed on x-ray

due to the orientation of the bones. Reported success rates for these traditional casting methods

are 11-58%.

PONSETI METHOD

This method was developed by Ignacio Ponseti, MD, of the University of Iowa. The premise of

the method is based on Ponseti's cadaveric and clinical observations. A 2014 Cochrane review

found this approach to yield signficantly better results than either the Kite method or a traditional

approach, though it noted that the quality of the evidence was not high.

The Ponseti method may be divided into seven steps, as follows.

Step 1

The calcaneal internal rotation (adduction) coupled with plantarflexion is the key deformity. The

foot is adducted and plantarflexed at the subtalar joint, and the goal is to abduct the foot and

dorsiflex it. In order to achieve correction of the clubfoot, the calcaneum should be allowed to

rotate freely under the talus, which also is free to rotate in the ankle mortise.

The correction takes place through the normal arc of the subtalar joint. This is achieved by

placing the index finger of the operator on the medial malleolus to stabilize the leg and levering

on the thumb placed on the lateral aspect head of the talus while abducting the forefoot in

supination. Forcible attempts to correct the heel varus by abducting the forefoot while applying

counterpressure at the calcaneocuboid joint prevent the calcaneum from abducting and therefore

everting.

Step 2

Foot cavus increases when the forefoot is pronated. If cavus is present, the first step in the

manipulation process is to supinate the forefoot by gently lifting the dropped first metatarsal to

correct the cavus. Once the cavus is corrected, the forefoot can be abducted as outlined in step 1.

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Step 3

Pronation of the foot also causes the calcaneum to jam under the talus. The calcaneum cannot

rotate and stays in varus. The cavus increases as outlined in step 2. This results in a bean-shaped

foot. At the end of step 1, the foot is maximally abducted but never pronated.

Step 4

The manipulation is carried out in the cast room, with the baby having been fed just before, or

even during, the treatment. After the foot is manipulated, a long leg cast is applied to hold the

correction.

Initially, the short leg component is applied. The cast should be snug with minimal but adequate

padding. The authors paint or spray the limb with tincture of benzoin to allow adherence of the

padding to the limb. The authors prefer to apply additional padding strips along the medial and

lateral borders to facilitate safe removal of the cast with a cast saw. The cast must incorporate the

toes right up to the tips but not squeeze the toes or obliterate the transverse arch. The cast is

molded to contour around the heel while abducting the forefoot against counter pressure on the

lateral aspect of the head of the talus.

The knee is flexed to 90° for the long leg component of the cast. The parents can soak these casts

for 30-45 minutes before removal with a plaster knife. The authors' preferred method is to use

the oscillating plaster saw for cast removal. The cast is bivalved and removed. The cast then is

reconstituted by coapting the two halves. This allows for monitoring of the progress of the

forefoot abduction and, in the later stages, the amount of dorsiflexion or equinus correction.

Step 5

Forcible correction of the equinus (and cavus) by dorsiflexion against a tight Achilles tendon

results in a spurious correction through a break in the midfoot, resulting in a rockerbottom foot.

The cavus should be separately treated as outlined in step 2, and the equinus should be corrected

without causing a midfoot break. It generally takes as many as four to seven casts to achieve

maximum foot abduction. The casts are changed weekly. The foot abduction (correction) can be

considered adequate when the thigh-foot axis is 60°.

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After maximal foot abduction is obtained, most cases require a percutaneous Achilles tenotomy.

This is performed in the cast room under aseptic conditions. The local area is anesthetized with a

combination of a topical lidocaine preparation (eg, EMLA Cream; AstraZeneca, Wilmington,

DE) and minimal local infiltration of lidocaine. The tenotomy is performed through a stab

incision with a round-tip (#6400) Beaver blade.

The wound is closed with a single absorbable suture or with adhesive strips.The final cast is

applied with the foot in maximum dorsiflexion, and the foot is held in the cast for 2-3 weeks.

Step 6

After the manipulation and casting phase, the feet are fitted with open-toed straight-laced shoes

attached to a Dennis Brown bar. The affected foot is abducted (externally rotated) to 70° with the

unaffected foot set at 45° of abduction. The shoes also have a heel counter bumper to prevent the

heel from slipping out of the shoe. The shoes are worn for 23 hours a day for 3 months and are

worn at night and during naps for up to 3 years.

Step 7

In 10-30% of cases, a tibialis anterior tendon transfer to the lateral cuneiform is performed when

the child is approximately 3 years of age. This gives lasting correction of the forefoot, preventing

metatarsus adductus and foot inversion. This procedure is indicated in a child aged 2-2.5 years

with dynamic supination of the foot. Before surgery, cast the foot in a long leg cast for a few

weeks to regain the correction.

Surgical Therapy

Preparation for operation

The operating room is kept warm, and a general anesthetic is used. The usual position is supine

with the foot resting over the contralateral leg in a figure-four position. Some surgeons prefer the

lateral decubitus position or even a prone position. A tourniquet generally is used, and the

surgical procedure is performed with the help of optical loupe magnification.

Incision

Options for incisions include the following:

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• Cincinnati incision

• Turco curvilinear medial or posteromedial incision

The Cincinnati incision is a transverse incision that extends from the anteromedial (region of

navicular-cuneiform joint) to the anterolateral (just distal and medial to the sinus tarsi) aspect of

the foot and over the back of the ankle at the level of the tibiotalar joint.

The Turco incision can lead to wound breakdowns, especially at the corner of the vertical and

medial limbs.To avoid this problem, some surgeons prefer to use either three separate incisions

(posterior vertical, medial, and lateral) or two separate incisions (curvilinear medial and

posterolateral).

Any approach should be able to address the release in all quadrants, as follows:

• Plantar - Plantar fascia, abductor hallucis, flexor digitorum brevis, long and short plantar

ligaments

• Medial - Medial structures, tendon sheaths, talonavicular and subtalar release, tibialis

posterior, flexor hallucis longus (FHL), and flexor digitorum longus (FDL) lengthening

• Posterior - Ankle and subtalar capsulotomy, especially releasing post talofibular and

tibiofibular ligaments and the calcaneofibular ligaments

• Lateral - Lateral structures, peroneal sheath, calcaneocuboid joint, and completion of

talonavicular and subtalar release

Surgical clubfoot release

In the past, clubfoot surgery was performed in a way that did not differentiate severity. The same

procedure was performed for all patients. Bensahel proposed a more individualized approach (ie,

addressing only the structures that are required are released). The surgery is tailored to the

deformity. For example, if the forefoot is well corrected and externally rotated, if there is no

cavus, but if there is still significant equinus, a posterior approach alone should suffice.

Any approach should afford adequate exposure. Structures to be released or lengthened are the

following:

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• Achilles (calcaneal) tendon

• Tendon sheaths of the muscles crossing the subtalar joint

• Posterior ankle capsule and deltoid ligament

• Inferior tibiofibular ligament

• Fibulocalcaneal ligament

• Capsules of the talonavicular and subtalar joints

• Division of associated ligaments around the subtalar joint

• Plantar fascia and intrinsic muscles

The longitudinal axis of the talus and calcaneum should be separated by about 20° in the lateral

projection, and the calcaneal angle should be a right angle to the shaft of the tibia.

The correction is held with wires at the talocalcaneal joint, the talonavicular joint, or both,

possibly with a plaster cast. The wound should never be forcibly closed. It can be left open to

granulate and heal by secondary intention or even grafted with split-thickness skin grafts.

Surgical treatment should take into account the age of the patient, as follows:

• In children younger than 5 years, correction can be achieved with soft-tissue procedures

• Children older than 5 years require bony reshaping (eg, dorsolateral wedge excision of

the calcaneocuboid joint [Dillwyn Evans procedure] or osteotomy of the calcaneum to correct

varus)

• If the child is older than 10 years, lateral wedge tarsectomy or triple fusion (arthrodesis)

is required (salvage procedures)

Posterior release steps, in brief, are as follows:

• Longitudinal incision

• Z-lengthened tendocalcaneus

• Identify neurovascular (NV) bundle

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• Tendon sheaths of FHL, FDL, and tibialis posterior released; tendons not elongated

• Ankle joint capsule opened; talofibular, calcaneofibular, and deep portion of deltoid

ligaments released (blunt dissection)

• Release of distal tibial and fibula ligaments

• Posterior release of the subtalar joint

• With foot held just above neutral, tendocalcaneum is repaired and skin closed

• Plaster-of-Paris cast in corrected position for 4 weeks, followed by splints until maturity

A posteromedial release (Turco procedure) is performed as follows.

Make a medial incision 8-9 cm long from the base of the first metatarsal to the tendocalcaneum,

curving it just inferior to the medial malleolus without undermining skin. Mobilize and expose

the tendons of the tibialis posterior, FDL, FHL, Achilles tendon, and posterior NV bundle.

Continuing the incision in the sheaths of FDL and FHL, divide the master knot of Henry beneath

the navicular. Divide the spring ligament, detaching it from the sustentaculum tali and the origin

of the abductor hallucis. Release the remaining contractures, starting posteriorly. Lengthen the

Achilles tendon (Z-plasty), detaching the medial half of the tendon insertion.

Retract the NV bundle and FHL anteriorly to expose the posterior aspect of the ankle and

subtalar joints. Then, incise the posterior capsule of the ankle joint under direct visualization, as

well as the posterior talofibular ligament (if necessary at this time). Divide the subtalar capsule

and calcaneofibular ligament.

Retract the NV bundle posteriorly, and divide the tibiocalcaneal part of the deltoid ligament.

Lengthen the tibialis posterior if it is contracted. Open the talonavicular joint and divide its

capsule, but avoid damaging the articular surface. Then, release the subtalar ligaments and

reduce the navicular onto the head of the talus, which should properly align the other tarsal

bones.

Ensure that the relation of the talus to the calcaneus and navicular is correct, and stabilize the

foot with Kirschner wires (K-wires). The first K-wire is passed from the dorsum of the foot

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across the first metatarsal shaft, the medial cuneiform, the navicular, and into the talus. A second

wire fixes the subtalar joint, and this should maintain the foot in the corrected position.

Apply an above-the-knee plaster-of-Paris cast, which is changed at 3 weeks and maintained to 6

weeks. The foot is initially held in slight equinus if there is tension on the skin closure, which is

corrected at the time of cast change. Splintage is continued for at least 4 months after surgery,

and night splints are used for several years.

The Ilizarov correction is used for recurrent clubfeet, especially in conditions such as

arthrogryposis. The calcaneum is held with two opposing olive-tipped wires. The distractor

force, in the form of heel-pushing distractors, must be posteriorly directed to prevent anterior

subluxation of the talus in the ankle mortise.

Postoperative care

Pay meticulous attention to the wound after surgery. If the skin closure is difficult, it is better to

leave the wound open and allow it to granulate for a delayed primary or secondary closure or

allow it to heal by granulation tissue. Skin grafts also can be used to cover the defect. The plaster

splint should be only lightly applied, and the wound should be inspected regularly.

The transfixion pins usually are removed in 3-6 weeks. The foot requires splintage in appropriate

footwear for 6-12 months.

NURSING CARE MANAGEMENT

Nursing care of the child with clubfoot is the same as for any child who has a cast . Because the

child will spend considerable time in a corrective device, nursing care plans include both long-

and short term goals. Conscientious observation of the skin and circulation is particularly

important in young infants because of their rapid growth rate. Because treatment and follow-up

care are handled in the orthopedist’s office, clinic, or outpatient department, parent education and

support are important in nursing care of these children. It is important for parents to understand

the overall treatment program, the importance of regular cast changes, and the role they play in

the long-term effectiveness of the therapy. Reinforcing and clarifying the orthopedist’s

explanations and instructions, teaching parents about care of the cast or appliance (including

vigilant observation for potential problems), and encouraging parents to facilitate normal

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development within the limitations imposed by the deformity or therapy are all part of nursing

responsibilities.

Nursing care Plan

• Nursing diagnosis 1: Risk for altered peripheral tissue perfusion R/T pressure from cast.

•Interventions

– Keep the casted extremity elevated to prevent edema.

– Check circulation frequently (Every 15 min for the first 1 h, hourly for 24 h and 4 hourly there

after.

– Assess for color, warmth, presence of pedal pulses and sensations of numbness or tingling.

– Signs of impaired neurovascular function are pain, pallor, pulselessness and parasthesia.

– Edema that is not improved by elevation indicates also neurovascular impairment.

• Nursing diagnosis 2: Risk for impaired tissue integrity R/T pressure from cast.

• Interventions

– When moving child in a wet cast, always use open palms to move the cast.

– Pressing with fingers indent the cast and cause pressure points which can lead to an ulcer.

– Turn the child every 2 h to allow the under surface of the cast to dry.

– Do not use heaters or fans to dry the cast as it causes uneven drying.

– When the cast is dry if the edges are not smooth or covered by a fold of stockinet smooth the

adges by applying adhesive tape strips (Petaling)

– If casted area covers the genitalia cover the edges of the cast covering the genital area with a

plastic or waterproof material.

– Keep the child in a semifowler’s position.

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– Teach the child nothing to put between the cast and skin.

• Nursing diagnosis 3: Parental health seeking behaviors R/T care of child with cast at home.

• Interventions

– If the cast is for the lower extremity discuss how much weight bearing is allowed, and the use

of crutches if prescribed.

– Reassure the parents that the child is comfortable with the cast.

– Demonstrate how to move or position the child and allow return demonstrations.

– If an abduction bar is used with the cast the parents should not use it as a handle to move or lift

the child.

– Encourage providing touch stimulation to the remaining body parts.

– If itching is a problem instruct them to apply a hand lotion or massage the area gently if it is

reachable.

– If not reachable blow cool air through the cast using a fan.

– Instruct not to put any thing inside to scratch.

Teaching Plan- contents

• Physical care:

1. Maintain appropriate muscle tone

2. Provision of comfort

3. Traction/ Cast care

4. Prevention of urinary stasis and constipation

5. Promotion of skin integrity

• Parent teaching:

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• How to apply devices such as Denis Brown splint.

• Explain the procedure

• Teaching of diversional therapy during application of traction/cast

• Caring of cast? (wet, how to dry)

• Assess for circulatory and neurological disturbance

COMPLICATIONS

Complications of treatment of clubfoot include the following:

• Infection (rare)

• Wound breakdown - Release skin retractors every 30 minutes, and release the tourniquet

before closing the wound and applying a cast

• Stiffness and restricted range of motion - Early stiffness correlates with a poor result

• Avascular necrosis (AVN) of the talus - A 40% incidence of avascular necrosis of the

talus occurs with combined simultaneous medial and lateral release

• Persistent intoeing - This is quite common; it is due not to tibial intorsion but, rather, to

insufficient external rotation correction of the subtalar joint

Overcorrection is associated with the following:

• Release of the interosseous ligament of the subtalar joint

• Excess lateral displacement of the navicular on the talus

• Overlengthening of tendon units

For residual deformity following the initial surgery, rule out neurologic causes of recurrence (eg,

tethered cord). A residual deformity may be either of the following:

• Dynamic - With residual adductus and supination that are fully correctable passively,

treat with split anterior tibial tendon transfer

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• Fixed - If scarring is not excessive and the patient is younger than 5 years, repeat the

release; if the patient is older than 5 years, a bony procedure to straighten the lateral border of the

foot is required

Options to correct adductus are as follows:

• Metatarsal osteotomy - This operation creates a secondary deformity to compensate for a

primary deformity in the tarsus; it rarely is indicated

• Cuboid decancellation

• Calcaneocuboid fusion - The Dillwyn Evans procedure consists of a medial and post

release together with excision and fusion of the calcaneocuboid joint ; it should be reserved for

patients older than 4 years; these two procedures aim to shorten the lateral side of the foot

• Lengthening the medial side of the foot (eg, talar osteotomy) - This is not widely

performed; AVN is a risk

Options to correct residual hindfoot deformity are the following:

• Heel varus - Open the medial wedge, or close the lateral wedge; lateral displacement os

calcis osteotomy is preferred

• Residual cavus and adductus - Perform a wedge tarsectomy

• Failed feet - Perform a triple arthrodesis

PROGNOSIS

Approximately 50% of clubfeet in newborns can be corrected nonoperatively. Ponseti has

reported an 89% success rate using his technique (including an Achilles tenotomy); others have

reported success rates of 10-35%. One study analyzed the correction progression of patients with

idiopathic clubfeet after the Ponseti technique. The data indicated that successive castings

resulted in reduced cavus and medial crease with a gradual correction of midfoot rotation,

adduction, and heel varus. Interestingly, heel equinus improved concurrent with midfoot

variables and also with final casting.

CONCLUSION:

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For children, one of the most difficult aspects of illness is immobilization. Throughout

childhood, physical activity is an integral part of daily life and is essential for physical growth

and development. It also serves children as an instrument for communication and expression and

as a means for learning about and understanding their world. Activity helps them deal with a

variety of feelings and impulses and provides a mechanism by which they can exert control over

inner tensions. Children respond to anxiety with increased activity. Removal of this power

deprives them of necessary input and a natural outlet for their feelings and fantasies. Through

movement, children also gain sensory input, which provides an essential element for developing

and maintaining body image. So correct care given at correct time can prevent immobility or

movement problems in children.

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John cloherty.P, Eric Eichenwald C, Annie, Hansen R. Manual of neonatal care. 7th

edition. South east asia: Lippincott Williams and Wilkins;2012.

Santosh Kumar .A. Manual of newborn care . 2nd edition. Newdelhi:Paras Medical

Publication; 2011.

Tauesch, Ballard, Gleason. Avery’s diseases of the new born. 8th edition. Philadelphia:

Elsevier Publication; 2005

DuttaD.C. Text book of Obstetrics.Culcutta.New central book agency: 2004

Marilyn Hocken berry,david Wilson.Wong’s Essentials of Pediatric Nrsing.9th

edition.Elsevier Publication.2009

Parthasarathy.Parthas Fundamentals of pediatrics.2nd edition.Newdelhi.Jaypee

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