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Clubfoot

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Clubfoot
Definition:
A clubfoot is a congenital deformity involving one foot or both. The affected foot looks like it has been rotated internally at the ankle. Without treatment, people with club feet often appear to walk on their ankles or on the sides of their feet.
It is a relatively common birth defect, occurring in about one in every 1,000 live births. Approximately half of people with clubfoot have it affect both feet, which are called bilateral club foot. In most cases it is an isolated dysmelia (disorder of the limbs). It occurs in males twice as frequently as in females.
Also Known as: Giles Smith Syndrome, Talipes Equinovarus, Talipes

Cause of club foot
Despite a great deal of study, the exact cause of club foot in isolation (not as part of a syndrome or other birth defect) is unknown. There have been some indications of a genetic cause, but these haven’t been confirmed. Most children who are born with a club foot don’t have a family history of the condition.
What is known is that if a baby boy has a club foot, there’s a 2.5 percent chance that his next-born sibling will have club foot, too. If a girl baby has a club foot, there’s a 6.5 percent chance that her next-born sibling will also have a club foot.

Risk Factor
Risk factors may include: * A family history of club foot * Genetic syndromes, such as Edwards syndrome (trisomy 18) * Neuromuscular disorders, such as cerebral palsy (CP) and spina bifida * Oligohydramnios (a decreased amount of amniotic fluid surrounding the fetus in the uterus) during pregnancy
Babies born with club foot may also be at increased risk of having an associated hip condition, developmental dysplasia of the hip (DDH). In DDH, the top of the thigh bone (femur) slips in and out of its socket because the socket is too shallow to keep the joint intact.

Signs and symptoms * The heel points downward, and the front half of the foot turns inward. * The calf muscles on the affected side are smaller than on the normal side. * The leg on the affected side is slightly shorter than on the other side. * The foot itself is usually short and wide. * The Achilles tendon is tight.
Complications
If a child and his parents strictly follow the doctor’s bracing regimen, treatment of club foot at Children’s usually takes place without complications and is largely complete by about age 4. But 20 to 30 percent of kids need additional treatment later in childhood for tendon tightness or to prevent recurrence.
Pathophysiology:
Theories of the pathogenesis of club foot are as follows: * Arrest of fetal developmental in the fibular stage * Defective cartilaginous anlage of the talus * Neurogenic factors: histochemical abnormalities have been found in posteromedial and peroneal muscle groups of patient with clubfoot. This is postulated to be due to innervations changes in intrauterine life secondary to a neurologic event, such as stroke leading to mild hemiparesis or paraparesis. This is further supported by a 5% incidence of of varus and equinovarus deformity in the spina bifida. * Retracting fibrosis (or myofibrosis) secondary to increased fibrous tissue in muscles and ligaments: in fetal and cadaveric studies, Ponseti also found the collagen in all the ligamentous and tendinous structures (except the Achilles tendon) and it was very loosely crimped and could be stretched. The Achilles tendon, on the pther hand was made up of tightly crimped collagen and was resistant to stretching.
Predisposing Factors:

Family history of clubfoot
Precipitating Factors:
Oligohydramnios
Position of the baby in the uterus

Bone growth arrest at roughly 9 weeks or at the fibular stage

Turning in of the heel or hind foot
Abnormal size of foot and calf muscles
Tight heel cord
Fixed plantar flexion of the ankle

Diagnostic Procedure: * Physical examination * Ultrasound * Ultrasound done while a fetus is developing can sometimes detect club foot. It is more common for your health professionals to diagnose the condition after the infant is born, through based on the appearance and mobility of the feet and legs. In some cases, especially if the clubfoot is due just to position of the developing baby, the foot is flexible and can move into normal or nearly normal position. * X-ray * A diagnostic test which uses invisible electromagnetic energy beans to produces images of internal tissue bones and organs onto film * Computed tomography scan ( CT, CAT scan ) * A diagnostic imaging procedure that uses a combination of x-ray and computer technology to produce cross sectional images (also called slices) both horizontally and vertically of the body. As CT scan shows detailed images of any part of the body, including the bones, muscle fat and organs. CT scans are more detailed than general x-rays.

Treatment:
All cases of clubfoot need treating - the earlier the better. Less severe and more flexible types are casted - the more severe and rigid types need surgery.
Casting
A series of plaster or fiber glass casts are applied to the foot and lower limb - these are replaced every few weeks, which each cast progressively moving the foot towards a more corrected position. The number of times the cast needs to be replaced will be determined by the severity of the clubfoot (but several months are not unusual). Most activities are not hampered by wearing a cast.

Surgery
If cast treatment fails or the clubfoot is rigid, surgery may be needed. This is not usually done until the child is between four and eight months of age.
There are a variety of surgical procedures which may be done in isolation or in combination: * Soft tissue surgery that releases the tight tissues around the joints and results in lengthening of tendons so the foot can assume a more corrected position * Bony procedures such as "breaking bone" and resetting the bone to correct deformities, or fusing joints together to stabilize joints to enable the bones to grow solidly together. * Tendon transfers to move the tendons to a different position, so they can move the foot into a corrected position.

Pharmacologic Management:
NSAIDS: Use mainly for management of pain of low to moderate intensity.
Example: Ibufrofen

Nursing Diagnosis: * Risk for disproportionate growth related to congenital disorder * Impaired physical mobility related to musculoskeletal impairment * Impaired skin integrity related to musculoskeletal impairment * Disturbed body image related to developmental changes * Social isolation related to alteration in physical appearance

Nursing Management: * Review pathology, prognosis and future expectations to provide knowledge base from which parents can make informed choices * Discuss the deformity and expected treatment in terms the parents can understand to rule out misconceptions and to provide accurate information about the deformity. * Encourage parents to hold and play with child and participate in care to promote bonding between the baby and the parents. * Assess and teach parent to assess for signs of excessive pressure on skin, redness, excoriation. These signs require immediate evaluation and intervention. * Elevate the extremity to promote venous return and prevents edema. * Stimulate movement of toes to promote circulation * Provide comfort measures such as soft music, pacifier, teething ring, or rocking to promote relaxation and may enhance patient’s coping abilities by refocusing attention.…...

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