11. When treatment for clubfoot starts soon after birth, the
foot grows to be stable and positioned to bear weight for
standing and moving comfortably. The goal of treatment is
to improve the way child's foot looks and works before he
or she learns to walk, in hopes of preventing long-term
disabilities. Treatment options include:
• 1. The Ponseti Method (Stretching and casting) - This
method was pioneered in the 1940's by Dr. Ignocio
Ponseti. A specialist manipulates the baby's foot with
their hands. The aim is to correct the bend in the foot.
Then a plaster cast is applied from the patient's toes to
their thigh to hold the foot in position. Each session is
generally done once a week. The manipulation and
casting are done very gently and the patient should
experience no pain.
12.
13. • At each session the plaster cast is changed, and each
time the foot is corrected a tiny bit more. The whole
process may be done 4 to 10 times (4 to 10 new casts
used). Toward the end of the series of castings, if the
whole foot is pointing down, children treated with this
method still need a minor surgery to lengthen the tight
• Once the foot has been corrected, the infant must wear
a special shoes and braces to maintain the correction.
This has been extremely effective but requires the
parents to actively participate in the daily care by
applying the braces. The child will have to wear the
bracing bars for 23 hours a day for about 3 months and
then only at night for 2 - 4 years. Splints/Braces may be
used after a few years of casting the feet. Denis -
Browne and Bell Grice splints are used.
15. • 2. The French Functional Method (Stretching and
taping) - This method consists of daily stretching,
exercise, massage, and immobilization of the foot
with nonelastic tape to slowly move the foot to the
correct position. These therapy sessions are
performed primarily by physical therapist for the
first three months, when most of the improvement
occurs, but parents receive training during this time
in order to perform some of the treatments a home.
The taping and splinting continues until the child is
two years old.
17. SURGICAL MANAGEMENT
• On occasion, stretching casting and bracing are not
enough to correct your baby's chibio Surgery may
be needed to adjust the tendons, ligaments and
joints in the foot/ankle. Usually done at 9 to 12
months of age, surgery corrects all of baby's
clubfoot deformities at the same time. After
surgery, a cast holds the clubfoot still while it heals.
It's still possible for the muscles in child's foot to try
to return to the clubfoot position, and special shoes
or braces will likely be used for up to a year or more
after surgery.
18. The surgery of the soft tissue or bone is not usually
necessary to treat the clubfoot. The 2 surgical
procedures are:
A. Percutaneous Tenotomy: It is needed in 80% cases.
In this, there is a release (clipping) of the Achillas
Tendon. It is a minor surgery & done under local
anaesthesia .
B. Anterior Tibial Tendon Transfer. It is needed in 20%
cases. Tendon is moved from the first toe to the 3rd
toe in order to release the inward traction on the foot.
Post-operative routines usually include, a period of
cast immobilization of upto 12 weeks followed by a
brace or corrective shoe for a period of 2 to 4 years.
19.
20.
21. NURSING MANAGEMENT
• Nursing Assessment
1. Obtain a family history of foot deformities
2. Obtain an obstetric history for risk factors
3. Perform physical assessment for presence of other
anomalies & classic foot position & ROM.
4. If late presentation, perform a thorough neurologic
examination to rule out causative factors.
5. Assess family coping and resources available for
lengthy treatment.
22. Nursing Diagnosis and Intervention
1. Risk for impaired parenting related to ineffective adaptation to
stressor associated with a diagnosis of clubtoot & the therapeutic
regimen.
Nursing Intervention
• Provide an accurate description of deformity and the importance
of treatment in the language that parents can understand
• Provide opportunity for parents to verbalize questions and
concerns.
• Encourage the parents to hold & play with child and participate
in care
• Demonstrate how to move or position the child and allow return
demonstrations
• Provide parents with a contact family that has been through the
treatment process for Support.
23. 2. Risk for impaired skin integrity related to Serial Casting
• Assess the cast, splint, orthotic device, or special shoes .
• When moving child in a wet cast, always use open palms to move the
cast.
• Turn the child every 2 h to allow the under surface of the cast to dry.
• Advice parents that due to rapid growth rate of infant, the cast or
splint may need to be replaced to prevent skin breakdown.
• Assess and teach assessment of excessive pressure on skin- redness,
excoriation, foul odour from underneath cast or pain.
• Assess and teach parent to assess for signs of excessive pressure on
skin, Ted,excoriation because these signs require immediate
evaluation and interventions.
• When the cast is dry if the edges are not smooth or covered by a fold
of stocking smooth the edges by applying adhesive tape strips
(Petaling) •
• Keep the child in a semi Fowler's position. Teach the child nothing to
put between cast and skin
24. 3. Ineffective peripheral tissue perfusion related to post
operative edema and pressure from cast.
• Assess for color, warmth, presence of pedal pulses
and sensations of numbness or tingling.
• Assess for signs of impaired neurovascular function
pain, pallor, pulselessness & parasthesia.
• Elevate the extremity to prevent edema in the post
operative period
• Protect and assess foot for injury.
• Check circulation frequently (Every 15min for first 1hr,
hourly for 24h & 4 houlrly thereafter)
25. 4. Acute pain related tissue and muscle trauma
secondary to surgery.
• Assess for signs of discomfort, such as
irritability, crying, poor feeding and sleeping,
tachycardia & increased B.P.
• Administer analgesics regularly for 24 to 48
hours after surgery
• Provide comfort measures such as soft music,
pacifier, teething ring, rocking and caddling with
parents.
• Encourage parents to administer analgesics
after discharge from hospital (when needed)
Discuss dosage & administration & dispel
misconceptions about addiction
27. • Developmental dysplasia of the hip (DDH) is an
abnormality in the hip joint that is usually present
from birth: The broader definition of DDH is an
abnormal growth of hip in which the ball at the top
of the thigh bone (femoral head) is not stable in the
socket (acetabulum). DDH was previously known as
congenital dislocation of the hip (CDH) or congenital
hip dysplasia. It was renamed to show better how
there are different degrees of abnormality (not just
dislocated hips).
28. ETIOLOGY AND RISK FACTORS
• The exact cause of DDH is not known. A number of risk factors can
raise child's chances having DDH, including a family history of DDH
and baby's position in the womb birth. The causes of DDH may be
congenital or acquired.
• Female sex (8:1)
• About 6 in 10 cases of DDH occur in firstborn children
• Large birth weight
• Children with a family history of hip dysplasia (parents or Siblings )
• Intrauterine malpositioning: Babies born in breech position
• Oligohydraminos (lack of intrauterine fluid
• Babies born with other packaging problems; for example, clubfoot
and torticollis
• Estrogen and a hormone (relaxin)
• Also associated with neuromuscular disorders-Cerebral palsy.
Myelomeningocele, Arthrogryposis, and Harsen syndrome.
29. Because of cartilaginous pressure
ossification centers are delayed in apperance
Structure of hip joint; acetabulum and capsule
may not be developed properly
30. Partial or complete dislocation of femoral head
from shallow acetabular cavity
Partial dislocation or subluxation
31. DEGREES/TYPES OF DDH
1. Acetabular Dysplasic : In mild cases, the ligaments and
other soft tissues around the hip joint are not tight, and they
allow the thighbone (femur) to move around more than
normal in the hip socket. There is delay in the acetabular
development evidenced by osseous hypoplasia of the
acetabular roof that is oblique & shallow; although the
cartilaginous roof is intact.
2. Subluxation: In more severe cases, the joint is loose
enough to let the ball at the top of the thighbone (femoral
head) come partway out of the hip socket. This is called
subluxation. The femoral head remains in contact with
acetabulum, but a stretched capsule and ligamentum teres
causes the head of the femur to be partially displaced.
32. 3. Dislocation: This refers to complete loss of contact
between the articular surface femoral head and
acetabulum. Dislocation is the most severe form of
DDH. The ball at the top of the thighbone fully slips
out of the hip socket (dislocates).
4. Instability: This includes the ability to subluxate or
dislocate the hip with passive manipulation
5. Teratologic: This refers to antenatal dislocation of
the hip. Usually occur in utero are much less
common.
34. CLINICAL MANIFESTATIONS
There may be no symptoms of CHD This why physicians
and nurses routinely test for the condition. It symptoms are
present, they may include .
• Legs that turn outward or appear to differ in length
• Limited range of motion
• Uneven folds of fat on the thighs
• Less movement on the side affected by CHD
• Delayed gross motor development( Sitting, crawling, and
walking)
• After about 3 months of age, one leg shorter than the
other
• A child who is walking may:
• Walk on the toes of one foot with the heel up off the floor
• Walk with a limp (or waddling gait if both hips are
affected )
