2. Introduction
• Clubfoot describes a range of foot abnormalities
usually present at birth (congenital) in which
child's foot twisted out of shape or position
• It is a complex deformity of the ankle and foot
that includes forefoot adduction, midfoot
supination, hindfoot varus and ankle equinas
• Deformities of the foot and ankle are described
according to the position of the ankle and foot
3.
4. Incidence
• Incidence is 1-2/1000 live births
• Males are affected twice
• Bilateral clubfoot occurs in 50% of the cases
5. Etiology
• Idiopathic in most cases
• Arrested or abnormal embryonic development of
skeletal and soft tissue deformity during 9 and
10th weeks
• Abnormal neuromuscular function or muscle
abnormalities due to primary germ plasma defect
that leads to ankle dysplasia
• Distal limb amniotic banding (constrictive
banding) around the limb in utero that cause
cutting of the circulation to the limb
• Abnormal positioning and restricted movement
in utero
• Familial tendency
6. Classification
According to etiology
1. Positional Clubfoot
• It is usually transitional
• Occurs due to intrauterine crowding and
responds to simple stretching and casting
2. Syndromic or tetralogic clubfoot
• Associated with other congenital abnormalities
such as myelomeningocele
• More serious type that is often resistant to
treatment
7. 3. Congenital clubfoot (Idiopathic)
• Occur in normal child and has wide range of
rigidity and prognosis
• Can be detected in the utero and most
common type
8. According to structure
• Talipes varus : an inversion or bending inward
• Talipes valgus: an eversion or bending
outward
• Talipes equinas: plantar flexion in which toes
are lower than the heel
• Talipes calcaneus: dorsiflexion, in which toes
are higher than the heel
Most cases are a combination of these positions
9.
10. • The most frequently occuring type of clubfoot
is the Talipes equinovarus (approximately 95%)
in which the foot is pointed downward and
inward in varying degrees of severity
11. Diagnostic Evaluation
• The defect is apparent and easily detected
prenatally through USG or at birth
• Comprehensive physical exam: affected foot
smaller and a transverse planter crease
• AP and Lateral dorsi-flexion x-ray of foot
• An increased risk of hip dysplasia is associated
with clubfoot deformities ; hip examination
12. Therapeutic Management
• The goal of treatment for clubfoot is to
achieve a painless, and stable foot
• Treatment includes three stages
a. Correction of the deformity
b. Maintenance of the correction until normal
muscle balance is regained
c. Follow up observation to avert possible
recurrence of the deformity
13. Correction
• Serial casting is begun shortly after birth
• Manipulation and casting are repeated frequently
every week to accommodate the rapid growth of
early infancy
• The extremity or extremities are casted until
maximum correction is achieved usually within 8
to 12 weeks
• Radiograph or USG is then evaluated to see the
correction of the deformities
• Failure to achieve normal alignment by 3 months
indicates the need for surgical intervention
14. Surgical Correction
• The surgical correction is usually not done until the
child is between six and nine months of age. Surgery is
performed to correct clubfoot and align the foot in a
more normal position.
• The surgical procedure usually consists of releasing and
lengthening the tight tendons/joint capsule of the foot.
• Pin fixation and releasing of tight joints and tendons
• Casting of the affected foot and leg is performed
• With severe deformities repeated surgical tendon or
joint release may be present
• Percutaneous heel cord (achilis tendon release) release
at approx. 2-3 months of age followed by serial casting
has decreased the number of children requiring
extensive surgery
15. • The foot is immobilized post operatively for 6
to 12 weeks and the child is allowed to walk
after the cast is removed
16. Nursing Management
• Care of the cast
• Observation of the skin and circulation
• Ensure imbolization
• Parents counselling and education
• Encouraging child’s normal development
within the limitations imposed by the
deformity
17. Developmental Dysplasia of Hip (Hip
Dislocation)
• Developmental dysplasia of hip describes a
spectrum of disorders related to abnormal
development of the hip that may occur at any
time during fetal life, infancy or childhood
• There is a disruption in the normal
relationship between the head of the femur
and the acetabulum
• It may be unilateral or bilateral and can be
mild to severe
18. Incidence
• 10 per 1000 live births approx.
• The left hip involved in 60% , right hip in 20%
and both in 20%
• Sixty percents are girls
• Caucasian children have higher incidence than
other groups
19. Etiology
• Exact cause is unknown
• Certain factors such as female child, first born
baby, family history, intrauterine position,
delivery type, joint laxity and postnatal
positioning are associated with DDH
20. Predisposing Factors
1. Physiological factors
• Maternal hormone secretion influence in
development of hip abnormalities towards
the end of pregnancy
• Increased maternal and fetal laxity related to
maternal estrogen hormone
• Intrauterine positioning
21. 2. Mechanical factors
• Higher incidence of hip dislocation is
associated with breech
• Other factors includes first born child, multiple
babies, large baby, oligohydraminos
3. Genetic Factors
• It includes positive family history
• 6% risk
22. Grades of Dislocation
1. Acetabular dysplasia (preluxation)
• Mildest form
• There is no subluxation nor dislocation
• There is apparent delay in acteabular
development evidenced by osseus hypoplasia
of the acetabular roof
• The femoral head remains in the acetabulum
23. 2. Subluxation
• Most commonest
• Subluxation implies incomplete dislocation of
the hip
• The femoral head remains in contact with
acetabulum but a stretched capsule and
ligamentum teres cause the head of the femur
to be partially displaced
24. 3. Dislocation
• The femoral head loses contact with the
acetabulum and is displaced posterioraly and
superiorly over the fibrocartilaginous rim.
• The ligamentum teres is elongated and taut
25.
26.
27. Clinical Manifestations
• It should be detected during newborn period for
the effective treatment
• In newborn features includes Ortolani and Barlow
sign positive, assymetrical gluteal fold, limited
abduction of affected hip
• After 6-10 weeks the baby may have limited hip
abduction
• Shortening of the limb on affected side
• Assymetrical thigh and gluteal fold
• Broadening of the perineum especially in bilateral
dislocation
28.
29.
30.
31. In older infant and child
• The affected leg will be sorter than the other
with telescoping or piston mobility ( head of
femur can be felt to move up and down in the
buttock when extended thigh is first pushed
towards the child’s head and then pulled
distally)
• Instability of hip on weight bearing , delays
walking and produces a characteristics limp
and toe walking
• Child stands first on one foot and then on the
other holding on side bearing weight on the
affected hip
32. • The child with bilateral dislocations has
marked lordosis and peculiar waddling gait
33.
34. Diagnostic Investigations
• Should be done during newborn period as the
treatment should be initiated before 2 months
of age
• Physical exam
a. Barlow test: to detect if the hip is sliding in
and out of the acetabulum
• Infant placed in table in supine position
• Abduct the hips by moving the hips and
knees apart
35. • If the hip feels like it can be pushed out the
back of the socket which is abnormal and
positive Barlow’s Test and is a sign of
instability in the hip
Ortolani test:
• As hip is abducted further, the examination
feel like clunk, the ball of the femoral head
slide forward as it slips back into the socket)
• Significant in infants who are 1-2 month
36.
37.
38. Galeazzi’s or Allis test
• Done among infant 3 mnth or older
• Child placed in supine position with the hips
and knees bent and feet flat
• Unevenness between the knees is examined
• If one knee is lower than other there may be a
dislocated hip on the lower side
39.
40. • Radiographic examination reliable only after 6
months because ossification of the femoral
head does not normally take place until 3-6
months of age
• USG
• CT scan
41. Management
• Treatment is begun soon as the condition is
recognized since early intervention is more
favourable to the restoration of normal bony
architecture and function
• The longer treatment is delayed, the more severe
the deformity the more difficult the treatment
and the less favourable the prognosis
• Treatment varies with the child’s age and the
extent of the dysplasia
42. 1. Newborn to age 6 months
• The hip joint is maintained by dynamic
splinting with the proximal femur centered in
the acetabulum in an attitude of flexion
• Several splint devices are available .
• Pavlik harness device is commonly used
• It prevents hip extension and maintains a
abducted reduced position
• It is worn continuously until the hip is proved
stable on clinical radiographic examination
usually in about 3 to 5 months
43. • When adduction contractures is present other
devices like skin traction are used to slowly and
gently stretch the hip to full abduction after
which wide abduction is maintained until stability
is attained
• When there is difficulty in stable reduction a hip
spica cast is applied and changed periodically to
accommodate the child’s growth
• after 3 to 6 months sufficient stability is acquired
to allow transfer to a removable protective
abduction brace
• Duration of treatment depends on development
of the acetabulum but is usually accomplished
within the first year
44.
45. Age 6 to 18 months
• Dislocation is not recognized until the child
begins to stand and walk when attendant
shortening of the limb and contractures of hip
adductor and flexor muscles becomes
apparent
• Gradual reduction by traction is used for
approximately 3 weeks
• Then closed reduction of the hip using general
anesthesia
• If hip is not reducible an open reduction is
performed
46. • After reduction the child is placed in a hip
spica cast for 2 to 4 months until the hip is
stable at which time a flexion –abduction
brace is applied
47. Older Child
• operative reduction with pre-operative traction,
tenotomy of contractracted muscle
• Osteotomy procedure to construct an acetabular
roof is usually required
• Cast is used after reduction
• Range of motion exercises help restore
movement
• After the age of 4 years the procedure is difficult
and are usually impossible or inadvisable in
children older than 6 years of age because of the
femoral and acetabular structures
48. Nursing Management
• Detection of DDH cases in the newborn during
newborn assessment and newborn care
• Observation of leg length, gluteal fold, hip
abduction test to detect cases
• Parents teaching about disease process,
therapeutic regimen, application and maintain
the reduction device
• Maintenance of device and adaptation of
nurturing activities
• Because of infant’s rapid growth the straps
should be checked and adjusted every week
49. • Parents instructed not to adjust the harness
without medical supervision
• Keep undershirt, firm cloths or rubber, knee
socks, under the strap of harness to prevent
rubbing of skin
• Frequently check for 2-3 times a day for
redness and gently massage healthy skin
under the strap to stimulate circulation
• Provide assistance to parents if necessary for
daily care and nurturing activities
• Cast care
