Definition Talipes Equinovarus (Clubfoot) is a disorder where the foot remains in an inward and downward position.

Clubfoot is present at birth. The Latin word talipes was compounded from talus (ankle) + pes (foot) since, with a clubfoot, the foot is turned in sharply and the person seems to be walking on their ankle. Equinoindicates the heel is elevated (like a horse's) and -varus indicates it is turned inward. Talipes Equinovarus could either be unilateral (affecting a single foot only) or bilateral (both feet are affected). Incidence Commonly called clubfoot, it is a congenital anomaly occurring at approximately 1 to 2 in every 1000 live births. Male-female incidence ratio is 2:1 Signs and Symptoms The heel is pointed away from the body and is drawn upwards. The foot is twisted in towards the other foot. The toes are pointed down. The affected foot and leg, will be stiff and smaller in size, when compared to a normal child. The calf muscle may be smaller than normal and underdeveloped. There will be lack of ankle joint motion. Anatomy and Physiology Two essential functions of the foot: 1. Reinforces body weight 2. Allows the body to move forward when running or walking In human anatomy, the foot is the lowest structure of the leg, consisting of 26 bones.

Facts about the foot bone: 1. The weight of the body is carried by the largest tarsal bones, calcaneus (heelbone) and talus (ankle bone). 2. To create a strong arch of the foot it is arranged longitudinally (medial and lateral) and transverse. Parts of the Foot Bone: Tarsus the posterior half of the foot composed of seven tarsal bones: 1. 2. 3. 4. 5. 6. 7. Medial cuneiform Intermediate cuneiform Lateral cuneiform Cuboid Navicular Talus Calcaneus

Metatarsals form the sole and are composed of 5 bones. Phalanges form the toes and are composed of 14 bones. Each toe has 3 phalanges with the exception of the great toe having only 2. Ligaments connects bones. Tendons attaches bone to a muscle allowing movements or a specific amount of elasticity. Pathophysiology

During the developments, the posterior and medial tendons and ligaments (at the back) of the foot fail to keep pace with the development of the rest of the foot.

Tendons and ligaments the posterior and medial parts of the foot down causing the feet to point downward and twist inward.

Bones of the foot are therefore held to the abnormal position.

If not corrected, the bone will be misshaped. Diagnostic Evaluation Physical Examination

Twisted foot appearance should be assessed and gently manipulated. If the straightened foot does not move to a normal position, true clubfoot is present.

Radiography

Use of x-rays is definitive diagnosis for clubfoot as it determines abnormal bone anatomy and assesses the treatment efficiency.

Management Nonsurgical management Ponseti Method Applies certain techniques to reduce and correct the deformity to promote normal foot mobility and position. Methods used are the following: 1. Manipulation - Slightly pivoting the bones and stretching the soft tissue 2. Placement of above the knee cast o Frequency of changing the cast is every 5-7 days to accommodate the rapid growth during the first year of life. o In most cases, severing of Achilles tendon (tenotomy) is done before the final cast is applied. The reason for doing this is to loosen the foot. The procedure is usually done in a clinic where a local anesthetic is used. A small cut (about 3 mm) is made above the heel of the foot to lengthen the tendon. After the procedure final casting is done. o Final cast is removed after 2-3 weeks when Achilles tendon is already healed. o After the final cast is removed:

Denis Brown Splints (shoes or boots attached to a bar) are used 23 hours each day for 3 months to maintain the normal foot alignment. For the next 2-4 years the splint is fitted during naps and nighttime only. Passive foot exercises (full range-of-motion) are executed by the primary caregiver to further maintain the position. Post-tenotomy management Observe for the following:

Drainage on the cast Foul smelling odor from inside the cast. Swelling, redness and irritation at the distal portion of the cast. High fever

Ilizarov Technique Method used for complex ankle-foot deformity. Ilizarov frames, the circular structure placed around the limb, are used in this technique which are attached to metal pins and are inserted through the bone. A frame is individually made for each patient and weighs approximately 7 lbs. Placement of the frame requires the administration of a general anesthetic and the procedure may last for several hours.

Surgical Management Posteromedial Release The last option for a clubfoot is the release of all tight tendons and ligaments in the posterior and medial parts of the foot. The structures are then put back together in a lengthened position. Tendon Transplant Done at 4-7 years of age when other corrective measures have been ineffective. Complications

Rocker bottom Foot

Vertical talus results from a forceful manipulation causing bone breakage. This then will give rise to a flat foot.

Recurrent deformity

The corrected foot may return to its deformed state if the parents or primary caregiver fails to apply the methods to further correct the position (e.g. passive foot exercises and Denis Brown splint). Nursing Interventions 1. Obtain a family and obstetric history for risk factors. 2. After delivery, assess the ankle and foot for a true talipes deformity by straightening the foot. Pseudo-talipes can be realigned to a normal position. 3. For infants with cast assess for circulation, redness and swelling distal from the cast and foul odor. 4. Monitor the infants temperature (for those who underwent tenotomy or surgery). Fever is the first sign of infection. 5. Cautiously evaluate crying. Infants cannot voice out pain. Crying may mean hunger, wet diapers, abdominal pain or tingling sensation from a tight cast. 6. Keep the cast clean and dry by changing diapers frequently. Use a damp cloth and dry cleansers in wiping. Water and soap causes breakdown of cast particles. 7. Place a pillow or padding under the casted area to prevent cast damage and prevent sores from heel pressure. 8. For children with traction, check and cleanse the pin sites frequently. 9. Explain to the parents the importance of passive foot exercises after the final cast is removed. 10. Maintaining the aligned position after the cast application is essential to prevent reoccurrence. 11. Administer analgesics as ordered for pain relief after a surgical correction. 12. Assess coping mechanisms of family and resources available for long-term treatment.

Exercise

Execution of passive foot exercises several times a day for several months to maintain the corrected foot alignment. Never forcibly evert or pronate the foot during clubfoot casting. This can cause damage to the bones.

Diet

Breastfeeding for infants younger than 4-6 months. For older infants, introduction of solid foods must have the interval of 5-7 days.