Clubfoot Presentation.ppt

8/20/2019 Clubfoot Presentation.ppt

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Congenital Talipes Equinovarus

(Clubfoot)



Anatomy/Terminology

•3 main sections

1.Hindfoot – talus,calcaneus

2.Midfoot – navicular,cuboid, cuneiforms

3.Forefoot –metatarsals and

phalanges





Anatomy/Terminology

• )arus$)algus



Talipes Equinovarus (congenitalclubfoot)

( *talipes+ -alus !bone#, es !foot#( -he heel inverted( -he forefoot / midfoot inverted / adducted

!varus#( -he an"le e0uinus

in utero displacement / mal alignment of thetalocalcanealnavicular / calcaneocuboid oint



Talipes Equinovarus (congenital clubfoot)



Incidency

()aries ith race / se%( aucasians 1,2$1444 , 5 6 7 2 1(Ha aiians &,8$1444(Maori 9,'(:,4$1444(;ilateral '4<, 1$3 of cases(=nilateral right > left



Heredity

(?enetic factors 14<, others sporadis(@nvironmental factors

Idelberger Identical !MonoABgotic# t ins 32,'<

Fraternal !CiABgotic# t ins 2,8<

Etiology

( -he e%act cause un"no n



1.1. Intrauterine Mechanical FactorsIntrauterine Mechanical Factors

- The oldest, Hipocrates- The oldest, Hipocrates - External mechanical forces- External mechanical forces →→

equinovarusequinovarusposture → the li aments, muscles,posture → the li aments, muscles,

!ones!oneschan es → articular mal ali nmentchan es → articular mal ali nment

- T"inin , hi h !irth "ei ht, primiparous- T"inin , hi h !irth "ei ht, primiparousuterus, hidramnios uterus, hidramnios



#. $euromuscular %efect#. $euromuscular %efect

- &hite, 1'#' ( ) peroneal $. lesion caused !*- &hite, 1'#' ( ) peroneal $. lesion caused !*

pressure at the intrauterine sta epressure at the intrauterine sta e - Middleton, 1'+ ( Mal development of the- Middleton, 1'+ ( Mal development of the

striated musclestriated muscle - Flinchum, 1' + ( Muscle im!alance due to- Flinchum, 1' + ( Muscle im!alance due to d*splasia of the peronealsd*splasia of the peroneals - itsila ( /oncluded that primar* soft tissue- itsila ( /oncluded that primar* soft tissue

chan eschan es →→ provo0in s0eletal deformitiesprovo0in s0eletal deformities



+. )rrest of Fetal %evelopment+. )rrest of Fetal %evelopment - Huter ( esult of an arrest of- Huter ( esult of an arrest of

development of the foot in one of thedevelopment of the foot in one of theph*siolo ic phases of its em!r*onic lifeph*siolo ic phases of its em!r*onic life





. rimar* 2erm lasm %efect. rimar* 2erm lasm %efect - Irani 3 4herman ( /TE5 is the- Irani 3 4herman ( /TE5 is the

result of aresult of adefective cartila ineous anla edefective cartila ineous anla e

produced !* aproduced !* aprimar* erm plasm defect,primar* erm plasm defect,

developin in thedevelopin in the6rst trimester6rst trimester



atholo *atholo *

- The foot is plantar 7exed at the an0le 3 The foot is plantar 7exed at the an0le 3su!talar 8oints, the hindfoot is inverted 3su!talar 8oints, the hindfoot is inverted 3

the mid and forefoot are adducted,the mid and forefoot are adducted,inverted 3 equinusinverted 3 equinus- Fixed contractures of the related softFixed contractures of the related soft

tissue 9the li aments, capsules, muscles,tissue 9the li aments, capsules, muscles,

tendons: maintained articular maltendons: maintained articular malali nmentali nment



). ;on* %eformities). ;on* %eformities

1. The Talus1. The Talus- Medial 3 plantar deviation of the anterior end ofMedial 3 plantar deviation of the anterior end of

the talusthe talus- <<declination an le= ( !* the lon axis of thedeclination an le= ( !* the lon axis of thehead 3 nec0 of the talus "ith the lon axis of itshead 3 nec0 of the talus "ith the lon axis of its!od*!od*

- >!liquit* the nec0 of talus ( medial tiltin of the>!liquit* the nec0 of talus ( medial tiltin of theanterior part of the talus 9adult ( 1#-+# de rees,anterior part of the talus 9adult ( 1#-+# de rees,fetus ( + -? de rees, /TE5 ( @-A de rees:fetus ( + -? de rees, /TE5 ( @-A de rees:





2. The Calcaneus2. The Calcaneus - Much less deformed than the talus- Much less deformed than the talus

- Rotated on its long axis inward &- Rotated on its long axis inward &downwarddownwardbeneath the talusbeneath the talus

- The sustentaculum tali usually- The sustentaculum tali usually

underdevelopedunderdeveloped& in close proximity to the medial& in close proximity to the medial

maleolusmaleolus3. T e !orefoot " Tibia

# $maller t an normal



;. )rticular Malali nments;. )rticular Malali nments

1.1. elationship of talus to distal ti!ia 3 6!ulaelationship of talus to distal ti!ia 3 6!ula - The talus has no muscle attachments, it- The talus has no muscle attachments, it

is sta!iliBed !* the an0le mortisis sta!iliBed !* the an0le mortis





#. elationship of navicular to talus#. elationship of navicular to talus



+. elationship of talus to calcaneus+. elationship of talus to calcaneus



. elationship of. elationship of/alcaneus to /u!oid/alcaneus to /u!oid!one!one

- The cu!oid is- The cu!oid isdisplace mediall* indisplace mediall* in

relation to therelation to theanterior end of theanterior end of thecalcaneuscalcaneus



/. 4oft-Tissue /han es/. 4oft-Tissue /han es

- The soft tissues on the medial 3 posterior The soft tissues on the medial 3 posterioraspect of the foot 3 an0le are shortenaspect of the foot 3 an0le are shorten

9li aments, capsules, muscles, tendons,9li aments, capsules, muscles, tendons,vessels, nerves, s0in:vessels, nerves, s0in:

- In eversion, the navicular 3 anterior end ofIn eversion, the navicular 3 anterior end ofthe os calcis move laterall*, in inversionthe os calcis move laterall*, in inversion

the* move mediall*the* move mediall*





%ia nosis%ia nosis

/linical picture (/linical picture (- /lu!li0e appearance/lu!li0e appearance

- %eep creases at the posterior aspect of the%eep creases at the posterior aspect of thean0le 8ointan0le 8oint- Mid 3 forefoot are adducted, inverted 3Mid 3 forefoot are adducted, inverted 3

equinusequinus

- The navicular !one a!uts the anterior 3 medial The navicular !one a!uts the anterior 3 medialmar in of the medial maleolus, on palpationmar in of the medial maleolus, on palpationcanCt insert a 6n er !et"een the t"o !onescanCt insert a 6n er !et"een the t"o !ones



adio raphic )ssessmentadio raphic )ssessment

(-he purpose is to define preciselB the anatomicrelationship of talocalcaneonavicular, tibiotalar,midtarsal / tarso(metatarso oint

(-o assess the degree of sublu%ation of thetalocalcaneonavicular oint / the severitB of thedeformitB before treatment

( -o provide an accurate guide to progress during thecourse of closed non operative treatment

( -o assess ether reduction of the talocalcaneonaviculardislocation / normal articular alignment have beenachieved



$ormal ran e of$ormal ran e ofroent eno raphic an lesroent eno raphic an les

D Talocalcaneal an le Talocalcaneal an le)nteroposterior vie"( +@ to de rees)nteroposterior vie"( +@ to de rees

%orsi7exion lateral vie" ( # to @%orsi7exion lateral vie" ( # to @de reesde rees

D Ti!iocalcaneal an le Ti!iocalcaneal an le

4tress lateral vie" ( 1@ to @ de rees4tress lateral vie" ( 1@ to @ de reesD Talo-6rst metatarsal an le Talo-6rst metatarsal an le)nteroposterior vie" ( to 1 de rees)nteroposterior vie" ( to 1 de rees











Treatment Treatment

The o!8ective ( The o!8ective (1. To achieve reduction of the dislocation or1. To achieve reduction of the dislocation or

su!luxation of the talocalcaneonavicular 8ointsu!luxation of the talocalcaneonavicular 8oint #. To maintain the reduction#. To maintain the reduction +. To restore normal articular ali nment of the+. To restore normal articular ali nment of the

tarsus 3 the an0letarsus 3 the an0le . To esta!lish muscle !alance !et"een the evertors. To esta!lish muscle !alance !et"een the evertors

3 invertors, and the dorsi7exors 3 plantar7exors3 invertors, and the dorsi7exors 3 plantar7exors . To provide a mo!ile foot "ith normal function 3. To provide a mo!ile foot "ith normal function 3

"ei ht !earin"ei ht !earin



- Treatment should !e started as soon as Treatment should !e started as soon aspossi!le, immediatel* follo"in !irthpossi!le, immediatel* follo"in !irth

- The 6rst three "ee0s of life are the olden The 6rst three "ee0s of life are the oldenperiod, !ecause the li amentous tissuesperiod, !ecause the li amentous tissuesare still lac0s under the in7uences ofare still lac0s under the in7uences ofmaternal sex hormonesmaternal sex hormones

- Mana ements extends until adolescentMana ements extends until adolescent



/losed $on->perative Method/losed $on->perative Method

- Elon ation of the contracted soft tissues !*Elon ation of the contracted soft tissues !*passive manipulationpassive manipulation → entle "ith a non→ entle "ith a nonirritative adhesive liquid, use lovesirritative adhesive liquid, use loves

- 4houldnCt stretch the midfoot !* forced4houldnCt stretch the midfoot !* forceddorsi7exion of the forefootdorsi7exion of the forefoot → roc0er !ottom→ roc0er !ottomdeformit* of the foot → transversed !reechdeformit* of the foot → transversed !reech

- The stretched position is maintain to the The stretched position is maintain to thecount of ten, repeated #@-+@ times eachcount of ten, repeated #@-+@ times eachsessionsession











)dvanta e ()dvanta e (

- ) d*namic corrective) d*namic correctiveforce is transmitted toforce is transmitted tothe footthe foot

- In expensive, appliedIn expensive, appliedeasil*, reapplied ateasil*, reapplied atfrequent intervalsfrequent intervals

- elativel* safeelativel* safe

- ;ein least li0el* to;ein least li0el* tocause pressure sorescause pressure sores



/losed reduction of the medial 3/losed reduction of the medial 3plantar dislocation ofplantar dislocation of

talocalcaneonavicular 8ointtalocalcaneonavicular 8oint- The success of reduction con6rm !* ) 3 The success of reduction con6rm !* ) 3

at G-ra*at G-ra*

- ) ( The talocalcaneal an le should !e) ( The talocalcaneal an le should !e#@#@ , the talo-6rst metatarsal an le J1, the talo-6rst metatarsal an le J1- at ( The talocalcaneal an le should !e +@-at ( The talocalcaneal an le should !e +@-



etention of reductionetention of reduction

- )!ove 0nee cast to maintain the reduction)!ove 0nee cast to maintain the reduction- Three persons Three persons

- The cast should extend from the toes to the The cast should extend from the toes to the

roin "ith the 0nee 7exed at A@-K@roin "ith the 0nee 7exed at A@-K@ to tocontrol the heel 3 prevent the cast fromcontrol the heel 3 prevent the cast fromslippinslippin

- roper 3 carefull moldin of the cast (roper 3 carefull moldin of the cast (calcaneocu!oid area, !ac0 of the heel, thecalcaneocu!oid area, !ac0 of the heel, themidtarsal 8oint area to prevent a roc0ermidtarsal 8oint area to prevent a roc0er!ottom deformit*!ottom deformit*



- The cast is chan e at #-+ "ee0s The cast is chan e at #-+ "ee0s- intervalsintervals → + months →→ + months →pol*prop*lene a!ove 0nee splintpol*prop*lene a!ove 0nee splint9hold the hindfoot in 1 -#@ of9hold the hindfoot in 1 -#@ ofeversion, the midfoot 3 forefoot ineversion, the midfoot 3 forefoot in#@ of a!duction, the an0le at @-#@ of a!duction, the an0le at @-of dorsi7exion, the 0nee 7exedof dorsi7exion, the 0nee 7exed

A@ : the splint is "orn onl* atA@ : the splint is "orn onl* atni ht 3 at nap timesni ht 3 at nap times



- ) pre "al0er clu!foot shoes is "orn) pre "al0er clu!foot shoes is "orn

durin the da*durin the da*- &hen the child !e ins to "al0&hen the child !e ins to "al0 →→"ear out7are 9tarsal pronator :"ear out7are 9tarsal pronator :

shoes, "ith outer lateral side heel 3shoes, "ith outer lateral side heel 3sole "ed es to encoura e "al0in insole "ed es to encoura e "al0in ineversion 3 a!ductioneversion 3 a!duction

- G-ra* periodicall*, if there is noG-ra* periodicall*, if there is noreccurents of deformit* after # *earsreccurents of deformit* after # *ears→ normal shoes→ normal shoes













































Treatment of resistant Treatment of resistantclu!footclu!footDMetatarsus adductusMetatarsus adductus*r ( metatarsal osteotom**r ( metatarsal osteotom*DHindfoot varusHindfoot varus

J#-+*r ( modi6ed McLa* procedureJ#-+*r ( modi6ed McLa* procedure+-1@*r (+-1@*r (D%"*er osteotom* 9isolated heel varus:%"*er osteotom* 9isolated heel varus:D%ill"*n-Evans proc 9short medial column:%ill"*n-Evans proc 9short medial column:

D icht!lau proc 9lon lateral column:icht!lau proc 9lon lateral column:

1@-1#*r ( triple arthrodesis1@-1#*r ( triple arthrodesis

DE iE i



DEquinusEquinus Tendo calcaneus len thenin plus Tendo calcaneus len thenin plus

posterior capsulotom* of su!talar 8oint,posterior capsulotom* of su!talar 8oint,an0le 8oint 9mild to moderate deformit*:an0le 8oint 9mild to moderate deformit*:am!rinudi procedure 9severe deformit*,am!rinudi procedure 9severe deformit*,

s0eletal immaturit*:s0eletal immaturit*:

D)ll three deformities ()ll three deformities (1@*r ( triple arthrodesis1@*r ( triple arthrodesis













Talipes Equinovarus (congenital clubfoot)





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Clubfoot Presentation.ppt