Assessing Children with Clubfoot: Difference between revisions

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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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Revision as of 03:13, 4 August 2017

Introduction[edit | edit source]

Not all Clubfeet are the same and it is important that all people treating Clubfoot use the same terms to describe the different types. The causes of clubfoot are not clearly understood. Most commonly, it is classified as “Idiopathic Clubfoot” which means there is no known cause. “Secondary Clubfoot” which occurs when there is another disease or condition that is causing or is linked to the clubfoot, such conditions are usually neurological or syndromic disorders such as Arthrogyposis or Spina Bifida. There is also a condition known as “Positional Clubfoot”, which is not really a true clubfoot at all as the foot is fully correctable. [1]

Each type of clubfoot has unique characteristics and may need specific treatment. Early recognition of the type of clubfoot one is dealing with can help guide appropriate treatment.

Classification[edit | edit source]

Although there is no classification system for clubfoot is universally used, clubfoot can be classified according to the nature of the deformity: [2]

Positional Clubfoot[edit | edit source]

Postural related (though technically these are not true clubfoot as they are correctable). A foot that at the time of birth has some of the deformity of a clubfoot but which is correctable by simple pain-free manipulation. Some children with this type of Clubfoot may benefit from 1 or 2 casts to hold them in a corrected position but they usually correct well and do not lead to any significant impairment. [3]

Idiopathic Clubfoot[edit | edit source]

In the Idiopathic Clubfoot, there may be an hereditary influence, in that if you have a relative, parent, or sibling with Clubfoot you are more likely to have Clubfoot yourself, or have a child with it (3 - 10% chance). Within the group of Idiopathic Clubfeet there is a wide spectrum of impairment depending on severity, and also on whether the clubfoot has been untreated, partially treated, poorly treated, or successfully treated.[3]

Untreated Clubfoot[edit | edit source]

All clubfeet from birth up to 2 years of age that have had very little or no treatment can be considered as untreated clubfeet.[3]

Treated Clubfoot[edit | edit source]

Untreated clubfeet that have been corrected with Ponseti treatment are termed “treated clubfeet”. Treated clubfeet are usually braced full-time for 3 months and at night up to age 4 or 5 years.[3]

Recurrent Clubfoot[edit | edit source]

This is a clubfoot which has achieved a good result with Ponseti treatment, but the deformity has recurred. The commonest reason is due to abandoning the braces early.[3]

Neglected Clubfoot[edit | edit source]

The neglected clubfoot is a clubfoot in a child older than 2 years, where little or no treatment has been performed. The neglected clubfoot may respond to Ponseti treatment, but also may have bony deformity that requires surgical correction.[3]

Complex Clubfoot[edit | edit source]

Any foot with deformity that has received any type of treatment other than the Ponseti method may have added complexity because of additional pathology or scarring from surgery.[3]

Resistant Clubfoot[edit | edit source]

This is a clubfoot where Ponseti treatment has been correctly performed but there has been no significant improvement. It is often found that this type of clubfoot is not in fact idiopathic after all and is secondary or syndromic.[3]

Atypical Clubfoot[edit | edit source]

This is a type of clubfoot dealt with in the advanced section of this course (chapter 15). It involves a foot that is often swollen, has a plantarflexed first metatarsal and an extended big toe. It can occur spontaneously but most often occurs after slippage of a cast.[3]

Secondary or Syndromic Clubfoot[edit | edit source]

A Clubfoot Deformity that is associated with an underlying medical condition that may have caused the clubfoot.

Spina Bifida[edit | edit source]

Congenital, neurological condition where there is failure of the formation of the bone or skin or both to cover the lower end of the spinal cord and nerves. It is often associated with neurological problems in the legs, and clubfoot. If cases present to the clubfoot clinic it is important to find out what the long-term prognosis is, and whether the child is likely to walk. If the child is likely to survive and walk then it is worth trying Ponseti Clubfoot Treatment. The success rate with simple manipulation is not high and surgery may be considered. Even if the child has a low likelihood of walking the parents might still like to try to get the feet corrected so that shoes can be worn.[4]

Arthrogryposis[edit | edit source]

Congenital condition where the child is born with a number of deformities of the joints. A severe case can have stiffness of the elbows, wrists, hips, knees, and feet. Severe cases are often unable to walk. Clubfoot is a relatively common association. Ponseti treatment can be tried and is often partially successful.[4]

Amniotic Band Syndrome[edit | edit source]

The cause of amniotic band syndrome is not fully clear, but children with this condition are born with tight skin and soft tissue bands around their limbs, constricting blood and lymph flow and causing swelling. Some cases are associated with clubfoot although in the one illustrated here it is only mild. Treatment of the tight band often involves surgery. If there is a clubfoot associated then Ponseti treatment should only be done with extreme care as blood supply to the foot can be affected and there is a risk of gangrene. These cases are best referred to a centre with surgical experience.[4]

Tibial Agenesis[edit | edit source]

Failure in the formation of the tibia. There is a spectrum of presentations from complete absence to a slightly short tibia. In this case there is only a very short tibia and the foot therefore adopts a varus deformity pointing to the midline. This is not a clubfoot deformity even though there is a similarity in the appearance. If there is doubt about the diagnosis, an X-ray should be taken. Treatment is very complicated and many surgeons recommend an amputation with below-knee prosthesis. There is little benefit in starting clubfoot treatment.[4]

Types[edit | edit source]

Individuals with clubfoot experience bone and soft tissues deformation and this abnormality can be presented in different shapes (abnormal alignments) and we should define the exact occurred abnormality in the assessing child.[5]

There are four variations of clubfoot:

  • Talipes Calcaneovalgus: characterized by marked ankle joint dorsiflexion, subtalar joint eversion, forefoot abduction and loss of concavity of medial longitudinal arch.
  • Talipes Calcaneovarus: Characterized by marked ankle joint dorsiflexion, heel inversion and forefoot adduction.
  • Talipes Equinovalgus: characterized by marked ankle joint plantarflexion, heel eversion and forefoot abduction
  • Talipes Equineovarus: This is the most common type and clubfoot which characterized by marked ankle joint plantar flexion and forefoot inversion, heel inversion, forefoot adduction and exaggerated concavity of the medial longitudinal arch.

Severity[edit | edit source]

There is no agreed method of grading the severity of deformity Pirani et al devised a simple scoring system based on six clinical signs of contracture. Each is scored according to the following principle: [6]

  • 0, no abnormality
  • 0.5, moderate abnormality
  • 1, sever abnormality

The six sings are separated into three related to the hindfoot (severity of the posterior crease, emptiness of the heel and rigidity of then equinus) and three related to the mid foot (curvature of the lateral border of the foot, severity of the medial crease and position of the lateral part of the head of the talus).

Thus each foot can receive a hindfoot score between 0 to 3, a midfoot score between 0 to 3 and total score between 0 to 6.

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. Africa Clubfoot Training Project. Chapter 1 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  2. Clubfoot,http://emedicine.medscape.com/article/1237077-overview#a4 (accessed 28 June 2017)
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Africa Clubfoot Training Project. Chapter 2 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  4. 4.0 4.1 4.2 4.3 Africa Clubfoot Training Project. Chapter 15 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  5. Talipes, http://medical-dictionary.thefreedictionary.com/talipes (accessed 28 June 2017)
  6. P.J.Dyer, N.Davis, The Role of the Perani Scoring System in the Management of Clubfoot by the Ponseti Method, J Bone Joint Surg [Br] 2006;88-B:1082-4.