Atypical Clubfoot: Difference between revisions
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== Introduction == | == Introduction == | ||
The “Atypical” Clubfoot has recently been recognized as a specific subtype of clubfoot. It can be treated but it needs a slight modification of the usual Ponseti technique, and specific attention to details. | The “Atypical” Clubfoot has recently been recognized as a specific subtype of clubfoot. It can be treated but it needs a slight modification of the usual Ponseti technique, and specific attention to details.<ref name=":0">Africa Clubfoot Training Project. Chapter 12 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.</ref> | ||
== Recognizing Atypical Clubfoot == | == Recognizing Atypical Clubfoot == | ||
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* The foot is tight posteriorly, giving it marked equinus, but less tight medially so there is not so much varus | * The foot is tight posteriorly, giving it marked equinus, but less tight medially so there is not so much varus | ||
* There is often a deep transverse crease across the middle of the sole of the foot. This is because the foot is flexed across the middle, the “plantaris” deformity | * There is often a deep transverse crease across the middle of the sole of the foot. This is because the foot is flexed across the middle, the “plantaris” deformity | ||
* The tibia can also appear curved | * The tibia can also appear curved <ref name=":0" /> | ||
== Comparison of Normal Idiopathic and Atypical Clubfoot == | == Comparison of Normal Idiopathic and Atypical Clubfoot == | ||
The normal idiopathic clubfoot is tight medially, while the atypical clubfoot is tight posteriorly and on the plantar aspect. Note also short and hyper extended big toes are common in atypical clubfoot. | The normal idiopathic clubfoot is tight medially, while the atypical clubfoot is tight posteriorly and on the plantar aspect. Note also short and hyper extended big toes are common in atypical clubfoot. <ref name=":0" /> | ||
== Causes of Atypical Clubfoot == | == Causes of Atypical Clubfoot == | ||
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* Not enough moulding around the foot and heel | * Not enough moulding around the foot and heel | ||
* Not enough knee flexion | * Not enough knee flexion | ||
* Below-knee casts | * Below-knee casts <ref name=":0" /> | ||
== Treatment of Atypical Clubfoot == | == Treatment of Atypical Clubfoot == | ||
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* The child’s mother can be encouraged to massage the foot if you teach her how | * The child’s mother can be encouraged to massage the foot if you teach her how | ||
* Once the swelling is reduced then the first step of treatment is to elongate the plantar tissues | * Once the swelling is reduced then the first step of treatment is to elongate the plantar tissues | ||
Foot abduction is less important than in normal idiopathic clubfoot and you should aim for 30 - 40 degrees. Also beware of over - abducting and creating a lateral crease. | Foot abduction is less important than in normal idiopathic clubfoot and you should aim for 30 - 40 degrees. Also beware of over - abducting and creating a lateral crease. <ref name=":0" /> | ||
=== Casting Phase === | === Casting Phase === | ||
The cast for an atypical clubfoot should maintain the elongation. There should be thin, snug padding and good moulding. The cast should go above the knee, and knee flexion of 100 degrees should be aimed at, to stop the cast slipping down. | The cast for an atypical clubfoot should maintain the elongation. There should be thin, snug padding and good moulding. The cast should go above the knee, and knee flexion of 100 degrees should be aimed at, to stop the cast slipping down. | ||
Good cast for an atypical clubfoot; note the toes well supported from below but clearly visible. Note the flexed knees to prevent the cast slipping off. | Good cast for an atypical clubfoot; note the toes well supported from below but clearly visible. Note the flexed knees to prevent the cast slipping off. <ref name=":0" /> | ||
=== Tenotomy === | === Tenotomy === | ||
There is no need to abduct the foot very much in an atypical clubfoot as the talar head is usually covered early. As soon as the talar head cannot be felt and the plantaris is treated then a tenotomy can be done. Sometimes full dorsiflexion is not achieved after the tenotomy and it is worth recasting after a week to gently improve dorsiflexion. | There is no need to abduct the foot very much in an atypical clubfoot as the talar head is usually covered early. As soon as the talar head cannot be felt and the plantaris is treated then a tenotomy can be done. Sometimes full dorsiflexion is not achieved after the tenotomy and it is worth recasting after a week to gently improve dorsiflexion. <ref name=":0" /> | ||
=== Bracing Phase === | === Bracing Phase === | ||
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* A close watch should be kept for recurrence of plantar crease and equinus | * A close watch should be kept for recurrence of plantar crease and equinus | ||
* Walking improves the hindfoot but emptiness of the heel can continue for some years | * Walking improves the hindfoot but emptiness of the heel can continue for some years | ||
* Good results are possible with care | * Good results are possible with care <ref name=":0" /> | ||
== References == | == References == | ||
Revision as of 00:14, 18 August 2017
Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project
Top Contributors - Naomi O'Reilly, Kim Jackson, Simisola Ajeyalemi, Rachael Lowe, Tarina van der Stockt, Rucha Gadgil, Meaghan Rieke and Olajumoke Ogunleye
Introduction[edit | edit source]
The “Atypical” Clubfoot has recently been recognized as a specific subtype of clubfoot. It can be treated but it needs a slight modification of the usual Ponseti technique, and specific attention to details.[1]
Recognizing Atypical Clubfoot[edit | edit source]
- The foot is short and cylindrical: “the short fat foot”
- The first metatarsal is often flexed and the big toe hyperextended
- The foot is tight posteriorly, giving it marked equinus, but less tight medially so there is not so much varus
- There is often a deep transverse crease across the middle of the sole of the foot. This is because the foot is flexed across the middle, the “plantaris” deformity
- The tibia can also appear curved [1]
Comparison of Normal Idiopathic and Atypical Clubfoot[edit | edit source]
The normal idiopathic clubfoot is tight medially, while the atypical clubfoot is tight posteriorly and on the plantar aspect. Note also short and hyper extended big toes are common in atypical clubfoot. [1]
Causes of Atypical Clubfoot[edit | edit source]
This is not fully understood. Some children are born with atypical clubfoot, but we believe others become atypical because of poor treatment. If the POP cast slips down (usually between the 2nd and 4th cast) then the foot is pushed into equinus and plantaris (the midfoot flexes in the middle). The POP stops any varus deformity and the atypical pattern develops.
Cast slipping may occur because of:
- Too much padding
- Not enough moulding around the foot and heel
- Not enough knee flexion
- Below-knee casts [1]
Treatment of Atypical Clubfoot[edit | edit source]
Manipulation Phase[edit | edit source]
- Recognize it early
- If the foot is very swollen then give it a “cast holiday” for 1 - 3 weeks to let swelling settle
- The child’s mother can be encouraged to massage the foot if you teach her how
- Once the swelling is reduced then the first step of treatment is to elongate the plantar tissues
Foot abduction is less important than in normal idiopathic clubfoot and you should aim for 30 - 40 degrees. Also beware of over - abducting and creating a lateral crease. [1]
Casting Phase[edit | edit source]
The cast for an atypical clubfoot should maintain the elongation. There should be thin, snug padding and good moulding. The cast should go above the knee, and knee flexion of 100 degrees should be aimed at, to stop the cast slipping down.
Good cast for an atypical clubfoot; note the toes well supported from below but clearly visible. Note the flexed knees to prevent the cast slipping off. [1]
Tenotomy[edit | edit source]
There is no need to abduct the foot very much in an atypical clubfoot as the talar head is usually covered early. As soon as the talar head cannot be felt and the plantaris is treated then a tenotomy can be done. Sometimes full dorsiflexion is not achieved after the tenotomy and it is worth recasting after a week to gently improve dorsiflexion. [1]
Bracing Phase[edit | edit source]
- A Normal Foot Abduction Brace can be used but the abduction should be reduced to 30 - 40 degrees
- Dorsiflexion can be increased gradually
- A close watch should be kept for recurrence of plantar crease and equinus
- Walking improves the hindfoot but emptiness of the heel can continue for some years
- Good results are possible with care [1]
