Talipes Deformity Case Study (Clubfoot)

Talipes Deformity or Clubfoot

Definition

Talipes deformity is a disorder of ankle and foot.  It comes from the Latin words talus meaning ankle and pes meaning foot.

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.

Bilateral deformity involvement accounts 30%-50% of cases.

True Talipes Disorder

Talipes deformity could either be unilateral (affecting a single foot only) or bilateral (both feet are affected).  Regardless of which extremity is affected, some newborns have developed a twisted foot appearance due to intrauterine position. However, with manipulation the foot can be brought into a straight position. This temporary abnormality is called a pseudo-talipes disorder. A true clubfoot cannot be aligned properly without further intervention.

Skeletal Anatomy of the Foot

Two essential functions of the foot:

  1. Reinforces body weight
  2. Allows the body to move forward when running or walking

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. Medial cuneiform
  2. Intermediate cuneiform
  3. Lateral cuneiform
  4. Cuboid
  5. Navicular
  6. Talus
  7. 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

Etiology

The exact cause of this deformity is unknown. But suggestions or hypotheses of its disease process are the following:

  • Genetic factor
  • Abnormal tendon insertion

Anomalous tendons may affect the alignment of the foot.

  • Retracting fibrosis (myofibrosis)

Collagen found in all ligaments and tendons are coiled and could be stretched with the exception of Achilles tendon (made up of tightly coiled collagen and cannot be stretched).

Thickening and scarring of fibrous tissue could cause the twisted foot appearance.

  • Neurogenic factors

Innervation changes during the prenatal period could be due to the presence of neurologic events or disorder such as, spina bifida. Studies show that 35% of children with clubfoot have neurologic impairment.

  • Oligohydramnios

Fluid leak during the prenatal period could cause restriction of fetal movements thereby, predisposing to a deformed foot.

  • Developmental arrest of fetal development

Disruption of the medial rotation of the fetal foot could result to a clubfoot condition.

  • Diminished Vascular Circulation

Disruption of the branches of the vascular supply of the lower extremity could contribute to misalignment of the foot.

Types of True Talipes Deformity


  1. Equinus (plantarflexion)
  2. Calcaneus (Dorsiflexion)
  3. Varus (foot turns inward)
  4. Valgus (foot turns outward)

Some children with this deformity have a combination of the types listed. For example, a child who walks on the heel with the foot turning outwards has calcaneovalgus disorder while the child who tiptoes with the foot inverted has equinovarus deformity.

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

Categories of treatment:

  1. For mild cases: manipulation, cast and splint application (nonsurgical management)
  2. For severe cases: surgery

Nonsurgical management

denis browne splint

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
    • Frequency of changing the cast is every 5-7 days to accommodate the rapid growth during the first year of life.
    • 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.
    • Final cast is removed after 2-3 weeks when Achilles tendon is already healed.
    • After the final cast is removed:
  1. 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.
  2. 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 frame

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 infant’s 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.

Discharge Plan

Medication

  • Acetaminophen (Tylenol) is an analgesic and antipyretic given for pain relief after traction or tenotomy.
  • Do not use Tylenol with NSAIDs or salicylates. Combined use predisposes the child to experience adverse renal effects.

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.

Treatment

  • Cast application
  • Physiotherapy
  • Surgery (last option)

Health Teaching

  • Cast care:

Frequently change the infant’s diaper to prevent soiling of the cast.

Use dry cleanser in wiping the cast.

Ongoing Assessment

  • Assess the circulation of casted foot.

Diet

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

Spiritual

  • The mother or the primary caregiver is the significant person for the infant; therefore, she should be at the infant’s side most of the time.
  • Convey expression of parents towards the child’s condition.

Possible Nursing Diagnosis

  1. Risk for Peripheral neurovascular dysfunction R/T mechanical compression (cast or brace)
  2. Risk for impaired skin integrity R/T cast application, traction or surgery
  3. Acute pain R/T muscular and tissue damage secondary to surgery
  4. Risk for Impaired Parenting R/T maladaptive coping strategies secondary to diagnosis of talipes deformity

NCP for Clubfoot

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Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

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