• Congenital clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus. Also referred to as Talipes equinovarus (TEV),
• congenital clubfoot involves bone deformity and malposition with soft tissue contracture .
• This condition requires early evaluation and treatment for optimum correction.
• TEV is the most frequently occurring type of clubfoot (approximately 95 %).
• The incidence of clubfoot is 1 to 2 per 1000 live births.
• Males are affected twice as often as females. Bilateral clubfeet occur in 50% of the cases. A positive family history is associated with increased incidence. Incidence varies with geographical location with the lowest incidence in China and the highest in Polynesia.
Common foot malformation
Talipes varus: inversion or a bending inward
Talipes valgus: An eversion or a bending’ outward
Talipes equinus: Plantar flexion, in which the toes are lower than the heel
Talipes calcaneus: Dorsiflexion, in which the toes are higher than the heel
– Heel and angle are pointed to the midline of the body
– Foot in plantar flexion and deviates medially, heel is elevated.
Pathophysiology of Club Foot
• The exact cause of clubfoot remains unknown.
• A strong familial tendency, with a 1 in 10 chance that a parent with clubfoot will have an affected child.
• Other possible theories as to the cause of clubfoot include arrested fetal developmental of skeletal and soft tissue.
• Distal limb amniotic banding, a condition in which the amnion forms constrictive bands around a limb in utero, cutting off the circulation to the limb and resulting in further abnormal or arrested development.
Diagnostic Evaluation of Club Foot
• Clubfoot is readily apparent at birth if it has not been previously detected antenatally.
• The affected foot (or feet) is usually smaller and shorter, with an empty heel pad and a transverse plantar crease.
• When the defect is unilateral, the affected limb is usually shorter and some calf atrophy may be present.
• Anteroposterior and lateral (maximal dorsiflexion) radiographs.
Therapeutic Management of Club Foot
• The goal of treatment for clubfoot is to achieve a painless, plantigrade, and stable foot.
• Once the diagnosis is established, treatment is ideally initiated in the newborn period and involves three stages:
(1) correction of the deformity, PLASTER CAST
(2) maintenance of the correction until normal muscle balance is regained, DENIS BROWN splint 2 footplates and a crossbar
(3) follow-up observation to avert possible recurrence of the deformity.
• Serial casting is begun immediately or shortly after birth.
• Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot .
• Manipulation and casting are repeated frequently (every few days for 1 to 2 weeks, then at 1- to 2-week intervals) to accommodate the rapid growth of early infancy.
• The affected extremity, or extremities, are casted until maximum correction is achieved, usually within 8 to 12 weeks.
Prognosis of Club Foot
• Outcomes are not always predictable and depend on the severity of the deformity, age of the child at initial intervention, compliance with treatment protocols, and development of bones, muscles, and nerves.
• Surgical intervention does not restore the ankle to an entirely normal state, with the affected foot and leg remaining smaller and thinner than the unaffected side.
• Ankle range of motion following surgery may be even less than that was present preoperatively. Many children with surgically corrected clubfoot, however, are ‘able to walk without a limp and run and play.
•Nursing care of the child with non surgical correction is the same as it is for any child who has a cast.
• The child will spend a considerable time in a corrective device; therefore nursing care plans include both long-term and short-term goals.
• Careful observation of skin and circulation is particularly important in young infants because of their normally rapid growth rate.
• Since treatment and follow-up car are handled in the orthopaedist’s office, clinic, or outpatient department, Parent education and support are important in nursing care of these children.
Parental education for Club Foot
• Parents need to understand the diagnosis
• The overall treatment program, the importance of regular cast changes, and the role they play in the long-term effectiveness of the therapy.
• Reinforce and clarify the orthopaedic surgeon’s explanations and instructions
• Provide emotional support
• Teach parents about care of the cast or appliance (including vigilant observation for potential problems)
• Encourage parents to facilitate normal development within the limitations imposed by the deformity or therapy.
Nursing care plan for Club Foot
Detection of club foot at birth
Application of cast to hold the foot in the corrected positions
Use of Denis Browne split, if less than one year
Shoes fixed with metal cross bars
Impaired physical mobility
Abnormal position of foot and ankle
Allow parents to verbalize their concerns
Explain to the parents the effect of the device being used
Knowledge deficit related to condition and treatment.
Ineffective family coping related to situation crisis of infant
The need to change the device as child grows
If the device is in effective, surgery may be performed
Support the foot after surgery with cast or club foot shoes
Potential for physiologic injury, R/T failure to provide appropriate care.
Care of children with plaster cast
• Preparation for cast application
– Explain to the child what to expect with casting.
– Allow the parent to accompany the child to the cast room to hold their hand and talk to them during application.
– Stretch a tube stockinette over the area to be casted and place soft cotton sheets over the bony prominences.
– Inform the child the cast feels cool when it is applied wet but, will feel warm when it starts drying.
Nursing care plan
• Nursing diagnosis 1: Risk for altered peripheral tissue perfusion R/T pressure from cast.
– Keep the casted extremity elevated to prevent edema.
– Check circulation frequently (Every 15 min for the first 1 h, hourly for 24 h and 4 hourly there after.
– Assess for color, warmth, presence of pedal pulses and sensations of numbness or tingling.
– Signs of impaired neurovascular function are pain, pallor, pulselessness and parasthesia.
– Edema that is not improved by elevation indicates also neurovascular impairment.
• Nursing diagnosis 2: Risk for impaired tissue integrity R/T pressure from cast.
– When moving child in a wet cast, always use open palms to move the cast.
– Pressing with fingers indent the cast and cause pressure points which can lead to an ulcer.
– Turn the child every 2 h to allow the under surface of the cast to dry.
– Do not use heaters or fans to dry the cast as it causes uneven drying.
– When the cast is dry if the edges are not smooth or covered by a fold of stockinet smooth the adges by applying adhesive tape strips (Petaling)
– If casted area covers the genitalia cover the edges of the cast covering the genital area with a plastic or waterproof material.
– Keep the child in a semifowler’s position.
– Teach the child nothing to put between the cast and skin.
• Nursing diagnosis 3: Parental health seeking behaviors R/T care of child with cast at home.
– If the cast is for the lower extremity discuss how much weight bearing is allowed, and the use of crutches if prescribed.
– Reassure the parents that the child is comfortable with the cast.
– Demonstrate how to move or position the child and allow return demonstrations.
– If an abduction bar is used with the cast the parents should not use it as a handle to move or lift the child.
– Encourage providing touch stimulation to the remaining body parts.
– If itching is a problem instruct them to apply a hand lotion or massage the area gently if it is reachable.
– If not reachable blow cool air through the cast using a fan.
– Instruct not to put any thing inside to scratch.
Teaching Plan- contents
• Physical care:
1. Maintain appropriate muscle tone
2. Provision of comfort
3. Traction/ Cast care
4. Prevention of urinary stasis and constipation
5. Promotion of skin integrity
• Parent teaching:
• How to apply devices such as Denis Brown splint.
• Explain the procedure
• Teaching of diversional therapy during application of traction/cast
• Caring of cast? (wet, how to dry)
• Assess for circulatory and neurological disturbance