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Paediatrics FCRS > Clubfoot > Flashcards

Clubfoot Flashcards

1
Q

What is this?

A
  • Congenital talipes equinovarus
  • aka clubfoot
  • Idiopathic deformity of the foot of unclear aetiology
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2
Q

Describe the epidemiology congenital talipes equinovarus?

A
  • MOST COMMON BIRTH DEFECT
  • 1:250 to 1:1000
  • highest prevalence in HAWIIANS AND MAORIS >
  • More common in MALES
  • 50% Cases are BILATERAL
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3
Q

Describe the genetics of congenital talipes equinovarus?

A
  • Genetic aetiology is strongly suggested
  • familial occurrence 25%
  • recent link to PITX1 transcription factor criticial for limb development
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4
Q

What other conditions are associated with congenital talipes equinovarus?

A
  • Hand abnormalitis - STREETER dysplasia
  • DIASTROPHIC DYSPLASIA
  • ARTHROGRYPOSIS
  • TIBIAL HEMIMELIA
  • MYELODYSPLASIA
  • PRUNE BELLY Syndrome
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5
Q

Describe the muscle contractures that -> clubfoot ?

A
  • NB CAVE!!!
  • Midfoot CAVUS ( tight intrinsics)
  • Forefoot ADDUCTUS ( tight tibalis POSTERIOR)
  • Hindfoot VARUS ( tight tendoachilles, tib post)
  • Hindfoot EQUINUS ( tight tendoachilles)
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6
Q

What does the bony deformity consist of?

A
  • Talar neck is medially and planetary deviated
  • Calcaneus is in VARUS and ROTATED MEDIALLY around TALUS
  • Navicular and CUBOID are displaced Medially
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7
Q

What do you see at presentation?

A
  • Small foot and calf
  • Shortened tibia
  • medial and posterior foot skin creases
  • foot deformity
    • HINDFOOT IN EQUINUS + VARUS ( rigid equinus and resistance to passive correction)
    • Midfoot in CAVUS
    • Forefoot in ADDUCTION + SUPINATION
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8
Q

What imaging is useful iin congenital talipes equinovarus?

A

xray

  • Turco view xray- dorsiflexion lateral xray =
  • HINDFOOT PARALLELISM BETWEEN THE TALUS AND CALCANEUS
  • Will see TALOCALCANEAL ANGLE <35degrees
  • FLAT TALAR HEAD
  • on ap - talocalcaneal angle <20 ( n20-40)
  • Talus 1st MT angle is negative ( n0-20)
  • hindfoot parallelism
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9
Q

What is the tx for congential talipes equinovarus?

A

Non -op

  • Ponsetti method of serial manipulation + casting trend for this cf surgery w improved long term results
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10
Q

what are the outcomes on the Ponsetti method?

A
  • Has 90% success rate
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11
Q

What are the indications for surgery in congenital talipes equinovarus?

A
  • Resistant feet in young children
  • Rocker bottom feet that develop due to serial casts
  • syndrome assoc clubfoot
  • delayed presentation >1-2 years of age
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12
Q

What age is surgery performed?

A
  • At 9-10 months so child can be ambulatory at 1 year
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13
Q

What does surgery involve in congenital talipes equinovarus?

A
  • Posteromedial soft tissue release and tendon lengthening
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14
Q

What are the outcomes of surgery?

A
  • Requires post op casting for best results
  • extent of soft tissue release correlates with long term function of the foot and patient
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15
Q

What surgery is suggested for older children and what age are they?

A
  • Medial opening or lateral column shortening osteotomy of cuboid decancellation
  • age 3-10
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16
Q

What further surgery is suggested for an even older child and what age are they?

A
  • TRIPLE ARTHRODESIS in refractory clubfoot
  • AGE 8-10
17
Q

When is a triple arthrodesis contraindicated?

A
  • In an insensate foot
  • due to rigidity and resultant ulceration
18
Q

What is the salvage procedure for a child who presents with clubfoot at 8-10 with an insensate foot?

A
  • Talectomy
19
Q

Can you describe the serial manipulation and correction for the Ponsetti method?

A

When born Weekly serial casting to firstly

a) correct midfoot cavus- by forefoot SUPINATION -by aligning plantarflexed 1st MT with remaining metatarsals not pronation as this would increase cavus
b) forefoot adduction- by rotation of calcaneus and forefoot around talus- lateral pressure on talus and rotating forefoot
c) hindfoot varus - by rotation of calcaneus and forefoot around talus
d) hindfoot equinus - by tendoachilles tenotomy Month 1-4 do a-c wk 8 to TAL- perform when foot is 70 degrees abducted and heel in valgus- full transverse

  • then Month 4-8 FOOT ABDUCTION ORTHOSIS (FAO) with Denis brown
    • Bar- shoes attached 70 degrees of abduction effective side and 40 degrees on normal side
    • 23 hrs a day for3/12 post correction
    • night time/nap time only until 4 years

​​ 2-4 years

  • Anterior tibial tendon transfer at age 2
  • ( 10-20% will need) for recurrent SUPINATION, VARUS or EQUINUS
  • required if shows supination of the foot is demonstrated during dorsiflexion ( a dynamic intoeing gait)
20
Q

What are the complications of the Ponsetti method?

A
  • DEFORMITY
  • RELAPSE
  • DYNAMIC SUPINATION- foot supination during the swing phase of gait and landing on the lateral for border up during stance
21
Q

How is dynamic supination corrected?

A
  • It occurs due to medial over pull of TIBIALIS anterior
  • incomplete reduction ot navicular changes action of tibialis ant from dorsiflexion to supination
  • Surgically with anterior TIBIALIS tendon transfer from medial cuneiform medial and plantar surface and base of 1st metatarsal to the lateral cuneiform and cuboid. Use whole tendon rather than split
22
Q

How will you tx a deformity relapse in a child <2yrs?

A
  • <2yr usually non compliance with FAO
  • tx repeated casting
23
Q

How will you tx a deformity relapse in a child >2yrs?

A
  • >2yrs tx initally w casting
  • consider TA tendon transfer to lateral cuneiform (only if lat c is ossified)
  • consider repeat TAL
24
Q

What are the complications of surgical tx?

A
  • RESIDUAL CAVUS- navicular placed dorsally sublimed position
  • PES PLANUS- over correction
  • UNDERCORRECTION INTOEING GAIT
  • OSTEONECROSIS OF TALUS
  • DORSAL BUNION- dorsiflexion of 1st MT ( FHB+Abd hallucis overpull 2ary to weaker plantar flexion) + overactivity of anterior tibialis tx with capsulotomy , FHL lengthening, fhb flexor to extensor transfer at MTPJ

Paediatrics FCRS (27 decks)

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