Congenital skeletal malformations

Maria Carmela L. Domocmat, RN, MSN

Intructor

Northen Luzon Adventist College 1

� a congenital deformity in which the foot is

twisted out of shape or position;

� Aka: clubfoot

Maria Carmela L. Domocmat, RN, MSN 2

Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

� dorsiflexion - t. calca´neus

� plantar flexion - t. equi´nus

� abducted and everted -t.val´gus or flatfoot

abducted and inverted - t. va´rus� abducted and inverted - t. va´rus

� various combinations

� t. calcaneoval´gus

� t. calcaneova´rus

� t. equinoval´gus

� t. equinova´rus

Maria Carmela L. Domocmat, RN, MSN 3

Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

� t. calcaneoval´gus� the foot is turned outwards with the toes pointing

upwards� t. calcaneova´rus

� the foot points inwards and up� the foot points inwards and up� t. equinoval´gus

� the foot points outwards and down� t. equinova´rus

� most common type

� foot is fixed in plantar flexion (downward) and deviated medially (inward)

Maria Carmela L. Domocmat, RN, MSN 4

Maria Carmela L. Domocmat, RN, MSN 5

http://img.tfd.com/dorland/thumbs/talipes.jpg

Maria Carmela L. Domocmat, RN, MSN 6

http://www.abdn.ac.uk/~gen155/graphics/clubfoot.jpeg

http://www.fpnotebook.com/_media/Ortho

PedsFootCF.jpg

Maria Carmela L. Domocmat, RN, MSN 7

http://1.bp.blogspot.com/_IZV_l47MkXQ/TRpGEJogmHI/AAAAAAAAAGw/X1VQqO

DtJG4/s1600/child_foot_clubfoot_intro01.jpg

o The true etiology of congenital clubfoot is

unknown

oExtrinsic associations include oExtrinsic associations include � Teratogenic agents (eg, sodium aminopterin)

� Oligohydramnios

� Congenital constriction rings

Maria Carmela L. Domocmat, RN, MSN 8

oGenetic associations include

o mendelian inheritance (eg, diastrophic dwarfism;

o autosomal recessive pattern of clubfoot inheritance).o autosomal recessive pattern of clubfoot inheritance).

o Cytogenetic abnormalities (eg, congenital talipes

equinovarus [CTEV]) can be seen in syndromes

involving chromosomal deletion.

Maria Carmela L. Domocmat, RN, MSN 9

oTalipes may be positional or structural. � Positional talipes is caused by abnormal pressures

compressing the foot while it's developing, as a result

of its position in the womb.

� Structural talipes is a more complex condition and

probably caused by a combination of factors, such as

a genetic predisposition

Maria Carmela L. Domocmat, RN, MSN 10

http://www.bbc.co.uk/health/physical_health/conditions/talipes2.shtml

o deformity is readily apparent at birth

o can be detected antenatally during the routine

development ultrasound scan around 20 weeks.development ultrasound scan around 20 weeks.

o X-rays may be needed to confirm diagnosis.

Maria Carmela L. Domocmat, RN, MSN 11

o treatment is most successful when started

early in infancy because delay causes muscles

and bones of legs to develop abnormally, and bones of legs to develop abnormally,

with shortening of tendons

Maria Carmela L. Domocmat, RN, MSN 12

� gentle, manipulation of foot with casting

� done every few days for 1 to 2 weeks then at 1- to 2-week

intervals

� Ponseti’s Method of treatment� Ponseti’s Method of treatment

Maria Carmela L. Domocmat, RN, MSN 13

Maria Carmela L. Domocmat, RN, MSN 14

� involves serial manipulation and plaster casting of the clubfoot.

� The ligaments and tendons of the foot are gently stretched with weekly, gently manipulations. stretched with weekly, gently manipulations.

� A plaster cast is then applied after each weekly sessions to retain the degree of correction obtained and to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct alignment.

� Four to five long leg (from the toes to the hip) are applied with the knee at a right angle.

Maria Carmela L. Domocmat, RN, MSN 15

LONG LEG CAST DENNIS BROWN SPLINT

Maria Carmela L. Domocmat, RN, MSN 16

http://www2.massgeneral.org/ORTHO/DennisBrownBrace.gifhttp://www2.massgeneral.org/ORTHO/BabyCast.gif

Maria Carmela L. Domocmat, RN, MSN 17

� Making A Difference: Caring For Clubfoot at

the Sinai Hospital of Baltimore at

http://www.youtube.com/watch?v=Rmkrrvw

MH4A&feature=player_embedded#!MH4A&feature=player_embedded#!

Maria Carmela L. Domocmat, RN, MSN 18

� done if nonsurgical treatment not effective � tight ligaments released� tendons lengthened or transplanted � Other surgical treatments � Other surgical treatments

- circumferential release: "cincinati incision"- Goldner four quadrant approach:

- medial release- posterior release- posteromedial release- tendon transfers

Maria Carmela L. Domocmat, RN, MSN 19

� extended medical supervision is required

� bcoz there is a tendency for this deformity to recur

(considered cured when the child is able to wear

normal shoes and walk properly)normal shoes and walk properly)

� care emphasizes muscle reeducation (by

manipulation) and proper walking

Maria Carmela L. Domocmat, RN, MSN 20

� heels and soles of braces or shoes

prescribed following correction must be

kept in repair

corrective shoes may have sole and heel lifts � corrective shoes may have sole and heel lifts

on lateral border to maintain proper

positioning

Maria Carmela L. Domocmat, RN, MSN 21

• Approximately 50-60% of club feet in newborns

can be corrected non-operatively.

• About 20% of infants requiring surgery need • About 20% of infants requiring surgery need

further surgery at a later stage.

Maria Carmela L. Domocmat, RN, MSN 22

Maria Carmela L. Domocmat, RN, MSN 23

Maria Carmela L. Domocmat, RN, MSN 24

• imperfect development of hip –can affect

femoral head, acetabulum, or both

• head of femur does not lie deep enough within • head of femur does not lie deep enough within

the acetabulum and slips out on movement

• occurs in females 7 times more often than males

Maria Carmela L. Domocmat, RN, MSN 25

Maria Carmela L. Domocmat, RN, MSN 26

o acetabular dysplasia� mildest form

� femoral head remains in acetabulum

o subluxation o subluxation � most common form

� femoral head partially displaced

o dislocation � femoral head not in contact with acetabulum

� displaced posteriorly and superiorly

Maria Carmela L. Domocmat, RN, MSN 27

o limitation in abduction of leg on affected

side

o asymmetry of gluteal, popliteal, and thigh o asymmetry of gluteal, popliteal, and thigh

folds

o Waddling gait and lordosis when child

begins to walk

Maria Carmela L. Domocmat, RN, MSN 28

Maria Carmela L. Domocmat, RN, MSN 29

� With child in a supine position, the right knee on the side of the subluxation the subluxation appears lower than the left because of malposition of the femur head.

Maria Carmela L. Domocmat, RN, MSN 30

� infant on a supine position.

� Doctor abducts the hips by moving the bent

hips and knees apart.

If the hip feels like it can be pushed out the � If the hip feels like it can be pushed out the

back of the socket, this is considered

abnormal.

� This is called a positive Barlow's Test and is a

sign of instability in the hip.

Maria Carmela L. Domocmat, RN, MSN 31

� As the hip is abducted further, the doctor

might feel the ball portion (the femoral head)

slide forward as it slips back into the socket.

Or audible click when abducting and � Or audible click when abducting and

externally rotating hip on affected side:

Maria Carmela L. Domocmat, RN, MSN 32

Maria Carmela L. Domocmat, RN, MSN 33

� directed toward enlarging and deepening the

acetabulum by placing the head of femur within the

acetabulum and applying constant pressure� proper positioning: legs slightly flexed and abducted � proper positioning: legs slightly flexed and abducted

� Surgical Ix

Maria Carmela L. Domocmat, RN, MSN 34

o proper positioning: legs slightly flexed and

abducted � Pavlik harness� Pavlik harness

� Frejka pillow: a pillow splint that maintains

abduction of legs

� Bryant’s traction

� Spica cast

� Closed reduction

Maria Carmela L. Domocmat, RN, MSN 35

� Hip abduction splint

� holds the hips in an

abduction position,

forcing the femur forcing the femur

head into the

acetabulum.

Maria Carmela L. Domocmat, RN, MSN 36

Maria Carmela L. Domocmat, RN, MSN 37

Maria Carmela L. Domocmat, RN, MSN 38

http://www.orthopediatrics.com/binary/org/ORTHOPEDIATRICS/images/hipimages/child_hip_devel_dysp_treatment01.jpg

Maria Carmela L. Domocmat, RN, MSN 39

http://www.lpch.org/media/image

s/conditions/ei_0239.gif

Maria Carmela L. Domocmat, RN, MSN 40

� A hip abduction cast for correction of

subluxation of the hip.

Maria Carmela L. Domocmat, RN, MSN 41

Maria Carmela L. Domocmat, RN, MSN 42

Maria Carmela L. Domocmat, RN, MSN 43

Maria Carmela L. Domocmat, RN, MSN 44

http://isakssonsgummifabrik.com/pics/babyfront.jpg

� open reduction with casting

� derotational osteotomy

� Pelvic osteotomies� Pelvic osteotomies

Maria Carmela L. Domocmat, RN, MSN 45

� femur is cut and rotated to make it easier to

keep the femoral head inside the acetabulum.

� When this procedure is done, the soft tissues

loosen up and the forces of the muscles tend to loosen up and the forces of the muscles tend to

keep the femoral head reduced.

� Once again, the child is put in a spica cast for

several months while the bone heals.

� A CT scan may be used to confirm successful

reduction before removing the cast.

Maria Carmela L. Domocmat, RN, MSN 46

Maria Carmela L. Domocmat, RN, MSN 47

� for children older than 18 months which may require

additional surgery to change the acetabulum

(socket) in addition to the femur (thighbone)� The problem has been present longer and the anatomy has grown � The problem has been present longer and the anatomy has grown

more distorted over the longer period of time.

Maria Carmela L. Domocmat, RN, MSN 48

Maria Carmela L. Domocmat, RN, MSN 49

� Several different types of osteotomies are used to

tilt the acetabulum in a more horizontal angle to the

floor. By doing this, the femoral head is less likely to

slide up and out of the socket with weightbearing. slide up and out of the socket with weightbearing.

� Types : Steele osteotomy; Salter osteotomy;

Pemberton osteotomy

Maria Carmela L. Domocmat, RN, MSN 50

� This can stop the femoral head from sliding

up and out of the socket.

� Over time this shelf of bone above the

acetabulum remodels and forms a deeper acetabulum remodels and forms a deeper

acetabulum.

� the bone of the pelvis just above the

acetabulum is cut to allow the bone to slide

out and form a new roof over the hip joint.

Maria Carmela L. Domocmat, RN, MSN 51

Maria Carmela L. Domocmat, RN, MSN 52

� uses a bone graft placed just above the hip

joint to create a new, wider roof, or shelf over

the acetabulum.

This keeps the femoral head from sliding up � This keeps the femoral head from sliding up

and out of the socket and, as it heals, makes a

larger weightbearing surface to spread out

the weight that needs to be transferred from

the femoral head to the acetabulum and

pelvis.

Maria Carmela L. Domocmat, RN, MSN 53

Maria Carmela L. Domocmat, RN, MSN 54

� not as common

� the entire acetabulum is cut free of the pelvis

and moved or dialed at the best angle and

then allowed to heal in that position.then allowed to heal in that position.

Maria Carmela L. Domocmat, RN, MSN 55

o Same with other clients with cast and

braces; pre- and post-op care

o Transportation and positioningo Transportation and positioning� use wagon or stroller with back flat or mechanic’s

creeper

� protect child from falling when positioned

� never pick up child by the bar between the legs of

cast (use two people to provide adequate body

support if necessary)

Maria Carmela L. Domocmat, RN, MSN 56

� A patient's guide to developmental dysplasia of the hip in children retrieved on September 4, 2011 at http://www.orthopediatrics.com/docs/Guides/dysplasia.html

� Massachusets General Hospital. Pediatric orthopaedic ailments: Clubfoot. Retrieved on September 4, 2011 at http://www2.massgeneral.org/ORTHO/ClubFoot.htmSaxton, Nugent, and Pelikan. (2006). Mosby’s comprehensive http://www2.massgeneral.org/ORTHO/ClubFoot.htm

� Saxton, Nugent, and Pelikan. (2006). Mosby’s comprehensive review of nursing [18th ed]. St. Louis: Mosby

� Talipes Equinovarus. Retrieved on September 4, 2011 at http://www.patient.co.uk/doctor/Club-Foot.htm

� Wheeless’ Textbook of Orthopaedics. Talipes equinovarus/Clubfoot Retrieved on September 4, 2011 at http://www.wheelessonline.com/ortho/talipes_equinovarus_clubfoot

Maria Carmela L. Domocmat, RN, MSN 57