RIZAL TECHNOLOGICAL UNIVERSITY

Boni Avenue, Mandaluyong City College of Nursing

In partial fulfillment of the requirements in NCM 108: A CASE STUDY OF:

MEDICAL TERM:

Talipes Equinovarus

SUBMITTED BY: Taduran, Cayela Rosary T.

SUBMITTED TO: Prof. Ramon B. Espares RN, MAN

BACKGROUND/INTRODUCTION

Talipes deformity is a disorder of ankle and foot. It comes from the Latin words TALUS meaning ankle and PES meaning foot. Commonly called clubfoot, it is a congenital anomaly occurring at approximately 1 to 2 in every 1000 live births. Approximately 50% of cases of clubfoot are bilateral. In most cases it is an isolated dysmelia. This occurs in males more often than in females by a ratio of 2:1. A condition of the same name appears in animals, particularly horses. There are different causes for clubfoot depending on what classification it is given. Structural TEV (Talipes Equinovarus) is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affected limb are also causes of Structural TEV. Genetic influences increase dramatically with family history. It was previously assumed that postural TEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. However, this is countered by findings that TEV does not occur more frequently than usual when the intrauterine space is restricted. Breech presentation is also another known cause.TEV occurs with some frequency in Ehlers Danlos Syndrome and some other connective tissue disorders, such as Loeys-Dietz Syndrome. TEV may be associated with other birth defects such as spina bifida cystica. Clubfoot or Talipes Equinovarus is a congenital anomaly in which the foot is plantar flexed at the ankle and subtalar joints, the hind foot is inverted, and the midfoot and forefoot are adducted and inverted. Contractures of the soft tissues maintain the malalignments. 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. Screening for club foot prenatally is a debatable topic. However, this is commonly done as it is easily identified using an ultrasound scan. Most fetuses undergo a 20 weeks gestation fetal abnormality scan in which club foot is one of the abnormalities that can be picked up. Some doctors have argued that club foot

may occasionally be associated with a syndromic disease and should therefore be screened. If no syndromic association is found prenatally, most fetuses with club foot are born and can live a normal life with medical treatment

Types of True Talipes Deformity

1. 2. 3. 4.

Equinus (plantarflexion) Calcaneus (Dorsiflexion) Varus (foot turns inward) 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
NON-SURGICAL: - mild cases: manipulation, cast and splint application (nonsurgical management) a. 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.

Denis Brown Splint b. 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 c. 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.

Ilizarov Technique

SURGICAL: If cast treatment fails or the clubfoot is rigid, surgery may be needed. This is not usually done until the child is between four and eight months of age. 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 infants 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. Possible Nursing Diagnosis 1. Risk for Impaired Parenting R/T maladaptive coping strategies secondary to diagnosis of talipes deformity 2. Risk for Peripheral neurovascular dysfunction R/T mechanical compression (cast or brace) 3. Risk for impaired skin integrity R/T cast application, traction or surgery 4. Acute pain R/T muscular and tissue damage secondary to surgery

ANATOMY & PHYSIOLOGY

The bones of the newborns foot are largely formed in cartilage, which is less rigid and more easily moulded by external forces than bone. With growth, the cartilage is gradually replaced by bone except for joint surfaces.

Bone Tibia: Slight shortening is possible. Fibula: Shortening is common. Talus: In equinus in the ankle mortise, with the body of the talus being in external rotation, the body of the talus is extruded anterolaterally and is uncovered and can be palpated. The neck of the talus is medially deviated and plantar flexed. All relationships of the talus to the surrounding bones are abnormal. Os calcis: Medial rotation and an equinus and adduction deformity are present. Navicular: The navicular is medially subluxated over the talar head. Cuboid: The cuboid is medially subluxated over the calcaneal head. Forefoot: The forefoot is adducted and supinated; severe cases also have cavus with a dropped first metatarsal. Movements. The joints of the foot move in many directions. Terminology can be confusing. Its useful to consider a standard nomenclature for ankle and foot movements.

Joints Ankle joint. This lies between the tibia, fibula and talus. Ankle movements are dorsiflexion and plantarflexion. Subtalar joint lies between the talus and calcaneus. The midtarsal joints include the talonavicular and calcaneocuboid joints. Subtalar, ankle and midtarsal joints move together and result in foot supination and pronation. Muscles Atrophy of the leg muscles, especially in the peroneal group, is seen in clubfeet. The number of fibers in the muscles is normal, but the fibers are smaller in size. The triceps surae, tibialis posterior, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) are contracted. The calf is of a smaller size and remains so throughout life, even following successful long-lasting correction of the feet. Muscles provide the power to make the foot joints move: Gastrosoleus flexes the ankle. Tibialis anterior extends the ankle and supinates the foot. Tibialis posterior flexes the ankle and supinates the foot. Long toe flexors flex the ankle and toes. Long toe extensors extend the ankle and toes. Peroneals flex the ankle and pronate the foot. Ligaments Stability of the foot is provided by ligaments. Ligaments are strong fibrous bands that connect bones and allow limited motion. In patient with clubfoot, contractures are seen in the calcaneofibular, talofibular, (ankle) deltoid, long and short plantar, spring, and bifurcate ligaments. Tendon sheaths: Thickening frequently is present, especially of the tibialis posterior and peroneal sheaths. Joint capsules: Contractures of the posterior ankle capsule, subtalar capsule, and talonavicular and calcaneocuboid joint capsules commonly are seen. Fascia: The plantar fascial contracture contributes to the cavus, as does contracture of fascial planes in the foot.

DRUG STUDY
Drug Nam e Ibupr ofen Classif Dosa ication ge Mechanis m of Action Antiinflammatory , analgesic, and antipyretic activities largely related to inhibition of prostagl andin synthesis; Inhibits both cyclooxyge nase(COX) 1 and Slightly more selective for COX1 Indication Contraindic Side ation Effects Adverse Effects Nsg. Considerat ion Administer in the morning with a full glass of water.

Analge sic, NSAID

Age 6 mos23 mos: 50 mg/1. 25ml

Relief of mild to moderate pain Fever reduction *Post surgery*

Headache &musculoskele tal pain Advanced kidney and liver disease Asthma Active GI bleeding

C/I with allergy to ibuprofen, salicylates, or other NSA IDS (more common in patients with rhinitis, asthma, chronic urticaria, nasal polyps)

CNS: headache, dizziness, insomnia, vertigo CV: Hypertensi on GI: diarrhea, abdomina l pain, dyspepsia, nauseavomiting

CNS: nerveroot lesion, asthenia CV: Angina

Patient must stay upright for 60min GI: after taking gastric/eso the tablet to phagealulc avoid ers, potentially serious RESPI: esophageal URTI, bron erosion. chitis, MUSCUL pneumonia M o n i t o OSKELE r serm TAl: calcium Back levels befor pain, e, during myalgia, and after joint pain therapy. Ensure adequat e intake of Vitamin D and calcium Encour age frequent small meals if GI effects are uncomfo rtable

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 infants 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 infants side most of the time. Convey expression of parents towards the childs condition.