CONGENITAL TALIPES EQUINO VARUS (CLUBFOOT)

Complied: dini noviani p Preceptor : Dr. Arsanto Triwidodo, SpOT,FICS, K Spine, MHKes

ANAMNESE
Allonamnesis with the patient's mother called Mrs. I on the 14th January 2013 on 10.00 am.

Name Age Sex Address Mother name Occupation Religion

An. J 5months male warakas

Mrs. I
Housewife Islam 10th January 2013 the 5th floor team B

Admitted
Taken from

HISTORY TAKING
CHIEF COMPLAINT

Both ankles bent inwards from birth

HISTORY OF PRESENT ILLNESS

A mother brings her 2 months old boy to a pediatric policlinic RSUD Koja. She noticed that both of her boys foot looks excessively turned inward since he was born. Twisted ankle is not accompanied by swelling, pain when held, and redness and can not be straightened out like a normal foot. Movement of the foot are normal. There is no abnormality at the other part of his body. Lump on spine denied. Patient's mother was worried about her son's leg. There is no fever, cough, shortness of breath.

Prenatal history (ANC)

During pregnancy mothers patient who have checked regularly to obstetrician midwife once a month to 8 months gestation, then weekly at 9 months gestation. During pregnancy was never sick, never taking drugs purchased alone, except vitamin obtained from obstetrician midwife. TT immunization 2 times. The first child was born 6 years spontaneously and second child born 3 years spontaneous. Age of the mother when pregnant patients 35 years (TB: 160 cm, weight: 50 kg)

HISTORY
Antenatal History: Post natal History :

Spontaneous labor at antenatal clinics assisted by Primary immunization a midwife on the 18th August are compeletely on 2012. 2 hours before partus, time. Patients patients mother admitted consume breast milk premature rupture of and soft porridge. The membranes. birth weight is patient was prone. 4300 grams, body length at birth 60 cm, Apgar score 7-9. Cried spontaneously.

HISTORY

History of family illness: No one in hIs family got disease like him

History of past illness: Others disease (-)-

MEDICATION HISTORY
Patients had consulted an orthopedic doctor at the age of 8 weeks. Then do the correction of serial cast 6 times until the age of 5 months.

Physical examination
Primary survey
Airway : Clear, patients can speak spontaneously. stridor (-), gargling () Breathing : Look : Spontaneous breathing regular, symmetrical chest wall movement. Not look any supraclavicular retractions, suprasternal, and intercostal. no muscle contractions seem a respirator. Listen : Vesicular breath sounds (+ / +), ronchi (- / -), wheezing (- / -) Feel The chest wall movement is palpable symmetricly with a frequency of 20 times / minutes Circulation : patients compos mentis skin cyanosis (-) carotid artery and radial artery pulse are palpable pulse 90 beats / minute, the content is quite, equal symmetric CRT <2 "

Disability : GCS: E4M6V5 pupil isokor (+ / +) direct light reflex (+ / +), indirect light reflex (+ / +) Exposure looks both ankles bent inward body temperature: 36.8 C

Secondary survey
General appearance

moderately ill

conciousness
Compos mentis

TEMP : 36,8 C
RESP RATE : 20x/mn
Nutrition NORMAL

HEART RATE : 80x/mn

PHYSICAL EXAMINATION
HEAD NORMOCEPHALY EYES ANEMIC CONJUCTIVA -/ ICTERIC SCLERA -/NECK LYMPYH NODE IS NOT PALPABLE THYROID GLAND IS NOT PALPABLE JVP 5+2 cmH2O MOUTH Lip cyanosis(-) pallor (-) Pharynx hyperemic (-), symmetrical, uvula midline

THORAX
INSPECTION Ictus Cordis is visible ICS LMCS PALPATION
Ictus cordis is palpable at 5th ICS LMCS

PERCUTION Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS

AUSCULTATION
Regular I II Heart Sound, Murmur (-), Gallop (-)

THORAX
Lung Examination

Inspection

:Symmetrical Supraclavicula retraction(-) Intercostalis retraction(-) Palpation :Equal vocal fremitus Percussion :Sonor in both lung Auscultation :Vesicular breath sound in both lung Wh -/-, Rh -/-

Abdominal Examination
Inspection Brown skin, distended abdomen (-) Palpation No Pain on palpation at Epigastric Liver not palpable Spleen not palpable Percussion No pain present on abdominal percussion Sound Dullness Shifting dullness (-) CVA (-) Auscultation Bowel sound (+) 2 times/minute. Arterial bruit (-), venous hum (-)

Extremity Examination Extremity examination

Status localist REGIO PEDIS BILATERAL

Bean shaped deformity (+) Forefoot and midfoot inversion and adduction (+) The lateral side of the foot convex, concave medial side, there are wrinkles on medial plantar feet (+) Hindfoot equines (+), heel drawn up and inversion, wrinkles in the posterior joint ankle.

Feel and movement:

Look

Legs can be made neutral position Forefoot can be positioned on the abduction and hindfoot can be position on the eversion

Laboratory findings
RESULT Hemoglobin Leukocyte Trombocyte Ht Eritrosit MVC MCH MCHC LED RDW Cloting time Bleeding time Ureum Creatinin SGOT SGPT Na K Cl 10.2 15.400 422.000 29 3.68 30 23 25 7 14,4 NORMAL 12 17 g% 5000 10000 150 450ribu 37 48 % 3.8 5.8 jt/mm2 <10 mm/time

11 4 9 0,4 53 53 143 3.88 112

5-15 1-6 10 45 mg/dl 0.4 1.5 mg/dl <40 u/l <40 u/l

RADIOLOGY
Rontgen photo after birth Type of photo : Pedis bilateral DP and lateral Description : DP Position : Talocalcaneal angle < 150 (Normally is 20400) (talus and calcaneus parallel because the heel inversion and adduction of the anterior calcaneus). Angle talometatarsal first > 150 (Normally is 0-150) because of varus Tibiocalcaneal angle > 900 Lateral position : Talocalcaneal angle in this position is < 25 (Normally is 30-500) Dorsoplantar shows the convergence of metatarsal base is abnormally increased. Impression : CTEV bilateral

Resume
Patient, a boy 5 months brought his mother to a pediatric policlinic RSUD Koja. She noticed that both of her boys foot looks excessively turned inward since he was born. Twisted ankle is not accompanied by swelling, pain when held, and redness and can not be straightened out like a normal foot. Movement of the foot are normal. There is no abnormality at the other part of his body. Lump on spine denied. Patient's mother was worried about her son's leg. There is no fever, cough, shortness of breath. Prenatal,antenatal, and postnatal history are normal limit. Primary survey in the normal limit. Secondary survey in the normal limit. Status localist Regio pedis bilateral based on look are bean shaped deformity, forefoot and midfoot inversion and adduction, the lateral side of the foot convex, concave medial side, there are wrinkles on medial plantar feet, hindfoot equines, heel drawn up and inversion, wrinkles in the posterior joint ankle

Resume
. Then from feel and movement are legs can be made neutral position and forefoot can be positioned on the abduction and hindfoot can be position on the eversion. Laboratory examination are Hb 10,2 g/dl is decreased, leukosit 15.500/uL is increased, hematokrit is decreased. From the rontgen photo pedis bilateral there is abnormal limit. Talocalcaneal angle < 150 (talus and calcaneus parallel because the heel inversion and adduction of the anterior calcaneus), Angle talometatarsal > 150 because of varus, tibiocalcaneal angle > 900, and dorsoplantar shows the convergence of metatarsal base is abnormally increased.

WORKING DIAGNOSIS

Congenital talipes equinovarus (Clubfoot) bilateral (typical)

DIFFERENTIAL DIAGNOSIS

Postural clubfoot

Metatarsus adductus (or varus)

Absensi or Congenital hypoplasia of tibia

SUGGESTED EXAMINATION

THERAPY
Serial casting (Ponseti methode) have done while patients aged 2 months 6 times

therapy
Pro Achilles Tendon Lengthening (ATL) bilateral
Preparation operation : IVFD N1B dpm Antibiotik Board Spectrum (Cefotaxim) 300 mg 1 hour before operation

Post operation: IVFD N1B dpm Antibiotik board spectrum (Cefotaxim 2x250mg) Analgesic (Ketolorac 3x10%) Analgesic (Tramadol drip 3x30mg)

Therapy
Picture after correction with ATL

therapy
Three weeks after tenotomi, the cast is removed, and the brace (dennis brown) is used immediately

prognosis
Ad Vitam ad bonam Ad Fungsionam

dubia ad
bonam

Ad sanationam dubia ad bonam

Definition and classification

Classiification : 1. Postural clubfoot 2. Idiopathic (Unknown Etiology) : Congenital Talipes Equino-Varus CTEV 3. Acquired, Secondary to : CNS Disease : Spina bifida, Poliomyelitis Arthrogryposis Absent Bone : fibula / tibia

Anatomy foot
Bone structure
Hindfoot : -Talus -Calcaneus Midfoot : -3 cuneiforme : medial, intermedium, lateral -cuboid -Naviculare Forefoot : -5 metatarsal -14 phalang

Articulations and Ligamentous Support

Epidemiology
Occurs approximately in one of every 1000 live birth In affected families, clubfeet are about 30 times more frequent in offspring Male are affected in about 65% of cases Bilateral cases are as high as 30 40 %

etiology
Some of these factors are : Abnormal intrauterine forces Arrested fetal development Abnormal muscle and tendon insertions Abnormal rotation of the talus in the mortise Germ plasm defects The mechanical forces or positional hypothesis

pathofisiology
Arrest of fetal development in the fibular stage Defective cartilaginous anlage of the talus Neurogenic factors Retracting fibrosis (or myofibrosis) secondary to increased fibrous tissue in muscles and ligaments Anomalous tendon insertions

Basic pathology
Abnormal Tarsal Relation Congenital Dislocation / Subluxation Talo Calcaneo Navicular Joint Soft Tissue Contracture Congenital Atresia

Diagnosis
- Equinovarus position, feet appear smaller and densely - The shape of the foot is very typical. Medial concave side while the lateral side more convex called bean shaped deformity - Posterior tuberosity of the calcaneus are hard to see and touched - On the lateral side of the dorsum pedis are bony anterior talus - Lateral malleolus located more posteriorly than the medial malleolus - Not to do a full - dorsiflexion At the foot dorsiflexion and eversion will be felt triceps surae and tibialis posterior tendon being stretched

Feet

Ankle, tibia, knee and leg

Ankle: Thickening and shortening of the ligaments and joint capsule in the medial and posterior ankle joint Tibia: os tibia torsion. Knee and leg: - hyperextension of the knee joint can occur when children start walking muscle atrophy gastrocsoleus accordance with increasing age

radiology
X-rays needed to assess progress of treatment

Treatment and management

The goal of treatment for clubfoot is to obtain a plantigrade foot that is functional, painless, and stable over time A cosmetically pleasing appearance is also an important goal sought by the surgeon and the family

Treatment and management

Konservatif (non operatif)

surgical treatment should begin shortly after birth 1. Gentle manipulation

Manipulation and serial casts Validity, up to 6 months ! Technique Ponseti Avoid false correction When to stop ? Maintaining the correction Follow up to watch and avoid recurrence

Ponseti tehnique
Always use long leg casts, change weekly. First manipulation raises the 1st metatarsal to decrease the cavus All subsequent manipulations include pure abduction of forefoot with counter-pressure on neck of talus. Never pronate ! Never put counter pressure on calcaneus or cuboid.

Ponseti tehnique
Cast until there is about 60 degrees of external rotation (about 4-6 casts) Percutaneous tendo Achilles tenotomy in cast room under local anesthesia, followed by final cast (3 weeks) After final cast removal, apply Normal last shoes with Denis Browne bar set at 70 degrees external rotation (40 degrees on normal side) Denis Browne splint full time for two months, then night time only for two-four years. 10.35% need Anterior Tibialis tendon transfer at age 2-3

Operative treatment
Indications Late presentation, after 6 months of age ! Complementary to conservative treatment Failure of conservative treatment Residual deformities after conservative treatment Recurrence after conservative treatment

Surgical treatment
Soft tissue operations : 1. Release of contractures 2. Tenotomy 3. Tendon elongation 4. Tendon transfer 5. Restoration of normal bony relationship

Complication
Infection (rare) Wound breakdown Stiffness and restricted range of motion:. Avascular necrosis of the talus Persistent intoeing: of the subtalar joint.

Prognosis and outcome

Approximately 50% of clubfeet in newborns can be corrected nonoperatively. Ponseti reports an 89% success rate using his technique (including an Achilles tenotomy). Recurrence rates of deformity were reported at around 25%, with a range of 10-50%.. The best results were obtained with children older than 34 months with a foot large enough to perform the surgery without compromise

Conclusion
Genetic and environmental factors are important in the cause of ICTEV. There is evidence that development of bone, joint, connective tissue, innervation, vasculature and muscle may each be implicated in the pathophysiology. Disturbance of the overall process of medial rotation of the fetal foot may be the common pathway linked to all these aspects of development. It is likely there is more than one different cause, and at least in some cases the phenotype may occur as a result of a threshold effect of different factors acting together. The hand is never affected in ICTEV, and thus explanation of its pathology is likely to lead to identification of genes whose effects are exclusive to the foot and lower limb. Advances in genetic mapping techniques, development of mouse models, improved understanding of the control of developmental processes and genetic epidemiology studies are all likely to help to elucidate the causes of idiopathic congenital talipes equinovarus, in the not too distant future.