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 pain when held. never taking drugs purchased alone. Lump on spine denied. The first child was born 6 years spontaneously and second child born 3 years spontaneous. Prenatal history (ANC) : During pregnancy mother‟s patient who have checked regularly to obstetrician midwife once a month to 8 months gestation. There is no abnormality at the other part of his body.HISTORY OF PRESENT ILLNESS A mother brings her 2 months old boy to a pediatric policlinic RSUD Koja. Patient's mother was worried about her son's leg. Age of the mother when pregnant patients 35 years (TB: 160 cm. except vitamin obtained from obstetrician midwife. There is no fever. cough. Movement of the foot are normal. then weekly at 9 months gestation. TT immunization 2 times. and redness and can not be straightened out like a normal foot. Twisted ankle is not accompanied by swelling. weight: 50 kg) . She noticed that both of her boy‟s foot looks excessively turned inward since he was born. shortness of breath. During pregnancy was never sick. body length at birth 60 cm. 2 hours before partus. Apgar score 7-9. . birth weight is patient was prone. Patients patients mother admitted consume breast milk premature rupture of and soft porridge. The membranes. Cried spontaneously.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. 4300 grams. time. : HISTORY History of family illness: No one in hIs family got disease like him History of past illness: Others disease (-)- . . Then do the correction of serial cast 6 times until the age of 5 months.MEDICATION HISTORY Patients had consulted an orthopedic doctor at the age of 8 weeks. symmetrical chest wall movement. Not look any supraclavicular retractions. the content is quite./ -). wheezing (. gargling () Breathing : Look : Spontaneous breathing regular. stridor (-). Listen : Vesicular breath sounds (+ / +). patients can speak spontaneously.8 C . equal symmetric • CRT <2 " Disability : GCS: E4M6V5 pupil isokor (+ / +) direct light reflex (+ / +). no muscle contractions seem a respirator. indirect light reflex (+ / +) Exposure looks both ankles bent inward body temperature: 36. and intercostal./ -) • 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. suprasternal.Physical examination Primary survey Airway : Clear. ronchi (. 8 C RESP RATE : 20x/mn Nutrition NORMAL HEART RATE : 80x/mn .Secondary survey General appearance • v • moderately ill conciousness • Compos mentis TEMP : 36. uvula midline . symmetrical.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 (-). Gallop (-) . Murmur (-).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. 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 -/- . Arterial bruit (-).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. venous hum (-) . concave medial side. 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 .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. wrinkles in the posterior joint ankle. heel drawn up and inversion. there are wrinkles on medial plantar feet (+) Hindfoot equines (+). 400 422.4 NORMAL 12 – 17 g% 5000 – 10000 150 – 450ribu 37 – 48 % 3.000 29 3.8 jt/mm2 <10 mm/time 11 4 9 0.4 53 53 143 3.68 30 23 25 7 14.5 mg/dl <40 u/l <40 u/l .88 112 5-15 1-6 10 – 45 mg/dl 0.Laboratory findings RESULT Hemoglobin Leukocyte Trombocyte Ht Eritrosit MVC MCH MCHC LED RDW Cloting time Bleeding time Ureum Creatinin SGOT SGPT Na K Cl 10.4 – 1.8 – 5.2 15. 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 . Patient's mother was worried about her son's leg. the lateral side of the foot convex. Lump on spine denied. • Primary survey in the normal limit. Twisted ankle is not accompanied by swelling. there are wrinkles on medial plantar feet. shortness of breath. concave medial side. She noticed that both of her boy‟s foot looks excessively turned inward since he was born. hindfoot equines. cough. a boy 5 months brought his mother to a pediatric policlinic RSUD Koja. pain when held. forefoot and midfoot inversion and adduction. and redness and can not be straightened out like a normal foot. There is no abnormality at the other part of his body. wrinkles in the posterior joint ankle . heel drawn up and inversion. There is no fever. Status localist Regio pedis bilateral based on look are bean shaped deformity.antenatal.Resume • Patient. and postnatal history are normal limit. Secondary survey in the normal limit. Prenatal. Movement of the foot are normal. Resume • . Angle talometatarsal > 150 because of varus. . hematokrit is decreased.2 g/dl is decreased. leukosit 15.500/uL is increased. From the rontgen photo pedis bilateral there is abnormal limit. 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. and dorsoplantar shows the convergence of metatarsal base is abnormally increased. • Laboratory examination are Hb 10. tibiocalcaneal angle > 900. Talocalcaneal angle < 150 (talus and calcaneus parallel because the heel inversion and adduction of the anterior calcaneus). 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 . and the brace (dennis brown) is used immediately . the cast is removed.therapy Three weeks after tenotomi. prognosis Ad Vitam ad bonam Ad Fungsionam dubia ad bonam Ad sanationam dubia ad bonam . Acquired. Postural clubfoot 2. Poliomyelitis Arthrogryposis Absent Bone : fibula / tibia . Idiopathic (Unknown Etiology) : Congenital Talipes Equino-Varus CTEV 3. Secondary to : CNS Disease : Spina bifida.Definition and classification Classiification : 1. lateral -cuboid -Naviculare Forefoot : -5 metatarsal -14 phalang .Anatomy foot • Bone structure Hindfoot : -Talus -Calcaneus Midfoot : -3 cuneiforme : medial. intermedium. Articulations and Ligamentous Support . 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 % .Epidemiology • Occurs approximately in one of every 1000 live birth • In affected families. 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 . knee and leg • Ankle: Thickening and shortening of the ligaments and joint capsule in the medial and posterior ankle joint • Tibia: os tibia torsion. Medial concave side while the lateral side more convex called bean shaped deformity •.dorsiflexion •At the foot dorsiflexion and eversion will be felt triceps surae and tibialis posterior tendon being stretched Feet Ankle.Equinovarus position.Not to do a full •.On the lateral side of the dorsum pedis are bony anterior talus •. feet appear smaller and densely •.Diagnosis •.Posterior tuberosity of the calcaneus are hard to see and touched •.The shape of the foot is very typical. tibia. • Knee and leg: .hyperextension of the knee joint can occur when children start walking muscle atrophy gastrocsoleus accordance with increasing age .Lateral malleolus located more posteriorly than the medial malleolus •. 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. and stable over time • A cosmetically pleasing appearance is also an important goal sought by the surgeon and the family . painless. Treatment and management . Konservatif (non operatif) • surgical treatment should begin shortly after birth • 1. Gentle manipulation . up to 6 months ! Technique “Ponseti” Avoid false correction When to stop ? Maintaining the correction Follow up to watch and avoid recurrence .• • • • • • • Manipulation and serial casts Validity. • 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. change weekly. • Never pronate ! • Never put counter pressure on calcaneus or • cuboid. .Ponseti tehnique • Always use long leg casts. followed by final cast (3 weeks) • After final cast removal.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.35% need Anterior Tibialis tendon transfer at age 2-3 . • 10. 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. after 6 months of age ! Complementary to conservative treatment Failure of conservative treatment Residual deformities after conservative treatment • Recurrence after conservative treatment .Operative treatment • • • • • Indications Late presentation. Tendon elongation 4. Release of contractures 2.Surgical treatment • • • • • • Soft tissue operations : 1. Tenotomy 3. Tendon transfer 5. Restoration of normal bony relationship . . Avascular necrosis of the talus Persistent intoeing: of the subtalar joint.Complication • • • • • Infection (rare) Wound breakdown Stiffness and restricted range of motion:. Prognosis and outcome • Approximately 50% of clubfeet in newborns can be corrected nonoperatively. • Recurrence rates of deformity were reported at around 25%. The best results were obtained with children older than 34 months with a foot large enough to perform the surgery without compromise .. with a range of 10-50%. Ponseti reports an 89% success rate using his technique (including an Achilles tenotomy). 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. connective tissue. development of mouse models. There is evidence that development of bone.Conclusion • Genetic and environmental factors are important in the cause of ICTEV. Disturbance of the overall process of medial rotation of the fetal foot may be the common pathway linked to all these aspects of development. in the not too distant future. 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. It is likely there is more than one different cause. The hand is never affected in ICTEV. innervation. joint. vasculature and muscle may each be implicated in the pathophysiology. and at least in some cases the phenotype may occur as a result of a threshold effect of different factors acting together. .