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Excerpt for Clubfoot, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions by , available in its entirety at Smashwords

Clubfoot,


A


Simple


Guide


To


The Condition,

Diagnosis,

Treatment


And


Related Conditions


By


Dr Kenneth Kee



M.B., B.S. (Singapore)

Ph.D (Healthcare Administration)


Copyright Kenneth Kee 2015 Smashwords Edition


Published by Kenneth Kee at Smashwords.com





Dedication


This book is dedicated

To my wife Dorothy

And my children

Carolyn, Grace

And Kelvin



This book describes the Club Foot, Diagnosis and Treatment and Related Diseases which are seen in some of my patients in my Family Clinic.



This eBook is licensed for your personal enjoyment only. This eBook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each reader.



If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy.



Thank you for respecting the hard work of this author.





Introduction


I have been writing medical articles for my blog http://kennethkee.blogspot.com (A Simple Guide to Medical Conditions) for the benefit of my patients since 2007.


My purpose in writing these simple guides was for the health education of my patients.


Health Education was also my dissertation for my Ph.D (Healthcare Administration).


I then wrote an autobiolographical account of his journey as a medical student to family doctor on his other blog http://afamilydoctorstale.blogspot.com.


This autobiolographical account “A Family Doctor’s Tale” was combined with my early “A Simple Guide to Medical Conditions” into a new Wordpress Blog “A Family Doctor’s Tale” on http://ken-med.com.


From which many free articles from the blog was taken and put together into 650 eBooks.


Some people have complained that the simple guides are too simple.


For their information they are made simple in order to educate the patients.


The later books go into more details of medical conditions.


The first chapter is always from my earlier blogs which unfortunately tends to have typos and spelling mistakes.


Since 2013, I have tried to improve my spelling and writing.


As I tried to bring you the latest information about a condition or illness by reading the latest journals both online and offline, I find that I am learning more and improving on my own medical knowledge in diagnosis and treatment for my patients.


Just by writing all these simple guides I find that I have learned a lot from your reviews (good or bad), criticism and advice.


I am sorry for the repetitions in these simple guides as the second chapters onwards have new information as compared to my first chapter taken from my blog.


I also find repetition definitely help me and maybe some readers to remember the facts in the books more easily.


I apologize if these repetitions are irritating to some readers.



Chapter 1


Club Foot


What is Club Foot?


Clubfoot is a medical disorder when the foot turns inward and downward.


It is a congenital condition, which means it is present at birth


Club foot (talipes equinovarus) is a deformity of the foot and ankle that a baby can be born with.


It is not clear exactly what causes clubfoot.


In most cases, it is diagnosed by the typical appearance of a baby's foot after they are born.




In about half of babies that are born with clubfoot, both feet are affected.


Clubfoot means the ankle and foot while equinovarus means the position that the foot is in.


If a baby has clubfoot, their foot has a typical appearance.


The foot points down at their ankle (doctors call this position equinus).


The heel of their foot is turned inwards (doctors call this position varus).


The middle section of their foot is also turned inwards and the foot seems quite wide and short.


It is fixed in this position and cannot be moved into a normal foot position.


The baby's foot is kept in this position because the Achilles tendon at the back of the baby's heel is very short and the inside tendons of their leg have also shortened.


If nothing is done to treat the problem, as the baby forms and begins to stand, they will not be able to stand with the sole of their foot flat on the floor.


The position that some babies kept their foot in may look as if they have clubfoot but, in fact, their foot can actually move readily into a normal position.


These babies do not have true clubfoot.


What causes Clubfoot?


Causes


Clubfoot is the most frequent congenital disorder of the legs.


It can range from mild and flexible to serious and stiff.


The reason is unknown, but the disorder may be passed down through families in some cases.


Risk factors are a familial heritage of the disorder and being a male.


Clubfoot is a relatively frequent deformity, affecting about one out of 1,000 births.


In spite of a large study, the exact cause of clubfoot in isolation (not as a syndrome or other birth abnormality) is not known.


There have been some indications of a genetic cause, but these have not been confirmed.


Most children who are born with a clubfoot do not have a family history of the condition.


If a baby boy is born with a clubfoot, there is a 2.5 % chance that his next-born sibling will have clubfoot, too.


If a girl baby has a clubfoot, there is a 6.5 % chance that her next-born sibling will also have a clubfoot.


About twice as many boys as girls are born with clubfoot.


Babies born to a parent who has clubfoot also have a higher risk of having a clubfoot themselves.


If both parents have clubfoot, this risk is higher.


Clubfoot may also have some relation to the position of the baby's foot when the baby is in the womb.


In most cases (around 80%), the baby has no other disorders other than the clubfoot.


However, in around 1 in 5 babies born with clubfoot, the baby also has another problem.


Most frequently, such problems include:


1. Spina bifida - a condition where the bones of the spine don't form properly, causing the nerves of the spine to lose protection and become damaged.


2. Cerebral palsy - a general term that describes a group of conditions that cause movement problems.


3. Arthrogryposis - a condition where a child has curved and stiff joints and abnormal muscle development.


4. Oligohydramnios (reduced amount of amniotic fluid surrounding the fetus) during pregnancy


What are the different types of clubfoot?


Types


1. A true (idiopathic) clubfoot accounts for the vast majority of cases.


This type is stiff or rigid, and very hard to manipulate.

The affected foot may be more flexible, with a condition known as positional clubfoot.


This flexible type of club foot is caused by the baby's prenatal position in the uterus (often breech).


2. Positional clubfoot can easily be positioned into a neutral (not curved) position by hand.


3. A third type is syndrome clubfoot in which the condition is part of a larger syndrome.


This form is normally more serious and hard to treat, with less positive outcomes.


Classification


Clubfoot is frequently broadly classified into two major groups:


1. Isolated (idiopathic) clubfoot is the most frequent form of the abnormality and happens in children who do not have any medical disorders.


2. Non-isolated clubfoot occurs in combination with other medical disorders or neuromuscular conditions such as arthrogryposis and spina bifida.


If the child's clubfoot is linked with a neuromuscular disorder, the clubfoot may be more resistant to treatment, require a longer course of non-surgical treatment, or even multiple surgeries.


Regardless of the type or severity, clubfoot will not improve unless treated.


A child with a clubfoot who is not treated will walk on the outer edge of the foot instead of the sole, form painful calluses, not able to wear shoes and have lifelong painful feet that frequently severely limit activity.


Parents of infants who have clubfeet and no other serious medical problems should be reassured that with proper treatment their children will have feet that allow an active and normal life.


There can be different degrees of foot deformity with clubfoot.


Some babies have milder foot deformity than others.


If a baby is diagnosed with clubfoot, a specialist (usually an orthopedic surgeon) will frequently use a grading system to grade the severity of the foot deformity.


A frequent method used for grading is the Pirani score.


With this grading method, a grade from 0 to 6 is given.


The higher the grade, the greater is the degree of foot deformity.


What are the symptoms of Clubfoot?


Symptoms


The physical shape of the foot may be different.


One or both feet may be involved.


1. The heel points downward, and the front half of the foot turns inward.
2. The calf muscles on the affected side are smaller than on the normal side.
3. The leg on the affected side is slightly shorter than on the other side.
4. The foot itself is usually short and wide.
5. The Achilles tendon is tight.

6. The foot turns inward and downward at birth; the child is unable to place the foot correctly.


The calf muscle and foot may be slightly smaller than normal.


How is clubfoot diagnosed?


Diagnosis


The disorder is identified during a physical examination


Prenatal diagnosis


The clubfoot of the baby can be diagnosed before birth with ultrasound.


About 10 percent of clubfeet can be detected as early at 13 weeks in a pregnant woman.


At 24 weeks, about 80 percent of clubfeet can be diagnosed, and this number steadily increases until birth.


If the child is not diagnosed pre-natally, clubfoot can be seen and diagnosed at birth.


There is about a 20 percent false-positive rate with ultrasound diagnosis.


Diagnosis after birth


Investigations that may assist the confirmation of a diagnosis of clubfoot are:


Clubfoot is usually diagnosed after a baby is born.


With improvement of ultrasound technology during pregnancy, increasingly, clubfoot is being detected during scanning before a baby is born.


All babies are routinely examined and checked over by a doctor shortly after they are born.


This is to look for clubfoot but also other problems that the baby may be born with.


Most frequently, clubfoot is observed and diagnosed during this postnatal examination because of the typical appearance of the foot as described above.


Investigations such as X-rays are unnecessary to confirm the diagnosis.


A foot x-ray may be done.


Computerized tomography scan (CT or CAT scan) may help.


What are the complications of Clubfoot?


Complications


Some defects may not be completely fixed.


Early treatment can increase the function and improve the appearance of the foot.


Treatment may be less successful if the clubfoot is linked to other birth disorders.


What is the treatment of Clubfoot?


Treatment


There have been some changes to the treatment for clubfoot over recent years.


Major surgery was often a frequent treatment used.


The results of medical researches have indicated that other treatments without major surgery, especially a treatment known as the Ponseti method, appear to provide the best long-term treatment for most children.


With proper treatment, however, the majority of children are capable of doing a whole variety of physical exercises with little trace of the deformity.


Most cases of clubfoot are successfully treated with non-surgical methods that may include a combination of stretching, casting, and bracing.


Treatment usually begins shortly after birth.


The Ponseti method is now the preferred treatment by most orthopedic surgeons all over the world.


The Ponseti method is normally preferred while there are other treatment methods available.


One good method is the French functional treatment.


The French functional method involves daily manipulation as well as immobilization with adhesive bandages and pads.


It is important that a baby who has clubfoot be referred to see a doctor specialized in treating this problem as soon as possible after birth.


The sooner Ponseti method treatment is begun, normally the correction of the foot deformity should be easier.


The Ponseti method is now a widely used treatment for clubfoot.


This treatment gives good results for most children and so major surgery is not usually needed to correct the foot deformity.


Treatment may involve moving the foot into the correct position and using a cast to keep it there.


This is frequently done by an orthopedic specialist.


Ponseti method should be started as soon as possible after birth when it is proven to be the easiest time to reshape the foot.


Gentle stretching and recasting is done weekly to normalize the position of the foot.


Generally, five to 10 casts are needed.


The final cast will stay in position for 3 weeks.


Once the foot is correctly in position, the child will wear a special brace nearly full time for 3 months.


The child will use the brace at night and during naps for up to 3 years.


Frequently the problem is a short tight Achilles tendon and a simple surgery is needed to release it.


Some serious forms of clubfoot will require surgical treatment if other non-surgical methods do not work, or if the problem returns.


The child should be monitored by a doctor until the foot is fully grown.


The goal of treatment is to obtain a functional, pain-free foot that allows the child to stand and walk with the sole of the foot flat on the ground.


Non-surgical Treatment


The initial treatment of clubfoot is non-surgical, regardless of how severe the deformity is.


Ponseti method


The most widely used method in USA and all over the world is the Ponseti method, which uses gentle stretching and casting to gradually correct the deformity.


Treatment should ideally begin shortly after birth, but older babies have also been treated successfully with the Ponseti method.


The specialist gently manipulates (holds, stretches and moves) the child's foot with their hands into a position in which the foot deformity is put right (corrected) as much as possible.


The details of the method are:


1. Manipulation and casting


The baby's foot is gently stretched and manipulated into the correct position and kept in place with a long-leg cast (toes to thigh).


Every week this method of stretching the foot, positioning and casting is done until the foot is largely improved.


For most infants, this improvement occurs after 6 to 8 weeks.


2. Achilles tenotomy


The tight Achilles tendon at the back of the foot is released.


A small cut is made and the tendon is lengthened so that the heel can drop down.


This is a minor operation and it can usually be done with just a local anesthetic.


The cut is very small and does not require stitches.


After this, their foot is put in a final plaster cast, usually for three weeks.


The child will then need to wear some special boots that are connected together with a bar.


They will need to wear these for 23 hours a day for three months.


Usually, after this they just need to wear the boots and bar at night or during sleep periods until they are 4 years old.


It is really important that the child continues to wear their boots and bar as the specialist advises.


If the boots and bar are not worn as advised, there is a chance that clubfoot can come back (recur).


This means that their foot position can become abnormal again.


3. Bracing


With the successful correction with casting, clubfeet have a natural tendency to recur.


To ensure that the foot will permanently stay in the correct position, the baby will need to wear a brace for several years.


The brace ensures the foot at the correct angle to maintain the correction.


This bracing program may require a lot of attention for parents and families, but is necessary to prevent relapses.


For the first 3 months, the baby will wear the brace essentially full-time (23 hours a day).


The doctor will gradually decrease the time in the brace to only at night and napping (about 12 to 14 hours daily).


Most children will follow this bracing regimen for 3 to 4 years.


There are several different types of braces all of which consist of shoes, sandals, or custom-made footwear connected to the ends of a bar.


The bar can be hard (both legs move together) or dynamic (each leg moves independently).


The doctor will talk with the patient about the type of brace that would best meet the baby's needs.


Babies may be uncomfortable during the first few days of using a brace and need time to adjust.


Assessment of the Ponseti method



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