Professional Documents
Culture Documents
Material and Methods
Material and Methods
Material and Methods
All children of less than 1 year of age with idiopathic untreated clubfoot
untreated clubfoot].
Thirty three cases, (forty one feet), underwent treatment by the Ponseti
Obstetrical history was recorded with regards to drug intake during first
Initial assessment of the patient was done regarding the deformity, any
35
Material and Methods
arthrogryposis etc.
Scoring of each foot was done according to the Pirani score, photographs
36
Material and Methods
37
Material and Methods
38
Material and Methods
LOGI Q500 pro series ultrasound machine and all ultrasounds are done
by one person.
39
Material and Methods
Following evaluations criteria are studied at each time USG was done.
40
Material and Methods
41
Material and Methods
Talar Length
After this the child was prepared for manipulation and cast application
42
Material and Methods
In this technique all the components of the deformity except the equinus
separately. The most essential step is to identify the various bones of the
foot, particularly the dorsolateral surface of the head of the talus. Both the
malleoli are easily identified and the medially displaced navicular lies
almost in contact with the medial malleolus. After identifying the tip of
the lateral malleolus, the finger is slid forward; the first bony prominence
that is palpated is the dorsolateral surface of the head of the talus that is
barely covered by the skin. The anterior end of the calcaneus can be felt
During manipulation the thumb is used to stabilize the talus and the index
finger of the same hand is put behind the lateral malleolus to further
43
Material and Methods
Cavus
with the hind foot so that correction of the adductus and varus can be
achieved. While applying the cast the sole of the foot should be molded
supination the foot should never be pronated as this increases the cavus.
supination and plantar flexion with the head of the talus as the pivot.
for 60 seconds with gentle pressure. After manipulation for 2-3 minutes a
thin well molded plaster cast is applied to maintain the correction. At this
calcaneus touched, leaving it free to move out from under the talus.
The casts are changed weekly after gentle manipulation. Care is taken not
to pronate the foot while it is being abducted. The initial cast is applied
44
Material and Methods
After the plaster sets the cast is extended to thigh with the knee in 90°
flexion.
As the foot abducts the calcaneus starts to dorsiflex. The aim is to achieve
about 70° of abduction of the foot under the talus. The foot can be
maintained in external rotation only if the talus, the ankle, and the leg are
stabilized in a toe to groin cast, while the knee is in 90° flexion. A below
knee cast can not immobilize the leg as the leg of the baby is round and
the anterior crest of the tibia is covered with baby fat, the cast can not be
molded, thus the cast rotates inwards with the foot. Further the below
Equinus
whole foot after adduction and varus have been corrected with the palm
under the sole of the foot. The heel is pulled down with the thumb and the
index finger of the other hand. The index finger of the other hand can be
to get at least 15° of dorsiflexion at the ankle joint. The heel should be
three weeks with the foot in 70° of abduction and 15-20° of dorsiflexion.
45
Material and Methods
tenotomy, the puncture wound is covered with a sterile gauze piece and a
cast is given for three weeks. The mother is told that there will be some
soakage of blood on the cast and the child is advised a broad spectrum
oral antibiotic for a week. If full dorsiflexion is not possible after the
tenotomy, the patient is called again after one week, for remanipulation to
Tibial Torsion
clubfeet have half the amount of external tibial torsion as that in normal
deformity of the heel can be gradually corrected by toe to groin casts with
the knee in 90° of flexion with the foot externally rotated under the talus.
46
Material and Methods
Cast Application
During the cast application an assistant holds the thigh with one hand and
the toes with the other. A soft roll is applied snugly over the foot
inch plaster cast is applied from the toes to just below the knee. Molding
of the cast is the most important. The foot is abducted with counter
pressure applied over the dorsolateral surface of the head of the talus,
with the forefoot in supination. The pressure should not be maintained for
so long as to create an indent on the setting cast. The heel should be well
molded taking care not to push it into valgus. During setting of the cast
the limb is supported by the leg and heel is not touched at all. The plaster
should be trimmed so that the nail beds are visible however a platform of
a cast should extend under the toes to prevent the flexion of the toes.
Plaster should be trimmed to expose the great toe, with the force being
exerted on\ the metatarsal heads. The cast is changed every week till the
last one which is worn for three weeks after which patient is put on a
brace.
Pirani scoring of the foot was done each week and decision of tenotomy
was taken once midfoot score was less than 1 and hind foot score
47
Material and Methods
BRACING
After the 3 week cast was removed the patient was shifted to an
abduction brace. The brace that we used was the Steenbeek foot
abduction brace, which comprises of open toe leather shoes with lace
closure and a strap. A round metal bar (6mm) connects the shoes which
the connecting bar is about the distance between the shoulders of the
child. There is an inspection hole on the medial side of the heel to inspect
that the heel is properly placed in the shoe. The bar is bent with a
the brace the knees are left free so that the child can do the kicking
Bracing has to worn for 23 hrs a day and it should continues until the age
child starts crawling , after which the child is shifted to nap time bracing
in which the brace is worn during the night and during any day time naps.
Total time of bracing is 12-16 hrs a day. This is to be followed till the age
of 4 yrs. Care is taken to look for external tibial torsion and heel valgus
while the child is on the brace, and if this occurs the rotation of the foot
48
Material and Methods
After application of the brace the patient was called up for follow up
visits as follows.
front one should look for forefoot supination and from behind look for
The treatment protocol after a repeat tenotomy remains the same as that
49