Club foot

Under clubfoot ( pes equinovarus, pes varus formerly called ) refers to a foot deformity. In addition to the most common, congenital form, there is also the acquired form, the so-called neurogenic clubfoot, which is usually caused by a disorder of the nerve supply.

Congenital clubfoot ( pes equinovarus et plantiflexus adductus congenitus ) belongs to the group of limb malformations and is a combination of various deformities of the foot, usually accompanied by a Einwärtsverdrehung ( supination ) of the foot ( plantar surface facing inward ) and abnormalities of the lower leg muscles. As a rule, come several misalignments together:

• The called supination or varus position of the hindfoot ( pes varus )
• Sichelfußstellung of the forefoot ( Pes adductus )
• Equinus ( equinus )
• Anspreizfuß ( Pes supinatus )
• Cavus Foot ( Pes excavatus )

This is associated with a shortening of the Achilles tendon. The therapy is usually started as soon as possible after birth. Even with Early-onset but the treatment is often difficult and tedious.

• 6.1 Guidelines
• 6.2 Acceptance Model
• 6.3 Execution of the orthosis
• 6.4 correction principles

Causes

A clubfoot can be congenital or acquired. On average about one in 1,000 children with this feature to the world, with boys being affected twice as often as girls. The cause of congenital clubfoot is not finally resolved. Are:

• Unfavorable position of the embryo in the uterus
• Amniotic band syndrome
• Strong and relatively long-standing reduction in the amount of amniotic fluid ( oligohydramnios )
• Concomitant with Neuralrohrfehlbildungen as a result of paralysis of the muscles of the lower leg
• Result of taking folic acid antagonists such as aminopterin or methotrexate in the 4th to 12th week of pregnancy ( Aminopterinsyndrom, aminopterin embryopathy )

Cause of the acquired clubfoot is the weakening of the peroneus longus and peroneus brevis of which are innervated by the superficial peroneal nerve.

As " Klumpfußmuskel " the tibialis posterior is called, which brings the foot in supination and plantar flexion.

Disease

The lumpy form, the congenital clubfoot following picture on:

• Equinus: plantar flexion of the ankle
• Supination of the hindfoot stronger than the forefoot
• Adduction of the forefoot

Developmental disorder in the lower part of the spinal cord, thus weakening the calf muscles ( gastrocnemius muscle ) and preponderance of the rear shin muscle ( tibialis posterior); further shortening of the lateral ligaments between fibula ( fibula ) and anklebone ( talus ) or heel bone ( calcaneus ): These tapes prevent the Nachvorne - Hiking the fibula against the talus in dorsiflexion, so that an increasing equinus produced.

In the lateral X-ray image of the infant is typical including a talokalkanealer angle of less than 30 °.

Treatment

The treatment depends on the etiology and severity of the deformity. Early treatment is important.

Operational

At the age of three months, a surgical correction of all conservative not redressierbaren structures should be carried out. This age is now generally considered to be the ideal time. The operation consists in an extension of the Achilles tendon, a so-called extended " posterior release ," continues here the erection between the talus and calcaneus is corrected.

In subluxation of the navicular bone also needs a " media release", with transection of the ligaments between the talus, navicular and medial cuneiform, reduction of the navicular bone and possibly lengthening the tendon of the tibialis posterior done. The aim of surgery is the most complete possible reduction of all components.

Conservative

Klumpfußgips: for the modeling is the classic plaster superior to modern plastics. You put clubfoot principle upper and not lower leg casts, since on the one hand a better redressment of the foot is possible to the outside, on the other hand, the short leg cast (especially with the existing equinus ) tend to slide down and then causes pressure points. Thus, the foot can be redressed as a whole compared to the thigh outward, the knee should be flexed at least 60 °. Here, the equinus is initially preserved. The final correction of the equinus is usually done by extending the posterior tendon of the tibialis.

Clubfoot by Ponseti

The treatment by Ignacio Ponseti provides for a specific manual redressment with gradual correction according to anatomical considerations. As a rule, can be reached after three to eight casts a complete correction without surgery. After completion of the Gipsredression done for three months the plant a special rail ( Dennis Brown splint or Alfa -Flex - rail), which must be worn all day at first. Gradually, the gestation period is then shortened during the day, so that the rail only at night or at nap time, must be worn until the age of four years from the end of another three months. This phase is necessary for successful treatment. Parents consistent system of rail is usually taught. The treated according to this method, children usually accept without problems wearing the aforementioned rail, one should admit the children already about 2-3 days for acclimatization. After Ponseti treated clubfeet physiotherapy is recommended during the first year.

Called clubfoot according to Bonnet Dimeglio, also called " French method "

The French method is a dynamic exercise therapy. The newborn child is entrusted in the first days of orthopedists a specialized pediatric physiotherapist whose use is crucial. The foot is initially corrected four to five times a week and after correction treated three to four times a week carefully. The position is minutely changed two to three months, dissolved the bonded tissue and stimulates the muscle to movement. After manual therapy in Tapingverbänden feet and lower leg plaster cast to be fixed. The treatment frequency is reduced upon successful result on twice a week. It is an important aspect that a newborn child, the motion is maintained in knees and hips. Failure to adjust the heel correctly, at the age of three to four months, a tenotomy of the Achilles tendon is performed

The French method machines very detailed and precise, the individual deformities of clubfoot. It is demanding for the therapist and thus difficult to reproduce. Therefore, this form of therapy can be offered by a few, but well-trained people only selectively.

Deposits

Correction in 3-point correction system:

Important:

Each of physiological correction marks are adjusted, the better is the correction capability. After the adjustment of the aid a further control of the overall position is necessary.

Anti - varus shoes

The anti- varus shoes medially narrower than a normal shoe, thereby correcting the abduction position of the shoe between the shoe joint and toe caps correction position against talipes ( Pes adductus ).

Characteristics of the anti - varus shoes:

• Heel counter
• Pronierende feet bearing
• Light wing paragraphs

Fixing and functional orthoses

Guidelines

If, in addition to the clubfoot deformity an inner circles averaging in the lower leg, the thigh must be included in the correction.

Model approval

Model approval in absolutely the best possible correction of the foot should be strictly adhered to when fitting of orthotics, night splints and deposits to assess the possibility of correction.

Execution of the orthosis

Possible from a lightweight flexible material such as polyethylene. These materials allow the foot lightweight micro - movements while creating a better compatibility of the correction. As an interior material closed cell cross-linked polyethylene foam is recommended; this may, however, result in children who are under the age of six months to a massive skin irritation. Therefore, it is often used in such children a chamois cloth or terry lining. The locks to fix the leg in the orthosis must always be well padded and especially wide enough, otherwise the lymphatic and blood circulation may be impaired.

There are structurally different orthotics available. There are those with:

• Plantar joint
• Extensions - flexion of the ankle joint
• Supination - pronation joint
• Abduction adduction joint in forefoot
• Correction trains
• Lower leg shell ( rail)
• Upper - lower leg shell ( rail),

Being the most common regulation is the upper - lower leg splint. The upper - lower leg splint is especially suitable for small children for retention. The knee joint always has to be flexed in the rail, so that the foot can be held in the direction of abduction. The splint is usually applied only at night, as the children grow strongest here. The abduction of the forefoot is most actively maintained by the muscles because the shortened medial muscles ( tibialis anterior and posterior, but also M. adductur hallucis ) compared with the lateral muscle group (especially peronaei musculus ) is overactive.

Correction principles

Feet - leg:

• With the knee flexed about 70 ° to 90 ° (severe cases 90 °, Light 70 ° )
• Redressment of the foot in maximum pronation and abduction.

The aim is the anatomic position in the front, middle and rear foot to reach and enable the mobility of the ankle, so that at optimal care, except for the scars and the calf atrophy of the affected limb deformity is no longer observed.

Historical

The Redressionsbehandlung of clubfoot has been described in great detail already by Hippocrates (370 BC). He also chronicles the creation of associations and redressierenden shoes.