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Congenital Talipes Equinovarus, (clinical tests in CTEV, clinical…
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clinical tests in CTEV
scratch test
dorsiflexion test
plumb line test
- This test helps to detect the tibial torsion.
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- The child is made to sit on a table with both the lower limbs hanging from the edge
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- . A line drawn from the center
of the patella to the tibial tubercle when extended down should cut the foot at the first or second intermetatarsal space normally. This is called the plumb line.
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- In CTEV, with medial rotation of the
tibia, it cuts the fourth or fifth intermetatarsal space and vice versa in lateral rotation of the tibia
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- In a newborn child, it is possible to dorsiflex the foot until its dorsal surface meets the anterior surface of the tibia.
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- This is not possible in CTEV and this
can be used as a screening test
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Classification
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Pirani’s classification
10 physical parameters
- Lateral curvature of the foot.
- Severity of the medial crease.
- Severity of the posterior crease.
- Medial mallelor navicular interval.
- Palpation of the lateral part of the head of the talus.
- Emptiness of the heel.
- Fibula Achilles interval.
- Rigidity of equines.
- Rigidity of adductus.
- Long flexor contracture
(Each scored 0 for no abnormality, 0.5 for moderate abnormalityand 1 for severe abnormality.)
Dimeglio classification
4 parameters are assessed
- on the basis of their reducibility
with gentle manipulation
& measurement with a goniometer
-In the sagittal plane: Equinus deviation.
- In the frontal plane: Varus deviation.
- Horizontal plane: De-rotation.
- Adduction of the forefoot in relative to the hindfoot.
Investigation
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Radiography-most important
- helps to know the exact angles of each deformity seen clinically inCTEV.
in AP view
Talocalcaneal angle
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Talometatarsal angle
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- Normal is 5-15°
- In CTEV, it is 0° to negative
lateral view
Talocalcaneal angle
- is reduced
(normal is 25–50°)
Tibiocalcaneal angle
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- Normal is 5-15°
- it is negative in CTEV
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Apart from giving the accurate estimate of the angle of the deformities, radiology helps in confirmation of the correction of the deformities by various treatment modalities
clinical features
club foot complex
primary deformities
- equinus
- varus
- cavus
- forefoot adduction
- internal tibial torsion
late changes
- degeneration of joints
- fusion of joints
secondary deformities
- foot size decreased to 50%
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- medial border is concave
lateral border is convex
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- forefoot is plantarflexed upon hindfoot
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- skin is stretched over the dorsum of the foot
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- callosities are present over the dorsum of the foot
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- stumbling gait
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- hypotrophic anterior tibial artery
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- atrophy of muscles in anterior or posterior compartments of the leg
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surgical
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indications
(5 R’s)
- Response not obtained to conservative tx after 6 months.
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- Rigid clubfoot (means forefoot deformities are corrected but hindfoot deformities remain uncorrected after conservative tx).
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- Relapsed clubfoot (means deformities are corrected initially, but relapse later, either partial or total).
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- Recurrent clubfoot (it is a type of relapse, the cause being muscle imbalance, which was overlooked initially).
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- Resistant clubfoot (very resistant to correction).
conservative
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Ponseti Method
- can be used in older children of 2 years age and also
- after failed previoius nonoperative techniques
has a very success rate
success
of the reduction is 90-98 percent
- better than Kite’s regime
- a better alternative than surgical correction, can avoid associated risks and complications
- a more flexible F& A procedure
- can be used in not only childhood but adulthood as well
tx phase
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Maintenance Phase
- child then wears a corrective foot orthosis full time (23 hours a day)
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- followed by night and naptime wear
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by external fixators
- a recent concept in the management of CTEV
- is reserved for difficult cases.
- 2 types of external fixator frames;
- Ilizarov, a Russian
orthopedic surgeon, design one.
- An Indian orthopedic surgeon, Dr. BB Joshi, design the second one. This frame is known as Joshi’s external stabilization system popularly called as JESS
When done in properly indicated cases, external fixator produces excellent results.
- It is a semi-invasive, bloodless surgery
- and can be done without a a tourniquet.
- Though technically very demanding,
it avoids all the complications of surgery and a postoperative scar.
- It is known to correct all the components of the deformities both bony and soft
tissues.
- The rate of relapse or recurrence is
comparatively less; and even if it does occur, the options of surgery are always open.
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remember order of correction of deformity
ADVERB
AD - Forefoot adduction is corrected first
V - Correction of heel varus next
E- Lastly correction of hind foot equinus
RB- this order is followed to prevent Rocker Bottom Foot which develops if foot is dorsiflexed through
hindfoot rather than midfoot
Three I’s for relapse
- Improper and inadequate conservative treatment and surgical release of contracted structures.
- Imbalance of foot muscles if left uncorrected.
- Internal torsion of tibia if overlooked.
Quick facts
Do you know how does a CTEV shoe differ from an ordinary shoe?
• It has a straight inner border, which helps prevent forefoot adduction.
• It has an outer shoe raise and this helps prevent footinversion.
• There is no heel and this helps prevent equinus.