Clubfoot: A Detailed Explanation

Introduction

Clubfoot, medically known as congenital talipes equinovarus (CTEV), is a common congenital deformity affecting the foot and ankle. The condition is present at birth and is characterised by the foot being twisted out of its normal position. Clubfoot can affect one or both feet and is seen across the globe, including in India, with varying degrees of severity.

What is Clubfoot?

In clubfoot, the foot appears to be rotated internally at the ankle, causing the toes to point downwards and inwards, and the sole to face backwards or even upwards. The tendons, muscles, and bones of the foot are tightened or misshaped, leading to this abnormal posture. Clubfoot is not a painful condition in infants, but if left untreated, it can cause significant disability and discomfort later in life.

Types of Clubfoot

• Idiopathic Clubfoot: The most common type, where the cause is unknown and the foot is otherwise normal apart from the deformity.
• Neurogenic Clubfoot: Associated with neuromuscular disorders such as spina bifida or cerebral palsy.
• Syndromic Clubfoot: Occurs as part of a syndrome or genetic disorder affecting multiple parts of the body.
• Positional Clubfoot: Caused by the baby’s position in the womb, often less severe and more flexible.

Causes and Risk Factors

The exact cause of clubfoot is not completely understood. However, several factors are believed to contribute:

• Genetic Factors: Family history increases the risk of clubfoot in a newborn.
• Environmental Factors: Certain external conditions during pregnancy, such as reduced amniotic fluid or maternal smoking, may play a role.
• Associated Conditions: Clubfoot may occur with other congenital abnormalities or as part of syndromes.

Symptoms and Appearance

The primary symptom of clubfoot is visible at birth. The typical features include:

• The foot (or feet) is turned inward and downward.
• The affected foot may be shorter and smaller than the normal foot.
• The calf muscles on the affected side are often underdeveloped.
• Limited range of motion in the ankle and foot.

In most cases, clubfoot does not cause pain in infants. However, if untreated, it can lead to difficulty in walking, abnormal gait, and chronic pain as the child grows.

Diagnosis

Clubfoot is typically diagnosed soon after birth through physical examination. In some cases, it can be detected before birth during routine ultrasound scans. The diagnosis is primarily clinical, based on the appearance and flexibility of the foot. X-rays may be used in certain cases to assess bone structure and severity.

Treatment Options

Early treatment is crucial for the best outcomes. The main goals are to correct the position of the foot and allow the child to walk with a normal gait. The primary treatment methods include:

1. Ponseti Method: This is the most widely used technique involving gentle manipulation and serial casting of the foot over several weeks. After achieving the desired correction, a minor surgical procedure called tenotomy (cutting of the Achilles tendon) may be performed. Bracing is required for several months to prevent recurrence.
2. French Functional Method: This involves daily stretching, taping, and physiotherapy, especially useful in infants under two months of age.
3. Surgical Correction: In severe or resistant cases, surgery may be necessary to lengthen or reposition tendons, ligaments, and bones. Surgery is usually reserved for cases where conservative methods fail.

Prevention

During Pregnancy, you can do things to have a healthy pregnancy and lower your baby’s risk of problems that affect the baby’s development:

• Don’t smoke or spend time in places with secondhand smoke.
• Don’t drink alcohol.
• Don’t use legal or illegal drugs that may be sold on the streets or take medicines that aren’t approved by your healthcare professional.

Prognosis and Long-Term Outlook

With early and appropriate treatment, most children with clubfoot can lead active, normal lives. Untreated clubfoot, however, can result in permanent disability, pain, and difficulty in walking. Recurrence is possible, especially if bracing protocols are not followed properly, hence regular follow-up with an orthopaedic specialist is recommended.

Clubfoot in India: Cultural and Social Considerations

In India, awareness about clubfoot and its treatment is increasing, but misconceptions and social stigma still exist in some areas. Government and NGO initiatives are working to improve early detection and access to treatment, especially in rural regions. Early intervention and community support play a vital role in ensuring children with clubfoot receive timely care and can integrate fully into society.

Nursing Care of Patients with Clubfoot

The role of nursing is pivotal in the management, rehabilitation, and emotional support of patients and their families as they navigate diagnosis, treatment, and recovery.

Nursing Assessment

The nurse’s initial responsibility is to conduct a thorough assessment, which includes:

• Physical Examination: Assess the position and flexibility of the foot, presence of creases on the sole, muscle atrophy, and limb length discrepancy.
• Developmental Screening: Evaluate for other congenital anomalies or syndromes.
• Family History: Gather detailed family medical history to identify potential genetic factors.
• Psychosocial Assessment: Assess the emotional and educational needs of both the patient (when age-appropriate) and family members.

Nursing Interventions

Management of clubfoot centers on correcting the deformity and maintaining the correction. Nurses play an integral role in the following interventions:

Ponseti Method

The Ponseti method is the gold standard for clubfoot correction and involves gentle manipulation and serial casting. Nursing responsibilities include:

• Assisting the physician during manipulation and casting procedures.
• Educating parents about the process, expected outcomes, and potential complications.
• Monitoring skin integrity under casts for signs of pressure sores, edema, or infection.
• Teaching caregivers how to monitor circulation, movement, and sensation in the affected limb.
• Providing emotional support to reduce anxiety associated with frequent cast changes.

Surgical Care

In severe or resistant cases, surgery may be required to release tight ligaments or tendons. Nursing care in the perioperative period includes:

• Preoperative teaching regarding anesthesia, postoperative pain, and recovery expectations.
• Monitoring vital signs and neurovascular status postoperatively.
• Maintaining cast and wound care, observing for bleeding, drainage, or infection.
• Pain management with appropriate medications and comfort measures.
• Encouraging gentle movement within the limits prescribed by the surgeon.

Physical Therapy and Rehabilitation

Rehabilitation is crucial in maintaining correction and promoting function.

• Coordinating with physical therapists for stretching, strengthening, and gait training exercises.
• Encouraging adherence to prescribed orthotic devices or braces, such as Denis Browne bar.
• Supporting the development of motor milestones and independence in mobility.

Skin and Cast Care

Proper skin and cast care minimize complications and discomfort.

• Inspecting skin daily for redness, irritation, or breakdown.
• Educating parents to keep casts dry and clean.
• Instructing families on safe methods for lifting and positioning the infant or child.
• Reporting any abnormal findings, such as foul odor, swelling, or increased pain.

Family Education and Support

One of the most important nursing responsibilities is to empower and support the family throughout treatment.

• Providing clear, age-appropriate explanations of the condition and treatment plan.
• Preparing families for the time commitment and follow-up requirements.
• Teaching the signs of complications that require immediate medical attention.
• Connecting families to support groups and community resources for emotional and practical assistance.
• Encouraging open communication and addressing parental concerns or misconceptions.

Psychosocial Considerations

The diagnosis and treatment of clubfoot can cause significant stress and anxiety for families. Nurses can help by:

• Fostering a supportive environment in the clinic or hospital.
• Validating emotions and encouraging questions.
• Offering reassurance about the excellent prognosis for most children with timely, appropriate care.
• Providing guidance on helping the child adapt socially and emotionally, particularly as they grow and interact with peers.

Complication Prevention and Management

Vigilance for potential complications is essential throughout treatment.

• Neurovascular compromise: Monitor for signs of impaired circulation, such as pallor, coolness, numbness, or delayed capillary refill in toes.
• Cast problems: Watch for cracks, soft spots, or tightness in casts that could indicate poor fit or increased pressure.
• Infection: Educate about recognizing fever, irritability, or discharge from the cast or surgical site.
• Recurrence: Stress the importance of follow-up appointments and adherence to bracing protocols to prevent relapse.

Long-Term Care and Outcomes

Children treated for clubfoot typically achieve good foot function and lead active lives. Long-term nursing care may involve:

• Periodic assessment for recurrence, growth disturbances, or gait abnormalities.
• Support for ongoing physiotherapy and orthotic management.
• Collaboration with multidisciplinary teams for holistic care.

REFERENCES

1. American Academy of Orthopedic Surgeons. Clubfoot., https://orthoinfo.aaos.org/en/diseases–conditions/clubfoot. Last reviewed 4/2023.
2. Cady R, et al. Diagnosis and treatment of idiopathic congenital clubfoot. Pediatrics. 2022; doi:10.1542/peds.2021-055555.
3. March of Dimes. Clubfoot., https://www.marchofdimes.org/complications/clubfoot.aspx. Last reviewed 6/2019.
4. National Health Service (U.K.). Club foot., https://www.nhs.uk/conditions/club-foot. Last reviewed 3/24/2021.
5. Riemen AHK, et al. Current understandings in congenital talipes equinovarus. Orthopaedics and Trauma. 2022; doi:10.1016/j.mporth.2022.09.001.
6. Pediatric Orthopaedic Society of North America. Clubfoot., https://posna.org/Physician-Education/Study-Guide/Clubfoot.
7. Rastogi A, et al. Long-term outcomes of the Ponseti method for treatment of clubfoot: A systematic review. International Orthopaedics. 2021; doi:10.1007/s00264-021-05189-w.
8. Kliegman RM, et al., eds. Talipes equinovarus (clubfoot). In: Nelson Textbook of Pediatrics. 22nd ed. Elsevier; 2025. https://www.clinicalkey.org. 

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