Definition & Pathophysiology

Clubfoot occurs when the tendons connecting the leg muscles to the foot bones are short and tight, causing the foot to twist inward. While the exact cause remains uncertain, research suggests a combination of genetic and environmental factors contribute to its development.

Risk Factors

• Male gender (occurs twice as often in boys)
• Family history of clubfoot
• Maternal smoking during pregnancy
• Oligohydramnios (reduced amniotic fluid)
• First-born child status

Clinical Presentation

Clubfoot is immediately apparent at birth. The typical clinical features include:

• Equinus: Foot pointed downward (plantar flexion)
• Varus: Heel turned inward
• Adductus: Forefoot turning inward toward the midline
• Cavus: High arch

Additional physical findings may include:

• Calf muscles that are smaller on the affected side
• Rigid foot deformity that cannot be easily manipulated to a normal position
• Deep creases on the bottom and medial side of the foot
• Shorter and thinner foot compared to an unaffected foot

Diagnosis & Assessment

Diagnosis of clubfoot is primarily clinical and typically made at birth based on physical examination. In some cases, prenatal ultrasound may detect the deformity before birth.

Diagnostic Assessments

• Physical examination: Visual inspection and assessment of foot position and flexibility
• Pirani scoring system: Clinical scoring system to assess severity and monitor treatment progress
• Dimeglio classification: Alternative grading system based on reducibility of the deformity
• Radiographs: May be used in older children but not typically necessary for initial diagnosis

Treatment Modalities

The goal of treatment is to achieve a functional, pain-free foot that enables standing and walking with the sole of the foot flat on the ground. Treatment usually begins shortly after birth.

Ponseti Method

The Ponseti method is the most widely used technique for treating clubfoot worldwide. It involves:

1. Manipulation and casting: The foot is gently stretched and manipulated into a corrected position, then held in place with a long-leg cast. This process is repeated weekly for 6-8 weeks.
2. Achilles tenotomy: A minor procedure to release continued tightness in the Achilles tendon (heel cord), performed in about 90% of cases.
3. Bracing: After cast removal, the child wears a brace (boots and bar) to maintain correction.
   • Initial phase: 23 hours per day for 3 months
   • Maintenance phase: 12-14 hours daily (nighttime and naps) for 3-4 years

French Method (Physical Therapy Method)

An alternative approach involving:

• Daily stretching and manipulation
• Taping and splinting to maintain correction
• Regular physical therapy sessions (typically three times weekly)
• Possible Achilles tenotomy
• Continued home exercises and splinting until age 2-3 years

Surgical Intervention

Surgery may be necessary when nonsurgical methods fail to achieve adequate correction or when the deformity recurs.

• Limited surgery: Targets specific tendons and joints contributing to the deformity
• Comprehensive release: More extensive surgery involving release of multiple soft tissue structures

Nursing Management

Assessment

• Complete physical assessment with focus on neuromusculoskeletal system
• Monitor growth and development milestones
• Assess skin integrity, especially under casts and braces
• Evaluate neurovascular status of affected limb(s)
• Pain assessment using age-appropriate scales

Nursing Interventions

Parent Education

• Demonstrate proper cast care techniques
• Teach correct brace application and removal
• Explain importance of compliance with treatment regimen
• Review signs of complications requiring medical attention
• Provide strategies for playing with child while in brace or cast
• Offer emotional support and connect with family support groups

Definition & Pathophysiology

In a normal hip joint, the femoral head (ball) fits securely into the acetabulum (socket). In DDH, several anatomical abnormalities may be present:

• Shallow acetabulum (socket)
• Underdeveloped femoral head (ball)
• Stretched ligaments around the hip joint
• Abnormal position of the femoral head relative to the acetabulum

Classifications of DDH

Risk Factors

• Female gender (more common in girls)
• Firstborn status
• Breech presentation during pregnancy
• Family history of DDH
• Oligohydramnios (low amniotic fluid)
• Other musculoskeletal abnormalities
• Improper swaddling with hips and knees in extension

Clinical Presentation

DDH often presents without obvious external signs, particularly in newborns. This makes screening and careful assessment crucial.

Physical Signs

• Asymmetric skin folds in the thighs or buttocks
• Limited hip abduction on the affected side
• Apparent leg length discrepancy (affected leg appears shorter)
• Galeazzi sign: Uneven knee heights when hips and knees are flexed
• Later signs (in untreated cases): limping, toe walking, or waddling gait

Physical Examination Findings

• Ortolani test: A palpable “clunk” felt when the dislocated hip is reduced
• Barlow test: Ability to dislocate an unstable hip with gentle pressure
• Limited abduction: Restriction of outward movement of the hip

Diagnosis & Assessment

Early diagnosis is crucial for successful treatment. The American Academy of Pediatrics recommends screening all newborns for DDH and careful monitoring during early well-child visits.

Diagnostic Methods

Screening Recommendations

• All newborns should be screened by physical examination
• High-risk infants (female breech presentation, family history) should receive ultrasound screening at 6 weeks
• Continued monitoring during well-child visits up to walking age
• Any abnormal findings warrant referral to orthopedic specialist

Treatment Modalities

The goal of treatment is to achieve a normal relationship between the femoral head and acetabulum to allow proper hip development. Treatment approach varies based on the child’s age and severity of the condition.

Treatment Based on Age

Pavlik Harness

The Pavlik harness is a dynamic orthosis that maintains the hip in flexion and abduction while allowing some movement. Key features include:

• Shoulder straps connected to foot stirrups
• Maintains hips in position of stability (flexed and abducted)
• Success rate of 85-95% when used before 6 months of age
• Allows for continued hip development

Hip Spica Cast

A hip spica cast is applied after closed or open reduction to maintain the hip in the correct position. It typically:

• Extends from the mid-chest or waist to the ankles or knees
• Includes both legs (though sometimes only the affected leg)
• Has an opening for diapering
• Is changed periodically during treatment

Nursing Management

Assessment

• Complete musculoskeletal assessment with focus on hip symmetry and movement
• Neurovascular assessment of lower extremities
• Skin integrity evaluation, especially at pressure points
• Pain assessment using age-appropriate tools
• Assessment of family coping and knowledge

Nursing Care for Children with Pavlik Harness

• Teach parents proper application and removal (if permitted)
• Demonstrate skin care and inspection techniques
• Show how to perform diapering and bathing with the harness
• Educate about positioning during sleep and play
• Explain the importance of regular follow-up appointments

Nursing Care for Children with Hip Spica Cast

Developmental Support

• Adapt activities to promote continued development while in harness or cast
• Provide age-appropriate toys and stimulation
• Encourage upper body and core strength development
• Monitor for developmental delays and refer for early intervention if needed
• Prepare for potential developmental catch-up period after treatment

Unique Features of Pediatric Fractures

Distinctive Characteristics of Children’s Bones

• Higher porosity: Children’s bones are more porous and less dense than adult bones
• Greater elasticity: Pediatric bones can bend substantially before breaking
• Thicker periosteum: The periosteal sleeve provides stability and aids in fracture healing
• Active growth plates: Physes (growth plates) are susceptible to injury and may affect bone growth
• Rapid healing: Children’s fractures heal more quickly than adult fractures
• Remodeling potential: Growing bones can correct angular deformities over time

Epidemiology

• Fractures account for 10-15% of all childhood injuries
• Peak incidence occurs during adolescent growth spurts
• Boys are affected approximately twice as often as girls
• Most common sites: forearm, wrist, elbow, clavicle, tibia
• Distal radius fractures are the most common pediatric fracture overall

Types of Pediatric Fractures

The unique properties of children’s bones lead to fracture patterns rarely seen in adults.

Incomplete Fractures

These fractures, common in children, involve a break through only a portion of the bone width.

Complete Fractures

These fractures involve a complete break through both sides of the bone.

Growth Plate (Physeal) Fractures

Injuries involving the growth plate are unique to children and can affect bone growth.

Diagnosis & Assessment

Clinical Presentation

• Pain, swelling, and tenderness over the injury site
• Decreased movement or unwillingness to use the affected limb
• Visible deformity or abnormal alignment
• Crepitus (grating sensation) with movement
• Bruising or ecchymosis

Young children may present with subtle signs such as:

• “Pseudoparalysis” – refusal to use a limb
• Irritability when the affected area is moved
• Guarding of the injured extremity
• Crying when positioned in certain ways

Diagnostic Approach

Treatment Approaches

Treatment of pediatric fractures aims to restore alignment and function while allowing the natural healing and remodeling processes to occur. The approach varies based on the fracture type, location, and patient age.

General Treatment Principles

• Accept greater angulation in younger children due to remodeling potential
• Consider remaining growth when evaluating acceptable alignment
• Prioritize anatomic reduction for growth plate fractures
• Use the least invasive method that will maintain adequate reduction
• Consider the psychological impact of treatment on the child

Nonsurgical Management

Surgical Management

Rehabilitation Considerations

• Range of motion exercises after immobilization period
• Progressive weight-bearing as directed by provider
• Strengthening exercises to regain muscle mass
• Proprioception training for lower extremity injuries
• Return to sports guidelines specific to fracture type

Nursing Management

Initial Assessment and Interventions

• Perform comprehensive assessment of the injury and child’s overall condition
• Apply temporary immobilization (splint) to reduce pain and prevent further injury
• Assess and document neurovascular status as baseline
• Administer appropriate analgesia and assess pain level
• Elevate the extremity to reduce swelling
• Apply ice to reduce pain and inflammation

Nursing Care for Children with Casts

Monitoring for Complications

Discharge Planning and Home Care

• Provide written and verbal instructions for cast/splint care
• Teach proper use of assistive devices (crutches, wheelchair)
• Review pain management plan and medication administration
• Explain follow-up appointment schedule
• Discuss activity restrictions and return-to-school plans
• Address potential developmental and educational needs

Special Considerations by Age Group