Congenital clubfoot is one of the most frequent deformities of the foot, with an incidence of about 1 per 1,000, and is also a common disease in pediatric orthopedics. Boys are two times more common than girls, unilateral slightly more than bilateral. At present, early diagnosis and early treatment are advocated. And there is already a set of more mature treatment plan and technology. The vast majority of children with the disease have their deformities corrected after treatment, with normal joint movement and no painful symptoms. If treatment is delayed, or even not treated, it can bring lifelong disability and physical and mental pain to the child. We hope that parents will pay attention to the timely diagnosis and treatment. The etiology of this disease is still inconclusive, and there are many theories.
(A) Genetic factors: The disease has certain regional, racial, and familial characteristics. Twenty-four percent of patients have a family history of the disease. Children with a family history are more likely to have recurrences than children without a family history.
(b) Neuromuscular disease: The study found that the affected limb muscle fibers have abnormalities and also found that the fiber cells contain contractile proteins, which is a factor leading to the recurrence of the deformity after the correction of the deformity. The nerves also have abnormalities, and clinically we found that the affected children are often combined with lumbosacral lamina cleft, and some children were also found to have poor toe movement and abnormal electromyography.
(iii) Vascular abnormalities.
(iv) Developmental: Stagnation of embryonic development process, abnormal fetal position, presence of viral infection, injury and other factors are under study.
Second, pathology I will only briefly mention a few points.
1, the posterior part of the foot, the medial lateral ligament muscle contracture tension, resulting in the displacement of the foot bone or even dislocation.
2, the main deformities are foot inversion, inversion, ptosis, internal rotation of the calf and muscle atrophy thinning.
3, research found that the foot ligaments are rich in collagen, these collagen is broken wave-like cells rich, easy to be stretched, especially the newborn period is more obvious. This is the theoretical basis for the success of conservative therapy massage, plaster or brace external fixation. In contrast, tendon tissue has few collagen cells that are poorly stretchable, so tendon contracture often requires surgical treatment.
Third, the clinical manifestation
The deformity of horseshoe inversion can be found in one or both feet after birth. The deformity gradually worsens with age, and bursa and callus often appear on the lateral edge of the foot after standing and walking. In unilateral patients, the calf muscles on the affected side become atrophied and thin. Also pay attention to the whole body examination, skeletal muscle abnormalities of the limbs, spinal deformities and urinary system abnormalities.
IV. Subtypes
1, postural clubfoot: may be caused by late pregnancy in utero position, deformed foot flexibility, by massage or brace external fixation can be more quickly cured.
2, idiopathic horseshoe foot: the cause of multi-factor, showing typical horseshoe foot performance, medium stiffness.
3, deformed horseshoe foot: multiple joint contracture, atypical horseshoe foot, foot deformity are very stiff treatment is difficult. Five differential diagnosis: clubfoot generally has two major types of disease.
(a) stiffness.
1, multiple joint contracture: after birth can be found in the limbs deformity, in addition to clubfoot, often involving the knee joint, upper limb wrist elbow joint, stiffness activity is limited. In severe cases, the shoulder and hip joints are also involved, and even hip dislocation.
2, cerebral palsy: for example, premature babies, born with cerebral hypoxia, etc., advanced neuronal disease, high muscle tone of the limbs, some children can see clonus, give stimulation joint tremors, inflexible hands and feet. When the child falls asleep, the muscle tone decreases and the joint tremors disappear, and the feet become floppy.
3, congenital clubfoot also belongs to this category.
(II) Softness.
1, congenital spinal nerve, spinal cord bulge, intraspinal tumor, spinal cord embolism, spinal tuberculosis, etc.
2, peripheral nerve injury.
3, pediatric paralysis.
In recent years, it is not common. These diseases are peripheral nerve damage muscle paralysis, muscle weakness, some patients incontinence. Six treatment treatment aims to correct the deformity, maintain foot flexibility and muscle strength, weight-bearing surface close to normal, and maintain the orthopedic shape without recurrence. If you can get close cooperation from parents more than 90% of patients can achieve such good results. Calf muscle atrophy is thinner than normal calves, and some children have slightly smaller feet but do not affect walking and shoeing. These problems are under research and treatment, but there is no complete treatment yet.
(A) conservative treatment: is not to do surgery (or do very small surgery) through manipulation and massage, coupled with plaster or brace external fixation to correct the foot deformity.
1, early diagnosis and early treatment. Treatment can be started 7-9 days after birth. Early orthopedic treatment is easy and effective. Children under nine months of age can generally be cured through conservative therapy. Children over nine months of age depend on the degree of stiffness of the child’s deformity, and the doctor will decide whether conservative treatment is possible.
2.Plaster external fixation is to come to the hospital every week to be massaged by the doctor and put in a cast. Usually 5 to 6 times in a row. Our hospital uses the external fixation of the brace, the massage technique and steps are taught by the medical staff to the parents, after the massage technique and the use of the brace can be operated independently by the parents, the brace is brought home by the parents to complete the correction. Generally, we come back in a month to review the next step of treatment. In the past five years, we have treated nearly 500 cases of children and have not found any parents who cannot master the massage technique, so parents can rest assured.
3, regardless of plaster or brace external fixation is to correct the inversion of the foot, the next step for most children to be through subcutaneous tendonotomy to solve the foot ptosis heel inversion. Attempts to correct foot drop by strengthening the extension massage may cause “rocking chair” foot deformity. That’s why we require those using braces to return to the hospital for a one-month checkup to prevent overcorrection.
It is a rule that “you must return to the hospital for a month to review”. “This is another principle: “The correction process should not be too heavy and the child should not be allowed to cry. These two principles are strictly observed. If the child does not cry, there will be no pressure on the skin. One month back to the hospital to review will not occur over-correction. Please rest assured that parents.
4, the last step is the longest, to persist until the child is three or four years old, because three or four years old are likely to relapse. Parents should give the child massage and use orthopedic braces. The purpose is to correct the internal rotation of the calf, restore the flexibility of maintaining joint mobility, maintain and strengthen muscle strength, and prevent the recurrence of deformity. The task is very difficult to establish contact with us and learn massage techniques and the use of braces. It is important to return to the hospital on time for review, as early treatment in case of recurrence is simple and effective. Delayed treatment often requires surgery child pain, increase the economic burden, the effect is also poor. The advantages of brace correction
1, absolutely no anesthesia, to avoid the risk of anesthesia. Especially a few months when the child is playing a cast, the child cries seriously without anesthesia to play the cast is quite difficult, the cast is not played well also has the risk of pressure injury skin. And the branch has great advantages.
2, we emphasize early massage calf muscles, promote muscle development, so that muscle atrophy as small as possible. Some children need acupuncture treatment. These put on the cast is unable to do.
3, the correction process is light, do not let the child cry, the child less pain, the child can fully accept.
4, because the child does not cry, the technique must be gentle, once the child cries parents will also deal with timely, so no major limb injury will occur
5.The cast is applied once a week, and the correction of the cast can be done in more than seven times, so the pain of the child is minimal and safe. According to our statistics, we can generally achieve the purpose of correcting the inversion of the foot in one month. It may be about one week earlier than playing plaster.
6, the massage technique is simple and easy to master, will not add burden to parents, we see illiterate old farmers can also master.
7.The child can be cleaned and bathed every day.
8, reduce the parents to come to the hospital for treatment and the economic burden of the trouble.
9.It is very humane, easy to get parents’ cooperation and much praise. There is no reluctance to use, or fear of trouble reluctant users. (B) Surgery generally refers to children over one year old or children with recurrence. There are many surgical methods depending on the age of the child and the degree of stiffness of the deformity.